Hello and welcome to another episode of Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. Today we are blessed with Lilia. Welcome back, Lilia. It has been a little while; we were just talking about that. How have you been? All is good. We're busy getting Jacksonville put together. I am heading there tomorrow for an early day. We've had some nice consults and things set up, so things are tracking along nicely with slow and smooth growth.
Today, we're going to talk about the fallacy of the 24-hour final. We are going to cover the shortcomings and issues that we used to experience and perhaps get into the downsides of making artistic decisions too quickly.
As I was thinking about this on my way to work this morning, I thought about how we all have a specific way we like our chicken or our burger. You go to a restaurant and order it exactly the way you want. You see one that is almost right, but you don't like ketchup, so you ask for it to be removed. It comes out, and it's just not perfect. It’s still a burger; it has been assembled. Who is to say it was wrong besides yourself? You are the only one with the taste buds and preferences to say that it’s wrong. That is the best example I can think of for why 24-hour finals can be an issue. It’s not that they are ever done "wrong," it’s just that getting that perfect "flavor" for a specific patient can be an issue.
We all have our preferences, and it’s really hard to get it right without being able to see, feel, and experience the result. I think a lot of people don't even know what their preferences are until they are in the midst of it.
Regarding the selection of teeth, we often tell patients during consults that I am not going to shove a book full of teeth in front of them to pick from. I can't tell what is going to be your perfect shape and size, and I don’t know you well enough after a one-hour consult. We find generally that when that first set of teeth goes in, the patients are the biggest critics of where things should go.
Let's talk first about what allows for a 24-hour final. When you do it the old way, it involved a lot of physical manipulation. We would take an impression, bring that to a lab, and generally make a regular denture off of teeth that we selected with a patient during the consult. We would order those teeth, have a regular denture made, and then glue it together. When you do it that way, you are locked into that decision, and anything that happens in the surgery is sort of stuck.
I’ve mentioned it before, but when we were starting in Jacksonville to do these 24-hour finals, we might have been the second or third center in the world to do it. It was exciting. We thought that putting all of this tech together to get teeth in right away would be exactly what patients wanted. We found over time—it probably took a good four years for me to really learn the lesson—that while it worked, there were drawbacks.
We used to combine technology like face scans. We would take a scan of the person's face so that the designer on the computer could see where the nose, eyes, and ears were, as well as the heights and the amount of lip support. You would combine that with the scans and build a cohesive model of their jaw. That file was then produced as a final.
As we've discussed with Dr. Lax before, there are different landmarks that give us guidance. If I am looking at a patient, the eyes are supposed to be parallel with the patient's set of teeth—their occlusion or bite. You can see that on a great scan. That was an expensive piece of equipment, and it was necessary for every office that offered a quick final. it was a way for our designers to have the confidence to make it. But when you get all of those parts and pieces together and line up everyone's schedule to make a final...
Maybe the data was just a little bit different, or the patient's preference was a little bit different. It can lead to a really disappointing scenario. I can see the dentist being disappointed that the patient isn't as happy as they thought, and I can see the patient thinking they had this idea of what they were going to get, but it’s not quite what they wanted. It's probably a letdown for both. I can see the frustrations on both ends; it’s a lot of decision-making right up front.
Can you imagine sitting down during the consult—which is when we would take the imaging—and having them pick the set and color of teeth right away?
I'm such an indecisive person with my personal decisions that I don't even know how that would feel. I already see our patients who have over a week and can still be a little indecisive, which is totally normal. I can't imagine being told, "This is the moment to pick out everything: the color, the size, XYZ." It’s a lot of pressure.
To give an example of that pressure—or really, it’s not even necessarily pressure. We have all had this scenario: I don't do much shopping, but I ski a lot. There was a year where I saw a particular ski jacket and I loved it. I thought it was the coolest looking thing. I loved where the zippers were and I really looked forward to getting it. Then I walked into a store in a little ski town and tried it on. It looked terrible on me. It looked like I was trying to be 15 again. I would have sworn that was the jacket I'd wear for the rest of my life. The point is, that was just a jacket, and we have all worn clothes before—I already know what colors I like. I'm sure you can think of many examples of a dress you see on the rack and think, "Oh, that’d be awesome," but then you try it on and it’s frustrating.
Like you said, it’s just clothes, but these are your teeth. It’s supposed to be permanent and there is a significant expense involved. Even if it looks good, maybe it was the wrong size because that particular brand runs different. We ran into a lot of those issues with a permanent final set of teeth right away, purely on patient satisfaction regarding the aesthetics.
I try to delineate this for people: it’s not that a 24-hour final doesn't "work." The bite could be perfect. The color could be perfect. But something could be wrong just enough, preference-wise. Maybe the material doesn't feel right, and right away you’re on the road to disappointment, frustration, and conflict.
That wasn’t a great feeling. This is a big psychological journey for these patients, and in a 24-hour final, you only get a small snippet of that journey. All of that emotion and selection is packed into a couple of visits. We used to see patients say, "That’s it? I spent $35,000 or $40,000 on this." What do you even say? You say, "Yeah, that’s it." And they say, "Well, you didn't even do anything. It was like two hours of work. What did I pay for?" Of course, there was a lot of work and scheduling behind the scenes. It was actually more expensive than it is now because it required lining up highly specialized, highly trained people to make a final overnight. We had a massive lab staff at the time.
In the consult, did patients ever question that they wouldn't get a "try-in"?
No, I think they were mostly excited about having a very limited window of time. It wasn’t until we saw those frustrations that we started asking if there was a better way to give them value and customization while still accomplishing the goals. Whether it’s a 24-hour final or our current seven-day process, the goal is to get the highest quality teeth in the mouth. Again, with a 24-hour final, you can get a good bite and center line. The difference is how the patient feels. The patient is the most important part. I feel like that would start to break you after a while if it was just patient after patient being bummed out—not all of them, but even the few make you feel bad.
Surprisingly, more than anything, what we would find is that the bite would be a little bit off. It’s very hard to capture that perfect bite right at the time of surgery. The patient has been open for a while, and you just have to work with whatever bite is available. More often than not, even if it only required a minimal adjustment, a patient would be very upset if we had to adjust anything.
They thought it was supposed to be exactly perfect. That makes sense, but from the perspective of the dental team, I know it can and sometimes needs to be adjusted. I can see the patient thinking, "I love everything, I shouldn't have to change anything."
I would say not being able to select their teeth accounted for maybe 20% of the complaints you’d hear under their breath. Probably 50% of the complaints were, "You just ground down what you said was a final." That was very frustrating for them. It was hard to explain that it wasn't a big deal because, to them, it is a big deal.
I don't want to instill an attitude that the bite shouldn't be perfect, but adjustments are often necessary. However, when you're adjusting zirconia at the finished stage, it can be damaging. You have to use the right amount of irrigation and keep it cool because zirconia is finicky. It's like a clay pot; the slightest thing can impart weaknesses, expose cracks, or lead to long-term fractures that might not show up right away.
I can see the anxiety from the patient’s standpoint—thinking this will be two or three appointments and then they never have to worry about it again. But they might not understand that we are a team working with them for the best end result. Having those extra appointments to try things in is what gives the best results.
That’s a perfect point. When we tried to get all the post-surgical records on the day of surgery to match with the pre-op data, it was very difficult because you were adding significant time to the surgical day. That can be overwhelming. One of the things I love most about our current protocol is that it's broken into little snippets: two hours on the day of surgery, then 30 to 45 minutes the next day, and the same the day after. None of it is overwhelming.
The "dark dirty secret" of the 24-hour final is that sometimes machines break, or a designer is sick or late. Occasionally—not often, but it happened—the teeth weren't done on time. A 10:00 a.m. delivery becomes 12:00, 1:00, or 2:00 p.m. You expose your shortcomings quickly and lose patient confidence.
For us, a double arch (top and bottom) surgery is generally two hours, including data acquisition. For a standard conversion denture elsewhere, it’s generally six to eight hours. When we were doing the straight-to-final product, it was about four and a half hours start to finish—about twice the time we take now.
I honestly feel like patients coming to us in these small windows each day is therapeutic for them. It’s almost like exposure therapy. Even though they are dealing with the aftermath of surgery, we are comforting them and they see it isn't as bad as they feared. By the end of the week, I think their fear of the dentist has actually decreased.
If you put me on a 10-hour or eight-hour flight, it’s not going to be pretty. I’ll tell you that right now. But if you put me on these little one-hour flights every few months, I’m hopefully going to get over that fear. I’m hoping that is what patients are experiencing. I think we do a pretty good job of conveying that to the patients and getting them to a point where psychologically nothing is overwhelming, and that plays into how the results go.
You can be more successful when a patient has a better attitude; an optimistic person is going to get better results. That is just the reality. It’s this weird world where if you start saying, "Oh, I’m going to lose an implant," for whatever reason, you’ve kind of willed that into the world. If we can get a patient to have some positivity coming into the procedure, generally it goes well. If they are positive about being in charge and knowing we won't go past a certain point without their approval, it can be very comforting.
The other "dark secret" of the 24-hour final is that I believe my old business partner and I were generally the only offices truly designing a true 24-hour, fully made prosthesis from start to finish. There is a "cheat" out there in the world. I’m not going to name names, but as a patient, you have to be careful when picking a 24-hour final location. What often happens is that they have different pre-made sizes and shapes of teeth—essentially pre-made arches—that then get retrofitted to the specific patient’s details.
The patient isn't going to know, and they aren't going to be told it's anything but custom. If they ask, they are told, "Yes, it’s custom to your implants." But the actual teeth, the core design data, and the customization are very limited when you are retrofitted to standard sizes.
If I'm a patient listening to this, what do I ask? How do I know?
I actually don't know the specific questions to ask to expose it; I’m just here to explain the method. It’s hard to think of a scenario where I would be okay with that as a practitioner. I guess if a patient is happy with the results, that's one thing. For us, a telltale sign of true customization is if a patient brings us a photo of their smile from when they were 22. Our designer will recreate that photo as best as he can. In my opinion, that is customizable.
There are plenty of "buttons" you can push to make a person think it was custom. Let's go back five or six years: maybe a patient wanted to point the canines last minute after the teeth were already made. You can alter that by hand before the teeth are processed. The patient thinks it was dialed in for them, but their core digital data hasn't changed. If we made a new set from that file, it wouldn't have that change.
In establishing a protocol where everyone is happy, it’s important to me that everything is custom from the ground up and that the file is as representative of the patient's mouth as absolutely possible.
It’s a slippery slope in full-arch dentistry. If I’m competing with a center that uses what I call the "shoe box method," it’s frustrating. What do I advertise? How do I say, "No, we’re better because we actually make it custom," when they are using all the same buzzwords like "custom," "implant-supported," and "quick-to-final"?
They can use all those buzzwords and marketing techniques, and I think that was one of the funnest parts of developing our style—breaking the mold. At the very beginning, we worked hard to market ourselves with the message: "Sure, you don't get teeth on the same day, but we're so digital we can get you to a finished product faster." We relied on bragging about our digital abilities.
Well, anybody can put a computer into the process and say they're digital. I was watching a local dentist recently bragging about how digital they are and showing off the "latest" scanning equipment. Being a nerd, I know that the equipment they had in the commercial is not actually the latest and greatest. It’s frustrating because that person then gets all the marketing benefit. A patient gets looped in, likes them, and they don't even know if that's the best; they’ve just been told it’s the best.
I think it comes down to research. A lot of times, patients just find a nice dentist they feel comfortable with. You don't want to be cynical, but if you're looking to get this procedure done, doing your own research from start to finish is best. Unfortunately, most people won't know the difference; it's up to the dentist to be upfront and honest about what they can do. It seems like everyone is bragging about technology that patients think is really good.
I tell patients every week in consults: I don't envy you trying to wade through this world. There is a guy who says he's digital but has terrible results and really just used a computer for the lab script. Then there are other guys who are amazing and truly all-digital. It's very hard for a patient to discern what to do.
Touching back on that, one of the coolest parts of rethinking our protocol was realizing that if I rely only on digital marketing, I'm not truly unique. Even if I have the absolute best technology, I can't hold myself out as different forever because everyone eventually puts a computer somewhere in their workflow. Patients aren't educated enough to discern between the better version and the "less better" version. Digital won't be a great marketing differentiator forever.
That realization allowed us to break the mold and ask: "What is our staying power? What are our core values?" At the end of the day, it's about being human and making decisions together with a patient—not forcing them into a scenario. It's about keeping them comfortable and allowing them input while using the most efficient techniques. We use a mix: some steps are done by hand and some are digital, and we put together the best flow of digital machinery to get that result.
Things are constantly changing. There are three main models of what they call photogrammetry. If we haven't explained it well before, photogrammetry is what allows for the accurate data of where the implant is located. It’s a scanner, but not in the traditional sense. Most dental scans are built by stitching a lot of pictures together to represent an object.
Photogrammetry, more or less, takes pictures of a "known marker" (a flag) and says, "I know exactly what is at the bottom of that marker, and I have enough pictures to say exactly where it is in 3D space." Photogrammetry does not allow for gum tissue or tooth scans because gum tissue is always changing; it isn’t a "known" geometric shape. For tissue and teeth, you still have to use the "stitched together" pictures, which are less accurate—or rather, not accurate enough on their own to determine implant position.
We use photogrammetry to get the exact implant position. There are three main units on the market; I’ve used all three heavily and believed in each one at the time. The digital world is always moving; it's not "set it and forget it." You always have to push the envelope. But as long as our data and results keep improving, I don't have to worry about bragging about who has the newest gadget. We get to brag about being personalized and relationship-based.
I realize that probably alienates a few people who might not want a dentist "all in their business" or to be their friend, but I think most people find it nice.
It's about working together in a forward manner. It's having everything in the perfect package. Do I want a dentist who's super nice and cool like ours? Yes. But I also want someone who has the knowledge, the technology, and the experience. It’s a great package to have.
It’s been a great career and process to really figure out the right protocol. Going to a finished product quickly was something that, as I’ve said before, wasn't originally approved of. Nobody thought that was a good idea and everyone shied away from it. I think I’ve said this before on a podcast, but I can remember when we first started doing 24-hour finals. I remember going to meetings for full-arch hybrids with my old business partner and trying to talk to other dentists about how it was possible and what the advantages were. We were literal pariahs. We might as well have had an offensive symbol on our heads.
Did that frustrate you at the time?
It was very frustrating because I was young in my career and I had colleagues I wanted to help. I was trying to give them a solution that addressed a lot of challenges, and it was a big eye-opening experience to realize that not everyone necessarily wants things to be improved. Some want things to stay the same or want to believe that they are the only ones capable of getting a good result. I try to keep that in mind. There are plenty of centers that do an amazing job—maybe even a better job than us, I’m not sure—but the biggest thing we try to impress on our patients and staff is how much we care about the result. We have assembled a process that is straightforward and gives patients peace of mind.
For us, 24-hour finals just gave the impression of too much speed and not enough patient involvement. Your system has to run at 100 miles an hour to get everything perfect in that timeframe, and it’s human nature for something to eventually happen. You can’t always be on time and perfect in that scenario. One person gets sick, and then what?
Exactly. It could be just the guy who delivers the teeth who is sick. Going back to the equipment, I tell patients all the time: I still have all the equipment I had when I did 24-hour finals, or better. Most labs and doctors with in-house labs have equipment that can produce a final. We could get a final to you today. If we do surgery at 8:00 a.m., that final can be in the mouth by 5:00 or 6:00 p.m. Our machines are more than capable of accomplishing that. It’s just a personal preference regarding the timeline.
24-hour finals used to take a lot more finesse to coordinate the machinery. Now it's sort of standard; most machines can accomplish those tasks. It’s not that the person doing 24-hour finals is the only one capable. In my opinion, it’s often that they are a young enough company that they haven't truly learned the lessons yet, or they are cutting enough corners to get away with it.
As a patient, I would feel good knowing you’ve tried it out. It’s not like you’re saying, "I don't like those other guys," without having ever tried their method. You did it to a very deep level.
I tried to get the whole world on it. To provide some education on where 24-hour finals were versus today: one of the reasons we were one of the only groups that could do it for a while was because you needed milling machines to cut the teeth and milling machines to cut the bar that held the teeth together. Traditionally, the part that screws into the implants was a full titanium bar that went across the arch. Combining those two technologies so they fit together, glued together, looked good, and performed well was a high-level experience.
The main competitor out there at the time was doing something similar, but the bar was the only thing that was custom-made that day. The channel or groove that the teeth sat in was cut such that they could essentially refit and reglue it, which leads to inaccuracy and wiggle room; it’s not perfectly made.
One thing we were really proud of was the connection we created between what our machines were cutting and where the bar was being made. In that world, you have two pieces that need to be perfectly made to fit together. When they are perfectly made, both of those machines have to be operational and a person has to be there to assemble them.
Things changed quite a bit when zirconia started looking good enough to use. The materials I was talking about previously weren't as good-looking; it was either a nanoceramic—which was a plastic with ceramic particles—or a PMMA, which isn't really strong enough for a long-term final. I remember things really changing when designs got simpler because we could use zirconia as a finished product. It used to look like a coaster—just plain white with no life, no variety of color, and no clarity. They call it "multi-layer" now, but back then, there was no translucency to it.
When we finally got good-looking zirconia, we also gained the ability to produce the restoration without needing the metal-milling machine to be operational at the exact same time. That’s when you saw a wave of more people doing a "straight to final" because it became easier to achieve the correct file. Now we live in heaven, basically, because the file that goes into the 3D printer for prototypes is essentially the exact same file that goes into the zirconia machine. If you go back 12 years in my brain, this is what I was hoping for.
Even when I first started three or four years ago, our printers were different. I remember the quality of our prints then versus now. When they showed us the first print on the new machine, I was stunned. I can only imagine what's to come. You have to stick with the latest technology or you get left behind very fast.
It’s a dance between staying on the cutting edge and staying a little bit behind to ensure reliability. We are currently in the middle of switching over our photogrammetry scanners for implant positioning. The main reason is accuracy. Right now, when I take a picture and ask the computer to calculate the implant positions for a designer, I don't have a definitive way to know if my machine is calibrated correctly without going through many testing steps.
The particular unit we are switching to has the ability to take a scan of a calibrated model and compare it to the data the computer is spitting out. If it compares them and finds a discrepancy, it tells you the machine is out of calibration. As a practitioner, that is huge; I know I’m giving good data. If I take a scan and I'm worried it's off, I can ask the software if it's correct, and it can verify it within a specific tolerance. It allows us to target areas of inaccuracy.
Once the machine makes the product, there’s another cool feature. We now have flags for this machine that we can put in the underside of the zirconia restoration and scan it. The software tells us how much that finished product matches the original digital file. We can much better pinpoint things that aren't perfect. Technology always has a failure point, and our goal is to limit exposure to those problems. We've all had a computer that works for three years, glitches one day, and works fine the next. Technology is finicky. It's about putting together reliability and being able to identify weaknesses.
It is about identifying where the problem originated and being able to hone in on those areas.
This is a side story: when I was between my undergraduate degree and dental school, I took a year off and moved back to Michigan. In Michigan, there's a big MLM called Amway that has a massive production facility. One of the coolest things about taking that year off was that I was only 20; I would have only been 20 in dental school at the time. Even though my test scores were good enough to get in, they mostly told me, "Listen, you’re going to be 20. You’re not really going to fit in yet. Why don’t you take a year off?" I was upset and disappointed at the time, but it was actually cool because I got to use my microbiology degree.
I worked in this production facility for a year doing contract work. We produced Johnson & Johnson baby lotion, L'Oreal kids' shampoos, and a lot of other products. It was a big manufacturing plant with huge mixing lines, and we had to test the raw materials going in and the finished product coming out. We were constantly testing for bacteria—is it safe or not?
During that year, there was a big release scheduled for ACT mouth rinse—specifically, "ACT x2," the second generation of the fluoride rinse. It was supposed to be a huge release with grand openings and a massive product launch. However, every time we tested it, the bacteria levels were off the charts. We couldn't figure out what was going on. We tested for weeks. In production, they just kept producing it the same way on the assumption that we would eventually find the problem and fix it retroactively so the schedule wouldn't be disrupted.
We had warehouses full of this stuff. Finally, the team figured out that the bacteria came from the shrink wrap. The original bottle had a simple sticker, but for this new version, they shrink-wrapped the whole bottle to make the branding look more cohesive and "sexy." The steam used to shrink the wrap was using dirty water—dirtier than it should have been. That tiny detail affected the whole delivery schedule and shipping.
The point of the example is that in manufacturing, the tiniest thing can throw the whole system off. We had checked the air samples a million times and never suspected the shrink-wrap steam. Similarly, in dentistry, you can get a full arch done in 24 hours, three months, or one week, and you can do it well. But it is all about the assembly of the entire process, because even your water can throw the whole thing off.
Patients are already scared as it is. If one thing doesn't go right, it makes everything that much worse for their mindset regarding dentistry in general.
It comes down to integrity—the integrity of the employee to relay the correct message and the integrity of the manufacturing process to stand behind that message. We do it right. We do full custom restorations. We don't take retrofitting shortcuts or use bait-and-switch tactics. Standing behind that is more important than the timeline.
I am grateful for the opportunity to have done 24-hour finals, but I don’t want to do them anymore. It leads to enough frustration and strife between patients that it’s not a world I want to be in. It has nothing to do with the capability of the machinery; it’s about the end-to-end experience. How can you give your employees a good work-life balance and give patients peace of mind? Putting that all together is why we moved away from the 24-hour final.
The intention of this podcast is to give the consumer something to think about. We gave them a lot to think about, even if we didn't give them all the answers on what to ask, because the industry is so entangled. Just do your research and go with your gut. Always your gut.
Lilia, I appreciate you coming on and discussing this with me. I'm sure we'll have you back very soon.
