Dr. Daniel Noorthoek: Hello and welcome to another episode of Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. With me today, I have our prosthetic restorative dentist, Dr. Sarah Lax. Welcome, Dr. Lax.
Dr. Sarah Lax: Thank you so much. Welcome back, I should say. Good to be back.
Dr. Daniel Noorthoek: Today we're going to be talking about prosthetics—full arch prosthetics. We're going to be talking about smile design: what goes into the smile, how you come up with your decisions, what you make, and a little bit of the "behind the scenes" of what that looks like. You know, what goes into it behind what a patient works through, what those things look like "after hours" if you will, and how we give instructions.
To start with, let's keep it simple and talk about the smile. Your job is very important—really the most important—because it's what people see, experience, and feel. If all goes well with the surgery, what I do should just fade into the background. It shouldn't do anything other than be functionally there. It shouldn't hurt; it shouldn't feel like anything. But the teeth are constantly there. There are things you have to overcome and things you have to shape correctly so that speech is a part of it. Walk me through when you start with a patient; walk us through the steps you go through first, and then we'll break it down into smile, teeth, function, bite, and all of those things.
Dr. Sarah Lax: Yeah, it's a pretty complex world when it comes to prosthetics and just restoring function and aesthetics. Like you said before, implants are a huge part of this process, but the restorative portion of all this is, I think, in the patient's mind like 95% of the whole experience. The surgery should go smoothly, quickly, and hopefully pain-free, but what happens afterward is the major part of all this.
Dr. Daniel Noorthoek: What's the biggest or most exciting visit that you typically see with a patient after surgery? Is it the first chance they have at looking at teeth? Is it the finished product? Or is it somewhere in between where they are doing a couple of sets so that they get to see them? Where in that process is it?
Dr. Sarah Lax: It's a little bit different for everyone, but I think for the most part the final reveal is when we get the most emotion and feedback.
Dr. Daniel Noorthoek: Is that because it's the end of the journey for them?
Dr. Sarah Lax: Yeah. It's like a weight lifted off their shoulders. It's like, "Wow, I made it. This is real." It's not just a plastic prototype—which are really great—but when they finally feel that final set of teeth in the nice, smooth material, they just feel back to themselves really.
Dr. Daniel Noorthoek: What part of the process for you on your side is the most difficult to overcome? Is it something intangible like the patient's significant other wanting it a particular way? Is it speech? Look? Shape? Bite? What’s the hardest part?
Dr. Sarah Lax: I would say dealing with their emotions throughout the process. Kind of letting them know that we're in this together. Although it's not perfect right now—maybe the day after the surgery—we're going to get there eventually together. Repeating that throughout the process and just calming down their mental attitude is key. You have to trust the process. I think sometimes that's the hardest because you're in pain after the surgery and the first set of teeth isn't 100% just right yet. Keeping that in mind, you have to just calm your nerves a little bit and trust that we're going to get there. It's only a couple of days away, but getting through those couple of days can be a roller coaster.
Dr. Daniel Noorthoek: And you're pretty good at that. I would say it's probably because you have a bunch of siblings and so you're used to kind of being tested; you're very "go with the flow." Thinking back to the hundreds of times I've done the tooth side of it as well, it is hard to try to communicate with a patient who is in pain and who just went through this big procedure that everything's going to be okay. They might be at a "10" and you're sitting down here at a "3" and you can't figure out why you're struggling to communicate properly. It can be easy to forget that it was a pretty big surgery and they are still in recovery.
Looking back on my career, even for just a single implant, if a patient was having a hard time with the pain, you think, "My goodness, Mrs. Smith and I are never going to get along." Then, next thing you know, the pain breaks and they’re your best friend. Communication during that process is important.
Physically, when you're getting the patient in for our particular system and you're getting a set of teeth upfront, what are the steps? What are you looking for in a smile? What are the "bridges" you're crossing over? What do you try to control first? How does that look different in the first set of prototypes versus, say, the third set?
Dr. Sarah Lax: There are two factors: functionality and aesthetics. Obviously, the main important thing is we want them to be able to eat anything they want—bite into crunchy apples—and we want them to speak clearly. So there’s juggling the prosthetic functionality, but there's also the aesthetic portion.
Dr. Daniel Noorthoek: Trying to manage both at the same time could be difficult. What are you trying to accomplish first? What's number one?
Dr. Sarah Lax: Number one is getting the teeth where they need to be. We want to make sure the bite—the occlusion—is ideal. Then we can focus on the aesthetics.
Dr. Daniel Noorthoek: Do you find that most of the effort comes in the tweaking for the aesthetics, or is it getting the teeth into a position where they can chew comfortably?
Dr. Sarah Lax: It's both. It's positionally getting the teeth where they need to be so they can chew and speak, but it's also shaping the teeth. The anatomy of a tooth is different for everyone, so we have to be hands-on with that part. Aesthetics are a huge portion as well. A lot of patients come in wanting something totally different, but they still want to look like themselves.
Dr. Daniel Noorthoek: Let's jump on that. Explain to the listener why we don't go through digital mock-ups or selection of teeth beforehand for our particular process. Why is that not something we discuss first?
Dr. Sarah Lax: I know it seems like a great idea. When you look at a set of teeth in a commercial or a magazine, it looks beautiful on the screen. But once you put it in your mouth, it looks extremely different. Right off the bat, we want to set our expectations. Patients can come in with inspiration and ideas, but it's all about the try-in process. It's about fine-tuning it for them. We spend time comparing different shapes and sizes and making sure we're communicating clearly.
Dr. Daniel Noorthoek: It was always frustrating because, for a conversion, it’s often a very standard run-of-the-mill tooth type. We used to take facial scans and mouth scans and prototype them to show the patient as a selling point. That may help with selling, but in terms of actually performing on the final result, it's very difficult because you've introduced a fixed thought of what they were going to look like. It muddies the waters. I also felt like putting them "under the gun" to choose right now, when they are used to not even enjoying their smile, was unfair.
Dr. Sarah Lax: I get the appeal of picking it out ahead of time. The problem is that reality and the "ideal" don't always mix properly. Sometimes reality is even better than the fake version. Sometimes symmetry—perfect symmetry—doesn't turn out so great. There's not a lot of personality in that. So sometimes we veer off and start creating different shapes to make them look human.
Dr. Daniel Noorthoek: I think the easiest way for people listening to understand would be that there’s "book smart" and there’s "street smart." There's "book smart" for teeth where we follow the rules—the Golden Ratio. Explain what the Golden Ratio is.
Dr. Sarah Lax: The Golden Ratio is nature's idea of perfect balance. It’s an equation—1 to 1.6. If followed, you can achieve a perfectly symmetrical, balanced anything. In dentistry, it’s how the teeth look visually and how they get progressively smaller and proportioned in height versus width.
Dr. Daniel Noorthoek: It’s standard across pretty much all of nature—seashells, paintings, even financial scales. So there is the "book smart" side and then there is the "street smart" side. If there's too much "street smarts" and flying by the seat of your pants, it'll be a mess. If there's too much "by the book," it lacks life. You’re the referee between book smart and street smart.
Dr. Sarah Lax: That’s a perfect way of putting it. We make sure everything is clinically where it needs to be, but from an artistic standpoint, we can have fun with it. We use the Golden Ratio as a baseline, but then we explore different options.
Dr. Daniel Noorthoek: In being a referee, how much of your day-to-day job is reigning the patient back into reality? Like, "We can't move this tooth here because it's what's holding your lip out." Is it a lot?
Dr. Sarah Lax: It's not a lot, surprisingly. They know these teeth need to be here, and then everything else we can work with. Usually, it's pretty easy to get that idea across. We rarely veer off so much that it affects what we need clinically. We stay in the safe limit.
Dr. Daniel Noorthoek: Do you find that patients are very moldable and receptive in the middle of this?
Dr. Sarah Lax: Very. We're changing so much. A lot of people love the idea of being able to try out different things. It is a process, and the journey together is really cool and special. We’ve got their back, and they know it’s going to work out in the end so they can relax.
Dr. Daniel Noorthoek: Personality plays a lot into the selection of teeth. If you are solely a "by the book" person, the patient gets left by the wayside and there is no personality difference. But it's fun figuring out who is who—who wants to rely on the book and who wants to be artistic—and finding that happy balance. Once you find that balance, you have a happy patient.
Dr. Sarah Lax: It's kind of like being a musician. There's a song, the notes, and the rhythm. You have to follow those to make it sound like the song, but what happens in between the notes—the character, the pizzazz, the riffs—that’s what moves people.
Dr. Daniel Noorthoek: Think of how many variations of the Star Spangled Banner there are. They’re all valid. You’re also a bit like a quarterback fending off outside influences—the brother's cousin's uncle who is a dentist or the sister-in-law who was an assistant for 36 years. They all want to weigh in.
Dr. Sarah Lax: There are a lot of cooks in the kitchen sometimes! It’s just managing everyone's expectations and communicating clearly every single day they are with us. Usually, it’s pretty smooth.
Dr. Daniel Noorthoek: What you just said reminds me of building a house. As long as the foundation is there and everyone agrees on the structure and the plans, the flooring or the shower can change. As long as my side (the surgery) is done properly, the house on top becomes personal flavor. Picking your foundation builder and architect is important, but so is picking your designer. If you look at pictures of teeth a dentist has done and they don't speak to you, you might not be cut out for that "interior designer."
It’s funny because even when patients say, "I’m not particular, just give me anything so I can eat," those people usually have a lot to say on the final product.
Dr. Sarah Lax: I would argue that it's often flipped! The people who say they aren't picky are the most picky, and the ones who say they are picky are way less so than you imagine.
Dr. Daniel Noorthoek: That's why in the consult I don't really pay attention to that! We’re going to go through the process and get there anyway.
Explain to me in listener terms what is happening in between the visits of teeth. Why should I feel comfortable? It’s easy to get the feeling that we're just shooting in the dark or "fumbling around" until we find a bite. Why are multiple prototypes an advantage?
Dr. Sarah Lax: From a patient view, it may seem like that sometimes. But you doing the surgery and taking the initial bite puts us in a good situation from the get-go. From there, we are fine-tuning. There are a thousand things going on behind the scenes. Once the patient leaves, we send all that information to our lab. Communicating with them is a huge discussion. They are trying to duplicate what we see in the office and translate that to life.
It’s more of an art and less of a science sometimes. Everyone's anatomy and jaw positioning is different. Speech also needs to be dialed in. Sometimes the exact ratio the book says doesn't work, so we have to veer off and try something else until we get it right. It's not trial and error; it's being willing to try something you didn't think of.
Dr. Daniel Noorthoek: I like to think of it like a car accident. The first thing a policeman does is find the facts: what cars were involved, who saw it, contact info. Once the basics are done, they can find footage to see if everyone's memory was right. They reconstruct the scene. The first several things we are doing do not involve the patient because they are fundamental basics where we need absolute accuracy from the best machines. It seems artistic later, but we are just saying, "We know what cars were involved and where they are; we're just trying to figure out who hit who." Reconstruct the scene. Get good information first. After that, you can get as wild as you want. We can make the teeth green if we want to—not that it’s preferable—but as long as the data is there, we can get what we want.
Dr. Sarah Lax: It takes a lot of stress off knowing we have that foundation. We usually get there pretty quickly, maybe after the second prototype on day three of the week.
Dr. Daniel Noorthoek: Day one is surgery. Day two is shuffling data so it corresponds to the basics. Day three is prototype number two, where we get fun and involve the patient. We dabble in that even after the first prototype.
I want people to watch this who might go somewhere else, too. This isn't just a Done in One advertisement; I want to increase the knowledge base. In the conventional way, you're still trying to get to the same path. We chose to get our data on day one and use it as a healing platform—like a diving board we're jumping off of. In the conventional way, things are glued together so you don't have that absolute accuracy to start. Because it's temporary, you can "play" at that point, let the implants heal, and then come back and do it again. We’re all doing the same thing at different steps.
Dr. Daniel Noorthoek: In traditional (non-digital) means, you use impressions. It's more tedious and involves more steps for the dentist and patient. Once you have good data, you fill in the holes. In the mainstream conventional way now, labs provide plastic printed prototypes, too. Back when I did it the old way, we’d take information, make wax rims, try them in to ensure lip support, then have the lab set denture teeth in them. The problem was that when they were in the mouth too long, the wax would heat up and distort. But if you managed that, you could get them in the right place.
I tell every patient that getting good information upfront allows for a more predictable outcome, fewer failures, and fewer problems. That’s why we make the finished product right away.
Dr. Sarah Lax: Exactly. Both ways get you to the same solution, it’s just the route you take. Doing it digitally is being more proactive. I use this analogy a lot: it’s like putting an arm in a cast. We want to control the healing process and let the tissue heal perfectly where we want it. You can deal with those steps later, but the outcome may be harder to reach.
Dr. Daniel Noorthoek: You took some arches off from a different office this morning—conversion dentures. It probably makes more sense today than ever how different that healing experience is versus what we do.
Dr. Sarah Lax: Looking at it hands-on—almost "nose-on"—the hygiene was terrible. The gums were so angry.
Dr. Daniel Noorthoek: It’s all in who is handling it. If you haven't managed it or lined it properly, it can be a disaster. Even the best-made temporary set of acrylic teeth is stickier and more porous than what we use.
How do you know when you’ve nailed it for a patient? What's the number one thing?
Dr. Sarah Lax: It’s an "aha" moment during the try-in. We place the teeth in and the patient says, "Oh wow, this feels right." It's intangible. They feel like themselves again. Across the board, that’s when we know we’re good to go.
Dr. Daniel Noorthoek: The Goldilocks Zone. You can just sense that it's right. What do you find the most challenging?
Dr. Sarah Lax: Understanding their goals and communicating clearly. Sometimes I'll reshape a tooth with my handpiece to what I think they are telling me they want. Bite is another trial-and-error thing. It can look perfect to me and on the scan, but the patient feels it's off.
Dr. Daniel Noorthoek: It’s interesting that we haven't talked about speech, because it usually just comes along with the process. It used to be the first thing I mentioned, but as digital dentistry has advanced and we can manipulate things off-site, it has dissipated more and more.
Bite is also my biggest challenge. Everyone has a different thought process. I remember showing you an occlusal scheme diagram and you’d never seen it before! We have digital tools to show where pressure is, we have scans and paper, but agreeing on what feels good really comes down to the patient. Most people have had a filling or a crown where they told the dentist the bite was off and the dentist said, "No, it looks fine." That is the hardest part. It's a science first, but the intangible part is the most difficult thing to nail.
Dr. Sarah Lax: Sometimes it's hard for the patient to relay what they are feeling. They don't have the words. We look, make an adjustment, and they still say it doesn't feel right even if it looks fine. You just have to trust the process.
Dr. Daniel Noorthoek: Let's talk high-level. I come in for my first set of teeth. What happens after my visit? What are you communicating to the lab?
Dr. Sarah Lax: It's about detailed instructions. We detail the changes and tweaks we went through and send that to our lab. They start 3D printing a new set of teeth with those changes.
Dr. Daniel Noorthoek: People would be surprised at both the complexity and the simplicity of that. It requires good pictures, scan files, and a shared vocabulary. But once we send a prescription, we are often talking in simple rotations.
Dr. Daniel Noorthoek: We ask them to rotate right, left, up, or down. You could call it yaw, pitch, and roll. We take six points of rotation. We follow anatomical markers to move them into the right position. These aren't complex algorithms; they are relatively simple moves. The Golden Ratio is already built into the standard the lab uses. Sarah doesn't have to measure every tooth with a gauge because that's the standard. The technology is complex, but the actual movements are straightforward.
Dr. Sarah Lax: Exactly. We want the patient to feel it is simple. We never want them to feel like we're stressed about their case.
Dr. Daniel Noorthoek: The lab is the most underrated part of the process. What I do as a surgeon is sort of on my own, but your role is all communication—with the patient, the assistant, me, and the lab. You're the conductor of the orchestra.
Dr. Sarah Lax: It is like an orchestra. Even with perfectly placed implants, we can have an undesirable outcome if the prosthetics aren't right. We have to talk the same language as the lab.
Dr. Daniel Noorthoek: What's the best compliment a patient can give you that makes you feel good at night?
Dr. Sarah Lax: It’s actually the opposite of a specific compliment. It's when they say, "No one realized these are fake teeth." They just hear, "Oh, you look great, something is different." When it doesn't jump out at you and the person just feels like themselves, that is number one.
Dr. Daniel Noorthoek: The ultimate sign we did our jobs is when a person says, "I feel like me." You feel the excitement and energy in them.
Dr. Sarah Lax: It’s that gut feeling. The vibe.
Dr. Daniel Noorthoek: It reminds me of shopping for a house with my wife. We went through a bazillion homes and walked into "the one," and we didn't even make eye contact—we just said "Draw it up" to the realtor. You can't find that in a textbook.
