Hello and welcome to Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. Joining me is Dr. Blake Hauer. Hello, Blake. And our lovely Nadia Davis. Hello. Welcome, Nadia. Nadia is our Boca office restorative head assistant extraordinaire. She has been on the podcast before but served to begin with as my surgical assistant and then decided that she liked teeth better. Today, what we're going to talk about is why teeth are better than surgery—no, what we want to talk about is the behind-the-scenes look. Not just the patient experience and the personal side of things, but what to expect, what Nadia's job and time with a patient will look like, and what the restorative process entails in one of our offices from a standpoint of what to expect and what is actually happening.

I think the easiest place to start is to talk about something that's a little uncomfortable: what does the healing look like leading up to meeting Nadia. From the surgery side to the restorative side, in our system, we don't do teeth the day of. The reason we don't do teeth the day of is that any time added to the surgery day is time the patient is going to be uncomfortable. Also, those teeth would cover the surgical space that needs time to bleed and clot. Rather than risking having to go in for emergency bleeding from underneath those teeth and adding extra time, pain, and trauma to the patient, we believe that leaving the patient without teeth the night of is simpler, cleaner, and more straightforward for them. They will be on ibuprofen to reduce swelling and pain. They will also be on some sort of pain medication and antibiotics to support them in their healing.

I generally tell patients they are going to be in about a five to seven out of 10 pain level. You might know more about that, though, because you see the experiencing side whereas I see the telling side. What does that look like for the patient? Is five to seven out of 10 fair? I think it's fair. The night following the surgery is about 50/50. Some patients come in and say last night was terrible, that they were bleeding all over the place and couldn't keep it in, or messed up the hotel. Somewhere, there is a hotel executive that absolutely hates us. Others have a pretty decent night. It is all dependent on the patient and how coherent they are after the surgery, because a lot of them are pretty out of it. For the most part, it is 50/50.

I think it is helpful if they have a family member, friend, or spouse come with them. If they have someone there to help take care of them, it makes for an easier first night versus having to be by themselves. When you are alone, you have nobody to depend on to administer medications and make sure that you are changing out your gauze—or not changing it out too frequently.

As for what they eat that first night, most are not eating. Only the bravest will try that out. Most patients just do protein shakes, Gatorade, water, or applesauce—something very easy to consume and soothing. Everybody has a plan until they get implants in the face, and then they go into shock and feel they can't eat anything except baby food.

I think one thing to add is that after the surgery, 99% of the time we are using sutures that are going to resorb, usually around five days. After the surgery is done, we are not really needing to intervene again. There is no second procedure to remove anything, and you are going to be working with the restorative team. Do you find that sutures ever get in the way or cause any issues? Or is it pretty much not an issue once the surgery is done and you have enough space to do everything you need? No, we have enough space. It is hardly ever that we have an issue. I think today is the only day that I maybe had one little suture in the way, and it was in the front. A lot of times you tie those around the abutments. It's not a big deal, though; they don't typically get in the way. I just scooched it over and pressed the hybrid on it. That's the cool part about the office—we are all under the same roof. If you needed me to take a look, I just call you in there.

If I need you, we'll do the same. I think that makes the experience really good. On the day after, when you're seeing them for the first set of teeth, I've seen you use a topical numbing gel. Is that something you do the majority of the time right away? Do you do that on every case?

I’d say yes. Most times, we advise that patients take something for pain before they come in, but I like to use topical so the pressure they feel from that first set of teeth is not as intense as it would be otherwise. I just want them to be comfortable. Most of them come in very nervous; they are swollen and convinced you won't be able to get teeth in. There is gauze, there is still some bleeding, and all that good stuff. I walk them through it and let them know that while it feels scary and crazy, we will get the teeth in. Most do fine.

It is worth adding that we have our patients covered with medications. You're typically on analgesics for pain, a steroid to help with postsurgical swelling, and an antibiotic. We even prescribe a narcotic for a couple of days if needed for pain control. We want our patients to be well-controlled.

It’s interesting to see how the process has matured. For Blake and me, having an escort in the room during surgery is tough because it almost always makes the behavior of the patient worse. There are very few exceptions where it’s a good thing. However, I can imagine it being a positive when delivering the teeth. I notice a decent amount of escorts, wives, or husbands coming in later in the process, but what about the day after?

On the day of surgery, an escort would be in the way because the patient needs to know they can trust the surgeon and the assistant. On day two with me, I love for them to come back. I enjoy the group setting and the team effort to an extent. I want them to have their support system there, but I don't love it when the support system tries to take over the design. I have to remind them that we are working within certain limits and to let me design the teeth to fit the patient. I am always receptive to feedback, as long as they don't go off the deep end. It’s going to happen regardless of education because we make it look fun. They see us making changes and suddenly they want "Tom Cruise teeth." As long as they understand we have biological and structural limits, it's great.

In many ways, you are like a tour guide. You're working the ride, and there is a time and place to look at different things. I can see how some people want to jump straight to the grand finale because they want to make sure they leave satisfied, leave happy, and leave with a set of teeth that make them feel like themselves—or even better. You know, do you find it tougher to get a good result through all the different try-ins and prototypes? Do you find it more difficult to work on a patient who is... and I’m not talking about the outliers who are excessively obsessive or pushy. But for the bulk of patients, is it better for them to be on the picky side or the not-picky side? If you could choose your last patient tomorrow to be one particular way, which would it be?

It’s somewhere in the middle. Not too lenient, but not too picky. I want patients to get what they want out of their investment, and I want them to feel heard. I like for them to leave feeling like somebody cared enough to try. Sometimes it can be hard to get information out of a person who is so accommodating that they become unhelpful. I like people to have an idea of the direction they want to go because it helps me navigate. But even when they have no idea or just say, "I don't care, I just want to get this over with," I still want to know what was "close to home." I want to know what they started with so I can get it in the ballpark. Even if they don’t care today, a few months down the road they are often the ones saying, "Thanks for making these; I feel like myself again."

In surgery, we take a tooth template and use it as a mold for the first design prototype. We try to line up many parameters. That first template is a working template. From that point, what are your goals? What goes into the process in terms of dimensions and rotations?

To keep it simple, I try to align the teeth to the patient's anatomy. I take into consideration their height, facial features, and their "before" teeth if we have photos. I try to gauge the ballpark of what they started with, with the exception of building them up. Once the teeth are aligned to the anatomy and facial features—like tooth size—we play with the shapes, without getting too crazy. Sometimes less is more.

Lip support and speech are also huge factors. The tooth position dictates how the facial features function. Anatomy guides the majority of the big movements, which then dictates the phonetics. I always start by following the natural anatomy and aligning the teeth to where the ridge is. From there, the patient lets me know if their lips look too flat, if they see too many teeth when they smile, if it looks too narrow, or if their tongue doesn't have enough space.

If a patient comes in and the midline is off on the first set, but they are immediately talking about lip support, do you address it right then?

I try to address as much as possible on day one. I am a fan of being as aggressive as possible with that first design to get them comfortable for day two. I can imagine how uncomfortable it would be to go home with a crooked set of teeth while trying to eat and speak. I don't want that for them.

Something I discuss often during training is that I try not to get it exactly right on the day of surgery. I want you to be able to see an extreme. For example, regarding the amount of tooth showing from the top lip, I might hide that more on the extreme side so we can judge the transition.

Choosing the right tooth size and shape is often a process of finding a balance, and sometimes that means starting with an extreme to find a clear direction. For example, if there is uncertainty about the appropriate size, I might provide the smallest or largest version possible. This helps the patient realize immediately what they don't like, which is much easier than trying to tweak a design that is already "almost perfect."

I can appreciate that approach because I do the same thing. If I'm unsure, I’ll go two sizes bigger to show them a distinct contrast. The immediate feedback is usually invaluable; a patient might initially recoil at "horse teeth," but as we refine the design, they sometimes realize they actually liked the bolder look. It's difficult to find that "Goldilocks" fit straight away without exploring the ends of the spectrum first.

Oddly enough, the cases where the day-one template looks almost perfect are the most difficult. When a patient is satisfied immediately, it’s harder to find the small nuances that would make the final result truly custom and superior. It’s fascinating to look back and wonder how we ever felt comfortable delivering final restorations within 24 hours. There are simply too many patient-dependent nuances to account for in such a short window.

When you receive a final or a prototype the next day, you are essentially locked into a single design. Our protocol allows for a "concierge experience" where you can test multiple versions. What looks perfect on a computer screen down to the micron doesn't always translate perfectly to the human face. By having those extra conversations and try-ins through the restorative team, we ensure the patient is heard rather than forced into a design based purely on digital measurements.

The old way relied heavily on pre-surgical measurements and picking a "flavor" of teeth from a catalog. We used visual scanning and biological measurements to predict the outcome. The problem is that the style someone chooses from a book before surgery is often wildly different from what they actually want once they see the teeth in their own mouth.

Actually looking good in person is the true test. That is the difficult part—even as a professional, I don't know exactly what to recommend until someone experiences it. We tell every patient that the reason we’ve moved away from selecting the teeth right away isn't because we lack the capability, but because we don't want to lock you into something that makes you look like a "goofball" or unlike yourself. Regardless of who chooses the path initially, it may be the wrong one. In my opinion, the patient becomes the world-leading expert on what is appropriate for them the instant that first prototype goes in. That’s when you start to realize, "I want that more rounded," or "I want it bigger."

Do you think the patients find the prototype visits enjoyable? Are they having a good experience with the customization after surgery?

Most times, patients seem to enjoy it, though there is some initial discomfort following surgery. Occasionally, patients enjoy it a little too much—they want to play "dress up" with the teeth—but for the most part, I prioritize making their time with the restorative team a positive experience. Most of them end up feeling like family and even want to pop up randomly. I don't want a patient to feel like they won't be listened to or that they can't voice an opinion. I want them to feel heard while also being respectful of the biological and structural limitations of the field.

Regarding the "chair time," how much of the appointment is actually spent working in the mouth versus discussing the design? On that first try-in, how long does it take until the teeth are comfortably scanned and you are finished working in the mouth?

I try to be as quick and efficient as possible. I'd say maybe 10 minutes. They’ve already been through surgery the day before, so I try not to prolong the "open mouth" part. We remove the cover abutments, seat the teeth, scan them, and take photos.

That 10-to-15-minute timeframe is pretty consistent through the subsequent days as well. On day two, it’s actually a little easier because you’re just changing out the teeth, scanning, and taking photos. It depends on the patient's comfort; if they are sore or sensitive, I take my time. My focus is purely on their comfort: teeth in, scan, then we talk.

And how long does the rest of the appointment take? They are scheduled for an hour—is it typically a 45-minute to one-hour round trip?

Yes, it’s about 45 minutes to an hour. And the majority of that appointment is spent talking with the patient.

That is exactly what we hope for and why we designed it this way. I always tell people that the most positive part of this protocol is that it removes the old burden where the restorative assistant had to grind, polish, rinse, and re-glue for the entire visit. That manual labor took away from the patient's experience and prevented you from getting to know them. If it could be 3 minutes of actual work and 50 minutes of talking, that would be ideal. That helps you understand what they are looking for and helps you "hear" their teeth more.

I would imagine, though, that day one is almost the shortest of all the prototype visits, even though the designs get more accurate as you go along.

I'd agree. They do lengthen in time as you get to know the patients and they become more comfortable and excitable with their feedback. By the time they reach the zirconia phase—say, a week after surgery—I describe it to people as wearing an old shoe. It might be a little uncomfortable at first, but by the last set, the seating against the gum tissue becomes comfortable.

When you get to the zirconia, are you still using topical? What is their discomfort level on the delivery day?

Lately, some patients have told me not to use it. It's moderate, I would say, but many feel it isn't necessary. The installation is straightforward and very similar to seating the prototypes. The only difference is we torque them in and close them up. Most times they feel better because the zirconia feels cooler going in than a resin print.

Comparatively, the feedback on zirconia is shocking. A lot of patients say it feels smaller and lighter. That "lighter" part always gets me because it is significantly heavier than the 3D print, but that is how they perceive it. In thousands of arches, I’ve only had one person say they felt heavy or annoying.

Once you have lined up the anatomy and the basics, how much work is dialing in the phonetics and speech patterns? Does it just come along with the process, or is there a specific period where you have to adjust things specifically for speech?

We try to gauge it with every try-in because any little change can lead to a shift in speech. We stay conscious of it at every appointment. If a patient's speech is off, but they want more lip support or bigger teeth, I am transparent with them. I let them know that if we go smaller, this is the result; if we go bigger, that is the consequence.

Every moving part has an effect. You're like the composer of an orchestra.

If you had to commit to one type of day—tomorrow is your last day—would you rather see a column of follow-up cleaning patients to see how they are doing, or start the new stuff with try-ins?

That’s a hard question. I love seeing my patients years later and hearing about them doing life with their teeth, but I also love the puzzles of building the teeth. I’m not answering that!

I would have guessed new patients would win because of your passion for the "puzzle." I was telling Dr. Hauer that you might even beat me in your desire to learn. I wake up and live to learn something new or find something out.

Documentaries are my jam; that’s my favorite kind of TV. I would have guessed that the puzzle side and the learning aspect would be what you leaned toward. I put you on the spot, though; that wasn’t very fair.

Doc, do you have anything else? I'll let you think of something.

I was going to ask Nadia to give us the top things that Dr. Hauer and Dr. Noruk need to change on a day-to-day basis.

All right, where do I begin? Let’s just preface this by saying we’ve only been doing cases together for a couple of months, so it's a limited sample size.

Is there a trend that we need to address or change? For instance, is the centerline or midline consistently off to the left? Is there something you see where, if someone else had done the case, you could tell it wasn't me just based on how that first template came in?

I want to say yes because the bites have usually been slightly misaligned. They’ve been kind of in a crossbite. I don't know—I don't really want to answer that. You guys are doing great; it’s going great.

She pretty much told us "don’t give me a good situation," so anything is an improvement now, right?

That’s the cool part: when you are under the gun making those decisions during surgery, that patient does not want to be there. They are fully sedated, they’ve been there all day, and you are trying to get the last bit of information to line up with the computers. Even if you get the data, the theme is that the patient is finished. The risk is ending up with a bite that is way off or in a crossbite. That stress and pressure is not positive. What’s cool is that regardless of how "off" my initial data is, the process of refining it becomes exponential, repeatable, and very much like following train tracks.

By the time we are ready to go to zirconia, we know we are right on the money. That’s really rewarding. I don’t lose sleep over my zirconia. I would go toe-to-toe with anyone in the country regarding the quality of sleep the night before a zirconia delivery. We have the smallest worries.

I just want to reinforce that you are getting a concierge service and high-quality time with our restorative team, which is unique. A lot of details go into this—functional bite issues, aesthetics, facial features, and lip support. We want to be clear that we are surgically driven but also prosthetically driven to give you a really nice result.

Nadia, my closing thing for you: is there one thing you have seen consistently help with the patient’s experience the night of surgery? Is there a top tip, like using a specific product? We mentioned the escort was a big one. What helps them have a good first night?

Do you think those head-wrap ice packs work?

I think if it makes for less work for the patient to do, then maybe they’ll use it more. But most head wraps keep the ice down too low on the cheeks; they’re awkward.

Back in 2020, we had a sales guy who insisted on recommending one particular head wrap. No matter how many times I told him to stop, patients would come into the consult saying they already bought it. It was maddening.

What about top tips for preparation? Is there anything a person can do to help you with tooth selection, or is it better to come in with an open mind?

I think it's best to come in with an open mind. Old photos help because they let me know what direction to head in, but as long as they trust the process and know they are in good hands, it makes for the best experience.

Trust the process and keep an open mind. There is a version of Nadia in each of our offices, and it’s cool to see how each location has its own lead person who takes charge and helps control the narrative of the surgeries.

Nadia, I appreciate your time. Dr. Hauer, I agree. Now we’re off to happy hour with the team. Maybe some sushi? You already had a sub today, though, so you're probably done. We have a list of good local places if anyone comes down for surgery. Did you like VNS?

That was my first time. Shout out to VNS Subs.

The VNS Italian classic sub is great. It's a Boca staple that started in the 80s.

We thank you for your time. Like, subscribe, and cheer Nadia on when you come to get your teeth done. We hope to see you soon on Beyond the Arches.