Scanners That See Everything: The iTero Advantage | Dr. Steven Glassman | EODP #2

00:00:06:37 - 00:00:26:48 Robert Norton Welcome back to the Evolution of Dental Podcast, brought to you by Evolution Dental Science. Today we're joined by a pioneer of digital ministry, one of the first eight to have adopted the Antero system in North America. The doctor on the forefront of the new art advanced restorative treatment program from Ontario. Hello, doctor Glassman, how are you today? 00:00:26:52 - 00:00:45:51 Dr. Steven Glassman I'm doing great, Robert. It's great to be here. I'm really excited with the partnership I've had with Evolution Dental Science for almost two years right now. So it's been great. Done some remarkable cases. Changing people's lives every day. So this is what I live for. 00:00:45:55 - 00:00:53:44 Robert Norton Excellent. How would you say this has shifted from when you first brought the iTero into your practice in 2008? 00:00:53:49 - 00:00:56:37 Dr. Steven Glassman It was actually, believe it or not, 2006. 00:00:56:38 - 00:00:58:32 Robert Norton 2006? 00:00:58:37 - 00:01:29:47 Dr. Steven Glassman Yes. 2006, I, as you said correctly, I was one of the original eight. Conversation, I went out of my laboratory. They started talking about this technology and originally they thought it would not be, a great fit for my office. They were looking for more of a bread and butter, a lot of volume crowns and stuff. And I was more comprehensive esthetic. And then, one of the VP's of Cadent, which, that was the company's name before it was iTero said, you know, let's get Doctor Glassman to do it. 00:01:29:49 - 00:02:02:01 Dr. Steven Glassman And so I got involved with it. Back then, it would take maybe for a single crown about six minutes, which today is probably 30 40s with the new technology. So, it was, groundbreaking. We did a double blind study comparing, the crown scanned with the Cadent iTero unit back then, as well as conventional taking a PVS impression and something that was like, 2 to 1 or 3 to 1 preferred the scanned crowns in terms of fit, contact and occlusion. 00:02:02:06 - 00:02:10:00 Robert Norton 3 to 1 is hard to argue with. And, so you moved from using it for restorative dentistry into ortho. 00:02:10:04 - 00:02:35:35 Dr. Steven Glassman That's also a very interesting story. At the time, one of my patients, pretty high up on the Invisalign, advisory board or, corporate ladder, so to speak. And he was also a patient. And one day he comes in and he's asking me about the scanner because I have been to all the convention shows, the Greater New York every year, trying to get the two companies to work together. 00:02:35:40 - 00:02:55:10 Dr. Steven Glassman And I hear from Align, “Not ready yet. We need to get more roots”. One day he comes in says, “What do you think of the technology?” I said, “Well, I love the technology, I’m not 100% on the company. The company needs a little bit more guidance.”. And a week later, Align I think paid $180-190 million for the technology. 00:02:55:15 - 00:03:19:25 Dr. Steven Glassman So to bring it into the ortho world, and then it became, all over, it started to expand. And the big change was going from the older units to the elements, which had more of that continuous scanning at that point. And it was really a gain for them because they realized that the scanned aligners fit better. If they fit better means the case is going to finish faster. 00:03:19:30 - 00:03:24:34 Robert Norton Absolutely. So how did that influence the way you practice dentistry? 00:03:24:39 - 00:03:59:58 Dr. Steven Glassman Well, as I got more involved with, doing clear aligners and having some background, I started to realize that orthodontics was the foundation for all restorative and perio. We can be so much more effective and so much more or less invasive by putting teeth in their proper position, putting crowns over the roots, looking at everything, and then when the restorative would fall in place, which a lot of these cases would have worn enamel or chipped enamel, we could sometimes just finish the case with, direct bonding resin. 00:04:00:03 - 00:04:25:59 Dr. Steven Glassman And even those cases that required a laboratory, you know, typically, cases that may have undersized upper laterals by using the ortho and leaving space, we can do our veneers, the case will look better. All these cases that, great learning experience. I had an associate who came in and he... his patient came in and broke a central incisor. 00:04:26:04 - 00:04:47:29 Dr. Steven Glassman And so what did he do? Like trained in dental school, he treats the symptom and the problem without looking at the cause. So he ended up doing a root canal post and crown on a patient that had a malocclusion deep bite, only to find out in three months, the tooth broke and needed an implant. And I went back and tried to educate him 00:04:47:29 - 00:05:08:31 Dr. Steven Glassman I said, you know, you set the scale against you by putting your case in something that was not lined up for it. And now the patient has to go through an extraction. It would have been better if you would have previsualized him, gotten back correct the deep bite, do the occlusion, and then finished the crown. So really this type of thinking has really revolutionized the way I see patients. 00:05:08:31 - 00:05:30:40 Dr. Steven Glassman I look at people through not just one set of glasses. This is my restorative glasses. And this is my ortho glasses. I look at them as both the ortho-resto glasses. How do we do it? And now, since Align has grown not to just be a company that made Invisalign and work with iTero scanners, but a complete platform. 00:05:30:45 - 00:05:50:20 Dr. Steven Glassman And the purchase of exocad five, six, seven years ago. The integration of those is really what separates it from every other company there. We have now a platform and we can bring aligners in many different ways. The doctor could recommend it, but also my CAD designers, my partners at Evolution Science can look at this and recommend to their doctors. 00:05:50:20 - 00:06:13:39 Dr. Steven Glassman “Doc, if you would just rotate these two teeth and quick to do that. But, let me show you my restoration. How much less enamel you'd have to remove.” Or maybe you can even do non-prep cases with it and those cases will hold up look better from it. So it you're directed at both from just to not just the doctors but the, the CAD designers that are working these cases every day. 00:06:13:44 - 00:06:20:03 Robert Norton Excellent. So a more comprehensive approach then. A more partnered approach with the laboratory. 00:06:20:07 - 00:06:37:03 Dr. Steven Glassman Correct. And you know what? You may get away, you know, in your early years doing dentistry that maybe you, hoping and pray that it lasts. But if you're practicing as long as I am, in this case, 41 years, you kind of see the areas that you miss. All of a sudden, you see, “Hey, this case I treated right!” 00:06:37:03 - 00:06:59:30 Dr. Steven Glassman It's holding up 21 years, 21 years. It's, you know, 25 years. 30 years, right? As opposed to the case, I just showed you the associated where the tooth broke in a few months. So, yeah, it really is less invasive. And the patients appreciate it because ultimately they will spend less money over a lifetime on their dentistry. 00:06:59:34 - 00:07:11:58 Robert Norton That's excellent. And so as far as I understand, you have a, sort of a facially, driven approach when it comes to, analyzing the treatment for a patient as well as the esthetics of the case. 00:07:12:03 - 00:07:43:19 Dr. Steven Glassman That’s correct. You know, big influences for me in my education were both John Kois and, Frank Speer. And they talked about facially driven treatment planning as opposed to, say, articulator, where we have models that have no face behind it. So typically when a patient comes into a practice, we will take one photo of everybody, even if it's the 16 year old that just has hygiene. We want that wide smile photo with the teeth slightly separated, slightly separately so I could see the lower incisal edges. 00:07:43:24 - 00:08:12:36 Dr. Steven Glassman And we'll use some of the Align tools. You know, that's the thing that I think a lot of people that are into digital dentistry don't really understand it. There are a lot of scanners out there. There are a lot. There are other software programs besides exocad, but this is really the only ortho resto out there. So when I can show a patient a preview with their face of what or where the teeth should be right there, they're more likely to say, you know, let me hear more about this. 00:08:12:36 - 00:08:45:10 Dr. Steven Glassman Let me see what it's for. So that's usually the starting point. And they don't, some cases don't need aligners. Maybe it's an all-on-x case or a denture case. Then we translate our photos to the typical ones we require for exocad. Which are the full face retracted, teeth closed, and then the full face smiling. That with an intraoral scanner, working with exocad, CAD designers, I could start to look at every aspect of the facial. 00:08:45:10 - 00:09:14:51 Dr. Steven Glassman See if a tooth has been chipped off, if the gingival margins don't look right. They have a gummy smile, and we can start the planning. And some cases, well, they may need ortho going backwards, some may need osis crown lengthening. So now I can communicate with my periodontist by bringing my CBCT into the facial planning, working with that and saying, where do we want to end our gingival margin? 00:09:14:51 - 00:09:34:12 Dr. Steven Glassman Where do we want to end our incisal edge? Now we can show a patient a preview of what this is going to look like using these tools, getting them to say yes. But after when they say yes, we now have to plan the case. And the plan for the case all starts with these spatially driven, and then we have the tools. 00:09:34:12 - 00:10:06:41 Dr. Steven Glassman In this case I just mentioned to you, we would have a, printed up a surgical guide for the periodontist, place down flat and put the gums where I want. But I know where the ultimate incisal edge is going to be, because I already have that together. So all of these platform tools working with it. And then, if we're doing same day dentistry, that's even better because I can have a patient in the chair, say we're doing our all-on-x case, we could scan them, and then we already have our digital wax up from it. 00:10:06:55 - 00:10:41:50 Dr. Steven Glassman We adopt that to either our scan bodies or our preps if we're doing full cases. And now the laboratory can send me the design that has been adapted to those preps, and I could print them in the office with my SprintRay. And so the patient can get a lab quality process in the same day where in the older days, you know, in the analog days, we'd have to take our PVS impressions, beg our laboratory to do a quick turnaround, which is typically 4 or 5 days, maybe later and hoping that everything fits well, looks well. 00:10:41:54 - 00:10:43:46 Dr. Steven Glassman Oftentimes they didn’t. 00:10:43:51 - 00:10:52:03 Robert Norton And so one of these tools you're referring to, I'm assuming is the exocad TruSmile videos and exocad Smile Creator perhaps? 00:10:52:08 - 00:12:43:23 00:12:43:31 - 00:12:49:09 Robert Norton And it's in office and it's an actionable CAD file, you can actually print these. It's not just Photoshop. 00:12:49:13 - 00:13:02:08 Dr. Steven Glassman Exactly! It's right in the office. I could go ahead and do this, print this up on the mouth. Once we have it together, they could do a trial. They can make it part of the previsuals. There’s just so many different ways we can use these tools. 00:13:02:13 - 00:13:05:48 Robert Norton Are there any tools upcoming that you're really excited to get into? 00:13:05:52 - 00:13:35:09 Dr. Steven Glassman Well, I think that the next phase for me is to, and they've been around there, but they're not under one platform. Think about this with our mobile phones and typically people are Apple or they're on droid. And so they have all these different tools. that work for them. I think that we're going to see more and more of that. Now when we do the exocad, or if we're using the iTero Smile Architect, typically the photos are only a two dimensional... 00:13:35:09 - 00:13:37:37 Robert Norton Right, you're doing 3D face scans in your office, aren't you? 00:13:37:39 - 00:13:59:02 Dr. Steven Glassman We're doing 3D face scans. So let me explain the difference in the value of that. When we merge those things. For a typical exocad, we only could see the patient's face directly on. It's like a cardboard cutout, but people want to see what their profile will look like. In certain cases we want to see the soft tissue changes from start, 00:13:59:02 - 00:14:20:39 Dr. Steven Glassman and even before. Right now, we can take 3D facial scans in the beginning at the end, but we're not quite there with the simulation. What am I talking about? If somebody has flared buccal teeth... their profile has changed, right? I like to show them not just where their teeth are, but where their lips are going to fall 00:14:20:43 - 00:14:45:39 Dr. Steven Glassman through. If we’re opening people's vertical dimension and they're over-closed. I like them to see what that's going to look like. Now, the cases that I'm going to show later on, we've changed the verticals, we changed the profiles. But I had no tool really to predictably plan the case, or even if the patient wanted to use that before they committed, see that before the commit treatment. 00:14:45:54 - 00:15:06:23 Dr. Steven Glassman That would have been helpful. I think that's the next thing. Again, there are a bunch of scanners out there, and I tell doctors the difference between the $20,000 scanner and the $200 scanner is not that much. Invisalign has one, when they take records, but it's only on the ortho side, not on the ortho resto side as of yet. 00:15:06:23 - 00:15:34:46 Dr. Steven Glassman I'm sure it will be, I use an inexpensive one called QLONE, where I typically take those photo, I'll sometimes take three facial scans, one with the retracted smile, one with the patient smiling without retractors, and one reposed because I want to see that that soft tissue lip and everything. So that's something I think is coming that I'm really excited about that. I'm also excited about 00:15:34:51 - 00:15:57:07 Dr. Steven Glassman Using some of the jaw motion. A lot of the times when we do our cases to our CAD designers, where we have a, a static way to take the bite, they just bite down in one position. Now, Align has upped their game in the last six months. So we can take multiple bites we can take for restorative. 00:15:57:12 - 00:16:19:51 Dr. Steven Glassman We could take for dentures or for full-arch cases. We could take a protrusive, a right lateral, left lateral retrusive, open bite. And so the CAD designers can put all that together. But it's still a series of static movements. There are other companies like MODJAW out there that will track dynamic movements of jaws, which they could put into it. 00:16:19:51 - 00:16:47:54 Dr. Steven Glassman Again, a lot of these things are for the elite practices that are focused on them because they're quite expensive. If we can take something and bring it to our mobile phone and affordable, which I gave you the example of the 3D facial scans, the next level is doing the jaw motion with your iPhone or your droid, and taking that file and having it to be integrated with the, exocad CAD designer. 00:16:47:54 - 00:16:56:19 Dr. Steven Glassman So we get a true dynamic. Which teeth are dodgy? Really important. How about implants or dentures? We want to make sure those forces are balanced. 00:16:56:24 - 00:17:07:21 Robert Norton So in your opinion the next phase is to and not just take multiple pictures from multiple angles, but multiple facial scans in different situations. So you can incorporate that simulation. Is that right? 00:17:07:26 - 00:17:08:46 Dr. Steven Glassman Correct. Correct. 00:17:08:50 - 00:17:21:51 Robert Norton That sounds pretty awesome. I'm sure the coming AI innovations will tie that together pretty well too, especially seeing what they're able to do now with the video, on a on a two dimensional representation. 00:17:21:55 - 00:17:39:42 Dr. Steven Glassman Yeah, they can see the outcome from it. You know, we've all been there and I've been there in my 41 years where we do a wax up on an articulator and the patient looks at it and they kind of scratch their head. It looks pretty good to me. I don't know how it's gonna be in my face. 00:17:39:46 - 00:18:04:03 Dr. Steven Glassman Maybe, we even put it on their face. But they're not going home for it. And then we go ahead and give them something. And they said, that's really not what I was looking for. That's really the stressful part of dentistry, not understanding the vision of your patient and having these tools to make sure. It’s so easy to do another design, click of a button, print up a new one before we go to it. 00:18:04:03 - 00:18:22:00 Dr. Steven Glassman It's actually when we have to do our final restoration that are milled and layered and custom stained. That's a lot of labor and time inclusive. And once they're bonded to the teeth, we can't take them off. We have to drill them off. Nobody likes taking off existing dental work. I can tell you that. 00:18:22:04 - 00:18:37:57 Robert Norton So are you doing any 3D printed try ins, like, snap-on smiles to demonstrate to the patients what it's going to actually look like in their mouth in the practice, or are you mainly relying on the video and two dimensional representations? 00:18:38:02 - 00:18:59:37 Dr. Steven Glassman I'm mainly doing the digital tools right here because I have that done immediately. I can show the patient a ortho only, simulation I could show them an ortho-resto. Here is another interesting story I had. I had a patient that had Invisalign done 15 years ago. She wasn't great about wearing her aligner. She comes back, very attractive 00:18:59:42 - 00:19:22:28 Dr. Steven Glassman lady. And then so we did the, ortho only, and then we did the resto and I would toggle back and forth just showing ortho, just showing resto in the software. Not only did it just do four veneers on the upper IT sizes, but it also did a little gingiva ectomy. And she said to me, I want that treatment. 00:19:22:33 - 00:19:50:06 Dr. Steven Glassman So it's just a simple thing that she meant. Added on another $9,000 to the Sheen plant and it's just going to fix that. But most doctors are not. Take the time now, you asked about the mock up smiles. Yes. Not as much. If somebody I find is that really pick a particular patient or it's something that I want to walk because, we've been working with the non prep print, the veneers. 00:19:50:11 - 00:20:07:46 Dr. Steven Glassman One thing about printing the materials are getting better, better high, more highly filled with ceramic. So they hold up better and they look great. So I've done that on a few cases with it. But we get that requires labor and time and it's a bit of a gamble a little bit of materials. 00:20:07:55 - 00:20:08:33 Robert Norton Yeah. 00:20:08:38 - 00:20:28:10 Dr. Steven Glassman A little materials. But I'm saying if the patient is not committed, we may have done this. I said, I don't really think you need that to get patient to commit. I think it's a good thing in terms of the planning before we're doing it. If we have a patient that is really particularly want to see it and work it up before we do it, that's the way, a way to go. 00:20:28:15 - 00:20:44:22 Robert Norton That makes sense, that makes good sense. And not to mention it's, it helps you meet the patient at their level of expectation so that, like you were saying before, all three of us, you, the lab and the patient can come together on a particular outcome and be happy with it at the end. Right? 00:20:44:27 - 00:21:06:50 Dr. Steven Glassman Correct. So let's say, for example, we show the patients really wide smile and we plan to do ten restorations on the upper right. And they're they're all in between. Let me see what it looks like with only eight restorations or 6 or 4. So very quickly we can eliminate those others eyes and show the patient what it would look like so they could find the best one that will match them. 00:21:06:50 - 00:21:27:23 Dr. Steven Glassman You know, obviously where we're talking about those comprehensive cases, budget comes into, you know, and you'd be surprised. I'm still surprised 41 years. Some people coming in you think can afford it won't do it. And other people you think that I mean I had a guy once that came in. I swear to God he looked like it was homeless and most doctors wouldn't give him the time of day. 00:21:27:23 - 00:21:50:30 Dr. Steven Glassman We found out later that he had a huge lawsuit against the city of New York. He was hit by a bus that had a Greek settlement, and the first thing that he want to do is fix his teeth. And so he came in there and one of the first upper, lower full arch implant cases I did about 12 years ago and case came a spectacular. 00:21:50:34 - 00:21:56:37 Robert Norton That's fantastic. Are there any such cases that you want to look at here today that we have, visuals for? 00:21:56:42 - 00:22:22:10 Dr. Steven Glassman Yeah. I think I like to, show the, one the first case. That's the very interesting one. So, here's my, my workflow for exams. And I think technology is making us rethink how we do examinations here. We start with taking that wide smile photo. As I said. And then I am now, doing my internal skin. 00:22:22:15 - 00:22:52:41 Dr. Steven Glassman I am encouraging the patient to look at that intraoral scan and point out things they think would be interesting. And the analogy I like to make it is if you've ever taken a, elementary school or middle school person to a museum, they have all these exhibits, but a lot of the exhibits are, are touchscreen and there's information, there that, are there and it gets the young students mind to want to ask more questions and want to learn more. 00:22:52:46 - 00:23:16:37 Dr. Steven Glassman The same thing here, once they see their skin and they relate much more to a digital scan than they do X-rays or the mirror in the mouth, and they start to ask me questions and I say, what do you think about that? You think they think things are healthy? Are there anything of concern? And so they may point out the inflamed tissue, they may, point out the chipped tooth, or the, the black filling on a tooth. 00:23:16:42 - 00:23:37:01 Dr. Steven Glassman So we're encouraging that we're going to, we use our a little magnifying glass to blow them up, and we have something that is in the, scan when we send the scan to the cloud. Typically the mode is we scan the patient, we download a view it, and then we put it to the cloud. We have these calls and it's called the oral health suite. 00:23:37:06 - 00:23:59:37 Dr. Steven Glassman What separates your oral health suite is they use terms that the patient will understand like gum health, tooth health alignment and bite. And every area we are concerned we can screenshot that patient. We also have a tool called near-infrared. Imaging is when we go to 12 we can pick up into possible carries before they show up on X-rays. 00:23:59:42 - 00:24:28:37 Dr. Steven Glassman So we these screenshot areas of concern. We can go into their, alignment and see if they have too much, contact on the facially, the lower incisors. And is that causing shipping or where do we have, fractions? All those information from them. So we're looking at it, breaking it down to all those things parallel. We can now look at gingival margins. 00:24:28:42 - 00:24:51:24 Dr. Steven Glassman We can look at tooth restorations often. I'll show them in a stone model. Stone model will pick up fractured teeth and fractured things. Before we show it up on the magnifying glass, we can look at the margins of fillings on it to see if there's any leakage and any of these areas we're going to concern. At the very end, we're going to go and press the button for outcomes similar to Pro. 00:24:51:28 - 00:25:13:58 Dr. Steven Glassman And while that's showing, we'll look at, the original photo, the photo that has the ortho correction and the full face photo that has ortho and resto. Now you again, if the patient doesn't really need ortho 25, 30% of the population, then we could just show them the restorative. That's why I like this method. I don't it's right there. 00:25:14:03 - 00:25:41:29 Dr. Steven Glassman It's right there. It's right there. I could do, if I think the patient would be a cosmetic value. I'll add that 32nd video. The video is the same on the align platform that I use them to invoke something that they're interested. Motion partial. I'll ask you where they spend their summer vacation, or if it's a woman getting married, I'll talk about the wedding of somebody who is a big fan of a sports team. 00:25:41:43 - 00:26:00:18 Dr. Steven Glassman Like, I know the evolution of big Buffalo Bills fans. I'll ask about how that game was, and all of a sudden you see the smile and the personality, and then they see it side by side with the eye version of it, ortho or ortho resto. And they go, oh my God, this is amazing. So this all lands to it. 00:26:00:19 - 00:26:23:58 Dr. Steven Glassman Now, before they leave all the screenshots and all the copies I have, I will share their report with them by a QR code. Everything that I've taken and that visit every video I'll be outcome simulator is incorporated. That and they take it on their Mil mobile phone. I will then escort the patient to the front desk and then I will tell them so and so. 00:26:23:58 - 00:26:49:18 Dr. Steven Glassman We spoke about these areas. We have some peril issues. We had some, restorative alignment issues. And we're going to finish this with some veneers on the case. And we have everything mapped to them. And they have the everything in their phone. We focus on problem consequence solution. So when they go back to their significant other or their parent, it's not just the I'm, I'm a, line item price on what it's going to cost. 00:26:49:22 - 00:27:04:07 Dr. Steven Glassman They're showing them and why they need it and what it's going to look like. So that will increase you all, so to speak, exactly. At least 35% increase in case acceptance by doing that 35% increase. 00:27:04:12 - 00:27:06:06 Robert Norton That's that's notable. 00:27:06:10 - 00:27:29:04 Dr. Steven Glassman And it's amazing. Okay. That's all I want to tell doctors. You don't have to have always the volume. You need the right patient to come in and the real clear skill is getting the asymptomatic patients to realize they have situations and to move forward. What have you mastered that you'll be doing way more close to your potential. 00:27:29:09 - 00:27:37:58 Robert Norton So you'd say that you'd use these tools quite a bit to diagnose the asymptomatic patients and really illustrate to them. Seeing is believing. Is that what I'm hearing correctly? 00:27:38:00 - 00:28:00:16 Dr. Steven Glassman See is believing. They see it. They want to see it. They're visual. We do it on all new patients, emergency patients. Unless they're in so much pain, I can't get a scan of them and hydrate hygiene we'll do once a year. And the good thing about the skin, if, say, they don't say yes, this year, we'll scan them again the following year. 00:28:00:16 - 00:28:21:13 Dr. Steven Glassman And then we can overlap the scan with a tool called time lapse. And time less will show me if the situation is getting worse. I had a patient from Britain they used, say, Britain's teeth. A lot of crowding took him ten years before he realized that the case was getting worse, and he finally decided to go through Invisalign. 00:28:21:18 - 00:28:37:57 Robert Norton Right. Because if you have a year or 2 or 10 lorded between the, between the two scans and images, it's pretty easy to illustrate the difference. Whereas if you're seeing your face in the mirror every day, the gradual change is it's sort of like watching grass grow. It's like one day it's not there, and the next day it is. 00:28:37:57 - 00:28:47:42 Robert Norton And you know, somewhere in between that change occurred. But it's hard to illustrate, especially when, let's be honest, regular patients, their focus is in teeth, like your eye. 00:28:47:47 - 00:29:15:16 Dr. Steven Glassman Correct? I could joke, I say it's like my hairline. I look at pictures from 50 years ago. Jesus. Where was all well? What happened? That other full head of hair? It's, You know, it happens. It's not linear. It happens over time. It's just like, the patient's enamel. And I say that to doctors. My big topic on this last presentation, which will refer to this case here, is had we been complicit with our patients enamel wearing away, it's. 00:29:15:16 - 00:29:17:57 Robert Norton A very pointed question. And that's true. 00:29:18:01 - 00:29:43:50 Dr. Steven Glassman Yeah. They go to I will say oh it's hard tooth brush aggressive then you're grinding. But there are other factors on there. There's acids in the diet. There's even a lot of people are anti depressives today. A lot of those patients will grind and clench your teeth and jaw motion and wear them down faster. Obviously there are, eating disorders that can contributed by Olympia anorexia. 00:29:43:55 - 00:30:03:02 Dr. Steven Glassman Some of the kids that all they do is suck on, iced tea or lemon all day or Frappuccinos between the acid and the sugar. These are all things that can do that. But it's all of a sudden the patient if you if you're ignoring it, this is going to happen to you. As the patient will say that I've been a patient here for 20 years. 00:30:03:07 - 00:30:18:25 Dr. Steven Glassman I come in every year. You tell me my gums, my teeth are fine. What happened to my teeth? Why are they so short? Why they're wearing down? Why can I see yellow underneath it? And it's because we're missing these signs and symptoms of tooth wear. 00:30:18:30 - 00:30:25:54 Robert Norton Absolutely. And, so this other, this other slide that you want to do, look at here, this other patient, 00:30:25:58 - 00:30:48:00 Dr. Steven Glassman So this is a really interesting case. She came in here for a second opinion and that was her full face photo. I would love to show her teeth. After smiling, but, she had a provisional on the lower right side from 29 to 31. And she was the dentist who was treating her wanted to go to the periodontist to do a crown lengthening. 00:30:48:05 - 00:31:09:01 Dr. Steven Glassman Of course, the teeth were so short. Let's think about it. Okay? The teeth were so short, but the doctor cut down the incisal edge, the coastal edges, so you get a crown on it. Does that make any sense to you? We want to. We want to make the teeth. So I looked for a mouth. We're measuring, central incisors that are seven eight millimeters. 00:31:09:01 - 00:31:36:16 Dr. Steven Glassman They should be 10 or 11. And I show her where throughout the mouth and I show, and we start to do some of the digital tools. And I said to her, and you look at her Big Macs, she's grinding and tension and so I said, you know, really let's I really want to replace the lost enamel and give you back the protective chewy motions so it will protect these teeth from continue to wear. 00:31:36:21 - 00:31:44:15 Dr. Steven Glassman And you don't have to go through a crown like that's a good news for you. So she was interested. Let's quickly show the next slide. 00:31:44:20 - 00:31:45:22 Robert Norton Absolutely. 00:31:45:27 - 00:32:06:41 Dr. Steven Glassman I'll go through this and I'll make a diagnosis both on and orthodontic checklist and areas they want to approve. And then if you go to the next one, I think I have one in black and white. That's the functional one. And I start to see where the contacts are and things that we want to change. So that's typically my exercise not so much through the patient. 00:32:06:41 - 00:32:29:22 Dr. Steven Glassman This is more I got the patient to say yes. So here is the wild smile photo. And we see with the outcome similar with smile architect. Again we could have done aligners. There's only one tooth. I think number seven was slightly overlap, but because the tooth needed a crown anyway, we eliminated the awful part of this and I just showed her the restorative. 00:32:29:22 - 00:32:54:51 Dr. Steven Glassman And she looks at this and she says, wow, this is pretty cool right? And let me let me, let me see more. So let's go to the next one. And now you have the video of that I'm ready to play it. She's talking. And now the upper and lower teeth have been restored. And at the very end, the final outcome looks very similar to the eye simulation through this. 00:32:54:55 - 00:33:16:23 Dr. Steven Glassman So she's seeing all this stuff on the glasses. We've opened up her the vertical a little bit, but that's still the area that's missing. We need to bring that. That shows the soft tissue changes of opening the vertical compared to and the profile once the soft tissue things are made. So that was the smile video that is on the iTero unit. 00:33:16:28 - 00:33:34:49 Dr. Steven Glassman If you don't have a scanner, which I, again, you know, I'm highly recommended, but, you can use this with the, the true video on the ETS. Okay. So you would send your laboratory these photos, and they end the video, and they can do the simulation with it. They can actually even do more with that. 00:33:34:49 - 00:34:02:52 Dr. Steven Glassman I can show them the opening of the vertical. In this case, we ended up opening her by five millimeters. I could simulate that better with a true smile video than I can with the, how could similar problem. But, the point is, is that these facial scans will show the profile from every angle with it. And so this when we do our design, we can show the design with the, the recommended treatment plans for it. 00:34:02:52 - 00:34:29:57 Dr. Steven Glassman So we have this is typically I take with the clone. It takes me about 60s to capture each one and then each one we export via Dropbox link to our CAD designer so they could. Now we can merge the 360 facial scan, and we can bring that into, the, with, with any of the design software. 00:34:29:58 - 00:34:30:54 Robert Norton Yeah. 00:34:30:59 - 00:34:49:55 Dr. Steven Glassman Exactly. All those things together. We have it and let's continue on. I think I brought some other photos again. This is my external lab partner. Now, the patient has said yes, we're now into the planning case, which means we have to design the case with the right provisionals. So we send all these tools to our exo CAD designer. 00:34:50:09 - 00:35:15:10 Dr. Steven Glassman The great thing about using, when we submit cases for same day dentistry, they're able to bring that skin folder right into their DB designer. They don't have to they don't have to download files and upload files. That goes right into it. So here's I think this was done. This is done by, Johnny Zo cad Johnny Jackson of your team, but he's now using the design. 00:35:15:10 - 00:35:39:52 Dr. Steven Glassman We have it all done together where we see the 360 facial scan with the Intraoral scan on it. And if I was doing any of these crowns, laughing or implants, I would also cut the CVC tear. So now we're planning it. We originally decided to open the bite, 3.5mm so that we have enough inter arch occlusal and then the preparations, especially in the molars. 00:35:39:52 - 00:36:07:41 Dr. Steven Glassman I was just flattening them. I wasn't taking them off, flattening them, going around there. So truly minimally invasive. The Provisionals were made after we, we agreed on our digital wax up, we could scan the patient, and then they could send me back the files so I could print the provisionals right in the office. So the uppers originally she agreed on it because the budget we're going to open, we're going to do the full arch upper and just the post your teeth on the wall. 00:36:07:46 - 00:36:27:05 Dr. Steven Glassman And then once we, finished the the upper lower arch, she didn't love the lower six lower and sizes. So I said, you know, I just came back from this new course on 3D printed veneers. I'm going to give you the deal of a lifetime. Let me just do non prep for the veneers on the lowers. Just to make up a difference in the occlusal. 00:36:27:19 - 00:36:47:38 Dr. Steven Glassman Because we when we're doing the final lower restorations, we decided to open up another millimeter for two millimeter a half for total of five millimeters because I wanted to make sure I had enough clearance on the molars. So when that was finished, we still had space between the lower interiors, which we now did our 3D printed veneers. 00:36:47:52 - 00:37:16:16 Dr. Steven Glassman And you could show you how the case turned out. Wow. That's that's that's the first day. If this is the new Vertical dementia 3.5, the uppers are done. So this is the final scan of, the Provisionals. They have the Provisionals are able to, to, to to merge them so I can get that done with the iTero to scan a full arch like that takes you less than five minutes. 00:37:16:21 - 00:37:39:01 Dr. Steven Glassman It's a continuous wave scan. And if I don't like to take a scan up, I'll go back and just erase that one prep. Maybe I'll do a little bit of tissue retraction. Maybe I'll make it smoother and go back to it. It just makes the dentistry so much less stressful and we're able to get ideal results. And because it's all digital is never an issue with the bite. 00:37:39:01 - 00:38:01:34 Dr. Steven Glassman The bite goes in typically with either no adjustments or minimal adjustments on the occlusal. So this was done. Let's go to the next, area. Now this is the final case after we finish the lower teeth against the upper final's another millimeter. So total about four and a half, I think. And you can look at her face. She looks terrific. 00:38:01:39 - 00:38:07:27 Robert Norton Oh, that's joy you can't hide. Look at that. What a transformation. 00:38:07:31 - 00:38:31:10 Dr. Steven Glassman Yeah. And we can see the comparison as you go along. Let's go. Another slide there. Here is our comparison. The original. You could see her lower third. The face is better now. She looks younger. She's happier. This is the comparison video I took originally with the iTero outcome smile video and the final video talking. And they look really compatible. 00:38:31:19 - 00:38:57:16 Dr. Steven Glassman Comparable to what we planned. And we delivered it. And again, efficiency. There's a lot of this stuff going back to the laboratory. The bite is off. Nothing. Everything is planned. And I as I say, my favorite line is if you, fail to plan, you plan to fail. And so really, really, here's the case. And I could have done it without my Zoc had partners at evolution sites. 00:38:57:16 - 00:39:24:06 Dr. Steven Glassman Really? They make it so easy to work with. And when I want to do same day dentistry, I just schedule in advance. I give them an update. How I'm doing over time, they take my scan with my original plan and then modify it. I get the STL files and something like this. I would print probably like in an hour in the office, which if I'm doing it analog in the mouth, I probably would spend an hour anyway and they wouldn't come out as good. 00:39:24:10 - 00:39:25:07 Dr. Steven Glassman That's excellent. 00:39:25:12 - 00:39:37:07 Robert Norton That is unbelievable. How does that relate to the advancements you're working on with the art? The art advanced restorative treatment program that, that they're looking at debuting soon? 00:39:37:12 - 00:40:01:13 Dr. Steven Glassman We are working with a our trial case, another, we have a great, volunteer, another Jackson from here called Josh, who has severe wear all of his teeth. He's missing his molars. But we want to also, with the art, which is funny because he, coming from restorative falls at the art would say, doc would change your plan with a vision line. 00:40:01:13 - 00:40:28:14 Dr. Steven Glassman We want to move him in this direction because we know what the final restoration. We do this right. All you need to do is take point one millimeters off the facial surfaces, and then, we will give them a restoration. And I think there is, I said earlier, going back to my message, a lot of restorative doctors are either focused, are focused on the, on the, restorative imperial. 00:40:28:19 - 00:40:51:43 Dr. Steven Glassman Well, a lot of them are in either cosmetics like veneers or on implants, and they don't understand the value of tooth movement by having our designers recommend to them about tooth movement. A simple thing. I would must have said in the last two years I must have four cases where we move teeth to put implants on upper laterals that were jelly missing, but we don't have the space. 00:40:51:48 - 00:41:19:52 Dr. Steven Glassman But now having to the ability to include cbc-tv in art and tooth movement and art, we can plan. Exactly how much will you left to move them. We can bring into our our our implant planning software so we know which implant we're going to put in there. We have it, all ready to go. So move the teeth first, place the implant, and then we'll typically will visualize them. 00:41:19:57 - 00:41:47:31 Dr. Steven Glassman And how do we do that? We will reserve it with our, zakat partners will, place our scan body in. We'll have pre bought our tie base in the office. And so we'll design it. We'll print it up in about 30 minutes. We'll submit that onto the tie base. And now they get a lab quality restoration. While the tissue is healing that they could wear for six weeks loftily before we finish the restoration. 00:41:47:36 - 00:42:07:55 Dr. Steven Glassman If I were to do this analog way, first of all, maybe I would do one to do doing multiple teeth. I could never do it. No. And and they would also not look great. They would break. I get frustrated. I couldn't get the pull out. So it's so much better done, digitally through the use of the software. 00:42:08:00 - 00:42:24:52 Robert Norton How would you, how would you recommend other doctors approach, injury? Because I think, like, you're right, I think a lot of doctors don't really appreciate how much ortho really plays into the the comprehensive treatment. How would you recommend they tiptoe into that? 00:42:24:57 - 00:42:47:19 Dr. Steven Glassman Listen, there are a lot of other. There are a lot of clear line is out there. Obviously, I'm biased towards that, but, I've also whatever gets you to the final set up, if you're going to use a competitor, that's okay. If you use it, use a different scanner, that's okay. But a lot of doctors and some that are very successful and very talented are just stubborn, right? 00:42:47:24 - 00:43:09:39 Dr. Steven Glassman They think the ortho is something that is an extra step. Three months, four months, six months. They're not looking. And to me, if you are cutting down teeth, if every, if every they would that there's that famous line. Right. If if, if every tool you have is the only tool you have is a hammer. Everything looks like a nail. 00:43:09:45 - 00:43:11:21 Robert Norton Everything's a nail. 00:43:11:25 - 00:43:39:29 Dr. Steven Glassman Everything's a nail to them. And those cases will be more invasive, which means more likelihood of endo and fracture. Nothing. Now, maybe you don't care, which I think more than not, most dentists do care. They have to be shown. That is easy to do that, especially if you're doing not every implant case you're doing is full arch. So if you're threading implants between natural teeth, your best friend, you want that path of insertion. 00:43:39:34 - 00:43:58:12 Dr. Steven Glassman You want to get rid of the mal occlusion. You know, you don't want to put an implant on a deep pipe that's going to put pressure and make the implant fail. You really need to know that. So I'm hoping, designers like you will be doing that or what I'm doing. I decided to make my own way to do this because I've been frustrated with some DCA. 00:43:58:24 - 00:44:23:29 Dr. Steven Glassman I've been. I've been, in, continue education for 21 years. Is that if that's the number line, I'm doing my my own, program coin. Glassman. Academy of Ortho Resto, trying to bring those doctors into the digital world and understanding the value of all these things. Same day dentistry. And you don't have to come in and become a master X, okay? 00:44:23:31 - 00:44:36:10 Dr. Steven Glassman We'll give you the tools so that you know how it works. And if that's what you want to do to do it. But to use these tools, I Carol on the platform has an XO cad light available to them that I usually way. 00:44:36:14 - 00:44:37:12 Robert Norton Yeah. 00:44:37:17 - 00:45:01:30 Dr. Steven Glassman Exactly. But if I, if somebody comes in without a bridge, I can make a design a bridge on that those preps and and prints something at 20 30 minutes from then they can go out. So there's a lot I could do with the design. I could do mockups from them. I could do occlusal guards, I could do crowns and some of the the restorations coming out of Midas are 70% filled. 00:45:01:30 - 00:45:22:43 Dr. Steven Glassman They're they're 80 approved for final restorations and will pay for that if you're comfortable doing that. My my feeling is that 3D printing will replace all milling in the future I agree. So you'll be you'll be doing same day dentistry with that. So I would say my course is going to help you master. Like car design suite. 00:45:22:48 - 00:45:47:15 Dr. Steven Glassman Understand art, how to use it. Look, care how to use designers, how to do ortho resto, how to do 3D printing, all these things that I think a lot of the other courses fail. They're typically either my colleagues who teach Invisalign, their focus on the clincher ortho. Only the guys I know from quoits or spear are focused on mostly on the restore, and some of them are way behind in digital. 00:45:47:20 - 00:45:55:54 Dr. Steven Glassman I'm going to be the first one that puts everything in perspective for those doctors that are little bit of a hand-holding to go through the process. 00:45:55:58 - 00:45:58:57 Robert Norton So a comprehensive approach, just like your practice, then. 00:45:59:02 - 00:46:22:49 Dr. Steven Glassman Correct. I get some of these patients go the insurance doc is and I said, you know, you're so busy trying to overdo diagnose treatment carries that they're missing stuff right in front of them that you should be seeing and recommending and explaining. And they're not everybody's going to go through it. But that's the beauty of it. You only need a certain amount to say at 35% increase in acceptance rate, what would that do to your practice? 00:46:22:54 - 00:46:24:51 Dr. Steven Glassman It would be amazing. 00:46:24:55 - 00:46:34:52 Robert Norton Absolutely. You're pulling more out of the existing patients, and it's not as though you were just trying to extrapolate more money from them. You're genuinely giving them better care because of it. Right? 00:46:34:57 - 00:46:54:43 Dr. Steven Glassman Okay. Are some of these some of these, undersized laterals we'll do direct bonding or somebody that's gotten shift incisors. Well, we'll give them enough over jet. We'll get the bite. We'll do bond, direct bond. It holds up really well. So we have a lot of choices today. We can do direct bonding. We can do injectable bonding techniques and we can do print the veneers. 00:46:54:43 - 00:47:03:50 Dr. Steven Glassman They're all less, they're more affordable and often more less invasive than doing ceramics is fantastic. 00:47:03:50 - 00:47:08:19 Robert Norton Now, I heard you mentioned the Midas system before. Is that something that you've incorporated in your practice? 00:47:08:24 - 00:47:24:37 Dr. Steven Glassman It's on my list right now. Like I always get gives me a checklist of what I could spend in a year. That's certainly, the next purchase for me is to do in some of the Midas stuff, because, see, the turnaround on the one thing that I want to explain to people out there is a million is typically one unit at a time. 00:47:24:37 - 00:47:37:58 Dr. Steven Glassman You can nail, you can print up to nine units on a midas. You can print a full arch with a, regular, a regular, or a printer, which, if we have time, I'd like to show the next case that I've got. 00:47:38:06 - 00:47:41:28 Robert Norton Yeah, absolutely. What, what would you like to look at? 00:47:41:33 - 00:48:00:05 Dr. Steven Glassman We actually as one of the first cases I did alumina. So let me, tell you about this patient. She came into my office 2017. One of the one of the smartest things I think I did. Some doctors are are great. They've taken courses to their own implants. Some have made their whole practice. I took a different turn. 00:48:00:05 - 00:48:24:09 Dr. Steven Glassman I brought in a board certified surgeon about 50 years ago. Right out of this program. We kind of hit together. We meshed. And, we both really were very influencing of each other's career. So this, was the x rays that came in. And this is our first patient. She's, I think 67 at the time, and she has a whole bunch of upper windows that are failing to. 00:48:24:10 - 00:48:49:01 Dr. Steven Glassman She wants a nice smile. So she came in with that. She wanted to know what the options are looking back and forth. The post, the lower poster, mandible. The bone is very thin, and she did have a bit of a budget. So we decided back at that time, 2017, to do an upper and lower extract everything. She went into dentures for 3 or 4 months, and this became a locator case. 00:48:49:06 - 00:49:07:28 Dr. Steven Glassman And we opened the vertical up, which she could show you that. And so this is the original, you know, you could do this on all your photos, looking at the one third of the face, the instance, the show that I'm also showing the profile, her lower jaw is sagging because she's over closed. Her upper jaw is out slightly. 00:49:07:28 - 00:49:15:16 Dr. Steven Glassman That's our rickets line. So very quick way to do make a diagnosis. It doesn't happen if you don't take photos. 00:49:15:21 - 00:49:20:33 Robert Norton And the what program did you use to mark this up with these, line references? 00:49:20:38 - 00:49:41:43 Dr. Steven Glassman So just a Photoshop lines on photos? Nothing. Nothing. This is two gums. Okay. That was her injuries. You could see she's missing a lot of bone on the lower, case. Yeah, this was a precision. I love these precision partials that nobody wears. She wants the partial. That was the dentistry splint. Everything. This is the 70s, 80 cases. 00:49:41:43 - 00:49:43:48 Dr. Steven Glassman How we used to do things back then. 00:49:43:53 - 00:49:46:28 Robert Norton Yeah. You see all the PFM work there? 00:49:46:33 - 00:49:54:57 Dr. Steven Glassman Exactly, exactly. Okay, let's go to the next one. Okay. So this is afterwards, and we'll give her we open it up. She looks younger right? 00:49:55:06 - 00:50:02:04 Robert Norton She does. That took ten years off her. And the speaking of Doctor Debbie, you practice with your with your wife. Correct? 00:50:02:09 - 00:50:12:02 Dr. Steven Glassman Yes. With one of the only couples that practice. And we share a desk in a 15 or square foot office in practice, 41 years and married 41 years. 00:50:12:07 - 00:50:14:17 Robert Norton You must work very closely together. 00:50:14:22 - 00:50:36:52 Dr. Steven Glassman We did. We did literally, literally physically. She is, the ambassador of the practice. She will get that comfort to patients. She'll listen. She's a much better listen than I am. And she could convince patients to trust us. Really, really good. Okay, look at the profile. Right. Has these increased better? Right. And so she looks better. 00:50:36:52 - 00:50:57:52 Dr. Steven Glassman She looks younger. So she disappeared from me for I think seven years. Didn't hear from her come back. And then she comes back to me with the next slide. And so she broke off her, one of the essential sizes of broke off, which she crazy glued and the flange broke out and she has a, crazy for your case. 00:50:57:57 - 00:51:21:18 Dr. Steven Glassman Yeah. Crazy girl. Right. So she she convinces me to, See what are the options? Can I convert this to a full fixed on case? So we lit the case, we brought everything off. We took our all our data, including our KPIs, because we had to convert the locators to multiple units, and we needed to decide what the angulation did. 00:51:21:18 - 00:51:44:49 Dr. Steven Glassman And we were able to do straight multi-unit. So from that Lumina is released. And now we're able to do our first full arch case with the help of, Josh Jackson and Evolution Science using easy rest. So let me show you that quickly. Next slide. And here is the iTero scans. Now first, I did this I would probably do something a little different a little longer arms. 00:51:45:00 - 00:52:08:40 Dr. Steven Glassman You want to overlap them. They're made out of zirconium. They're very easy to scan. They're autoclave level. So this was done in a very early version of alumina. And from that the the PMS were made when and let me show you how they fit using the exo CAD. We took her original design and we modified it slowly. This is an all our next case that we did today. 00:52:08:45 - 00:52:30:57 Dr. Steven Glassman And now that's our 3D printed. Everything was perfect. You could see on the left side the bite is slightly open and now she wears that. Make any facial changes. We scan that in the mouth and after about another four weeks, we finished the final zirconium. Let's go show that that's her final zirconium. Eight weeks later, we use the bar on the lower because it's a bit of a cantilever. 00:52:30:57 - 00:52:51:37 Dr. Steven Glassman On the upper is also coning with Powerball screws. And let's look at her photos. That's her final restoration. Look how great she'll she looks younger now than she did. In the second stage with the over dentures, she looks even better. That's what it looks like in the mouth. Look at the occlusion. The access. That's what it looks like. 00:52:51:37 - 00:53:06:51 Dr. Steven Glassman The X-rays is the bit of a cantilever on it. You. She's been fine with it. Here we are. Okay, so that's her original. That's her finished with the, the fixed hybrid on restorations? 00:53:06:55 - 00:53:18:34 Robert Norton Absolutely. And you can see it really changed the shape of her face in a positive manner. And you can see the progress from the original photo all the way through. The all on X is incredible. Any final thoughts? 00:53:18:39 - 00:53:23:04 Dr. Steven Glassman Listen. Go digital. Before we plan, we must digitally scan. 00:53:23:09 - 00:53:27:52 00:53:28:13 - 00:53:31:32 Dr. Steven Glassman My pleasure. Take care now as well. 00:53:31:37 - 00:53:49:49 Robert Norton Thank you for joining us for this episode of the Evolution of Dental Podcast, brought to you by Evolution Dental Science. These podcasts are available on YouTube, Spotify, Apple Podcasts and of course, your favorite platform. Please don't forget to like, subscribe and share this video with all of your dentists and dental technician friends. We look forward to seeing you on the next one.