The Hybrid Digital Workflow: Full-Arch, exocad & In-House Production | Dr. Daniel Greenbaum | EODP #36

00:00:05:04 - 00:00:23:02 Robert Welcome back to the Evolution of Dental Podcast, brought to you by Evolution Dental Science. We share the stories of the people and the technology changing the world of dentistry. I'm your host, Rob Norton. And for those of you who are veteran watchers, you might notice that things are a little different around here right now. And I'm wearing headphones. 00:00:23:02 - 00:00:42:08 Robert That's because I am at the HQ up in Buffalo, New York. Happy to be here right next to Catherine, today's guest. Well, full disclosure, I've known today's guest for a long time. I already know he has a great story. He built an implant center with a lab inside. He's got machines, technology. He's hands on with all of it. 00:00:42:09 - 00:00:52:24 Robert He's got zygote surgeons on staff down the hall from him. And now he's cleared his schedule to teach doctor Daniel Greenbaum. Welcome to the podcast. Let's get right into it. 00:00:52:26 - 00:01:19:08 Daniel Robert. Thank you. It's an honor to be here on the podcast. And I love dentistry, I love sharing, so a podcast is just a way to connect with others and to share what I do. So thank you for this opportunity. We met, we connected when I purchased XO CAD in 2018 and you were my trainer. We connected instantly. 00:01:19:10 - 00:01:44:01 Daniel We had a shared passion for technology and everything dentistry. And we've had countless conversations about so many things within the world of dentistry. Not just design and not just XO CAD. We've hung out every year at the lab day meeting, so we became fast friends. And so a conversation with you is just something that I'm used to and I always look forward to. 00:01:44:02 - 00:01:49:09 Daniel So today is is no different, except that I think we'll cover a lot of topics that we want to share. 00:01:49:15 - 00:02:11:00 Robert Absolutely. I'm looking forward to sharing some of the conversations that we've had with our audience. Because I'm a dental learn, I think it's fascinating. And anybody who watches must think it is true, because why would you be here? Right. So one of the things that you mentioned early on when we first started talking is that that you went back to school for Implant and Perrier Fellowship. 00:02:11:02 - 00:02:25:20 Robert Like I remember thinking to myself, like that was a that's a lot of extra years that not everybody would is happy to dive into. What were you what were you hitting in your practice that made that, like a non-negotiable thing? It made you pursue that? 00:02:25:22 - 00:02:52:12 Daniel You know, I'll tell you my my evolution and how I ended up being this surgical professor or a designing surgical prosthetics. It really starts at the beginning, where in high school, I got very into automotive repair and bodywork. That was something that just really appealed to me, because I loved taking things apart and putting them together. And that's what drew me to dentistry. 00:02:52:13 - 00:03:11:20 Daniel Doctor Arnold was a legendary prosthodontics and Manhattan. What a huge influence on my on my trajectory. And I wanted to visit his office. And I saw torque wrenches when he was tightening an implant crown. And I saw him do some bonding and composites, and instantly I saw the Bondo and all the body work that I did in the cars. 00:03:11:20 - 00:03:39:24 Daniel And I was like, this is science medicine, which which I was attracted to, and it's bodywork and restoration. And I was hooked at that moment. And I took the pass into dental school and having the open mind, there's a lot of avenues and directions that we can take. And I realized that if I go into prophylactics, I could follow it with a surgical fellowship, placing implants, doing dental alveolar surgery. 00:03:39:24 - 00:04:15:22 Daniel I wouldn't be doing massive maxillofacial or traumas, but that wasn't what appealed to me as much. And the capstone on my dental training after becoming a professor was to do a fellowship, to do a ton of bone grafting, extractions, implant placement, sinus lifts, which gave me just this, this surgical confidence to be able to do within my practice everything from diagnosis and treatment planning to surgical treatment, the lab work, the designs. 00:04:15:22 - 00:04:23:13 Daniel I have an in-house lab and I play a major role in in all of the fabrications and then delivering the restorations. 00:04:23:15 - 00:04:42:13 Robert That's one of the things that we kind of connected on early, is your drive to bring so much of this stuff in-house. A lot of doctors feel like, you know, the lab is a bottleneck, whether it's in-house or otherwise. And here you are. You've put two milling machines down the hall from you. You have a full on lab scanner as well as your oral scanner. 00:04:42:15 - 00:04:50:26 Robert What did that actually change about how you practice dentistry? Like once you once you were also the technician because you don't just have milling machines your hands on. 00:04:50:28 - 00:05:07:18 Daniel You know, everyone is different. For me, I love knowing how everything works. I'm a tinkerer and and I'm not saying this is the only way. This is something that I love and I ask myself almost every day, why do you do all this? And do you want to outsource more? And yes, I. 00:05:07:20 - 00:05:12:09 Robert Don't know any other doctor that carries a laptop or the next okay. I don't go with them everywhere they go. 00:05:12:10 - 00:05:33:15 Daniel Everywhere I go. I haven't actually got a dog. Oh. That's true. So for me, it was the curiosity to just to to know how things work so I could communicate and collaborate better. But old habits die hard. In my residency, I had to do all my own fabrication. And the answer that I always come back with is you love it. 00:05:33:16 - 00:05:55:13 Daniel You do it because you love it, and it allows me to, you know, to lean in and do more for these cases and also to share and to connect with, with others. I can't really always do this amount or scale, but at this point, I love doing it and it's absolutely changed every type of treatment that I do. 00:05:55:13 - 00:06:04:00 Daniel I think that was your question. How has it changed how I treat? We can come up with some specific examples, like what types of cases are you thinking about? 00:06:04:02 - 00:06:27:22 Robert Well, I mean, what examples come to mind, for example, like something that you would have approached different, you approach differently now that you've had this lab in-house and you've gotten very hands on with every process involved with building out these restorations, these these full. I like I like how you put it, not full arch, but full mouth rehabs. 00:06:27:24 - 00:07:04:10 Daniel The word that comes to mind is prototyping. When we talk about full mouth and the way that I treat now, versus when I graduated. My program in 2011 is totally different. And let's talk about have some show and tell digital dentures. This is a milled monolithic denture. So digital dentures for example, the way I'm able to design a prototype try it in is just is a total shift. 00:07:04:10 - 00:07:28:00 Daniel So for example, on the, you know, the digital denture category, someone will come in with a denture that's ill fitting that they hate, that's broken even. And I'm able to really do a next visit denture. And the way we do that is even if it's broken, I can repair it, realign it, take some photos to just take some notes and then take that repaired. 00:07:28:00 - 00:07:52:22 Daniel Rely on denture to the lab, put it in the lab scanner, do a denture duplication scan, which Robert taught me how to do and use that. Bring that into zakat. Based on my notes, I could print a prototype. I bring that to the second appointment. I try it in often we stick the landing at, but I could still, based on that, take some notes and modify modifications to my design. 00:07:52:22 - 00:08:07:02 Daniel I send my patient home with the prototype. They love it. They're like, wow, this is the best thing. And then that's printed. So I'm able to do rapid prototyping with printing, and then I'm able to go ahead and mill a complete denture. 00:08:07:08 - 00:08:21:19 Robert Like what's something that you thought would be easy and turned out not to be and vice versa, like something you thought was prohibitively difficult. And then you sat down at the bench for the first time and you're like, actually, this is just to me. 00:08:21:22 - 00:08:27:07 Daniel Oh. That's that's a good question. I mean, I would say. 00:08:27:09 - 00:08:28:13 Robert Sorry. 00:08:28:15 - 00:08:51:14 Daniel So, so we have to give respect to the methods and to the people who who produce the work to say that that nothing is easy. It's based on years and years of learning and growth. So we have tools that make us more efficient. We have tools that allow us to produce stronger, more reliable prosthesis and also to have resilience. 00:08:51:16 - 00:09:17:03 Daniel But everything you know requires close, close attention the the room or the space for error. There's just different errors when it comes to milling versus casting. So I would say that nothing is easy. Everything requires a, you know, attention from how we're aligning our meshes, how we're scanning. Right. If we, you know, if we look at where we can get errors in the new world acquisition, right. 00:09:17:04 - 00:09:43:20 Daniel Scanning you have stitching errors. And the whole topic of photogrammetry is to circumvent stitching errors with inter oral scanners on the lab. And we have calibration of machines. We have shrinkage factors, we have oven settings. There's nothing that I would say is, you know, that could be done without focus. What the tools allow us to be so much better. 00:09:43:20 - 00:10:17:00 Daniel And you know, something that is surprisingly easy. You know, let's let's talk about an easy one is when we talk about fixed on on teeth. I love the workflow of designing a wax up ahead of time. If we're doing. Here's the example case, let's say we're doing teeth six through 11 maxillary canines canine in esthetic cosmetic Dentistry case, we could design a wax up ahead of time and produce nothing that that's what we produce. 00:10:17:00 - 00:10:47:02 Daniel The digital wax up, prep the teeth and scan them into orally. Step out of the clinic margin eight. Mark the margins. Align the new scan to the wax up and go ahead and print a temp. That is really easy. Now you don't have to be the one to do all the steps. You can work with a team. You can work with a remote designer who's doing that design, sending you an STL or even remotely starting your printer. 00:10:47:09 - 00:10:56:06 Daniel But that's something that to me is relatively easy and so much better than the old ways. 00:10:56:08 - 00:11:14:07 Robert Absolutely. I think that's one of my favorites to frankly. And it's really it's really rewarding when you're showing somebody for the first time and they think that this is beyond what they can do. They saw it on the internet, and then they maybe took a chance and bought X, okay. And they're like, I don't know about all this. 00:11:14:07 - 00:11:45:22 Robert And then you show how easy it is and how effective it can be. Whether you print the temporaries, you create some kind of putty matrix or regardless, like you just boom, not only are you sending a patient out with temporaries, but then the temporaries that look like what you intend to deliver as a final. And so they really get that extra rewarding feeling from, from, from visiting your clinic, you know, and it helps differentiate those clinics from, from, you know, just Joe Schmo down the street, you know, doing things the old way, so to speak. 00:11:45:25 - 00:12:00:18 Robert And you mentioned outside CAD designers. So like, where's your line for where you generally keep stuff in house. Because I know you do a lot of work with yourself, but what do you what do you hand off to other other staff members or outside designers? 00:12:00:20 - 00:12:31:10 Daniel So I'm I'm a unique bird because I took to design and I really like it. And I've done 100% of my full arch designs since 2018. And I pulled up some, some numbers. I've done hundreds of arches. So my line within my workflow of the hand off is different. Probably that than others. I love doing the designing and I think that every dentist should know certain basics of design. 00:12:31:12 - 00:12:38:14 Robert I'm here at one of our CAD design stations. If you're looking for greater control and flexibility within your digital design workflow. 00:12:38:14 - 00:12:50:26 Schedule a meeting with me or send us a direct message. I'll personally walk you through CAD, help you understand the available options. Determine the right configuration for your lab or your practice. Now back to the show. 00:12:51:01 - 00:13:16:21 Daniel So within my workflows, the hand off within my practice within the lab is I'll do the design and start either the printer or the mill. My team will load pucks. My team will put resins in the printer. They'll send me the shrinkage factor. And I'm designing. So I'm doing the cat, I'm doing the cam I'm starting. And then they they take it from there. 00:13:16:21 - 00:13:42:14 Daniel So they'll do the green state hand finishing before it goes in the centering oven. They'll center. They'll stain and glaze. I still love all the steps. So once in a while I'll glaze an arch. There's an arch that I recently did, which required a lot of melanin staining in the gingiva. And it was a case that I was just, you know, I wanted to have my hands on. 00:13:42:14 - 00:13:52:18 Daniel So so I did that. But the handoff is usually after the starting the technology. Yeah. 00:13:52:24 - 00:14:04:01 Robert That made that make sense. I mean, you can concentrate on the parts where your skills are most valuable and then hand off the, the management of the production off to the team. 00:14:04:03 - 00:14:31:15 Daniel Right. I do want to say, though, so that I don't look like a complete nut that I started after multiple years to to flirt with the idea of outsourcing some designs. And I'm working with one designer who's been doing my my crown and bridge cases. So I'll just scan pre-op and we've done about half a dozen together. I'll send them to the pre-op and then I get a wax up. 00:14:31:22 - 00:14:58:02 Daniel And that is the type of case that I spoke about. Where then I'll prep, I'll scan the margins, and I'll use this really beautiful pre-op wax up, and then I'll merge that with my preps and I'll make the and I'll make a provisional that's ready to go in. And you hit the nail on the head. Before when you were talking about a better quality temp, it looks like the final. 00:14:58:04 - 00:15:25:22 Daniel I'm going to add a point that the gingiva, the gums, heal so nicely because you don't have overextension. It just it's it's a perfect fit. And again in terms of communication this is something that's my favorite part of it. You know, classically or the older way was a dentist would prep impression temp trapped impression in a bag and send it to the lab. 00:15:25:24 - 00:15:48:09 Daniel Right. And bring the patient back for insert. And there was a mystery in the back, right? You don't really get to see what it looks like until you open the mystery bag and try it it. And, you know, then there's the decision. Is it acceptable enough? Is it good enough? And hopefully it's exactly what you wanted. But maybe it's not. 00:15:48:12 - 00:16:11:06 Daniel What you get in this workflow is literally the day of prep. You're trying in the design. You're looking at it, taking it, you know, a few notes. It could be gorgeous, perfect modify final. It could be lengthened canines by one millimeter make these slightly less bulky. But you're you're you're prototype so you're temp rising but you're prototyping simultaneously. 00:16:11:13 - 00:16:16:26 Daniel And that is like something we've unlocked, which is incredible really. 00:16:16:26 - 00:16:36:27 Robert It really is. It's really fascinating to see that going, taking that and being able to literally try it in the patient's mouth to see how it truly is going to look, because you don't really you can, you can, you can plan, you can plan all day long and you can get very, very close. Sometimes you can get extremely close. 00:16:36:27 - 00:16:43:24 Robert But at the end of the day, you know, it's you don't truly know what it looks like until it is in the patient's mouth. 00:16:43:26 - 00:16:44:14 Daniel Right. 00:16:44:14 - 00:16:58:07 Robert And being able to prototype like that, it's it's a very powerful way to move forward. And so same day through on basically every billboard. Now where do you feel like that's misleading or where do you think it really can be delivered on? 00:16:58:09 - 00:17:16:28 Daniel You know, I think a lot about the people who are going through dental challenges and life challenges that lead to the dental problems, and then the dental problems create more life challenges. It's sort of this snowball effect. 00:17:17:00 - 00:17:17:26 Robert Yeah. 00:17:17:28 - 00:17:43:24 Daniel Effect. And we we mark it in a way to to connect with people who've given up and same day teeth is a concept that we clarify when they come in, you know, they'll they'll come into the office. You know, I don't I don't use that exact phrase. But many people will come in and say, do you do the same day teeth? 00:17:43:25 - 00:18:03:09 Daniel And the answer is you will never walk out of here without teeth. The day I pull teeth is the day I put teeth. So you get teeth the same day. It's not the final teeth. It's not one appointment. Dentistry. When we're dealing with a full mouth or a full arch, you know you can get a same day crown from a dentist. 00:18:03:12 - 00:18:42:06 Daniel You know, or some of these newer printed materials are looking promising for same day dentistry. But what it does is it gets somebody comfortable with the idea of, you know what? If it's going to be quick, I can do it, and we can do things very quickly. And we we never let them walk without teeth. So something that, you know, I have within my, my practice because I have the lab and because I have the abilities from the design and technology standpoint and from the surgical standpoint, I can confidently say that if you come in for full arch, you're leaving with teeth in your mouth. 00:18:42:08 - 00:19:21:16 Daniel In eight years, I've never told somebody you're getting a, you know, a fixed restoration. And they leave with it that year because I've acquired many different skills implant placement, zygomatic pterygoid implant placement. So if I have to pivot because the alveolus falls apart, unforeseen lack of density, I can pivot if I have to reprint something or I have these lab skills just from the fact that I was covered in dust in the lab for, for years, you know, having many tools in my toolbox, I think is something that applies to all of us in the lab industry. 00:19:21:16 - 00:19:33:19 Daniel In the dental industry, we're not replacing tools, we're adding tools. And the more and more tools and techniques you add, the more resilient and capable you are. 00:19:33:21 - 00:19:47:27 Robert That makes a lot of sense. And one of the things I wanted to ask is what indicates to you when you have to pivot and change directions and say, pull zygomatic into the into the equation. And how do you handle a situation like that? 00:19:48:00 - 00:20:27:02 Daniel So the the great thing is that we are in an age of incredible technology, and we can usually, almost always foresee the problems. We have to spend time acquiring diagnostic data, CBT scans and planning our work. So I don't think that it is common to have to pivot to is Ida. We know that the alveolus looks like it's not going to hold implants, and we know it's going to be a zygote case or a terrible case. 00:20:27:04 - 00:20:50:20 Daniel So the cases that I call a pivot are cases where I'll I'll prepare my patients at a time and prepare myself and my team at a time saying this, this is a borderline case. We're probably needing to do a zygote, but it'll be a game time decision if we can get, you know, tipped implants and we can get conventional full arch implants will take that path. 00:20:50:20 - 00:21:25:14 Daniel But we have a dental implant center needs to have every size implants, every type of implant. So I keep a tremendous inventory, you know, when when I use the word resilience, it's not just lab materials, but it's it's implant sizes. It's implant systems. So having every size zygote and pterygoid on hand, having every size multi-unit abutment so that, you know, you can if it's zero, 1730, 45, 52, 60, you know, they really cover a broad range. 00:21:25:14 - 00:21:43:16 Daniel And then they also come in all different heights, 1.52.5. Yeah. So the the ability to always pivot or always select the right components and the right techniques in the moment is how you optimize outcomes. 00:21:43:19 - 00:22:02:24 Robert That makes a lot of sense. Can you would you mind taking us through like one of the. So say you have like a quote of the standard all on X sort of situation. What is what is your workflow? Patient walks in the door. Hi doctor Daniel, I need teeth. Where do you take it from there? 00:22:02:26 - 00:22:28:22 Daniel So so once we've we've gotten to know them, right? It's always the person first. We don't just look at it as as teeth in the mouth, but we we we nurture, we build that rapport, we earn that trust, and they're ready to roll. So I'm I'm a real hybrid of of classic analog or legacy techniques and modern technology. 00:22:28:22 - 00:23:01:07 Daniel And I'll say my, my favorite method will sound a little bit old school. I'll walk you through it, but I'll tell you why I love it. So I love doing Aljunied impressions for my full arches. Sometimes I do an internal scan, but I do alginate impressions in porous stone model because in 30s I'm able to get the vestibule, the palate, a lot of data, which is hard to get when you're using an internal scanner. 00:23:01:08 - 00:23:31:00 Daniel Is it possible with special specially designed retractor and special technique 100%. And some mouths scan really nicely and I'll look in the mouth and I'll see a beautiful ridge, lots of keratinized gingiva and maybe like 20% of my patients. We take all digital all the way through. But I'm going to use the 8020 rule here and say that while impression material, the the goop as I call it to my patients is not comfortable, it's, it's 30s. 00:23:31:00 - 00:24:01:21 Daniel And these people don't like being in a dental chair. So I do the I do the 32nd alginate impression. I pour that and my lab scanner scans it. I import those into actual CAD. And I'm designing, you know, imagine a complete denture. But it's it's monolithic. It's printed. It's just crown and bridge resin. So I go into my surgery with with complete dentures, with monolithic complete Ventures, I actually print, let's say we're doing a maxillary arch. 00:24:01:21 - 00:24:26:06 Daniel So I'm printing a two, two dentures and a third one that has windows. I call it the window guide. I don't call it a surgical guide because I don't want to confuse with fully guided with sleeves. It's not guiding the drill as much as it's guiding me and knowing where the ultimate teeth are, the designed or the plan teeth. 00:24:26:13 - 00:24:52:20 Daniel And it's helping with implant timing, multi-unit apartment selection. So that's what we use that for in the surgery. This is where I told you I'm old school as well. I love a denture conversion. I I've printed intraoperative temps screw direct to the multi-unit abutments. That's that's the rage right now. I think it's a wonderful technique. It's so cool that we can do it. 00:24:52:21 - 00:25:27:21 Daniel And I do it sometimes. But I'll tell you that what works so nicely, repeatedly and quickly within my hands is the denture itself. You put over the multi-unit abutments and you pick up. There's many different ways. Now, the the original smart denture conversion is a classic and it's awesome. And there's a lot of ways to do it, but I love picking that up because it doesn't rely heavily on risk aligning meshes, modifying the design and sending it to the printer, waiting on that. 00:25:27:21 - 00:26:02:13 Daniel And we have glitches. So that's my workflow. Send the patient home with the screw. Retain every time they heal, and then the direct to the multi-unit abutment printed temp is not a step that I skip, but it's something that I bring in later. They've healed. I scan the soft tissue I design, and I print a prototype. This is perfect for trying to make sure that the contours, the tooth shape, the form, everything is right. 00:26:02:15 - 00:26:12:15 Daniel This is based on a photogrammetry scan or a soft tissue scan. And then we gather the confidence to move forward into milling. Azer Konya. Arch. 00:26:12:18 - 00:26:23:12 Robert Sounds like you have a much more hybridized workflow than than we typically hear you. Sounds like you're incorporating a lot of analog techniques there. 00:26:23:14 - 00:26:54:00 Daniel Yeah, I mean, it it classically was making a a verified master cast with analogs. That analog approach has been left behind. So acquisition later is is with photogrammetry. All the design is with digital technology. All the production is with with Cam and digital. But the day of surgery I like to just pick up. It's quick. I have nothing against the full arch printing. 00:26:54:00 - 00:27:14:28 Daniel I think that it's a wonderful way for collaboration between the clinicians and the technicians, and I do it sometimes, but oddly for me, because I have my hands in it, I can do an analog pickup faster than I can do a conversion and a printing. 00:27:15:01 - 00:27:20:10 Robert So because you get everything on hand in-house and you're familiar with all the technology that's there. 00:27:20:14 - 00:27:47:04 Daniel Yeah. You know, and I'll say this, Robert, I'm not advocating one technique over the other, but what I will advocate strongly to anyone who does the the digital workflows and printing intraoperative printing. So you're doing your photogrammetry capture stitching, doing your soft tissue capture is be proficient in a conversion because you're only as good as your plan B. 00:27:47:07 - 00:28:18:09 Daniel And what if your your printer is on the Fritz unexpected. What if there's there's a glitch, an unexpected, you know, unexpected glitch. You're you're relying on humans, right. And and technology and you know, your your relationship with your technician and your technology is strong. But you humans are humans. And maybe your your technician got sick that day. Do you want to cancel a surgery or do you want to say I have a back pocket plan? 00:28:18:09 - 00:28:49:08 Daniel I can just do a denture conversion. And and so the plan B points, I didn't explain why I print two dentures, but that resilience in printing is if I'm doing the pickup and we have the patient bite down into place, almost always we align it in the right position. But one time patient was sedated and didn't have them bite down into the right position. 00:28:49:13 - 00:29:18:01 Daniel The amount of time it takes to grind out the the cylinders, as opposed to a few more bucks printed back up. You're only as good as your plan B and and I'll I'll tell you that I had a patient right before the podcast who fell into this workflow. And it wasn't anterior chaotic canine. It was, second molar to first premolar with two implants in between. 00:29:18:01 - 00:29:38:25 Daniel But the temporary has two Pontiacs. And she cracked her provisional restoration. And instead of, like the olden days, having to repair I actually when I printed, I had print it too, because I knew it was possible that maybe she can break it. So instead of her calling them, saying she broke her temp, saying, okay, let me go to the printer. 00:29:38:25 - 00:29:55:01 Daniel Every one of my case pans has a backup print within it because I just want it ready to go. So resilience is such a strong thing for us to just be able to to pivot, move forward and deliver excellent care consistently. 00:29:55:03 - 00:29:57:00 Robert Just have that on hand, ready to go. 00:29:57:01 - 00:30:18:07 Daniel There we go. And having a digital final printer on hand is is an equivalent ready to go. I might be, you know, an extreme in how how much I've produced ready to go. But for for the docs who are listening, you know your breakers, you know who's going to who's going to bust things. Just print. Print 2 or 3. 00:30:18:07 - 00:30:37:02 Daniel Or when you're ordering from the lab, you know, have them have them print an extra. Ask them not not to glaze it or something. You know that that maybe it doesn't have to cost as much if you're not taking it to completion, but you're having a raw product that'll allow you to, you know, to to pivot. 00:30:37:04 - 00:31:06:16 Robert And it's better to have a spare tire than be stuck on the side of the road, even if it's not the right tire, you know, even if it's not the full size, that's a good one. And one of the things I really like is lately I see more and more. I see you sharing a lot of these cases online through your social media, and some of them have been pretty, pretty out there, pretty unusual types of cases that I don't normally see as much like, there's one where you have these special attachment types with the where the where the pallet was missing. 00:31:06:20 - 00:31:14:28 Robert I think he was the cancer patient. Can you talk a little bit, a little bit about that case or any other cases. I think they come to mind. 00:31:15:01 - 00:31:46:00 Daniel Yeah. The, the, the unique cases where you get to bring technology and, and feel like you're, you're trailblazing or on the Vanguard because you're, you're treating something that doesn't come along often with this new tech is exciting and fun. And this case that Robert is talking about is is a cancer patient who had a tongue cancer, and he had to have a reception of his tongue, and he lost about 90% of his tongue. 00:31:46:00 - 00:32:13:10 Daniel And they did a graft. So he had he has soft tissue there, but his residual tongue is minimal. He's barely capable of movement. And if you don't have a tongue, the the implications of that are tremendous things that we don't think about. It's a critical organ for speech. It's a critical organ for eating. When we chew food, we take for granted. 00:32:13:10 - 00:32:34:01 Daniel How does the how does the food end up between our teeth? Right. And it's the musculature of our cheeks, and it's our tongue that is constantly repositioning the food between the teeth so that we're able to go through the chewing cycles. If you don't have a tongue, the food just falls into the center and it can end up back on the teeth. 00:32:34:01 - 00:32:59:18 Daniel And the same problem is the palatal vault, the roof of the mouth. Without the tongue, the food will get lost up there, because the tongue sweeps the palate and brings the food back to the teeth and brings it to the back of the mouth to swallow. So that's a that's a long introduction about the tongue, you know, to, to get to the point of my patient who lacked a tongue. 00:32:59:18 - 00:33:24:20 Daniel So he needed what's called a palatal augmentation prosthesis. And a palatal augmentation is something that drops the palate. Classically it was a complete denture because many of these patients were a complete denture that was flat almost across from tooth to tooth, or if they were dentate, if they had their teeth. It's like a partial denture, a cast metal framework, but if they have all their teeth, they still get that framework. 00:33:24:20 - 00:33:46:18 Daniel But the palatal major connector is just flat across or filled acrylic. What was really cool about this case was that it was a marriage of of two concepts that I had never thought of. I, you know, I give credit to a dear colleague of mine, Doctor Anthony Lucio, also here in new Jersey, and that's Barry Park, who's a brilliant prosthodontics. 00:33:46:18 - 00:34:09:21 Daniel And he showed a case, an operator case where he made a fixed arch, a full arch, screwed to implants and then a removable obturator. And when I saw that, it was like an moment for me, my patients, who was on the maxilla and he wanted fixed teeth, and I said, no, we have to make a denture and it has to snap in. 00:34:09:24 - 00:34:31:15 Daniel Once I saw Anthony's case, I was like, yeah, I'm going to make fixed teeth. So I made a fixed arch, and then we made just the removable palate for him and for him. He absolutely loves it. It's life changing because he's able to eat more, more comfortably in public. He was eating with a plastic spoon to just always sweep the food from from his palate. 00:34:31:17 - 00:34:32:25 Robert Oh poor man. 00:34:32:26 - 00:34:42:10 Daniel Now the food is directed toward his residual tongue, and he's able to swallow and eat more comfortably. 00:34:42:13 - 00:34:45:28 Robert And you use like some kind of special attachments with those, I think. Right. 00:34:46:01 - 00:35:10:28 Daniel This is an area that I've just started to explore and I'm excited about for, you know, to to share here on this show. It's the concept of semi precision attachments for removable dentures. There are a lot of classic connections that were used, different types of dovetail in cast metal and different types of era attachments. So extra coronal and intra coronal attachments. 00:35:10:28 - 00:35:37:26 Daniel But they just they don't really work with milled zirconia. Right. An ERA is like two skinny that it can easily crack off. And the dovetailing it doesn't work. You can't mill a tiny dovetail. So what I use is what's called a sage attachment. It's like a ball. It's a 2.2mm diameter ball. And it has a, you know, a nylon matrix. 00:35:37:26 - 00:35:58:01 Daniel So there's the patriarchs and the matrix and the attachment system. The patriarchs is the ball here. And the matrix is the is the attachment that fits over it. What I really liked about it, I was searching to find the right attachment that I could mill into a monolithic or Konya restoration, and the reason I selected this one was a number of reasons. 00:35:58:03 - 00:36:04:02 Daniel They had a library file available for XO cat. Okay. 00:36:04:04 - 00:36:05:09 Robert Important factor. 00:36:05:14 - 00:36:27:13 Daniel Yeah. Factor. Right. It has to have a library I don't want to scan it and use, you know, made up. I want to use really precise geometry if it's going to work with the system. Second thing is it can't be something to obscure. I think a lot of my clinician colleagues in the audience will know exactly what I mean. 00:36:27:13 - 00:36:56:06 Daniel When an oddball attachment or implant comes through, you really get a little frustrated because you can't order components easily. It's hard to identify what it is. Things have to be certainly like somewhat mainstream, so that it's a service to our patients. If they relocate, that they're able to get the, you know, their prosthesis service. So the sage is pretty mainstream. 00:36:56:07 - 00:37:23:10 Daniel You can order the components through one of the big part, supply houses. So that was an important thing. And then what I realized is that it has enough beefy ness to it or heft in the in the connection from the from the part to the ball. It has a pretty good diameter without much length. It was. If it was a very long attachment, the torque could lead to breaking. 00:37:23:10 - 00:37:49:03 Daniel But I believe it's strong enough to Milan zirconia and it's a resilient attachment. So what resilience here means is that the prosthesis can, you know, can can move on the attachment. So it's not taking the full load of the prosthesis. But you have resilience and you can build rest seats that that take the support load. And where it's not supported it's a resilient attachment. 00:37:49:03 - 00:38:10:27 Daniel So it's an attachment that I'm experimenting with bringing into more of my partial denture designs. And in this case, if you look at it, it supports a pallet. And that was the most common question that that people asked me. Aren't you worried that the attachments will break off and answers, no, not at all, because it's not under a load. 00:38:10:27 - 00:38:40:03 Daniel It's only acting as a retention device. But he's chewing on the teeth, he's chewing on zirconia, and the attachments are acting to retain a removable appliance. And as long as you you modify you, you know, you you mitigate or work around any design that you're doing that the load is not 100% on the attachment. It's shared by receipts and shared by a hard palate. 00:38:40:03 - 00:38:49:28 Daniel I believe that this specific attachment and I have no conflict of of of interest. I don't have a with the company or or those. 00:38:50:02 - 00:38:51:25 Robert Million dollar endorsement. 00:38:51:27 - 00:39:17:22 Daniel Oh it's just I think for me it's emerging as I fell in love with semi precision attachments and classic removable prosthodontics is something we left behind and started doing a lot more like individual stud attachments for for over dentures. But now I'm bringing back semi precision attachments with this and I always stand behind my work. I think that we have to always do that. 00:39:17:24 - 00:39:27:04 Daniel We have the ability. So. So anything that I'm experimenting with, you know, I, I stand behind it. If it doesn't go as planned plan B. 00:39:27:12 - 00:39:43:00 Robert Plan B, so if there's a doctor listening to this who's just thinking, man, maybe I do need to get in on digital digital industry, maybe I should bring some of these processes in house. What would you say to them? Where would you say they should start? 00:39:43:02 - 00:40:11:13 Daniel We've chatted about this, Robert, and it's it's something that I know you and I share excitement about you as a guy who who is able to to train incredibly, I've been trained by you, and I know how many people you train on the on the scanning, acquisition design, milling fronts. It's not just the technology that you buy, but it is the reseller of that technology. 00:40:11:15 - 00:40:37:12 Daniel And don't just shop for price. It's like dentistry. I'm going to give the the analogy of a full arch restoration. We have patients who call the office. How much is it all on for. And they're not it's it's not a product that you're comparing. You're you're really looking at an experience and a service rather than a product. You know who's who's delivering this product. 00:40:37:12 - 00:41:04:01 Daniel How are they supporting this product? Will they stick the landing the right way? And when you're buying an internal scanner or XO, CAD or a mill, it's who is who's behind that when you need help, when you need to learn. How do I do this? How do I do that? The computer is not working, right. It's it's the right support. 00:41:04:03 - 00:41:35:19 Robert I wholeheartedly agree, I mean, obviously I'm a little biased, but I wholeheartedly agree. It's really your it's more than the technology itself. You're forming a relationship with the people you you acquire the technology from and they're beholden to you. They have a responsibility just like you to your patients. Like we have a responsibility to make sure that when you take that printer, when you have that software and you've taken the risk, your hard earned dollars and invested into this, that you're it's not just a piece of technology. 00:41:35:19 - 00:41:58:08 Robert It's your time. It's the process of how it's incorporated into your lab or your practice and how and how to make it fit you. And it does lead me to the next obvious question, at least in my opinion, which is, what are you excited about? Like what's what's coming down the pipeline that you've seen that just really gets you excited for the next wave of dental technology? 00:41:58:10 - 00:42:45:19 Daniel What I'm most excited about and I don't think I'm I'm unique in this answer. Other guests on your show have said this, but is AI. AI is is another tool, right? We spoke about, you know, our tools and our toolbox and how how are we going to leverage AI? That's a very general answer. More more specifically, what I would love to see happen with adaptive AI learning is to take the fundamental concepts of full arch design to really train AI in in occlusion so that we can get much faster outputs and higher quality outputs of of designs. 00:42:45:20 - 00:43:07:02 Robert It's funny for for the first, I'd say ten or more years of my of my instruction in teaching, I was training mostly dental technicians these days. I trained maybe one technician a week, and I find them training 5 or 7 doctors and three assistants and doctors. I don't need to teach you occlusion. You went to dental school for that assistance. 00:43:07:02 - 00:43:34:00 Robert On the other hand, that's a very difficult concept to convey to somebody who's maybe sitting chair side every day, but not really thinking about the functions of teeth. And one of the things that, as you said, garbage in, garbage out. One of the most frustrating things to overcome as a designer, as a CAD technician is bite scans. Frequently we just get bad bites, and if you have a bad bite, then your design is not going to be any good. 00:43:34:06 - 00:44:00:22 Robert One of the episodes that we did really early on with was with Bjorn with Bite Finder, and they're constantly innovating this, this. If they have an AI program where you can it links directly in with CAD and you can upload your designs and you can have two arches that are completely out of occlusion, completely different sources. And somehow or another, they have the magic sauce to bring them together into perfect occlusion already every time. 00:44:00:22 - 00:44:22:03 Robert And I'm excited to see that technology go from just getting better bites from the scans, and where that starts to tie into the occlusal interactions and design as well. I think you're I think you're on the money there with that man. This has been a really, really good episode. I've really enjoyed our conversation. I always enjoy talking to you, but it's been really fun to share this with. 00:44:22:03 - 00:44:31:14 Robert Weather audience. Man, where can people find you online if they want to follow you or learn more about, like your mentorship programs, or even go to your clinic. 00:44:31:16 - 00:44:54:03 Daniel So you can find me on Instagram at everything Prosecco. And then also my practice Instagram is at Smile Again. And Jay. The more we share within our industry, the more we grow, the better we get. So you can find me there. Come visit. Give me a call. That's. You know I love connecting. 00:44:54:06 - 00:44:57:28 Robert Doctor Daniel Raymond, thank you so much for being here. This is a blast. 00:44:58:01 - 00:44:59:26 Daniel It really was. Thank you Robert. 00:44:59:28 - 00:45:18:15 Robert And thank you, everyone else, for tuning in to this episode of the Evolution of Dental podcast. Look for us on all the social media platforms as Evolution of Dental Podcast. Look for us on all the streaming platforms for your podcasts. We're there. We post new episodes every Friday. Please remember to like, subscribe, share the show with your friends. 00:45:18:15 - 00:45:28:13 Robert Drop us a comment at this episode sparks. Any ideas for you? We'd love to respond to you and bring more people on that you'd love to see. And remember, never stop evolving.