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Fixed x Dr. Pallotto: Streamlined Success: Modern Approaches to Digital Dentistry: Part 1

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A full-arch case can look “digital” on paper and still fall apart on the day that matters. We bring on prosthodontist Dr. Tony Pollotto to get brutally specific about what makes All-on-X predictable and what quietly creates chaos, especially when you’re trying to deliver same-day teeth and keep the bite right. From his early years in a high-volume ClearChoice model to launching his own implant and prosthodontic center, Tony shares the operational decisions that separate a smooth surgery day from an exhausting one.

We dig into analog versus digital dentistry workflows, why scan-based systems can be great for provisionals yet risky when you push them into finals, and what it really takes to become fluent in Exocad. Tony makes the case that “design” is the hardest problem in full-arch implant dentistry because it sits at the intersection of tissue, phonetics, hygiene, esthetics, implant position, and biomechanics. We also talk AI in dental CAD design, where it’s genuinely useful today, and why knowing what an ideal prosthesis should look like matters more than knowing every click path to build it.

You’ll also hear a thoughtful shift toward conservative treatment planning: when a patient wants a double-arch, but the smarter long-term play is a combination case that saves restorable teeth. We wrap with Tony’s current same-day workflow preferences, why he has doubled down on CBCT-based alignment for efficiency, and how he thinks about PMMA, early zirconia, and timing finals around tissue stability.

If you’re building a full-arch implant workflow, refining your digital process, or debating in-house design versus outsourcing, this one will sharpen your playbook. Subscribe to The FIXED Podcast, share this with a colleague, and leave a review with the biggest workflow change you’re making this year.

Welcome And Guest Introduction

Speaker 2

My name is Dr. Tyler Tolbert. And I'm Dr. Soren Poppe. And you're listening to The FIXED Podcast. Your source for all things implant dentistry.

Tyler

Hello, and welcome back to the FIXED podcast. We have on a very special guest today, Dr. Tony Polotto. He is here. He is a prosthodontist, and you may, um, recognize his face if you're into the, uh, Instagram world of Full Arch. He's got some excellent case documentation on there. He's also done some educational, uh, courses with our good friend Dr. Sven Bohn, who's been on the show a couple times. Um, and he has been on some other podcasts as well, so it's very likely that you've seen him before. But if you haven't, you're in for a treat. He's got a lot of really good information, um, and, and very multidisciplinary information for us that I think is gonna bring some new perspectives to the show. So Tony, thank you so much for sparing your time

Tony

man. Thank you, Tyler. Thank you, Soren. It's, uh, it's good to be here. I appreciate what you guys do. I've definitely listened to your podcast

Tyler

Yeah

Tony

and some good guests, so it's a pleasure and

Tyler

Oh, awesome. Yeah. I appreciate it. You don't have to just say that, you know?

Tony

I mean, that's how you start, right? No, I mean, I mean

Tyler

Yeah, fair play. Fair play

Tony

about a dozen or so of them, and, uh, they've all been good.

Tyler

Oh.

Tony

yeah, man

Tyler

Oh, that's fantastic, man. I really appreciate that. Um, so yeah, so for the uninitiated, could you kinda just give us a general background on your education, um, how you got up to this point, you know, uh, you know, how would you define yourself a- as a professional?

Tony

Yeah. Um, if, if I'm long-winded here or anything, just jump in at any time.

Tyler

Go ahead

Tony

uh, yeah, I mean, I started my college education studying engineering and, um, studied engineering for about three years, and then I decided I wanted to spend more of my time treating people and patients and, uh, engineering was getting a little tough at that time, so I switched

From Engineering To Dentistry

Tony

majors and, that was Marquette back in the day, good time in Milwaukee. I took a little time off before I went to dental school, and, um, that was kinda like a bit of, of the cadence through each major change in my career is like take a little time off, reassess things, understand what's important. but ultimately, I migrated towards dentistry. My dad was a dentist, and my grandpa was actually a dentist, so I, I had that kind of in my mind, but I, I wanted to do my own thing for a while, and I think that's what led me towards engineering. But, um, ultimately back on the dentistry track, and I went to NYU, uh, NYU was a great experience. Loved living in New York and had a lot of great friends and great times there and, uh, met, met my mentors that kinda shaped, a lot of my mindset even today. So I, I attribute a lot of that back to the NYU days. Um, people will say like, "Why prosth?" You know, I think it was... It's, it's not, it's not so profound, I guess. I guess just when you get in the clinic and you start migrating towards different structures, it's like endo, eh, not, not really feeling that stuff. Uh, oral surgery, yeah, that was cool, but I think the prosth bug bit me first, and, um, I just was really amazed by a, a lot of, a lot of the faculty in the prosth clinic and just kinda buddied up with them, let's say. And knew that I wanted to go that direction, um, but I mentioned that my dad was a dentist, and almost, I almost felt like some, some bit of an obligation, and maybe not an obligation, but, um, a calling to practice with him for a while before I went into prosth residency. I always looked up to my dad, and he was a great dentist, and I just wanted to have that experience with him before jumping back into education. So again, I took a year off and

Tyler

Yeah.

Tony

for a year as a general dentist learned a lot, like a totally mad respect for all the different disciplines that general dentists have to versed in, you know, on a daily basis. So that,

Tyler

Yeah

Tony

helpful for me to, to see that and to how to talk to patients and learn how to be in a big practice and just learn kinda the soft skills around dentistry outside of what you learn in dental school.

Tyler

Right.

Tony

that-

Tyler

It, it's interesting because I, I think, um, I, I, I love that you took some time right after school to just do dentistry and kind of figure that out and explore that. I really like that kind of concept of having these sort of interstitial moments between stages in your career where you can sort of reassess things. And I'm curious if, you know, during that year working with your dad, any point did you question whether or not you wanted to go back to do, uh, prosthodontics, or did it just further inspire you to be like, "Oh man, I have so much more to learn. I gotta go hit the books and come back a little later"?

Tony

it's just like dentistry is so humbling, and it's, it still is, but it's just like, man, this

Tyler

It is.

Tony

like

Tyler

All the time

Tony

hard. Like, I, I need to learn more. you know... And, and I would dabble in with some like, you know, fixed pros cases my first year out and, and I look back at the documentation on those cases, and of course you, you, you laugh at what you see from back then, but that was part of it, right? And that was part of just, just finding your footing. And, um, so yeah, to answer

Tyler

Yeah

Tony

it, it reassured me that, uh, I had a lot of questions still unanswered. And, um,

Tyler

Mm-hmm.

Tony

I applied to a couple different programs and I, I was looking for a program that had, um, a, a good set of, um... say this? Just b- basically like f- uh, foundations in fixed pros and implant pros. I was, I

Soren (2)Soren

Mm-hmm.

Tony

interested in that. I, I probably had a little bit of subconscious fear that being a prosthodontist might turn into doing partials and dentures as a career, and I was kinda like, "Eh."

Tyler

think that's a reasonable fear. Yeah. Yeah

Tony

A- and as much as I, I do like dentures, and I, I can't speak so highly of partials, but I do like dentures, um, I, I was like, "Oh man, I... If I do this, I gotta be doing like fixed pros," and, and that's what I was most interested in. So, um, University of Illinois Chicago had a great program and, and still does, um, they were really at that time... Let's see. graduated pros in 2015, so I was going in in 2012. Um, they were really known as one of the early like heavy implant programs for a pros program. there's a few others out there, but, uh, Ken Knorrenschild and Steve Campbell, um, they were, they were really pushing pros

Why Prosthodontics And Implant Focus

Tony

towards like the surgical side of implants at the time um, kinda like integrating it into curriculums. So I was just like super fortunate timing-wise. That, that was luck, right? Like I, I'm from Chicago area too, so worked out really well. And just, man, spent, spent good time there, made more friends, more mentors and, um, yeah. I mean, we could have a whole podcast on what you learn in residency. I'm sure you guys have heard that from other people too. But a, a lot

Tyler

Oh, yeah

Tony

lot of pearls. And, um, I'll, I'll bring my dad back into the story again here because- When I decided to go into prosth, it was kinda like, "Okay, I'm gonna go into general practice for a year, and then now, okay, I'm gonna go into prosth residency," and I, I left, and that general practice was with him. And then when I came out of prosth, um, I was thinking initially, "You know what? I'm gonna go back into my dad's practice, kinda carve out a subset of fixed prosth, and, you know, there's a need," this and that. And like maybe a month away from my graduation, a good friend of mine who was, uh, a year older, who was a resident at UIC Chicago, um, University of Illinois Chicago, he was working at Clear Choice, and he was like, "Man, like

Tyler

Mm-hmm.

Tony

know you're into this stuff. Like you should come check it out, that Chicago is probably gonna need a prosth soon, and they need a second prosth. They're slammed," blah, blah, blah. um, I was like, "No, man." Uh, it was Phil Ruckman. I was like, "Phil, I'm going to work with my dad. good." uh, he was like, "Just check it out." And I was like, "Okay." So I talked to my dad and he s- he, my dad was like, "Well, you know, if you don't check it out, you're, you're always gonna wonder, so go for it, you know?" And I did, and I was

Tyler

Good advice

Tony

I was like, "Damn, this is like, this is amazing." You know, I went in and, this was, like I said, probably 2015-ish, and yeah. It was maybe the day I went in, four arches. At that time it was all on four. It wasn't all on X, but all on four, arches, lab, everything in sync, prosth surgery lab, all that, um, the whole business side of it, and I, I was kinda hooked. And, went back and had a talk with my dad, and basically ended up doing Clear Choice and private practice for about six years. um,

Tyler

Oh, wow. Okay

Tony

cool. Just like, uh, I ended up going into that Chicago role at Clear Choice and, and running the center and taking the lead prosth role, and eventually kinda grew with another prosth brought in, um, just amazing oral surgeons and worked alongside them. But also just kinda like keeping, keeping that private practice side alive and, um, yeah, did, did the implants in my family practice and my dad's practice. And, um, my... I didn't, I didn't mention this, but my wife is a dentist too, and she was, she was running that practice as well with my dad. yeah, just lot,

Tyler

Very cool

Tony

of dentistry. You know how it is.

Tyler

Yeah. So

Soren (2)Soren

Yeah

Tyler

um, you know, I'm thinking about that, that era, so coming out around 2015. You know, Clear Choice, uh, is rapidly growing around this time and, uh, this is still very much an analog world, I assume, right? So these are-- We're making dentures, we're converting them in the mouth, we're doing pickups with temp cylinders and all those wonderful things. Um, what was kind of the role, uh, of a prosthodontist at that time? And h- in what ways did, you know, your, your, uh, education over at the University of Illinois Chicago kind of feed directly into that fixed pros work over at Clear Choice?

Soren (2)Soren

I'm gonna-- Before you, before you, uh, talk about that, Tony, I'm gonna jump in real quick with the, with the second question. Um, d- what, uh, w- as you talk about

ClearChoice Life In The Analog Era

Soren (2)Soren

that, I'd love to know the transition during Clear Choice of kind of like was there a change... You were there for six years, so was there a change from analog into digital in Clear Choice? Or, um, were you kind of doing analog the whole way? Um, I would just love to know. You know, Clear Choice is kind of like our, our founding situation in a lot of places. Like they, they were the one that kind of revolutionized that, so I'm curious

Tony

sure. Yeah, um, the, the first part of that as far as my role, you know, largely w- the role as a restorative dentist still today in, in All-On-X procedures and, and a lot of full mouth cases, right? It's, it's meeting the patient and, um, especially in that environment, it was consults, uh, lots of consults and lots of treatment planning, right? Like, who's a candidate? who's gonna be a good candidate for this type of procedure that we offer? And if they're not, where's the best place for them? Uh, we partnered with a lot of local dentists for patients that weren't candidates. assuming that they were, uh, an All-On-X candidate, really treatment planning the case, collaborating with the oral surgeons, um, being there on surgery day. At, at that time, as you said, like analog, there's just so much more to do hands-on within the surgery.

Soren (2)Soren

Mm-hmm.

Tony

it was, it was everything from making sure the lab had everything dialed in for you that day, and then setting the teeth once the, um... or setting the arch once the teeth and reduction was done, and making measurements and, um, pickups and, and all of that surgery. And then, yeah, just deliveries at the end of the day. Usually, we would do about four arches a day, so deliveries would be happening, you know, between and 1:00, the first double, and maybe 3:00 to 4:00 the second, and get- making sure bites were dialed in, and then all the phase two work, as those patients came along. And then largely, you know, complications happened too, so just troubleshooting. And it, it was, it was like the same type of stuff as we do now in digital, but, um- You know, it's just a little bit more work because it was analog. Like now when there's trouble with occlusion

Tyler

That's, I think that's understating it.

Tony

You know, every- everything just

Tyler

Yeah

Tony

longer and was a little bit more sweat, you know? Um,

Tyler

Yeah,

Tony

the question about like

Tyler

for sure

Tony

changes, so my whole time there, we were analog for all of the surgery side, um, but started

Soren (2)Soren

Mm-hmm.

Tony

more digital for like the phase two, right? So like milled try-ins, printed try-ins, but never got to the digital surgery. Um, then kinda this'll segue into sort of my next chapter, but around COVID time, then it was like things were changing in the company and I was just kind of... It was more me. I was just kinda looking for something else, and like I said, I was in private practice most of that time too. And I just had this like vision of creating an environment. I, and I always liked digital workflows too. I didn't mention that, but, um, all along this time I was like, you know, this is... Stackable guides were kinda cool then, and I was designing my own guides and printing and just like tinkering a whole lot. So I had this vision of like, I could, I could do so much of this, and I enjoyed doing the surgery as well. Um, I could do so much of this in like a smaller footprint. I don't need this massive 747 of space and people and everything. So, uh, I, I around COVID, I made

Leaving Corporate To Build A Startup

Tony

the transition and I thought about, you know, purchasing a practice for a little bit of time, and then very quickly decided, uh, I, I kinda wanna just make something, that's where the idea came to, to do a startup. And, uh, yeah

Tyler

So that was around 2020, 2021, or when was the

Tony

20. Took another year off, so... And it, it took to build the, the practice, it took like, uh, shoot, it took almost, almost two years probably. But, you know, I was doing,

Tyler

Yeah

Tony

moonlighting here and there. Um, had a couple other gigs and yeah, it was probably around that 2020, yeah

Tyler

Yeah.

Soren (2)Soren

What was the,

Tyler

us about, I was just

Soren (2)Soren

Okay

Tyler

tell us about the startup itself, kinda how did that take form? What was the mission behind it, and, you know, what, what were you, you know, really looking to focus on? Did you do digital right off the bat? You know, this was kind of still somewhat early in the full arch digital world a little bit, you know, kind of a transition phase.

Tony

So I did. Um, I went, went right to digital. I probably did like a few analog pickups here and there. What were we doing back then? It was, um, like smart denture conversion mostly. Um, did a, did a little bit, but quickly, I would say first cases even into digital, but I wasn't doing photogrammetry yet. It was like scan-based systems, which, which worked well. So

Tyler

Mm-hmm.

Tony

thing was how do I become more efficient for the surgery? Like, like you guys and, you know, that's really what we were solving for at the time. so yeah, scan-based systems, kinda used them all. Um, you know, the, the s- things that we develop on our own and some of the systems that were out at the time. But they worked well for printing and then, um, you know, then you kinda learn the hard way of how can you translate these systems that are working surgery day like, "Oh, this is great. We could scan and we could print. Could we just mill instead of print? Will it work?" you know, you learn the hard way that some of those things don't transition into finals that work in provisionals. um, yeah,

Tyler

Mm-hmm.

Tony

wa- that was a huge learning curve. I think back to starting the practice, the vision was to really have like a, a very one-on-one focused environment where I could do custom work for my patients and kinda control the whole process. Um, you know, control everything in-house, the milling, the printing, the designing. So I got ExoCad around that time, was doing all the design and, um, just l- learn a, learn a lot of hard, hard lessons. Yeah.

Soren (2)Soren

Another beast. Yeah.

Tony

man

Soren (2)Soren

Do you still, uh, do you still-- Well, I guess before I forget, I just kinda, I was curious before what I was gonna ask earlier was, um, when you were at Clear Choice, what was it, was there a couple pros, a couple surgeons, and a couple lab techs? Or h- what did the team kinda look like? 'Cause you, like you said, it was a huge, huge situation and, and at that time, you know, they were definitely probably doing more volume than they are now. I was just curious what, what kinda that looked like.

Tony

So on the pross side, it, it was always a two pross center. Um, there was times, like in the beginning when I was doing the whole thing myself, and it, it was just kinda crazy. So it w- most of the time it was two pross. Um, and both of us... Like, the way I liked to run it was we kinda had mirror, mirroring roles so we could flip-flop each other. Um, Ghaith Darwish, a good friend of mine, spent most of the time with me as the pross, there at the time. But as far as surgeons go, yeah, I mean, we, we had some really heavy hitters in the Chicago area. There was about four or five surgeons, and we never had a full-time only one surgeon covering all days. It was like, you know, Dr. Hagen was there on Tuesdays, Dr. Chin on Wednesdays, uh, Dr. Zawada on Mondays. So they each had their day, and was really cool from, from my perspective to be able to learn because they all had little different styles, right? And,

Soren (2)Soren

Yeah, absolutely

Tony

so that, that was badass. And, just like you, you learn so much about the medical side. They were running all their own sedations. Uh, we would bring in anesthesia every once in a while, but mostly running all their sedations, so that was cool. lab techs, yeah, I mean, functioned best with three, but it fluctuated, you know. Uh, we would outsource some

Soren (2)Soren

Wow

Tony

some stuff in-house. But yeah, it was quite a machine for sure.

Soren (2)Soren

It's definitely an operation.

Tony

was some serious

Soren (2)Soren

What, uh... So you said that you got exocad. Now what, um... Are you, like, still doing all your own designs? Uh, you know, how does that, how does that function in your practice today? Um, it's something that we've, like, tried to and considered tackling in our, um, you know, offices. Uh, it get, I think it gets a little bit harder when you have, you know, multiple offices 'cause then it's, you know, if you hire one person on full-time, we don't expect our doctors to all learn it. But I'm curious what, what you do in your current office now.

Tony

So I, I do all my designs and, um, I, I'll touch on that

Designing In Exocad In-House

Tony

with this other portion of the practice. So when I started, uh, MADE, which is the, the implant and prosth center that was the startup, it was me by myself for about two years. And, um, I was

Soren (2)Soren

Mm-hmm.

Tony

for the, the right person to come along to join the team as far as the right prosth. and Don Kim, who's with us now, he came along and kinda just fit that role. And, and for me it was, I always liked doing the design part, and you might think like, "What does that have to do with like who joins you as a team member?" But, um, I just, I felt like it was so important that it would be really hard for me to have another team member, another prosth with me if we weren't like at least sort of in sync on that part of things. uh, Don is like super into design. He's probably at the office designing right now or from home or something. But, um, he came in about a year and a half ago, maybe a year ago, and, um, yeah, like I've gone through bouts of overwhelmed with the workload of doing the design and the lab work and the surgery and the prosth, and been like, "Oh, I've, I gotta outsource this stuff." But have kept coming back to just continuing to do it because it's one of those things like the more you do it, the better you get at it, right? And the better you get at it, the harder it is to outsource it because then it's just never the way that you want it to be. And then it's almost like the better you get at it

Soren (2)Soren

Yeah

Tony

you have to do it more efficiently, and we all know there's more tools coming on the AI side, more workflow efficiencies. it's actually become so efficient to do my own design. Uh, I, I had a double today and I do the procedure, take the records, do the design, print the case, and of course my team helps with some of the manufacturing. Like we have steps that are delegated. I'm not saying you have to do everything. But, um, for me personally, controlling that design part has been really gratifying and, um, it's a love-hate relationship for sure. And

Tyler

So yeah, so you mentioned, you mentioned AI there, right? And, and that's something that is definitely going to be, you know, transforming our industry, um, significantly over the next, you know, year or two years and, and so on and so forth, and it already has really. Um, so I'm curious, I mean, when you're, when you're doing your designs currently, is there some AI integrated in that as well that's starting to automate some of those processes? Um, is that something that you're, you're looking to have more automated over time? Do you always wanna-- kinda wanna have your own touch on it? And furthermore, as that continues to develop, is it still worth it for people to go through the learning curve of learning exocad from start to finish when AI is catching up so quickly?

Tony

that, that's a

AI Design Reality And Limits

Tony

tough question. Um, what, what, what do other people tell you when you ask that question? I'm curious. I-- 'cause I gotta think about how answer it

Tyler

So

Soren (2)Soren

I think

Tyler

I,

Soren (2)Soren

I think it depends who you ask

Tyler

We haven't asked a bunch of, of guests that question. I think that I, I have been having that conversation, and it seems like the general sentiment of people who have not taken the dive into exocad are kind of like, "You know what? AI's catching up to this stuff so fast." Um, people aren't even caring to learn computer programming anymore because all the AI is, you know-- all, all code is just gonna be written by AI in the future. There's no, there's no purpose in learning these things. So, like, the, the general mentality is that's, it-- there's a decreasing return on investment if you were to go and try to learn everything about exocad when AI is probably gonna eclipse you by the time you get there

Tony

So, so I, I would say I don't disagree, um, but it's one of those and type of responses. Like, the thing with exocad that's tough is that, it, it's not a terribly difficult program to learn, but to get really proficient at it that it's like a language, you know, and it's like you don't even think about

Tyler

Mm-hmm.

Tony

that does take a long time. That takes a lot of reps.

Tyler

Yeah

Tony

it, it's not like, oh, like AI or exocad, oh, I guess I'll learn exocad if I use it for two years, that's great. It, it's like you may need two years to get really good at it. So that's,

Tyler

Right

Soren (2)Soren

Mm-hmm.

Tony

Um, you know, uh, I guess I could answer for myself. I'm, I'm still planning to continue to use it as a tool to treatment plan and design my cases. Um, I'm not using any real AI tools for design at this point. Um, you know, th- there's some generative design ideas and concepts in play right now that I think are probably pretty promising. But at the same time, what I've seen so far isn't, isn't really coming close to what you could do just with a manual design, you know, customizing it yourself. But that, that's probably gonna change, right? And, and to be honest, I, I hope it does. It'll make, make things a lot more efficient and a lot, uh, more powerful for sure. yeah, it's, it's a tough one. For people that aren't designing in exocad yet, I, I guess I'd answer it this way: If it's interesting to you and you think it's gonna be fulfilling and keep you motivated and keep you excited, absolutely. Like, it's a great tool.

Tyler

Yeah

Tony

if you're like, "Man, like, do I have to learn it? I really, it's really not like number one, two, and three on my list of things I wanna learn this year," then no, I, I don't think you h- I don't think you have to learn it. I, I think it's important probably to partner up with someone who's good at it and, can provide that resource for sure. do I think we're at a point where we could just rely on AI design? I, I, I personally don't think we're there yet. And, um,

Tyler

Mm-hmm.

Tony

but it's changing by the day,

Tyler

Yeah, I mean, I definitely see, you know, in the near future getting to where a lot of the, you know, like let, let's look at the tech world, right? Which is probably, you know, three to five years, maybe more ahead of the curve of where dentistry is at, right? So, you know, there's still human beings involved in these processes. It's just higher order stuff, right? Like all the, um, you know, all the menial tasks get automated very quickly, but then some of the higher order, more creative things still remain more human, right? So, you know, if the AI designs, uh, and, and I've seen, you know, some of these programs are coming out that'll, you know, you, you input your records and it's gonna spit out design in three minutes, right? I've seen them, not something I'd be comfortable putting in the mouth, but it's probably like 80% there, And so then if you just know enough to take it from 80 to 100 and give it the sort of nuances that make it more surgically and, and prosthetically copacetic, know, you probably save yourself a whole lot of that groundwork, right? And I, and I think it will probably, and, and this is someone that's very ignorant about exocad in, in total, so, you know, I'm, I'm humble here. But I think that, you know, for people like yourself, you'll probably see where those AI can get you to that 80% very quickly, and then all of that nuance and expertise you have takes it to that sort of craftsman level, um, you know, with, with your expertise. That, that's kind of what I see happening in the near future.

Tony

and, and that's for people not using exocad yet, it's that you pretty much nailed it, Tyler. It's they need to be able to understand what the ideal design looks like, right? And, and why, right?

Tyler

Totally.

Tony

with the tissue, how pros, surgery, all this, uh, comfort, phonetics, uh, all play together. So yeah, kn- knowing what the

Tyler

Yeah

Tony

is to look like is more important than maybe even knowing each little critical step of how to get there, because either,

Tyler

Right

Tony

who's designing now can do it or AI soon. We'll see.

Tyler

Yeah. And, and I think too, you know, for AI to be really be able to get the whole comprehensive picture, it needs to know how to process information than what I've seen so far, right? Like what I've seen so far is, you know, here's the patient's current, you know, teeth. It's gonna make sort of a generic wax up, and then it's gonna take, you know, some fiducial markers and a post-op scan, and it's gonna marry all that together and make something that looks like a hybrid design. It's going to need, you know-- it needs phonetic information. It needs, um, to be able to process 3D images to like really get that sort of human, you know, clinical input in there to really start getting nuanced to the point where you could take this from start to finish and get a final that someone's actually g-really gonna be happy with, I think. And I, I'm not seeing that yet, but it's all, it's all a matter of, of time and, you know, just data aggregation, I think.

Tony

Right

Soren (2)Soren

I do like what you're saying about, um, like how the, how the prosthetic interacts with the tissue, how the prosthetic interacts with the tissue to the bone level. And the, and the thing is, you know, if you don't have that information or you, if you don't provide that inform- if you out- are outsourcing your arches to a lab, um, you know, you don't really know in some ex- in s- especially some of these larger labs where they have a ton of designers. Um, I feel like there are a t- a lot of dentists that are relying on that designer to kind of make those decisions. They just say, "Here, you know, here's my upper/lower bite. Here's my, here's my photogrammetry." Um, you know, th- these changes are what I want from the patient's base teeth. Um, but, uh, you know, it is incredibly important to, you know, go over those details with the lab of how much tissue pressure do you want for this particular patient. You know, what, what things happened in surgery that you need to, um, really kind of like hone in and let them know. And ultimately, like some of these designers, y- you really don't know what their, their background is. So I do think that that's a huge plus for any clinician that knows exocad and any clinician that, um, you know, is at the point, like you were saying, where it's almost like a language where you can just make those changes kind of, of seamlessly. And that's definitely something that I'm envious of that you can do, because for me, sometimes it takes, you know, four or five times to my lab being like, "Hey guys, no, I-- this is what I want." And it can be really frustrating. Um, I, I've tried tackling exocad, but I just haven't had the t- the time to, to, to learn it myself. And it is, it's a, it's a beast. Like, th- I think they, every renovation they do of it, it gets better and easier, and they do use like little bits of AI here and there. And, um, I think the program as a whole is getting easier. Um, I really like a world where, uh, where... And I'm sure this is gonna come because I'm sure exocad knows that they're gonna be competing with some of these programs that are trying to do full autonomous AI designs. Um, but I really like a situation where, um, you know, they kinda marry the two together, right? Where you have a lot of the, maybe the basics that you can do with an AI-generated, um, wax-up or, or like segmentation or, you know, these different, these different situations in, in exocad. But then, um, it just makes it so much easier for any clinician to go in there and be like, "Okay, well this is actually what I want done. Maybe I can do it much easier." And I think that that's gonna come probably sooner than full autonomous AI software.

Tony

be great if we could use Whisper Flow or some voice dictation to just tell it and it make that adjustment. That's-- gonna happen.

Soren (2)Soren

Yeah.

Tony

amazing.

Soren (2)Soren

I'm sure. Yeah.

Tony

But yeah, the,

Tyler

Yeah, I

Soren (2)Soren

So,

Tyler

just be able to

Tony

design is a, it's probably one of the harder problems that we have to solve in full arch because, you know, the, the

Tyler

Yeah

Tony

we learn, we train, we advance as clinicians. The lab side, we learn things, we make mistakes, we advance, like there are machines that have, need maintenance on and this and that, like that's that. But the, the design side, this like tough situation where we wanna outsource it, we want it to be AI, we want a lot of these things, but it, it's just tough because there's so many designs needed, and I, I just don't know that there's like that many qualified designers that know

Soren (2)Soren

Yes

Tony

and dentistry. I'm su- you guys have probably had this discussion before, but it's like you need to marry a, a really good lab technician analog with a really good computer, uh, you know,

Soren (2)Soren

Mm-hmm.

Tony

Not the right word, but you know what I mean.

Tyler

Yeah

Tony

it's just we don't have that many of those people out there. There's some, not enough for what we need

Soren (2)Soren

Well, I'll say too that, um, you know, like you were saying, I feel like a lot of those parts, like for example, the surgery, once you get to a point where, you know, you're doing these surgeries at volume, I feel like every case is pretty-- I mean, obviously each case has its own challenges, right? But you're, you're still placing the implants kind of in the same area, kind of in the same way, and it becomes almost a situation where, um, it's, it's very repeatable. Every case is pretty repeatable. Now, obviously, you're gonna have cases where you have to do palatal approach or maybe you need advanced implants, zygomatic implants or, or whatever it may be. Um, but I do think that there also is probably a whole world of, of fixed dentistry that needs more, um, information, and that is like, uh, stuff like how, how long can your, your cantilever be, you know, between two implants, right? Before you place a zygomatic implant. And, and I see, you know, there are studies out there that say like, okay, well, well maybe a two-tooth cant- pontic is okay or, or a three-tooth pontic. But in reality, like, um, I think that that's like the engineering side of fixed is really interesting as well. Um, and I think that that's gonna, you know, those-- there will be advancements there to have more predictable success in cases. Um, and we're seeing it already. You know, like you were at Clear Choice in, in 2015, and they were doing all-on-4 on every single case. And I'm sure that they were probably playing around with cantilever lengths and like trying to, trying to deal with that. And now we're placing six implants to avoid that cantilever. Um, but the next thing will be like, okay, we can't have a span that long between your tilted and your pterygoid because we see failures, you know, at this rate. Um,

Tony

But, but

Soren (2)Soren

and I'm excited for that because...

Tony

you'll, you'll, you almost

Soren (2)Soren

Go ahead.

Tony

a system to assess each case individually real time, you know? Like in a design, and Sven has, Sven has been working on this with some of his software to assess the prosthetics. But, you know, every case is so different, width, height, ev- everything, the bite forces are different, position of implants, all of that. So it's like you almost need to feed that design into a software that can tell you acceptable or not. And then after a lot of cases, you start to generate some rules. You start to understand what... Right, right now we, we kinda know intuitively and, you know, it's a feel thing. It's not so much of an absolute

Soren (2)Soren

Yes.

Tony

you know?

Soren (2)Soren

Right, and I agree. Like, you can't stick a, an anterior implant against a t- I mean, people do, and, and we've seen it work, but like, you know, in general, like you said, maybe you shouldn't do that.

Tony

Try not to.

Soren (2)Soren

Um,

Tony

yeah

Soren (2)Soren

yeah. You know, so I was

Tyler

No, go ahead, Torn

Soren (2)Soren

Okay. I was just gonna, I was just gonna kinda transition into, um... I would love to hear a little bit about, and Tyler, if you have more questions about this, feel free to jump in. But,

Tyler

Yeah.

Soren (2)Soren

I, I'm curious, you know, at your clinic, you know, the Made, um, Dental Implant Center, uh, you know, I just wanted to know what, what kinda stuff you're doing. Are you doing just fixed? Are you doing printed dentures? Are you doing printed partials? Kinda what is all of the, um, the, the things that you're doing in your practice, and where are you bringing digital into that? Um,

Tony

Um,

Soren (2)Soren

curious about that

Tony

so it, it made we, we are full scope pross. So, um, and it's not just specific to fixed pross. We mostly fixed pross. That's, you know, the direction that

Combo Cases And Full Scope Prosth

Tony

the patient population has gone with what they want and what kind of their needs are. But we'll do some dentures. I, I haven't done a partial in quite some time, but, um, as, as far as denture workflows go, for prototypes and try-ins and things and different steps of the process, um, you know, we've, we've just... That's been tough. De-denture workflows have been tough because you want to print. We haven't really seen the materials perform the way that we would like them to long term. So then it's like we-- okay, can we mill these prosthetics because now we're in a digital workflow with printing, so it, it's a real pain to transition back to analog. So can we take an STL and can we mill it? Okay. Yeah. How are we going to do that? Two parts, one part, uh, you know, there's lots of different milling strategies there. Really for higher aesthetic demand cases, analog processing is still kind of what we rely on. Um, a-as much as I would love to be straight digital workflow for dentures, um, i-in some cases we do mill, but, um, when, when we're really high aesthetic needs, definitely processing still. Um, so that, that's on the denture

Soren (2)Soren

What um Yeah. And what, can you, can you go over what your favorite, um, like process is for a denture? Or is it just the standard, uh, you know, analog-based process?

Tony

standard. I mean, we may use digital to get us

Soren (2)Soren

Yeah

Tony

us into our tooth try-in faster. So, you know, trays with a

Soren (2)Soren

Mm-hmm.

Tony

on, do, do everything in one step. But yeah, it's n- really nothing too exciting on that side, just pretty, pretty much standard analog. but honestly, like the dentures probably that's like a, a couple percentage of the... maybe 2% of what we're doing in our practice. It's mostly fixed on implants. Um, I also prepped a bunch of teeth, so we do teeth cases. I love combination cases. You know, there's a lot of cases that come

Soren (2)Soren

Yeah

Tony

patients are candidate for upper all-on-X, but lower teeth can be restored and, you know, they've gone to five places and they've been told, "Oh, you need a double. You need a double." A- and maybe it's more predictable to save some teeth and maintain some teeth. So I think like the treatment planning side of things, I look at a case, uh, you know, I- I've, been fortunate to have a lot of experience, see a lot of things go well and a lot of things go bad. You start to just think with the mindset of like, what's gonna get this patient to a successful outcome and what's gonna keep them out of trouble, right? So it's like i- if I'm seeing a case where, say an hourglass, hourglass shaped mandible, and it's like, okay, there's some teeth there that could be restored. They're not great, but what's the alternative? And you start to take into all these factors. So we do a decent amount of fixed on teeth too. Um, and, and we do stay in the digital workflow with that too. I've, I've gone to pretty much full digital on teeth as well. Um, you gotta work with a good lab technician that understands digital, obviously, but I try to stay away from PBS as much as possible. Uh, veneers still use PBS, um, yeah, conventional fixed pros, digital.

Soren (2)Soren

No, I think that I, I really like that because... And that's something that actually in our clinics we're transitioning to as well. You know, Tyler just hired, Tyler just hired a pros. He's starting in a, in a month or two. Um, our other big clinic, which is Boise,

Tony

Nice

Soren (2)Soren

pros for probably two years now. Um, I have a, a GP dentist that, that does a lot of crown work. Um, and we are doing a lot more cases where, uh... 'Cause we get, I mean, like, and it's hard, like it's, it's, it's really difficult I find sometimes when you have a patient that's been to three places that all of them quoted them doubles for, right? And the patient in their head, they're like, "No, I am doing a double no matter what." And, and you're looking at these teeth and you're kinda like, man, like, it's, it's really not necessary to do that. But, um, I feel like the more volume and cases that, that I've done at least, and I, and I think I speak for Tyler and, and our other partner, Caleb, it's almost like the more conservative you get because you see the cases that you take all those teeth out, place the implants, and then if something goes wrong, man, it gets stressful very quickly. Um, and, and I have a handful of cases where I'm like, man, I really wish I would've, uh, you know, maybe, maybe done crowns and maybe they wouldn't have lasted them 20 years, but now that this issue happened, uh, it, it maybe it would've gotten another five to 10. Who knows? Um,

Tony

And

Soren (2)Soren

and you know, you can't go back and, and make regrets on these cases 'cause you'll, you'll just drive yourself crazy. But I do think being more conservative is better for the patient long term.

Tony

and, and I agree with everything you said. The, the other thing I'd add is the way that we position ourselves as full-arch implant centers, and you know how marketing is, there's a lot of patients coming to us that haven't been to a dentist in a very long time, right? So a l- we're attracting those patients that need full-mouth rehab. It doesn't mean for sure on implants. They, they just need a lot of dentistry basically. And if, if you're only able to provide the implants, um, there's a lot of patients that really aren't gonna get the best treatment. So you'll, you'll have plenty that need all-on-X treatment plans. But yeah, those combo cases, I mean, starting to just see more and more and more of them. Um, it's just... And it's,

Soren (2)Soren

Yes

Tony

f- honestly, I like them a lot. They're fun, they're predictable, satisfying for sure

Soren (2)Soren

I've-- Yeah, my patients have loved them too. Um, I think, you know, it's kinda like the saying, if, uh, if all you have is a hammer, right, everything, everything looks like a nail. So, so if you're able to do some of these different combo cases, like a lot of, a lot of fixed clinics just don't have the ability to do that. But, um, but you're 100% correct where, uh, you're-- I mean, and I'm sure the MAID clinic is as well, but we spend a absolute ton of money on marketing, and we get a lot of patients in our door that, that they just aren't fixed cases. They are, um, FMR cases. So, uh, we're trying to kinda like slowly transition our clinics into, um, being able to do some of that. Uh, so when those cases come along, then, um, we can provide a, a, a even better service to these patients than just, you know, FP3, FP1, denture, what have you.

Tony

100%.

Soren (2)Soren

Uh,

Tyler

So I'm curious, the,

Soren (2)Soren

Go ahead, Tyler.

Tyler

the... Yeah, I'm curious about, so we, we kinda talked about your, you know, scope and the different, you know, treatments that you're offering patients, talked about treatment planning things. So let's kinda just talk about, you know, if we're just looking at fixed prosth. You know, patient comes in, um, looking to do a double arch. From start to finish, and, you know, and however much you're comfortable divulging, what is your workflow right now that you feel really confident in that, you know, gets results very predictably from surgery all the way through prosth and, and final?

Tony

Um, Most routine probably, um, I like a workflow where I, I've pretty much always been like a get teeth the same day of surgery. I know there's some like next day workflows things. Um, my patients always leave with a printed prosthetic day of surgery. What workflow I use to get them there? You know, I... A lot of workflows work well. Um, fiducials, CBCT workflow. I've done more and more CBCT workflow lately as that's become more predictable. Um, I just... F-for me, fiducials

Same-Day Teeth Using CBCT Workflows

Tony

in the mouth, sequential extractions work well in the mandible, but fiducials in the mandible is unpredictable, and I can do it predictably, but I, I wish I could share some slides when, and Sven and I do a course, Arch Nemesis, where I show slides of mandibles and workflows and results of bites that are good. I'll tell you, and you guys know it too from doing these surgeries, it's just painstaking to make that happen accurately in surgery. All of the effort that goes into getting the alignments correct. Um, I've done it is splint things together with PVS and bite reg, and I eventually got to the point where the result of a good prosthetic solution at the end of the day was gratifying, but it doubled the length of time spent in surgery. So maybe the last, the last year, uh, really seriously the last year, but probably the last two years or so, Sven and I and some others have been like really going down, doubling down on the CBCT workflow just so we could get a very efficient surgery. Um, and, and that's a whole system of like how the sedation looks so that you could get the CT scan quickly after surgery. There's just like a lot of operational steps that, are part of that sequence. But that, that's where we've gotten to mostly. I'd say, know, at doubles, that's my go-to is CBCT workflow. Uh, a single upper arch, a palatal fiducial works fine. Um, that's,

Tyler

Yeah

Tony

my go-to there. Um, but yeah, so same day, and then it's just kinda depends on the case. Like, I've been moving patients to finals sooner than I historically have. Um, I, you know, we're set up to be able to do next day zirconia, and I've done it for sure. Um, I, I don't find that to be like super useful in my specific practice. I'm not against early zirconias as long as you're open to maybe making changes later and remaking them if you need to. but, but for us, milling PMMA has been great. So if I've got someone that I want in a more refined prosthetic, a stronger prosthetic, we'll mill PMMA, and we could go to PMMA as quick as next day or post-op or, you know, eight-week phase two. But, um, most of my patients end up in PMMA pretty early, even though that the printing materials have gotten better I just like PMMA and I--

Tyler

Mm-hmm.

Tony

kind of my go-to. And then finals, typical patient is kind of getting into final probably around eight to 10 weeks. for me, that's enough time for tissue to get to where it needs to be, and it, it just depends on the case, how you manage the tissue in surgery, all those little steps. But yeah