The Fixed Podcast

Fixed x Dr. Pallotto: Streamlined Success: Modern Approaches to Digital Dentistry: Part 2

• Fixed Podcast

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 47:16

Your full-arch case can look perfect in CAD and still land in the mouth with a crooked bite and hours of adjustment. We get specific about why that happens and what to change, starting with a simple discipline that pays off fast: retorque multi-unit abutments before phase two photogrammetry and before you commit to the next prosthetic step. When insertion torque is low, we talk through the most underused tool in implant dentistry, waiting longer, so stability drives your timeline instead of your schedule.

Then we dig into a stage two records workflow that can dramatically improve accuracy when you move from PMMA to zirconia. The big shift is scanning what stays the same. Instead of trying to align worn provisionals and “garbage” soft tissue landmarks, we remove the prosthesis, clean it, and 360 scan the intaglio as the primary fiducial marker. We pair that with arch scanning, scan caps, and photogrammetry, keeping the intraoral prosthetic scan focused on the bite. The goal is simple: fewer alignment errors, fewer reprints, and a delivery that needs little to no bite adjustment.

We also break down a CBCT alignment approach that uses segmented skull data as the fiducial, plus practical details on radiopaque caps, sandblasting shiny markers, and even sedation timing so a stable post-op cone beam happens without chaos. We wrap with gear choices, 3D printing speed versus accuracy, and zirconia design lessons like softening embrasures so “pretty” doesn’t become “broken.”

If this helped you rethink your workflow, subscribe, share it with a colleague doing full-arch, and leave a review. What part of your stage two process are you most ready to change?

Welcome To FIXED Podcast

Speaker 3

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.

Soren (2)Soren

one, are you torquing all your case-- You know, you torque your cases during surgery, right? At the, at the post-op, are you re-torquing every single time? Um, and if, if you have a implant, you know, that's maybe under 30 Newton centimeters, um, are you then waiting longer to, to place that patient, uh, or into, into finals? Uh, and then, like, are you-- when are you re-torquing when a, when a implant is maybe under the value of what it should be?

Tony

So standard, standard workflows now, um, every case will get retorqued before phase two

Retorque Timing And Torque Thresholds

Tony

photogrammetry. So i-in our practice, that would be eight weeks.

Soren (2)Soren

Mm-hmm.

Tony

So yes, um, torque wrench on, torque to spec, and then take photogrammetry records. So that would be assuming high stability, which nowadays we, we can get with almost all cases, but there are some cases where maybe you have a hollow mandible, you've got something unique, and an implant's not to high torque. wait longer. You know, I might wait three months. It might... Depends on the case. Um, yeah, I'll wait a little bit longer. I, I, I definitely want to torque the abutments before I'm making that next prosthetic. Now, if you're going to next day zirconia, you just are certain that everything is torqued at surgery, and then it's getting delivered. You know, it's not really, retorque it the next day. But yeah

Tyler

Right. Yeah, that makes sense. So when, when you get to that stage two phase, is there anything, you know, nuanced there? Because, you know, what's, what's kind of typical, right, is like they come in for phase two. Maybe they've been in an imprinted prosthetic, maybe they've been in a mill prosthetic. Doesn't really matter. Everyone has preferences. Um, we're gonna, you know, make sure the bite is, is relatively good. We're gonna take new records. We're gonna scan the teeth. We're gonna scan a bite, take some photos. We're gonna take those bridges off. We're gonna retorque all the multi-units, do some PG. We're gonna do some soft tissue scans, and then all that's gonna get married together into a stage two design. Are there any nuances in there that have helped you make this a little bit more predictable in going from that PMMA to the zirconia? And do you usually have like a try-in prior to zirconia? How do you, how do

Phase Two Records For Full-Arch

Tyler

you usually navigate that?

Tony

Um, so, so here's a really, really big, big one. Um, I don't scan... So let's say the patient comes in for phase two records. It's eight weeks, typical sequence.

Tyler

Yeah

Tony

Me or my assistant, we're not scanning anything in the mouth, um, of the prosthetic. So, so the first appointment will be, um, I like to take a pan just to get a, a global view of things. if there's a need for a PA or a CT scan, we could always do that, but a pan gives me a quick view of everything. then, um, prosthetics come off are cleaned, and assistant is 360 scanning the prosthetics. So that, that is a massively important step that differs from if the prosthetic stays in the mouth and we're scanning and we're using soft tissue to align, or if we're using other contours on the arch to align nothing, Tissue's not gonna be a good marker, and the prosthetic itself, in many cases, is not the same on the occlusal surface or in the lingual or buccal or facial of

Tyler

Mm-hmm.

Tony

It's not the same as it is in the

Tyler

Mm-hmm.

Tony

So what you're aligning back to

Tyler

Mm-hmm.

Tony

side is, you know, you've, you've all seen the all blue alignment. It's not gonna be anywhere close to that. um, what we do is I don't polish or, um, adjust the intaglio of the prosthetic of any interms, any same-day surgery or prototype because I want my intaglio to be my big, huge fiducial marker for everything, my intaglio of the prosthetic. So that 360 scan is really just getting a perfect intaglio that can merge back to the design prior. And so taking it back to what I'm doing in the clinic, my assistant 360 scans the teeth. While she's doing that, I'm torquing abutments, scanning the arch with some scan caps on, then photogrammetry, then prosthetics back in the patient's mouth, the only scan of the prosthetic in the patient's mouth is the bite, So the benefits here are it's re-

Tyler

Okay. Yeah, that, that's the part that I was wondering about.

Tony

So it's

Tyler

Yeah.

Tony

It's really

Tyler

Okay

Tony

really accurate, and it's easy for the patient. It's easy for the team. There's a lot of little sequence steps in there that could be delegated and systemized. Um, so the, the big part there is the designer, whoever's doing the design, has to know kind of like why you're doing those things and what to do with all the data that you give. But that, that should definitely result in a very close to no bite adjustment or no bite adjustment at all delivery of what- whatever comes after that

Tyler

Yeah. So this, this is, this is interesting because when I was first being taught how to do this by my lab, we were told that, um, we're scanning in the mouth, right? We're not taking the prosthetic out, doing 360 scans. So this is totally new to me. This is, this is very interesting. But they, they wanted me to get the junction of the soft tissue. They wanted me to get some rugae. They wanted to use soft tissue to align the prosthetic to the soft tissue scan and see where any discrepancies in the soft tissue have been. So I, I guess what I'm trying to figure out is I, I, I hear you about the intaglio being a fiducial marker to align the previous design to the current prosthetic. That's great, 'cause nothing's gonna change there, right? Um, but how are they then, uh, aligning that to the new soft tissue scan? How do they figure out where there's gaps in between the prosthetic? How do they get it all in the right place?

Tony

So you have to deconstruct the prior project. So the prior project you would, you

Tyler

Hmm

Tony

the designer would export out of that project prosthesis first that you're aligning into the 360 scan, and then the prosthesis plus the old tissue, okay? And then merge that in to

Tyler

Mm-hmm.

Tony

and then the old tissue and the scan caps in again.

Tyler

Mm-hmm.

Tony

your new photogrammetry data from phase two and your new soft tissue data can link in. So it's a, it's, it's a multiple step process.

360 Scanning The Intaglio For Accuracy

Tyler

Yeah.

Tony

and there, there's some

Tyler

Okay, so now they can see the delta there.

Tony

There's some like, there's some really... I could show you in Exocad, and I'm happy to do it, we could jump on another call and do that. But, um, it sounds like a lot of steps, but it's, it...

Tyler

I, I don't, I honestly don't need to see it.

Tony

you're probably like, "That sounds..."

Tyler

I just need to know it works.

Tony

works extremely well and, um, it's,

Tyler

Yeah

Tony

it's easy now in the clinic. It does take a few

Tyler

Yeah

Tony

on the design side. It's a lot faster for a designer to just say, "Okay, you know, scan the arch, the maxilla with the prosthetic in, take the prosthesis off, scan the scan caps, get

Tyler

Yeah

Tony

align the two." that's way faster, but it's not as good. And it... You're

Tyler

Yeah

Tony

the difference of two or three minutes on design side and the difference in you adjusting the bite manually or not, and it's, you know

Tyler

Yeah.

Soren (2)Soren

And, and potentially another prosthetic, another print, another design

Tony

And every-

Tyler

Yeah, and, and so...

Tony

in the

Tyler

Sorry. Yeah, so some of the

Tony

it all builds, and you know this too, like it all builds on the last step. So using these concepts from surgery day to next day PMMA or post-op PMMA, and, and nowadays, this is another thing about insertion torque. We used to be like, "Oh, don't touch the implants for three, you know, up to five weeks or up to six weeks." I-- Most of my cases, I'm comfortable taking things on and off at any time, assuming that we have good stability. So there's no... This is a personal preference. It may be controversial, but that's my concept. Um, so for me, I'm, I'm thinking about what is going to get my design steps equal what I need in the clinic as soon as possible. So the sooner you could do that, the better. yeah. you were gonna say something, and then

Tyler

So what I'm, what I'm... No, no, no, that, that was fine. That was fine. Um, I appreciate it. Uh, so what I'm taking away here, 'cause I- I've often wondered, you know, why is it that at stage two, you know, sometimes, uh, 'cause generally what, what we've done in our clinics is, you know, they're in a printed temp, then we do the intraoral scans I already described. We'll get back a milled PMMA, and then that's kind of our last, you know, final draft before we go to finals, and we'll see how the bite is there. Sometimes absolutely spot on, beautiful, wouldn't touch it. Other times, you know, they're only hit on the right side, and I gotta make some adjustments and stuff. But, but the scanning protocol was all the same. So I, I guess what I'm taking away from this is that there's discrepancies when we do the intraoral scanning because they're not really-- they're trying to align this old design, and this prosthetic's been worn for some time, um, and that's just not as accurate as if we could scan the intaglio, which is virtually unchanged.

Tony

And in, if you're pr-

Tyler

Wow.

Tony

the prosthetic that you're using as the reference at phase two, was supports on the occlusal, and okay, you might not be using the occlusal to align, but there were supports on the lingual also, and that was polished.

Tyler

Yeah, it was hand finished.

Tony

it was hand-finished on

Tyler

It was hand finished, yeah

Tony

probably polished or there was stain added. So, you know, things... It's all different. Yeah

Tyler

No,

Soren (2)Soren

That's, yeah

Tyler

and there's nothing about the record taking here that would take any longer, right? Like, you're, you're gonna take it out the mouth.

Tony

f-

Tyler

Yeah, you're-- Yeah, it's, it's even better. It's more accurate, it's cleaner. Yeah, I love that. I- I'm probably starting this tomorrow. I think this is brilliant.

Tony

Nice

Soren (2)Soren

So patient sits down. Do you guys take a bite first, then remove the prosthetics and then scan 360?

Tony

N- no. Uh, you could. Depends on...

Soren (2)Soren

'Cause you can, like our-- their software allows you to take a bite first

Tony

Um, I guess you could. That's just the-- my system. It-- Another thing that I try to do, and, um, this is kind of like a operational discussion, but I really try to make it so I, when I come into the room, I could do all of my steps within that time that I'm in the room with the patient. So it's like we've

Tyler

Yeah, of course.

Tony

it

Tyler

Yeah

Tony

okay, assistant's gonna take everything off, they're gonna clean the prosthetics, they're gonna scan the prosthetics, and then once I'm seeing them scan or they're finishing their scans, that's when I come in and start torquing abutments and putting scan caps on. You know? So it's just...

Tyler

Yeah.

Tony

do it however you want. It's just kinda what

Tyler

Yeah

Tony

Yeah.

Tyler

Yeah.

Soren (2)Soren

Is your

Tyler

scanners, I, I don't know if this is universal, but we use Prime Scans and some others now. But, um, I found that if I take a bite first and then I do a 360 scan outside the mouth, 'cause we use like a, uh, a denture wash workflow, it's, it's actually kinda similar to what you're describing. Um, yeah, I find that if I get the bite first, it seems to align it a lot better, and then if I put it back in the mouth and then I take a bite. Don't know why, couldn't tell you, but just for whatever reason, just seems to work a little bit better, at least with Prime Scans. I don't know. What were you saying there, Soren? I think I cut you off.

Soren (2)Soren

Um, I, I lost it.

Tyler

That's fine.

Tony

But yeah, that's, that's a, that's just, it's, um, that's a really big topic. And, um, yeah, we talk a lot about that, uh, with... 'Cause people, that's, that's huge. You still see a lot of people trying to use the ma- you've got a FP3 and you're trying to align with soft tissue. It's just... And

Tyler

Yeah

Tony

when the bite's off. It, soft tissue's kinda garbage in my

Tyler

Yeah Yeah, no, I think this is transformative. This is one of the best, like nuggets of information we've gotten on a podcast in a long time. This is great. Um, I am curious if we could dive a little bit more into the CBCT workflow. I've had, I've had a, um... I did an episode, I don't even know if it was on Fixed or some other show, but did an episode with, uh, a fantastic dentist down in, uh, uh, Western Australia, um, named Dave Odowling. He, he kinda walked me through the CBCT workflow, at least at that time. Um, and it was so completely over my head at the time that I, I still don't completely understand it. So could you just kinda give us like a layman's explanation of how this works and, and why it works so well?

Tony

Uh, so the pre-op design, the pre-op design is relative to the segmented skull, right? So e- all of the coordinates

CBCT Skull Fiducial Workflow Explained

Tony

are going to be, um, basically aligned back to that initial pre-op. And there's, there's some segmentation steps of the maxilla and the mandible have to be segmented and then pulled in to match the intraoral bite there's two train... schools of thought here. Um, some people will have the patient in let's say centric occlusion in the cone beam say, "Okay, the skull is in the right place. That's my restorative bite position."

Tyler

Yeah

Tony

What I prefer to do, and, uh, I've worked on this with Sven quite a bit, what we like to do is get the patient in the correct restorative position with our intraoral scans. Um, and, and that's a deprogrammed position, whether you're using a leaf gauge, a Lucia jig, point guidance by manual manipulation, whatever it is to get them into what we feel is a good restorative position. If we call it CR, we can. get them in that position, and then the segmented skulls get brought into that intraoral Okay? So you've got your pre-op project where the skulls are not just like the skull that came out of the CBCT, it's the separate maxilla, separate mandible brought into the intraoral scans. And then after surgery...

Tyler

Okay

Tony

through surgery, and there's really no, um, there's no restorative workflow steps in the surgery. Um, other...

Tyler

Yeah, you're just doing surgery

Tony

surgery. And, um, you, you need photogrammetry, so you take your photogrammetry data. You can even skip your soft tissue scan. Uh, I, I get a soft tissue scan. I

Tyler

Mm-hmm.

Tony

to have it as a reference, but you can even do without that. then after surgery, the patient's getting a cone beam with some radiopaque marker that's gonna show up in the cone beam, and now that data is aligned back into the pre-op using the skull. So the whole skull is the fiducial. So instead of, you know, aligning to three points in the mandible that you scanned, it's the whole mandible that's your alignment section. And,

Tyler

Hmm.

Tony

that results in a really broad, big service, surface that is able to be the fiducial, that there's no question in where that is aligning back to the pre-op. So

Tyler

And tell me about the radiopaque marker

Tony

yeah. So the way we used to do it is just the, um, I forgot the product number, but the Neodent suture caps, those, those are pretty

Tyler

Mm-hmm.

Tony

caps for scanning. They show up pretty well

Tyler

I think it's, uh, one oh s- one oh six four two eight, I believe it is.

Tony

Yeah. So, and

Tyler

I

Tony

there's like

Tyler

think so.

Tony

and slightly tapered one. Yeah, there's a

Tyler

Mm-hmm.

Tony

th- they scan pretty

Tyler

Yeah, yeah.

Tony

I'm sure there's many others. So you just need something that

Tyler

Mm-hmm.

Tony

well with the intraoral scanner and that your photogrammetry output has the same geometry and shows up in a cone beam, you're good. Um,

Tyler

Yeah.

Radiopaque Caps And Scan Body Tips

Tyler

Perfect. Okay

Tony

Sven has worked on getting something, you know, that's taller and has dimensions that are going to align better and are shielded from scattering, and those things do matter. Um, you can get better results when you have a better alignment, obviously. um, kind of the, the

Tyler

Yeah

Tony

of it is what I just said, use a cap that shows up in the cone beam

Soren (2)Soren

Are you sandblasting your Neodent suture caps?

Tony

Yes

Soren (2)Soren

Yeah. Okay. I was gonna say, 'cause, 'cause out of the package, th- they're...

Tony

there's a

Soren (2)Soren

I act- I actually use the, the Nobel, like, Peak caps, um, because they're white and, and, you know, it picks it up without, without blasting them. Um, but the Neodent ones are, like, a little bit shiny, and sometimes it, it, you know, doesn't, doesn't work great, and you have to sandblast them first

Tony

was it 106.268? Is that what you said? I think those are the ones that I use.

Tyler

yeah, 106, 268. Yeah, yeah, yeah.

Tony

sandblast them

Tyler

we might have some slightly taller ones. Um, but yeah, that and we-- the Nobel ones were 31145. It was just like a little white cap. Not the mushroom or anything like that, just like a little white cap. But I don't, I don't know that those are radio opaque. I'm not sure if they scan well.

Tony

Yeah

Tyler

Um, but yeah, no, that, that's, that's really interesting. And, uh, and you mentioned-- I was curious too, a little while ago, you mentioned when you said the CBCT workflow, there was a, uh, like a sedation nuance there. Like how they, how they get brought out and then moving over to the CBCT, what, what was the pearl there?

Tony

I don't run my own anesthesia. We have anesthesia team in the office and, um, same company, but a couple different providers depending on the day of week, and general anesthesia for most cases. And as you know, some patients wake up slow, some patients wake up fast, and some

Tyler

Yeah. Yeah

Tony

depending on what their sedation of choice is, they'll wake up slow and fast. So really just dialing that in and having the sedation team know like where you're at with the surgery. Um,

Tyler

Yeah. Okay

Tony

it like they joke like, "I'm gonna hit the button," right? So they will try to time it so that on my last stitch and when I'm giving my local at the end of

Sedation Timing For Post-Op CBCT

Tony

the

Tyler

Mm-hmm.

Tony

patient is like popping up and getting

Tyler

Mm-hmm.

Tony

So, and, and you know, we get to the point where it's almost like that every time. So, know, I,

Tyler

Mm-hmm.

Tony

not finishing surgery and waiting a half an hour for them to lay there and wake up slowly. So that part's fast, and then just having my sedation team know that my goal is to get the patient in a wheelchair and get them, you know, 20 feet down the hallway to get a cone beam. Obviously, they have to be safe

Tyler

Yeah

Tony

to do that, but that's the goal. And usually within 10 to 15 minutes after surgery, we're able to do that. So that's

Soren (2)Soren

Do you need to have some sort of, uh, like position the patient's in in the post-op se-

Tony

Yeah, great question.

Soren (2)Soren

Doesn't matter 'cause you're gonna segment the mandible from the maxilla

Tony

yeah. So it doesn't matter. Uh, I... The, the main thing is they, it... You just need a quality scan where they're not moving. So that every once in a while that can happen. You know, they're, they're so quick out of sedation that they're still moving a

Tyler

Oh, yeah

Tony

Um, but again, as long as assistant knows it has to be stable and you've got a good modern cone beam. We've got a, um... What cone beam do we have? Um, can't I even think of the name of it right now? It'll come back to me in a second, but yeah,

Soren (2)Soren

The

Tony

modern.

Tyler

Oh, sure. used Access, yeah

Tony

um, yeah, they don't,

Soren (2)Soren

It's okay.

Tony

It'll come to me. They don't have to be in any specific head position

Soren (2)Soren

Got

Tyler

Okay

Tony

Yeah

Soren (2)Soren

it. That's really interesting, and that's something that, you know, I don't even know... You know, it's funny, Tony, because a lot of the stuff that you're talking about, I feel like, um, it's, it's every day for you and you're probably talking to, to Sven and, and these other, you know, big pros guys, but it's not the norm for most, uh, most full arch just providers. Like we're, we're kinda still just I guess in the, in this-- I mean, the, the thing is the f- even like photogrammetry is like advanced for a lot of people doing fixed, right? Um, so like fiducials and photogrammetry is kind of like next level stuff. And then when you're talking about, um, CT alignments and like different, different ways to do it, like it's just really cool to hear because, um, you know, it allows-- We definitely learn from it. Um, I don't even know if our-- I'm pretty sure our lab, they don't even do like CT segmentation scans. Uh, but maybe they would, and it's something that we probably should play around with Tyler, because I, I love the idea of not having to do a, a wash or to do a, a fiducial marker. 'Cause you're right, the, the lower fiducial markers are like my least favorite thing to put in because, you know, sometimes you nail it and it takes two seconds. Other times it's like, you know, you have a, a hollow mandible, you're trying to place one in the retromolar pad and like you get it in there and it, and it just is moving the second you put it in, and it's frustrating. Um, okay. S- another question I had for you is, uh, what's like-- what are all the, the different equipment that you use in your office? Like what scanner do you like to u- I'm sure you use it a lot, so what scanner do you like to use? What 3D printer do you like to use? What, what, uh, materials you like to print in? I'm curious.

Tony

Yeah. So, um, we use a lot, uh, full arch doctors like all the toys and, um, dentists in general do, and my assistants like cringe when we bring something new into the practice. But yeah, we've, we've narrowed it down to a handful of things. On the scanning side, uh, Trios is what I'm scanning with now. Um, so, uh, this Trios has gone through some changes, but Trios

Scanners And Photogrammetry Gear Choices

Tony

4 is my main surgical scanner. there's some great stuff on the market, so I'm interested in like Shining Elf and some new stuff, but I,

Soren (2)Soren

I've heard Alpha's great

Tony

I, I've played with it bench top, but I've never scanned in the mouth with it. But probably that would be

Soren (2)Soren

Yeah

Tony

strong contender for a next scanner if I needed one today. Trios is, is working okay though. like everything wired, so, um, this might be, have been talked about before, but you know, you've got wireless scanner, wireless photogrammetry, all this wireless stuff un- until the surgical environment where something's not working. So the more wired that we've had, the better. Um, even like recently my wireless mouse in the surgical op, I was like, "I need a wire on that thing." So that's been just a kind of a cr- uh, across the board. in terms of photogrammetry, we have, um, a MicronMapper and an iCam, and what else do we have?

Soren (2)Soren

Do you have a preference?

Tony

Yeah, I use, um... Th- this is like probably overly complicated, but I use the MicronMapper in surgery, and I use the iCam for all my phase two zirconia data. Um, MicronMapper, I, I just... That's what I started with in photogrammetry and I'm, uh, you know, it's just, I think it's, the software is very fast and efficient. The scans are fast, and I do like that I could see, um, the angulation in the MicronMapper

Tyler

Aviation. Yeah.

Tony

So that's pretty awesome.

Tyler

Yeah, that killed it. It's awesome.

Tony

And you

Tyler

Yeah. The only thing, the only thing that I, I want them to change about this, and I, and I, I love my current mapper, I love knowing about aviation, I wish it would start to tell me that before the scan ever finished. Like, if it's got two that it's lined up and that they're, you know, beyond 30 degrees or whatever, I wish it would just be like, "Hey, you, you should know this now before you try to scan this whole thing." And so that would save me a lot of time. That's the only thing I wish that they would change. I wish I didn't have to scan the whole arch for it to tell me that two were too divergent. We should, please, and it comes right back to me. Please.

Tony

so I, I actually had a situation like that happen, uh, was it th-this week or last week? But, uh, you know, when you're parallel approach, you kinda... The, the thing that we

Tyler

Mm-hmm.

Tony

now is like, it's not always about just getting the, the abutments as parallel as possible. Sometimes you want them divergent, you know? So

Tyler

Claire?

Tony

So I was scanning and I was parallel approach. I knew I was gonna be out there in angulation, um, but that happened. I

Tyler

Yeah

Tony

get one, and then I was like, I just, I only care about those two because the one being blocked doesn't matter right now. I just wanna see the divergence. So that exact

Tyler

Right.

Tony

And, um, y-

Tyler

Yeah

Tony

to you, I'm not making this up, and I, I'm, I'm not like hard and fast on the 30 degree, although it is a decent reference as like a max ceiling. Um, it was

Tyler

I'm not there.

Tony

and I was like,

Tyler

Oh.

Tony

and I was like, "No way." I just like started laughing with my assistant. It was like, "Well,

Tyler

Yeah.

Tony

anything."

Tyler

Yeah. Yeah, yeah. We, we've got a 30-degree rule in the office, but sometimes I'm just like, "You know what? We'll figure it out in the post." I don't know.

Tony

I've been there.

Tyler

I'm not talking about like 40 degrees or something, but, you know,

Tony

that.

Tyler

there's, there's something we

Tony

there are scenarios

Tyler

can do.

Tony

it makes sense. Uh, but yeah, so, so

Tyler

Yeah

Tony

cool and, um, I use it for surgery. And, you know, I think the jury is still out on the whole discussion of passive fit, what's passive enough, what's not, what... This

Tyler

Yeah

Tony

in back to our course, like we spend... We've got three days where we talk about this

Tyler

Yeah

Tony

but we-- I think we can all agree that the closer you are to the trueness of the mouth, the better. And, um, I do, I do like the, the connection of the ICAM scan bodies to the MUAs. And for me, I've had a better clinical result in terms of, um, my fits for my final

Tyler

Really?

Tony

I went through a phase and, and the tough thing about all the manufacturing side is when something doesn't go right, it's really hard to discern like what step it was. Um, but I did have a phase where, uh,

Tyler

Mm-hmm.

Tony

were breaking, un-unfortunate for us,

Tyler

Hmm.

Tony

was also at a time when we were changing some other things in manufacturing. Um, changing zirconia was one of the things, so that, that can be a variable obviously, but sintering times, th-

Tyler

Just the material

Tony

So there's a lot of things, and we kind of made like a blanket sweep to change a few things. It's probably not the best idea, but usually you want to change one variable at a time and see.

Tyler

One at a time. Yeah

Tony

things and we got everything resolved and I was... Once something is working, it's difficult to take the risk to change it. So one of those

Tyler

I,

Tony

ICAM.

Tyler

me, I totally understand.

Tony

Um, yeah

Tyler

Very interesting. Well, I mean, I, I think the studies do show it is, you know, m- it is the most accurate, you know, down to, you know, something that is questionably clinically significant, but it is the most accurate system. So it does make sense to be using that in stage two, whereas MicroMapper is definitely a lot more nimble in a surgery, I would say. You know, I think that's a fair statement.

Tony

for sure.

Tyler

Yeah.

Tony

Um, then

Tyler

Yeah

Tony

Yeah, printing is a great topic. It's super passionate about printing. It's just amazing. You could design something or think something up and manufacture it right there in front of you. Um, start, I started with, what did I start with? The, uh, E1 back in like 20, 2019, I think it was. 2019 probably.

Tyler

Is that, is that an Einstein

Tony

the

Tyler

or

Tony

the En- the Envision one, the bigger one.

Tyler

Oh, oh, okay. Envisioned it. Yeah, okay. Okay. Yeah

Tony

Envision One E1 and the, some, the precursor to Flexera Resin was on that. And yeah, it's, you know, printing surgical guides and study models, you

Tyler

Mm-hmm.

Tony

night guards,

3D Printing Speed Accuracy And Resins

Tony

that whole sequence. And,

Tyler

Yeah

Tony

evolved into a couple Einsteins you know, I, I honestly, I love those printers. I think they were great printers, the company and the support. We all know about, about that side of things. Um, but yeah,

Tyler

Mm-hmm.

Tony

they have worked. I, I'm down to one still working and have moved on from Einsteins to now I have, um, right now functioning, what do we have? We've got one Einstein, DentaFabs, um, which I like quite a bit, and, uh,

Tyler

Mm-hmm.

Tony

Elegoo for printing models, which is a kind of a hobbyist printer, but man, that thing is awesome for models and dies and, uh, non-intraoral stuff. It's badass.

Tyler

Yeah. Very nice. So I, I've heard a lot about the Dentafab, and that was something that we were looking at, um, a couple years ago when we were starting up our offices. We ended up going with Formlabs, which has been really, really good. It's been a solid product. It, it just doesn't misprint. It's very user-friendly. They, they have some very decent proprietary resins. Um, but w- what I heard about the Dentafab was very, very fast, bloody fast. Um, but I did hear some things about... And, and we do a lot of pterygoids, so there's, like, some longer spans, about some distortion that would come along with those longer spans. Is that something you've experienced? Has it gotten better? You know, should we be taking a second look at that?

Tony

I would take a second look. I mean, I, I haven't had any issues, so I demoed one for about six months. I, I had it a while. Um, it was before one of the courses we did, and that was, that was a model that, uh, it was like probably the third or fourth person to use it, and even that one had gone around the country, and that one was really accurate. And like you said, it was very fast. but I, I found some of those inaccuracies on the distal extensions when we were really pushing it. There was a time when we were doing six-minute arches and things did get, um, with RapidCeram and, and remember, we're

Tyler

Yeah

Tony

360 scans, so I'm-- I have data on hundreds of arches aligned to the wax up. So I'm, I'm seeing like on a regular

Tyler

Yeah.

Tony

it is, where-

Tyler

So you can see that, yeah

Tony

and, and on prints that are, were in like the 12-minute range, I wasn't seeing those distortions. When it was bumping below 10 minutes, six minutes was the, the one that was kinda like the max speed, I was seeing them there. Um, but yeah, now, now

Tyler

Okay.

Tony

I, I still have some Flexcera left, so I print some of that on the DentaFabs, and now DentaFab has some really cool resins coming out. Um, they're a whole line of different resins, but ceramic filled and all that. You just, I mean, y- you give

Tyler

Wow. So they're, they're totally open source then?

Tony

You give up something with speed, though. Like s-

Tyler

very nice

Tony

I think as of right now, there's a limit on how fast we could go without losing some accuracy, and it's just what you're comfortable with

Tyler

Yeah. Well, I mean, the difference between six and 12 minutes when you're, you know, used to

Tony

Yeah,

Tyler

30 minute, you know, it, it, it's kind of negligible. So yeah, and I mean, that's, that's definitely something that we might be, you know, looking at for sure. Would, would, would you say that it's, uh, you know, in terms of like assistants using it and things,

Tony

Yeah.

Tyler

easy to pick up, good UI, very user-friendly? Okay. And like the program and stuff is nice nesting?

Tony

switched it. So it went from, uh, Chitubox to their own software, that was, like, a couple months ago. The new software's awesome. It's like, uh, the supports, I... Knock on wood, I don't even think I've had a failed print on an arch on that printer yet. Like, the supports are so thin. They're, they're like

Tyler

Okay

Tony

supports that just wipe off. Um, yeah. It's pr-

Tyler

Oh, that's awesome. Yeah. Okay. All right. You've convinced me. We gotta, we gotta try this out then. This, this sounds

SorenSoren (2)

sounds

Tyler

great. We got a few offices opening up, so maybe we'll, uh, let one of them be a test kitchen for Identifab. That sounds great.

Tony

and as far as resins

Tyler

Awesome.

Tony

you know, it, it's really specific to what your need is in the office. Like for me, as I mentioned before, I like to get my patients to PMMA early as possible, so I don't, I don't

Tyler

Yeah

Tony

one of these really viscous, heavily filled resins, um, that, that are a little bit more laborsome to post-process, a little bit more sensitive to alcohol. I don't have a huge need for that in my practice. I have it. There's certain cases I wanna use that, but a lot of times I'll use a weaker resin like a Flexera Ultra that's easier to post-process, less viscous, um, can print on, uh, my Einsteins, can print on the DentaFab. So it's, it's all what tool you need. Um, some, some of these resins though, they're

Tyler

Yeah

Tony

like can we use these as permanent restorations? It's kinda crazy, these ceramic

Tyler

Right

Tony

these ceramic resins.

Tyler

Yeah. Yeah. You mentioned, um, towards the beginning of the, of the podcast, um, you know, things will... A, a design might work in the print, you know, something you can deliver same day, but then that doesn't always translate to milling a final. Can you kinda t- speak to that a little bit, like some of those things that might kind of come up?

Tony

I, I, I had learned a lot the hard way with FP1s in this, this realm. So I would design things as super anatomic, um, you know, really d- uh, deep embrasures and, um, you know, tis- tissue

Tyler

Yeah

Tony

optimally everywhere. then I would mill in PMMA and okay, good, we're, we're still fine. Um, and then you go to mill in zirconia and then things break, right? And then the green stating too, I'd, I'd get in

Tyler

Mm.

Tony

and green state these arches and make these... use a disc and make these deep embrasures, and you just s- some things just because you can make it doesn't mean it's gonna survive. So now we've gone

Designing Zirconia That Does Not Break

Tony

to rou- rounding

Tyler

see. Okay

Tony

lingual embrasures, softening things. Um, it's all in the design and how you post-process it, uh, or s- uh, green state it, I should say. But yeah, that's,

Tyler

Okay. Okay. Yeah, no, that makes sense

Tony

work up until final.

Tyler

Yeah, no, that, that's, that's fair. I mean, things can look really good, you know, on a digital wax-up, but then when you start getting into, you know, something that's in your hand and then ultimately has to be in a mouth, which is just a machine designed to break things,

Tony

Yes.

Tyler

you know, it, it can be a lot different for sure. Very cool. Very cool. And are you doing-- You mentioned FP1s. Are you doing a lot of full arch FP1?

Tony

a lot, um, but I definitely do them. Yeah. Yeah. Um, the, uh, the FP1 discussion is, uh, the... And this may be a little controversial too, but I think the jury is still out on what the gold standard is there on the restorative side. Um,

Tyler

Mm-hmm. Oh, definitely. Yeah

Tony

the surgical side, we know we- we've come a long way. We know a lot of things. Um, I personally like to up my game with soft tissue. That's kind of like what's next for me in the next year or two, is to take some really good soft tissue courses. Um, on the restorative side, you know, that's a whole discussion. Are we better direct to MUA with zirconia? Should we be putting bars in the zirconia? FP3 is a

Tyler

Yeah

Tony

easier to discuss that, but FP1's, I don't know

Tyler

I mean, it, you know, it seems like-- I mean, I see a lot of people that do, uh, you know, tie bar substructure. Obviously, the argument for that would be strength. But then you, you know, you talk about soft tissue adhesion and how, you know, you kinda-- it's a little bit more complex when you have FE1s and a hyper-polished, um, zirconia is gonna be a lot kinder to tissue. You can even actually get adhesion, whereas with titanium you, you really don't, um, get that true, um, adhesion to tissue

Tony

with the bars too, uh, and, and I've had this happen with my own cases, is you just, you need space. And in FP1, you just run out of space for a

Tyler

Yeah

Tony

the zirconia. I mean, I've had bars break, I've

Tyler

Yeah

Tony

break. Um, I've got one on Instagram I think of me flexing an FP1, and is broken in the middle and the bar is just flexing. Uh, you know, you look at these bars, they're super thin. now the discussion

Tyler

Yeah

Tony

in chromium cobalt because it's, it's more rigid than titanium, which, you know, maybe that's, that's

Tyler

Hmm.

Tony

approach. Um, but yeah, we're still... There's a lot to be figured out still in that whole area of full arch. Yeah.

Tyler

What is your opinion on, uh, segmented versus splinted for, for FP1 specifically, obviously

Tony

like it, but it's, you know, things have to make sense in terms of where the implants are gonna be, definitely. And,

Tyler

Yeah

Tony

the discussion of what's enough to maintain clamping force for a segmented You know, is two abutments okay? personally don't feel that comfortable with two MUAs. Um, there may be some cases you could get away with it, but if I built my practice off of having arches segmented on two MUAs, you know, I, I'm not comfortable with that level of complication that I might have,

FP1 Segmented Vs Splinted Tradeoffs

Tony

you know, down the line. And three, three I'm probably okay with, and then there's a discussion about i-integrating a implant level implant into that three, but then all of a sudden the convenience of kind of goes out the window. So, you know...

Tyler

Yeah, that's, that's for sure. We, we've experienced that. We, uh, we did a, uh, a three on six course last year, and we, we've all done some three on... I actually did one today. You know, we, we still do them, you know, fairly frequently. And, uh, at the time we, we tried some implant level stuff. We did, you know, TRI implant system and, um, there were some challenges associated with that for sure. I think there's, there's still some ways to go to make that a little bit more user-friendly. Um, I can see some of the advantages that can come along with implant level restorations for FP1. Um, I can see where that makes sense. But, uh, yeah, I mean that was, that was, uh, when it came to, you know, after things were placed and it came to actually getting photogrammetry and getting things restored, that was, that was challenging. I mean, anything is the first time you do it, but I think that there's still some innovation, um, to be made there for sure.

Tony

about FP1

Tyler

Yeah.

Tony

FP1's not a new concept. We've been doing full arch FP1 for decades, but it's been implant level,

Tyler

Sure. Yeah.

Tony

it's like...

Tyler

Yeah

Tony

the-- if you asked what the gold standard is, that, that really is the gold standard. Um, but

Tyler

Right

Tony

away all of the conveniences just about that we've, we've gained in our workflows so far. So that's the tough part. Yeah.

Tyler

Of course. I mean, yeah, the, I, I think the one kind of devious thing about, you know, just FP3 is how comparatively easy it is, right? With multi-units and, um, just doing everything full or splinted. Like it's, it's... There's a lot less, uh, nuance to it than some of the other things we've been talking about. But, you know, we're gluttons for punishment. We, we, we try to make things more complex. We want to offer more complex treatment and, you know, that's kinda how we get our rocks off with this. But, um, but yeah, no, I, I think, I think you're smart to not do a ton of FP1, but certainly be doing that. And, um, I, I've been looking through your Instagram even while we've just been recording here. Um, and, uh, you've got some really, really cool stuff.

Tony

you

Tyler

anyone hasn't checked them out here, I think I had you pulled up. What, what is your, uh, Instagram handle for everybody, just so they can check you out?

Tony

Pilato

Tyler

Okay. Okay. Simple enough. Very nice. Yeah, you got a, you got a great page there. And, um, y- you've mentioned your, your course with Sven a few times. I, I'm not sure that we've plugged that well enough. Can you, um, talk about what gets covered? When's the next course? How do people sign up? You know, let's, let's sell the course. I think, I, I think you guys are just some of the smartest guys in our industry, seriously

Tony

you. Um, so the next course is August 13th through the 15th. It's in Bozeman, Montana.

Tyler

Mm-hmm.

Tony

Sven is from Bozeman,

Course Details And Common Prosthetic Mistakes

Tyler

Mm-hmm

Tony

his practice is and his lab. So we spend one day in the lab and two days in classroom, and it's all full-arch restorative. So, um, the title of the course is Arch Nemesis: Full-Arch Prosth Complications. So certainly we talk a lot about complications, but it's difficult, as we found when we did the first course, it's difficult to talk about complications without talking about some of the foundational stuff. So we, we cover a lot from tr-

Tyler

No question

Tony

diagnosing, um, everything from meeting the patient through red flags on that side of things, then through workflow, selecting workflows, go through all the different workflows, um, design, final restorations, screw selection. It, it's a pretty big course. It probably should be a week long instead of three days, um, but we got a lot of good feedback the last one that we did, and made, made a couple little tweaks to dial some sections in. But yeah,

Tyler

Mm-hmm.

Tony

it's a, it's a cool course. Um, I think e- everybody walks

Tyler

Yeah

Tony

like they've, they drank through a fire hose in terms of full-arch prosth, definitely.

Tyler

That's cool. So do you think it's ideal for people who are, I mean, just starting full arch, who have been doing it for 10 years, really anyone that's having complications they don't know how to get on top of? I mean, who, who's the ideal person? Or just about anybody doing full arch really?

Tony

just about anybody. The initial vision of it was it was gonna be like a more advanced full-arch course, um, for the clinician who's got,

Tyler

Yeah

Tony

know, hundreds under their belt, and they're really looking to level up. But I mean, the way I think about it at least is like if, if you could avoid a few complications, uh, the course is worth it for you even if you're a beginner, because r-

Tyler

No question about that

Tony

Just, you know, patient expectations are tough. The whole thing is tough when you have things go sideways, prosthetically or surgically. So yeah, I, I think the

Tyler

Yeah

Tony

is pretty, pretty broad. Um, we did have some newer to full-arch docs in the first course, and there's quite a few sections in it where Sven and I do kinda like dialogue back and forth, and it's almost like a open forum, and you could tell by some of the questions that

Tyler

Mm-hmm.

Tony

was a, a pretty big range of knowledge in the group. But it, it was neat because

Tyler

Yeah

Tony

learning from other people and questions back and forth. It's a very dynamic environment. So yeah.

Tyler

Yeah. No, I, I think that sounds like a lot of fun. What would you say, like, uh, across that broad spectrum of experience, what are some of the most common foibles that you see in prosthetics? You know, people are doing this or that wrong, it's, it's like they need to attend to this, and it's, it's just common in, in that whole crowd

Tony

one pe- thing that people come into a course like that is with is like they want their surgery day workflow to go smooth, They don't wanna like have this whole

Tyler

Mm-hmm.

Tony

of surgery happen or whole morning and then put the arch in and it's like not what they saw on the computer or what the designer sent in the viewer.

Tyler

Yeah,

Tony

bad bite on surgery day. That, that's kind of like,

Tyler

Yeah, that's, that's everybody. Yeah

Tony

included, like I want that to go smooth. Um, but then, then it's like you, you start with something like that and then

CR Records Condyles And Compounding Error

Tony

there's all these other questions that, uh, you think of along the way like, "Oh, what, what scanner? How did you scan? What would the records look like? What was the pre-op records look like?" I mean, that's a huge one. A lot of these bad bites, since we're relying on the pre-op jaw relationship, a lot of our

Tyler

Mm-hmm.

Tony

come in with these mutilated occlusal schemes and they're just... They, they've got no consistent home base that they're going to, and we just take a bite and we're like, "Oh yeah, we'll design a new bite." Well, when you put the arches in, the bite that you took is the bite that, that jaw relationship is what you're gonna get on surgery day if you're going off of an alignment to your pre-op. So the CBCT workflow

Tyler

Right

Tony

has shown us some crazy stuff. Um, we look a lot at the condyles. So, um... And I'm going on a big tangent here, I know. But, um, this is, this is im-

Tyler

Go ahead, please

Tony

So own cases, I, I show a whole bunch of them where I'm like, "Oh no, that patient was like they were in centric Like, "No, my, my bite was good, guys." the po- the post-delivery, uh, bite error, that's Sven, that's your issue on the cone beam alignment or designer, that's your issue. But then now we've started to look back at our condyle position when the segmented skulls are pulled into the pre-op iOS, I will tell

Tyler

Yeah

Tony

so many times when those condyles are asymmetrical in the fossa,

Tyler

Yeah

Tony

plenty of cases that I can show you that the, the relationship of the condyle asymmetry mirrors the relationship of the error in the, in

Tyler

In the mouth.

Tony

exactly, and it's like it's eye-opening. So

Tyler

Yeah. Not a coincidence.

Tony

a coincidence. Yeah. So a lot of effort should be made for just getting good CR records at surgery day or knowing how to deprogram. So we cover all that stuff, um, and,

Tyler

Okay

Tony

on and on. Yes.

Tyler

Very nice. Very nice. Yeah, I, I definitely think that there's a lot to be learned at the, you know, stage zero section of things. I think it kinda gets, um, you know, it's like an exciting thing. You close the case, the assistant comes in, they're scanning everything, and you're like, "Oh, that looks reasonable to me. That looks like a bite," and then you're kinda just going from there. A lot of times there's not any deprogramming happening. We're not looking at where the condyles are seated in the CT if we're looking at a CT workflow. Um, so I think, you know, we, we mentioned earlier, like compounding error, right? Like if, if it starts bad, like it's not gonna get any better. Like it only gets worse over time.

Tony

you have to,

Tyler

so yeah, that, that, that's

Tony

you

Tyler

really important

Tony

when to accept that error too, because, you know, you have a patient with, uh, uh,

Tyler

Sure. Yeah

Tony

teeth and the major dental phobia and, and then like, okay, we're gonna accept that error and we know we're gonna

Tyler

I had one.

Tony

you

Tyler

Yeah.

Tony

So

Tyler

Yeah, I had, I had one literally last week, and we could maybe keep him in the chair about eight minutes, and all of his teeth were mobile. And I was like, "Yeah, that's a bad record, but yeah, we're gonna use that."

Tony

have to start someplace

Tyler

And, uh, we'll, we'll know that, yeah, the first set, you know, that's gonna be our, a very, very rough draft. Just a little bit rougher than usual. Um, but we'll go from there

Tony

other, other than like,

Tyler

once we have something stable.

Tony

as, as I say, other than, um, surgery day workflows, like the big discussion a lot of people ask is like final restoration designs. Are you using a bar? Are you, are you comfortable

Tyler

Mm-hmm.

Tony

MUA? Like what

Tyler

Yeah

Tony

that's obviously a really big discussion too. People, um, experienced and inexperienced are looking for guidance there.

Tyler

Yeah, definitely. I mean, gosh, when you said clamping force, I was like, man, that just brings that whole episode series with Sven Bone right back in the, the forefront of my brain. I, I think about clamping force all the time, and anytime someone tries to sell me on a screw, I say, "But you, you know the clamping force though, right?"

Tony

Oh, man. Yeah.

Tyler

that's,

Tony

him,

Tyler

yeah, a lot, lot could be said for that

Tony

him on, I won't even try to get into that because I, I won't even get close to, to what he talked about, I'm sure.

Tyler

Yeah, no, he'll, he'll start whipping out the equations on you and you're like, "Okay, here we go."

Tony

Hey,

Tyler

You, you probably remember why you got out of engineering when he starts getting into that.

Tony

That's true.

Tyler

Oh, that's great. Um, well, Tony, we, we certainly appreciate, you know, the time that, that you've been able to spare and all of your expertise. I mean, I, I've personally come away with things that are literally gonna change how I do stage two, like, tomorrow. Like, I'm literally in the morning huddle, we're gonna be talking about how we're doing it now. And I'm very interested to see how that, um, you know, creates some predictability in our stage two. But man, so many other things, so many pearls. I, I think you're doing, um, some amazing th- things both in your own practice with Made, with, uh, Archnemesis, your courses. Again, everybody, I, I highly recommend, uh, doing that course. You're talking to, again, two of the smartest people in our industry. Um, you know, thank you so much for coming on and sharing all that with us. We're, we're really honored by it

Tony

I appreciate you guys having me, and I hope to be able to come back

Final Takeaways And Closing

Tony

and talk sometime again. It was fun. Love talk and shop

Tyler

Yeah. Literally anytime, man. You'll, you'll certainly be welcome back. Thank you

Tony

Awesome. Thank you