Fixed x Dr. Ryan Sloan: The Comprehensive Approach: Balancing Prosthodontics and Surgery: Part 1

A patient walks in asking for full arch dental implants, but their teeth are not quite “terminal.” Another patient has one arch that is clearly headed for All On X, while the other could be saved with a full mouth rehabilitation. Those are the moments where implant dentistry stops being a procedure and becomes a decision making framework. We talk with prosthodontist Dr. Ryan Sloan of Smile Now Boise about how a prosthodontist plus surgical GP team expands options without overwhelming patients or compromising ethics. 

We get specific about the gray zone between saving teeth and extracting for a fixed hybrid. Ryan shares how he starts with dental fatigue, patient values, and a clear problem list before he ever sells a solution. We also unpack what happens when the dentist and patient disagree, how to honor patient autonomy without abandoning clinical standards, and why the ability to say “we’re not the right practice” can protect everyone involved. 

From there, we dive into the technical workflow of combination cases: sequencing an All On X arch against crown-and-bridge FMR, leveraging sedation wisely, coordinating multiple dental labs, and using temporaries as the proving ground for occlusion, vertical changes, and design. Ryan also explains his occlusion priorities and why he prefers milled PMMA temps over printed provisionals for natural teeth right now. If you’re building a more comprehensive implant practice or refining your full mouth treatment planning, this conversation is packed with practical takeaways. Subscribe to the FIXED Podcast, share this with a colleague, and leave a review with the one treatment planning principle you refuse to compromise on.

Transcript

Welcome To The FIXED Podcast

Speaker 2 0:40

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 0:50

Hello, and welcome back to the FIXED Podcast. Today we have on an illustrious guest, Dr. Ryan Sloan. Um, so he is actually a prosthodontist and partner at Smile Now Boise. He works hand-in-hand with Dr. Stott, who you're probably familiar with from the show. And we wanted to bring him on because in Boise in particular, we started doing something that we may roll out in some of our other offices as well because it has gone quite well, um, where we have a prosthodontist/surgical GP duo. Now,

Meet Prosthodontist Ryan Sloan

Tyler 1:19

this could break down in a whole lot of different ways. Dr. Sloan not only does the prosth side of things, but he's al- actually a surgical dentist as well, so he's doing a lot of his own cases. Um, but what he has brought forward to, um, Boise is a more comprehensive suite of services so that we can do hybrid treatment as well, not just doing, uh, fixed arches, but also FMR. Sometimes those are on the same patient. You know, you'll, you'll see those patients oftentimes, they're sure having a derm- terminal dentition on one arch, but maybe not the other. Um, you know, how do we combine those? How do we do, you know, optimally invasive treatment for everybody, um, and figure out those solutions? And so bringing on someone like, um, Ryan has really opened up, um, the possibilities for Smile Now Boise. And we just wanna talk to him about, you know, his experience and his expertise. So Ryan, thank you so much for sparing your time to come on the show.

Ryan 2:03

Yeah, thank you so much. It's good to be here

Tyler 2:07

Yeah. Awesome. So, um, if you wouldn't mind, uh, just doing kind of a brief intro of everything up to Smile Now. Kind of give us an idea of, you know, where you're from, where you went to school, your beginnings as a prosthodontist

Ryan 2:19

Yeah, absolutely. Um, so originally I grew up in Albuquerque, New Mexico. So I don't meet-- I don't-- No matter where I go, I don't meet a lot of people from New Mexico. So, um, it's a,

Tyler 2:29

sure.

Ryan 2:29

it's a

Tyler 2:30

You're one of the first for me

Ryan 2:32

it's a good state to be outdoors in. So you know, if you like outdoors, there's a lot of really cool stuff out there. Um, but I did my undergraduate degree in, um, at a small school in Virginia. Uh, I did my dental school at the... what is now called Texas A&M College of Dentistry. At one point it was Texas A&M Baylor College of Dentistry. At one point it was just Baylor College of Dentistry. But, um, it's been owned by Texas A&M for a while. And so, um, and then I did my prosthodontics residency at the University of Tennessee Health Science Center in Memphis. Um, so I-- But I actually lived in Mississippi just south of Memphis, so I've kinda lived all over. I, uh, graduated from that in s- dental school in twenty eighteen, finished my residency in twenty twenty-one, and then I went to practice for about a year in Reno. And it's, it's funny, Dr. Stott and I were actually, um, in Reno at the same time. We overlapped a little bit, but we never, never actually met each other. Um, and then he made his way over here to Boise, and I made my way over here to Boise at a, a different practice. Um, and that practice it, it didn't really work out for me. But as, uh, as I was exiting that practice, um, I was talking to an oral surgeon friend of mine, um, in town, and he said, "Hey, you know, you should really get to know this Dr. Stott guy. He's kind of an all and ex whiz and, and, uh, you know, he's a really cool dude." And I was like, "Sure. I mean, I'll, I'll talk to anybody." I'm, I'm-- I firmly believe it's never a, never a bad thing to have a conversation about anything and should never really turn that down. So, um, got to meet Dr. Stott. Uh, well, you know, Caleb, uh, came over to the practice, and he was doing a surgery, and we chatted and just kinda hit it off from there. So, um, it's, uh, you know, I've kinda been all over. I-- My, uh, really lame claim to fame is that I've lived in all four time zones in the continental United States, so that's not much. That's, that's all I got. Um, but it's been

Tyler 4:24

no, no,

Ryan 4:26

so been at,

Tyler 4:26

that's good

Ryan 4:27

and practicing with Dr. Stott now. I'm coming up on two years, so.

Tyler 4:32

Very nice. Very nice

Soren 4:33

Can you, uh, can you walk us through a little bit on, um, you know, your journey into, to implants? Did you do-- did you get any of that experience in your prosth residency? Um, you know, when, when did you kinda start, uh, like journeying into full arch and, and fixed?

Ryan 4:50

Yeah. Yeah, it's a really good question. Um, so prosthodontics residency is, is so good in so many ways. Um, if there's one maybe, uh, not a downfall, but if there's one challenge that like a prosthodontic residency has, is that, um, you're trying to cover so much in so little time. Um, so during my residency we did dive, you know, implants was hit heavily,

Residency Training And Implant Reps

Ryan 5:12

like very hard. But at the same time, you're also trying to learn full mouth rehabilitation. You're also trying to master partials and partial design, uh, just making really good dentures. Uh, my prostho residency also had a really, uh, heavy focus on, um, TMD and, and the joint, understanding the joint, um, while at the same time trying to understand material science. You know, my, my master's was on, uh, you know, bonding zirconia and, um, at the same time also a really heavy teaching component. So you're working with the undergraduate. So, um, what on, on the really good side is a really broad base of experience in all things, you know, uh, implant, restorative, surgical. Um, is also, um, we didn't-- we were able to get our feet wet in a lot of things, but didn't necessarily have a super high number of repetitions in every one of those, right? So there was a, a significant component of my residency that was devoted to implants, um, and, uh, kind of the traditional way of doing it, you know, extract, graft, denture, um, but also immediate loading. Uh, understanding the soft tissue was hit really hard because, um, we would work pretty closely with the, the periodontal residency. So I felt really blessed there to work with a lot of really talented periodontists. Um, and yeah, so I loved it. I think as I was coming out, I was just hungry to get repetitions in, you know, just because you get this really broad base and then you just want to go, go do a thousand cases, right? So

Tyler 6:37

Right. I- I'm curious, so I, I've seen it done differently in different residencies. When you were doing fixed cases or, or, you know, any type of, you know, surgical case, were you actually the one doing the surgeries or were you having to coordinate with like another like oral surgery residency or periodontic residency?

Ryan 6:54

Yeah, yeah. Um, so we, uh, with oral surgery, they weren't as, um... Oh, how do I say this, uh, nicely? They weren't as interested in, uh, sharing surgeries with us. So we would work with them, but, um, there was no, there was no, um, doing part of the surgery. With the periodontal department, um, we would actually plan the surgery together, sit down. Um, they do half the surgery, we do half the surgery. And then we also had, um, uh, surgical prosthodontic faculty that would come in and lecture and oversee surgeries where we would be the ones doing the surgery entirely. And so it was, um, there's kinda these three niches of us working with our surgical prosthodontics faculty, working with perio and doing everything fifty-fifty, and then working with oral surgery. Um, and it would just be the traditional surgery and restorative silos. Um, and you know, it, it actually was a really great experience because I got to see kinda every, every aspect of how each of those workflows functions, right? And it was-- I mean, I, I loved it. It was great

Soren 7:55

That's great. Yeah, we, um, you know, I love the fact that, uh, transitioning from that kind of environment into, into a fixed one really opens your eyes to, you know, all the different-- and Tyler kinda hit on this earlier, but all the different possibilities that these patients have when they come in to get care. Uh, recently, you know, I hired an associate in my office, and although he's not a prosthodontist, um, he's a general dentist that had done a good amount of like cosmetic FMR style cases. Um, and a lot of these patients that come into our door, uh, they're just looking for a solution, right? Like, you know, they, they might think that that solution is all implant-based, but being able to kinda offer them the gambit of treatment and, and letting them know like, "Hey, no, you know, we absolutely can save some of these teeth if that's, if that's your goal," uh, I think it's a, a much more well-rounded patient approach. Um, and luckily, we're able to, um, a lot of the patients we're treating, they are, you know, full... whether it's full mouth implants, full mouth crowns, whatever it may be. Um, you know, these patients are just looking for a solution that most general dentists just don't feel comfortable providing. They, they don't feel comfortable, um, doing a, a whole case. Maybe they don't have, uh, anesthesia to provide these patients. And a lot of the patients, you know, they, they are patients who have issues with, uh, um, going to the dentist. They're, they're nervous about it. And, uh, one thing I've seen in our clinic is that, um, you know, we're turning away a lot less patients because we're able to provide, uh, you know, maybe, maybe a bridge where we can't place an implant or, um, you know, a whole arch of FMR and then against a lower, uh, a lower fixed case. Uh, a, a question I have for you, and, and I-- and this is probably a difficult question to kinda start off with, but it's, you know, when-- what, what's your mentality around, you know, when do you take out teeth versus saving those teeth? And how do you, um, do you kind of let the patient dictate that more? Like, I know everybody has a different treatment style, so I'm curious on yours and, um, kinda how you tackle those questions from patients when maybe there's, um, you know, a, a situation where they definitely could go FMR, but they're also on the edge a little bit where, um, it would be okay taking those teeth out as

Saving Teeth Versus All On X

Soren 10:14

well.

Ryan 10:15

Yeah. I mean, I, I love that question because it's a question without an answer, right? So which also makes it

Soren 10:22

Yeah.

Ryan 10:23

Which makes it the most fun to discuss, right? Um, but it's probably the, the most relevant question you can ask, especially in a, in a practice that's heavy on ONX is that's something we need-- we discuss with our patients l-literally every day. And so, um, the way... I don't know if I have, you know, the magic answer or God's gift to, you know, treatment planning, but the way that I've kinda settled into, um, making that decision with my patients, uh, first thing I always do is I just try to put myself in their shoes, understand what they're wanting. And usually, you know, we'll find that some patients have experienced this severe dental fatigue where, um, y- let's put whether their teeth are restorable or not, let's put that aside and just understand where they're coming from. Um, some of them are just so done with their teeth, right? To where they're just exhausted. They've had thing after thing popping up and, and, uh, they're just done with their teeth, and I, I wanna understand that, um, because, um, doing a f- FMR on a patient that hates their teeth, uh, is just a recipe for unhappiness all the way around, right? Um, but once I understand where-- what their philosophy is because if they... Some other people are on the other end of the spectrum where they think, "Hey, I love my teeth. I hate the idea of losing my teeth. I'll do anything to save my teeth." Um, then we start having a conversation about prognosis, right? And understanding, okay, if we save this tooth or this tooth, if we try to save most of the teeth or some of the teeth, I just want you to know what my crystal ball's telling me about how long this may or may not last, right? And then, um, after I understand where they're coming from, my next train of thought is, okay, where do, where on the spectrum do I find these patients? Because sometimes we'll have patients come in with a really healthy set of teeth and maybe a few issues. You know, maybe they have one bad tooth or they've got some crowding, and they're asking for im-- you know, teeth out and implants in, and those are patients we just have to turn away and just say, "Hey..." And, and obviously we have a really good conversation and, you know, "This is why this isn't wise, and your teeth are healthy and you're young." Um, but in the end, if they're insistent, um, we just have to turn those patients away, right? And but in, in a sense, that's actually a pretty easy decision 'cause the teeth are really healthy. On the other far end of the spectrum, we might have, uh, patients who come in and teeth are pretty bombed out. There's-- They're, they're terminal no matter how you look at it. And, uh, once again, it's actually an easy conversation because if they wanna save their teeth, there's nothing I can do to save them. So we've zeroed in on this middle ground of patients, right? Where, um, the patient might be philosophical about it and say, "Okay. Well, I'm, I'm open to saving my teeth. I'm open to taking them out." Um, and then I'm also on the fence because I'm saying, "Hey, I, I definitely could save these teeth. Some of them have a higher prognosis than others. Some of them don't." Um, and that's where, that's where the, the consultations go from being 20-minute consultations to maybe an hour, and maybe we need to get you back next time 'cause we g- you gotta think about this, right? And so as we're in that gray zone, um, the, I don't try to have any, like, preconceived notions of, of where I'm gonna take this. I start to try to develop what my recommendation would be But I wanna have conversations with them, and I always start down-- start out with just painting a picture of where they're at. You know, and that's one thing I picked up in, in Prost residency is don't ever try to even worry about the treatment plan until you've de-developed your problem list. And so I'll sit up, and this is actually something I devo-- I, uh, picked up from Caleb, Dr. Stott, is that I'll just, uh, screen grab their pano, and I'll just go through after I've gathered all my data and done a comprehensive exam, and I'll just draw pictures on every tooth with them on our, on our big TV and say, "Okay, you've got a cavity here. You have some gum disease here. You've got, you know, um, you know, a failing implant here. You've got X, Y, and Z, a periapical radiolucency. This is likely an infection." I'll just paint the picture for them. And as we paint that picture, um, a lot of times the gray zone starts to get a little more narrow, where we start to, um, understand each other. And I, I-- by that time, I hope I've understand what-- understood what their goals are. If they're heavily focused on saving their teeth versus if they're kind of ambivalent versus if they're tired of their teeth. As we paint a picture of where they're at, that allows us to have these conversations which are, "Okay, let's go down the-- let's go down certain roads together, right? If we were to save your teeth, this is what it would take. It would take, you know, extract and graft here. You got three teeth that aren't savable. We'd have to do s-three single implants here. You've worn your teeth. Um, do you like the way your teeth look? Are you mostly interested in function?" Um, and as we start to figure out what going down that road would look like, the patient usually gives me the answer, and they say, "You know what? That sounds good, and that's what I wanna do." Or they might say, "Man, that sounds like a lot of work, and I don't, I don't want to even-- I don't wanna do that." Um, and then I say, "Okay, let's go down the other road of implants. Um, this is what it'd look like. You know, take teeth out, put implants in. Our lab's gonna design your teeth. You walk out with teeth same day, heal for two months." And we have that conversation. Um, and once again, I get a sense for what the patient's response to that is. And then, um, I'd say eight times out of ten, the way the patient is leaning and the way I'm leaning are usually the same, where we're like, "Okay, we both know we could-- we, um... But we've had a really good conversation. We've, we've developed a problem list, and now, um I'll speak and, you know, based on X, Y, and Z, probably makes more sense to keep your teeth. And then, um, the only times where it starts to get hairy is when I, I start, as we have that conversation, I'm leaning towards I really wanna keep your teeth or I really wanna take your teeth out and the patient is opposite saying, "I absolutely have to, uh, you know, I'm, I'm... I totally disagree." And this is where... So, you know, we've narrowed it down from a thousand consults down to, you know, maybe 5% of them where it starts to get a little sticky because a patient and I will disagree on what's best for them. And this is where I don't have an answer yet, but I, I do strongly believe in a couple things. One, I, I strongly believe that the dentist is the expert, right? But I also, I'm a pretty big believer in patient autonomy and if the patient... I- if I can, uh, justifiably... Like let's say a patient wants to take their teeth out but I'm kind of leaning towards I feel like it'd be best if you keep them. Um, i- if I could kind of stand in front of, like, let's say stand in front of you guys and provide s- a justifiable reason why I would allow that patient to exercise their autonomy and take their teeth out, then, then I'll do it. You know, I might, I might say, "Ma'am, this is unfortunate and I'm, you know, uh, this isn't what I would recommend but you, you do have this number of problems and it's actually a very justifiable decision." Um, if I can't sleep with myself that night, you know, if I can't, uh, go home feeling like I did the patient a service and we're disagreed, um, we're disagreeing, then I'll, I'll just, uh, let the patient know we're not the right practice. And, uh, that's what it kind of comes down to is if I can, if I can go home and sleep, if I can justify it in front of my colleagues, um, then I'll let a patient disagree with me and exercise their autonomy. If I, uh, if I'm not gonna feel like I did them a service, if I can't sleep with myself, you know, uh, live with myself, um, then I- I'll just let the patient know, "Hey, I'm, uh, we-- this might not be the right practice for you." Um, and so, uh, that was kind of a really long-winded answer to a, a really awesome question. Um, but that's kinda how I just start big, have conversations and work down to like the nitty-gritty and only every once in a while are the patient and I really at odds with what we wanna do.

Tyler 17:32

No, I, I really like that answer. Um, I think that starting first with the problem is always a good place to start, and I like how you kind of walk... You're walking with the patient, right? You're just explaining all these issues they have, putting them all in context, and then, you know, through that you're finding a road to the solution at the same time. And I, and I really like it. And I also like how, you know, you have the power of no. I think a lot of times in, in large practices people may feel pressure to fit people into, you know, the box of clinical treatment that they offer and, you know, there's, there's no need to hamstring people into this. Like, if they... If it's indicated for them to get this done, and they're reasonable people, and they understand all the problems they have, and, um, you know, everything should be aligned towards that and they still don't wanna go with it, that's okay. They- You don't have to be convincing anybody to do anything. Um, there's plenty of people who need this and are, are gonna be logical and, and understand what you're bringing to them. Um, and, and like you said, I mean, it, it all matters, um, you know, you're- you have to live with yourself, and you have to, um, sleep good at night, and, you know, you're never going to regret a case that you didn't take. Um, if there's things that are red flags or reasons that, you know, you think maybe you shouldn't be doing this, then just don't do it and things get a lot simpler. So I definitely like that, and I think that, too, you know, it helps when, know, a provider like yourself has a much larger clinical box of things that you could do to treat a patient. Because, you know, you're not particularly incentivized to go straight for, uh, edentulating somebody 'cause you could do a lot of things prior to that and then edentulate them again, you know, or edentulate them some time later if you need to. So it- it's good that you have, you know, so many, uh, things in your toolkit. So I'm curious, so I know that, you know, you guys are doing some FMR in Boise. Um, are you doing root canals? Are you doing buildups and crowns? You doing fillings? I mean, are you doing absolutely everything? Like, how, how does that really work within the context of a, of a comprehensive practice like Smile Now?

Ryan 19:22

Yeah, that's a, that's a really great qu- great question. I'll, I'll tell you what we have not had to grapple with is I am not doing root canals, so there's no, uh, there's no decision-making there. That's, uh... I, I haven't done root canals since my last year in dental school, and that's,

Tyler 19:35

Great.

Ryan 19:36

got a great team in, in, uh, around me in town of people that I work with, and I have no interest in doing a root canal. So, um, but in terms of, in terms of, you

What Cases A Comprehensive Clinic Accepts

Ryan 19:45

know, the-- like a filling or a single crown like that, um, as we've gotten busier and busier, uh, you know, Caleb and I have had to have these discussions about, okay, what does it make sense for us to accept, um, in terms of treatment? Because, um, we, we do... I don't know if maybe this is just a, you know, a, uh, a, like a mental hurdle that all dentists have to get over, but you just kind of want to help everybody, right? So patient comes in, and if they just need a single crown, um, o-of course I'm like, "Yeah, I'll do a crown for you," or, "I'll do some fillings." Um, but as we've gotten busier and busier, I've, I've had to grapple with that and say, "Okay, I think it makes more sense to, like, let's find a good, um, family dentist for you." I've got several in town that I, you know, really like and enjoy working with and just trying to make the-- make a referral, um, because, uh, time is so limited, you know. And, and every, every hour of chair time that I spend on something, um, like, like a, uh, you know, a s- a single crown or a filling is an hour of time that I may not be able to spend doing, uh, something more comprehensive. And that's not to say that like I'm, I'm a... The last thing I want to say is I'm above that because, you know, I know a lot of really, really good dentists who do fillings way better than I do, right? And, and I'm not even close to saying that, but I, I've learned y- at some point, you have to, um, understand what you're good at and understand what you-- where you want to focus your practice and try to zero in on that. Um, and so that's, that's a work in progress, actually. Not the, uh, endo part, but everything else, being able to understand when is the, the right case to accept in our-- who's the right case to accept in our practice. If it's not Onyx and it's not FMR, um, versus who's the right case to work with a, a, uh, you know, a family dentist in town with. So I don't have a great answer for you, but, um, every case is different. I just try to, like I said, work-- walk with the patient. That was a really good way that you put that.

Tyler 21:33

Sure, sure

Soren 21:34

yeah, I wanna mention too that, um, you know, I think that the, the pathway that you take down patients where you're giving them these different options or these different roads that they can take, um, and when you get to the end, if you guys don't align, that's also a great opportunity, um, or I shouldn't say opportunity, but it's a great, uh, assessment of, of red flags with a patient. If that patient is, is totally unwilling to accept your treatment, um, you know, odds are that they probably would not been the best patient to work with in general. Um, and who knows, and I mean, I know we, we, we all deal with comprehensive cases. We've dealt with patients that, you know, nothing is gonna make them happy. So, um, you know, by not taking on that case that the patient, you know, maybe is trying to push you towards, it probably is saving you a world of hurt in the future where you might have, um, done that treatment for the patient, they spent all this money, and then no matter what you do, you know, it's not gonna be great. And unfortunately, like I wish there was a way to, to tell that for every patient because obviously there's, you know, we all run into these patients, but I think it's a, at least a good, uh, middle ground. Um, and I think the other point I wanted to make is, uh, you know, a challenge that you have that I think that Tyler and I probably don't is the fact that because you have all these options for patients, I'm sure it's a very tight line that you have to walk where, uh, you're giving patients options, but you're not overwhelming them with options as well. Because a lot of times the patients whom are coming in with all these issues, they, like you said earlier, have gone through all this dental fatigue where they've been, you know, maybe doing one root canal, one crown, one implant here and there, um, and they just want a solution from somebody. Um, so I really respect that, you know, being able to navigate that while also, um, still, you know, selling treatment and being able to complete treatment on the patient. Um, it's a, it's a cool thing and it's, and I'm, and I'm really happy that we're able to offer it in Boise. We're able to offer it now in Denver and then, um, you know, Tyler had just, has just hired his associate on as well, um, who also is a prosthodontist, right Tyler?

Tyler 23:54

that's correct. Yeah

Soren 23:56

so it's just, it's great that, um, we're slowly transitioning our offices into a more comprehensive solution for patients, not just, uh, you know, a fixed clinic where, where every single, um, patient is a hammer and all we have... I'm sorry, every single patient's a nail and all we have is a hammer.

Tyler 24:14

Some, some patients are hammers actually, now that

Soren 24:16

I mean,

Tyler 24:17

you say it

Soren 24:17

true too. Absolutely. Ugh

Tyler 24:20

Um, yeah, no, no. Great, great points all around there. And, um, yeah, I, I definitely think that it's, uh, it's a, it's a bit of a luxury to have, you know, such a small suite of, of a clinical, uh, repertoire because, you know, it's pretty obvious to me what cases are mine and, and which ones aren't. Um, but, uh, something I am curious about is so when you do have patients whom, uh, who need a hybrid on, on one arch, and then they need maybe some FMR on the other arch, how do you typically sequence that, right? So typically it's mouth. Now, of course, you know, uh, if we're doing just an all-fixed case and we're edentulate and someone put in implants, you know, we put a patient to sleep under general anesthesia. We go in, take, you know, teeth out, put in implants. They get new teeth the same day. You know, uh, ev-everyone kinda knows how that goes, especially if you listen to the show. What happens if, let's say, you're doing an upper, um, arch, and then on the lower we're just doing a full suite of crowns or veneers or something like that? How do you typically sequence that? Do you take advantage of that sedation and do, um, some of that lower treatment as well? Or, you know, how does all that work?

Ryan 25:22

Yeah, so that, that's a really awesome question. Um, I think in terms of Uh, what you mentioned at the end there, taking advantage, advantage

Sequencing Hybrid And FMR Together

Ryan 25:29

of sedation. Um, I th- I think that's always a good idea, you know. So if I can, if I can prep some teeth at the same time that I'm doing, um, implants, uh, one, I, I think sometimes my staff might hate me because they have to set up, you know, three times as many things, and they, they're transitioning these carts of setups, you know, in the, into the surgical suite. But, uh, that aside, uh, it's always a good idea to take advantage of sedation and hopefully not to have to sedate people more than you need to. Um, but it does... Uh, from a diagnostic perspective, it can get a little challenging where if you have to do, um, if, if you're looking at this from the perspective of who do I have to work with in order to make this, uh, case successful, uh, at least the way we have it right now in Boise, we're using, um, a different lab for our All-On-X than we're using for our crown bridge. And so, um, that, that's kinda where the rubber meets the road in terms of complexity, is making sure that, um, y- you know, 'cause if you, if you are using just one lab, you can kinda have the lab, the same lab design the sa- the crowns at the same time that they're designing the All-On-X, and you can kinda do it all at once. Um, but I, I guess I'm a little picky, and I've, I've got my people I like for certain things. Um, and so the... My step one, whenever I, whenever I'm looking at that and I'm like, "Okay, this is complex," step one is always, for me, just a smile and occlusion design, right? And so, and I can have either lab do that, just say, "Hey, on the upper is All-On-X," so you have total freedom in terms of where you're placing the teeth. Um, and as you know, our labs do really good at that, um, getting pre-surgical designs ready. Um, and then on the lower, if you're ever doing a smile or occlusion design, you're, you're bound by where the future margin of that crown is gonna be. And it's really important that whoever's doing that pre-design understands that, so that they're not putting, you know, a crown and bridge tooth somewhere off in space where they're, you're never gonna have a margin there. So as long as, as long as my lab technician understands, "Hey, you know, my, my crown and bridge is, is bound to a margin. My All-On-X is a, you have a little more freedom there." Um, then getting that initial smile design, um, you can use pretty much anybody y- you want. Um, at that point, then if the crown and bridge is very, um, if the teeth aren't gonna be changing position or shape all that much, like let's say they're getting a FMR because of caries, but the overall shape of their teeth is, is pretty straightforward and you're n- I'm not gonna be doing any major, you know, shape changes, then it's pretty, uh... It doesn't necessarily matter what order you go in, 'cause you could get an All-On-X upper, um, to prototype state or, uh, to prototype, um, or even in, in the healing teeth. You can get those in prototypes, and then you can catch up on the lower, um, because the occlusion's not gonna change that much. Um, where it really matters is if the... Like let's say in this example, the lower occlusion is, is a wear case, and we're gonna rehabilitate to, um, you know, we're changing the height of the teeth, we're opening the vertical, and we're gonna have a lot more cusps and teeth in different kind of restorative positions. Um, then you kinda do have to, um, phase it out to where, you know, I might get somebody in healing teeth Top. Um, and while they're healing, we can, we can prep an arch down below and get them into temporaries there, and then we can design their upper prototype to their lower temporaries. And so you just kinda play this game of back and forth and which-- where's my limiting factor, which teeth are the ones that are changing the most. Um, and then once, once you're in a nice set of, um, FMR, you know, crown and bridge temps and a nice set all on X temp, you know, the prototype, um, then everything's golden and you could restore, you could restore in whatever order you want. Um, and that's, that was a huge takeaway from prostho residency is that the, the key to successful final is a successful temp. Um, if I got-- if I figure out and work out all my design changes and all my design issues and my occlusion and my vertical and the temporaries, you could, in theory, restore one crown at a time and be just fine. You know, nobody would ever do that. But, um, at that point, it's just convenience. You know, does the patient wanna get their upper final done, or do they wanna have their, their lower crowns done? Um, and like I said, we're working with different labs, so we would phase it. But in theory, you could also just do them all together if you have one lab taking care of everything for you.

Tyler 29:31

So I'm curious too, you know, when you're doing those combination cases, how are you typically looking to set up your occlusion? Let's kind of stick with that prototype of, you know, upper, um, fixed and then lower FMR. Um, how do you-- what are, what kind of occlusion are you generally going to be aiming for? Um, and in that respect, you know, do you need to address one arch over the other first in order to maybe establish an envelope of function per se or, you know, what, what would you say to that?

Ryan 29:59

Yeah. So for my occlusal, occlusion is one of those things where you talk to 20 dentists and you'll, you probably get 20 different answers. And, and I don't pretend to be like a, a huge occlusion, you know, occlusion guru,

Occlusion Principles For Mixed Cases

Ryan 30:10

but I, I try to follow really good principles, right? And so as I've, as I've learned about occlusion, I've realized there's some things that everybody agrees on that are really simple and that we, you know, um, that nobody... it's not controversial at all. And then there's some things that we, um, believe we know to be true, and then there's some things that, um, there's a lot of controversy on and people don't necessarily agree with, right? So I always start with, okay, what's, what's like the most important thing that everybody's gonna agree on? And that's the, y- the simultaneous bilateral even posterior contact, right? So just all the teeth touching in the back at the same time. And I don't think anybody would, um, disagree or that that's the most important thing, is to have all the teeth touching equally at the same time, especially in the back. Um, and then you start talking about the role of the front teeth, right? And, um, if the front teeth are healthy and they're in good shape, I do like to have the front teeth coupled. And, um, this is where you start to get into these little nuances where we may not have a lot of literature to support this, but we have decades of occlusal gurus g- giving their, their opinions, right? But from what I, what I've seen in natural teeth, we... it's nice to have the anterior teeth coupled. It's nice to have anterior guidance, preferably on the canines as you're going laterally. Um, I like to have my canines hit with the e- the same intensity that my posteriors hit, but I like to have my incisors, um, hit with a little less intensity, you know, to the point where you're, you're dragging shin stock instead of holding it. I think that does a couple things. I, I think when you have natural teeth, it prevents the natural teeth from destabilizing because the upper maxillary teeth are at such an angle, um, and you can destabilize them if they're hitting hard. When you're talking about implants, then you're, you're kind of, you know, you're, you're playing this game of, well, uh, should my implant occlusion be designed the same as my natural tooth occlusion? And I think in this case, the safest and best answer is, uh, should be pretty close, right? And so, um, in that hypothetical scenario, I would have a little bit of relief of the anterior teeth. Um, and it does help stabilize the lower teeth, but also it helps, um, like if you look at the concept of, uh, long centric, that's kind of a, a Dawson, uh, concept. It gives people just a little bit of space on those front... And I'm talking micro, but it keeps them from feeling like they're locked in. You know, you mentioned the envelope of function and, and, um, if the anterior teeth are hitting heavier, um, there's a chance that the patient can feel kinda like they're locked in. Um, and so you give them just a little bit of w-wiggle room up front. And I, I-- And then the next thing you talk about as well is, is anterior disclusion just as important with implants as it is for natural teeth? And it, it may not be, I don't know that we have the literature to support either way. But it does make sense to me to keep the disclusion up on the front teeth, on the canines, um, because the closer you get to the TMJ, the, the closer you are to that fulcrum. And, and, um, I can just see when my, when, when my patients have posterior interferences on their side to sides, and I get rid of those, I can see everything just look, feels smoother to them. Um, but I always couple that with, uh, I say, "Hey, I'm gonna, I'm gonna check your grinding your teeth side to side, but I never want you to do this in real life. Like, I never want you to be a tooth grinder, so I'm gonna check it, but don't do it," right? Um, so yeah, simultaneous bilateral posterior contact, coupled anterior teeth. We need enough overbite to be able to have anterior and canine disclusion, 'cause if, if the overbite's not there, it's not gonna... Uh, if the coupling's not there, you won't have it. If the overbite's not there, you won't have it. And then I just try to make sure there's not, um, you know, maybe a little bit of group function with the premolars, but no big posterior interferences. Um, and then I think once you've checked all those boxes, um, kinda the more esoteric stuff beyond that, you know, starts to be, you know, uh, whatever your preference is. But as long as I've done those things, I feel like I've done a, you know, a good service to the patient.

Tyler 33:53

Yeah

Soren 33:54

Um, I think that's a great answer. Uh, a question that I had previously before we got into occlusion was just when you're, when you're temporizing teeth, uh, are you doing this with printed material? Are you-- You know, like, what, what's your, your preference on natural teeth for, um, for your, your attempts? And in, in my clinic, we are using the same material as our, as our, uh, fixed cases to temporize for, you know, the period of time. Um, but I don't know if that's the correct way to do it, and I'm, and I'm just curious, like, what, what you found to work the best, um, when you're doing these, you know, hybrid cases of fixed over, over natural dentition.

Ryan 34:35

Yeah, so I've tried everything, you know, chairside, uh, printed and milled. And I'm actually, at least for the time being, and the technology in printed is changing all the time, um, but for the time being, I'm, I'm shying away from, um, printed temps on my natural teeth. And, uh, my first round of temps, like as I prep people, I'll just put them in chairside, you know, Integrity, ProTemp, Bis-Acryl type of temporaries, um, from a matrix. Um, and I'll, I'll let them try that out for a little bit, gives them a chance to see everything. And, but obviously even with my best chairside skills, I'm never gonna,

Printed Versus Milled Temporaries

Ryan 35:09

I'm never gonna have like a fit or closed margin the same as a nice set of milled temps. And so for my, my natural tooth, I'll, I'll have them, I'll have them spend a couple of weeks in my chairside temps, and then I'll transition them to, uh, milled crowns. And I've just found I, I like the fit, the margination, and the color on milled, um, milled PMMA temps on my natural teeth so much better, um, than I do on the printed. And printed works really nicely for All-on-X, but for whatever reason, I just haven't been super happy with the margination, um, and the fit and the e-everything just is a, a little less... Gives me a little more, uh, problems than if I just go straight to milled, um, from my chairside temps. So I know, you know, there's a lot of gurus out there about 3D printing, and I-- my experience in trying to do those was that I had to increase the cement space. Um, but even when I did that, I just was never quite happy with the, the fit. And then, like I said, you don't always have as many, you don't have as true of like a color replication. And so if I'm trying to give my patients a real idea of what their final color is gonna look like, I feel like I get a more true, um, a true test drive there with a set of mill temps. So, um, that, that might evolve as things go on, um, just because that technology in 3D printing is changing so much, but that's where I'm at right now.

Soren 36:24

When you are milling your temps, are you segmenting those or are you doing them individual for a full art, for like a FMR?

Ryan 36:31

yeah, I, I just treat every case... I look at every case, uh, individually. If, if my preps are nice and tall and I've got really good axial retention, I'll do maybe groups of two. You know, I've done singles and, and tho- that didn't work out very well for me. So I'll do groups of two or three if I have really great retention. If the teeth are a little shorter, I don't have the axial retention that I want, then I'll group, you know, half an arch or even a full arch. And, um, as I'm working with my lab technician, that's just one of the, one of the aspects of my RX to them, you know, is, you know, telling them how many... You know, I'll give them free wi- freedom too to make that decision. I'll say, "This is what it looks like to me, but if you feel like you need to change that, let me know." Um, but my, my preference would be, you know, two to three because you can work with them easier and it also allows them to floss and it, it's, uh, you can replace segments easier. Um, but I'm, I'm open to doing even a full arch of splinted if, if the retention's there or if I know the patient's like a heavy bruxer, so

Tyler 37:28

Would, would you, would you actually do a, a full arch, uh, splinted final on the FMR or is that always gonna be, you know,

Ryan 37:34

Oh, no, no. Just, just for the temps. Sorry. Um, for the finals, it's always palatal shingles. Yeah. You know, I mean, that's an interesting question about stabilizing periodontally involved teeth and if, if there's a role for that, you know, in 2026. Um, but I don't know. I'll, I'll leave that up to the, you know, the smarter minds than mine to figure out if that's still a valid treatment plan. But no, I haven't, I haven't done splinted finals

Tyler 37:57

Yeah, I actually did a surgery today on a patient that had some really serious periodontal disease, and he actually splinted all of his teeth with calculus. And, uh, it, it, I think it gave him probably another few years on his teeth, so I think there's something to be said for it.

Ryan 38:09

Yeah, no, there you go. Especially satisfying to knock out when you're pulling the teeth, right? So

Tyler 38:15

Yeah, it's satisfying, but, uh, this one I actually closed my eyes for. It was, it was something. But, um, I'll send you the video. But anyway, um, yeah, so no, that, that's, those are some really great insights because, yeah, when it comes to doing combination treatment like that, especially when you're using multiple labs, that, that really kind of made me kind of complexify that in my mind, um, and not really see, um, you know, how you would wanna approach that. you know, uh, I would say d- far as, like, planning these cases, you know, uh, between... Especially if you're working between two different labs, you know, how do you kinda get that communication across with, you know, how things are pre-oped and how that initial setup goes between the, between two arches?

Ryan 38:56

I think the, the short answer there is just to over-communicate. Um, so I, I think, you know, sometimes people give me a hard time for this, but, uh, maybe I'm a little wordy with my patients, and I'm definitely, um, wordy with the labs. So I, I actually don't-- I don't like checklists with labs. I don't like, uh, the checkbox. Um, uh, one thing I've just picked up is that if I just write a narrative to the lab and say, Hey, this is what we're doing, this is what, you know, you might notice about this case, this is what we want."

Lab Communication That Prevents Errors

Ryan 39:24

And then always, um, uh, you know, part of good communication is not just being understood, but ensuring that you can't be misunderstood, right? And those are kinda two different things. So I'll always explain what I need, and a lot of times I'll explain what I... make sure that they can't misunderstand what I'm saying. Um, and I've just found by over-communicating and by submitting lab RXs that are narratives, you know, paragraph style, um, I can, I can end up getting, uh, more of the result that I want than if I, if I fill out a lab RX with just like, you know, clicking a few boxes or checking some boxes, um, 'cause it leaves too much out of my hands and too much in the hands of the lab techni- And it's not really fair, right? Like I've... In prosth residency, I did a, a ton of lab work, um, and I know just how hard it is to, to make miracles on the lab bench. Um, but when there's like a, uh, a lack of information about like what is the, you know, what is-- what do they want here, you know, it's, it's even more unfair to our lab technician friends. So I, I think just out of fairness and to be, to be, you know, good stewards of their time, giving them, uh, an extra measure of, uh, information so that they understand kind of the nuances of what we want, I think that's, that's good practice. Did that answer your question? I don't know if that was an answer to your question or not

Tyler 40:35

No, no, no, it, it absolutely is. And I think, you know, good communication is definitely essential when you're working between, um, you know, multiple labs. I mean, that, that just sounds like a lot. Um, but, uh, but no, no, that, that's very good. And, and I, I actually like your bit about not using checklists because I think sometimes, um, you know, having... I, I worked in a lab myself for some time and, you know, when you're just kinda going through checklists, it's kind of like y- can get really focused in on just, like, these little bits of everything and maybe not getting a whole comprehensive narrative together. Whereas when you just write everything down and someone has to sit there and, like, read this, maybe it takes them a little bit more time, but they'll certainly get a much better and more accurate portrait of, you know, what you're trying to convey if they're not just going through a list, right? Um, so I, I like that, especially if, if, if you've got a complex case, you know, write a narrative, and I think that makes more sense. Um, so I'm curious too, you know, when it comes to working alongside, uh, Dr. Stott, um, you know, you guys do have a little bit of an overlapping skill set as well. So, 'cause y- you're both surgically treating, you know, hybrids and, and, and doing those types of cases. How do you guys typically divvy cases up? How do you figure out who's doing what, and do you work together on the same cases sometimes?

Ryan 41:40

Yeah. Yeah, no, that's a great question, and it's, it's always in flux. But the way we've kind of, uh, uh, you know, the division of labor is, is that he's primarily surgical, um, but always willing to help on the restorative as needed. Um, and I'm, I'm probably maybe seventy percent restorative

Dividing Surgical And Restorative Work

Ryan 41:58

and thirty percent surgical. Uh, you know, I'm just making those numbers up, but it's, uh, it's about what it-- how it plays out. Um, and so, uh, the hard, the hard part is not actually, you know, Dr. Stott and I figuring out how we wanna split our time, but it's actually, uh, scheduling, right? And so translating that, uh, vision to our staff, to the front desk, to our assistants, and making sure that, you know, everything is scheduled appropriately, um, just because certain things will, will play out differently on the schedule. You know, um, all-on-X takes-- You have to block off a big portion of the day. You have to, you know, depending on if you're working with a CRNA, you have to work with their schedule. Um, but some of these restorative things, uh, you know, we're planning these out weeks and months in advance, and so they'll be on the schedule before I even know that I might have a surgery that day. Um, so the, the division of labor is pretty easy. He's primarily surgical, and I'm, I'm about, you know, two-thirds to one-third, but, um, translating that to a really successful, uh, schedule with our staff has been a challenge.

Soren 42:56

Oh,

Tyler 42:56

Yeah, I can certainly believe that. How, how long do you have to block out for, say, like a, a full arch of, uh, crown preps? I have no idea

Ryan 43:03

I mean, I'll, I'll... If it's just one arch, either way, I'll pretty much book the whole day. Um, if it's two arches, it's definitely the whole day. If it's one arch, you know, it depends if I'm doing just premolar to premolar. It depends on if the patient's gonna need a lot of breaks. Are they sedated or not? But two arches, it's always a full day. And even then, you know. So I, I'm not the, I'm not the speediest either. I know people can prep faster than I can, but, um, if I'm prepping two arches and getting them into temps, you know, I just know I'll be going home at probably 5:00 or 6:00 that day, wrapping up the case, and I make sure to tell the patient that as well