CBCT, AI, and Implant Success: Insights from Dr. Steven Vorholt

When someone is starting to practice or buying a new practice, to me, the CT, and obviously I'm biased because I've used these for 10 years, is a necessary piece of equipment. I couldn't practice without it, even if I wasn't doing implant surgery. I mean, the amount of pathology you find for endolesions or fractured teeth or orthodontic treatment planning, it's amazing. Welcome to the Phil Klein Dental Podcast. Today, we're going to be diving into a game-changing technology in modern dentistry, truly game-changing. CBCT imaging. We've heard all about it, with its ability to enhance diagnostics, streamline workflow, improve precision and accuracy, and even boost case acceptance. In this episode, we'll break down what to look for when purchasing a CBCT machine and why the features a salesman typically highlights may not be the most important factors to consider. while we'll focus primarily on how cbct enhances implant procedures the reality is that this technology benefits nearly every aspect of dentistry improving outcomes across a wide range of treatments if you've ever wondered whether cbct is the missing piece in your practice stay tuned we've got the insights to help you make the right decision Joining us today is Dr. Steven Vorholt, a board-certified dental implant specialist practicing in Santa Barbara, California. Beautiful place to live. Dr. Vorholt has helped over 1,000 dentists place their first implants and has educated thousands more through lectures, webinars, and podcasts. He has his own podcast called The Full Arch Podcast. Dr. Vorholt, welcome to the show. Thank you so much for having me. Yeah, we really are very happy to have you. And you did a great webinar for Viva Learning. The title of that for our audience is Mastering Implants with CBCT, Essential Insights for Precision and Efficiency. Again, talking to the audience, if you're looking to get an idea of what's happening, the latest and the greatest, that one hour webinar covers a lot of material. And one of the things you address in that webinar is the fact that when dentists are looking to purchase a CBCT machine, they have top of mind some criteria that may not be really what's important. Absolutely. And I think those of the listeners who have watched that webinar or are going to, I speak a lot faster on webinars. There's quite a bit of content in that 60 minutes. I somehow squeeze it in. I'm a little bit slower on podcasts so we can take our time here. But when I bought my first CT, it was in 2000. And I did my first initial implant training in 2015. And I placed about 70 implants that year with what I call the Pano and a Prayer because I didn't have a CT. And I didn't know what I was missing at the time. And thankfully, there was no catastrophic issues. The second year in 2016, I placed about half as many. And then I purchased the CBCT at the end of 2016. And what had happened was I had become, I was in that doldrums of the Dunning-Kruger where I started to realize what I didn't know. And the CT is what enlightened me again to... feel confident in moving forward with more surgeries. And then the numbers increased back to beyond what they were at the beginning. But when I was buying that first CT, you go to these conferences and you walk into the vendor hall and the CT companies, the imaging companies usually have the biggest, best, coolest booths. There's a lot of money in imaging for a good reason. And when you're walking around, it's very easy to get kind of tricked into the salesmanship of the machines. And the three things that I looked for, and this is all personal experience that I've now, as I've helped other people look at CTs, kind of seeing this as a theme, is its field of view, its rendering quality, and it's the voxels. And it's all the technical stuff. Because dentists are very technical. It's our best and our worst friend that we want to know all the details. And so if a salesperson comes over and says, oh, you've got to use our machine. Our voxel is 0.07 microns or something. That sounds fantastic. You look at the field of view. The field of view shows the whole skull. Well, we can talk about whether we want to see the whole skull or not. There's a lot to talk about there. And then the other big thing is you're walking around these vendor fairs and you see these big screens with these beautiful renderings. It looks like someone's actual skull you could pick up and hold in your hands. And how much value is actually in those things. But those are the flashy things that salespeople would kind of talk to you about. The more things I bought, the more equipment I've done, the longer I've been a dentist, the more I realize the things that the salesperson leads off with is probably not what I should really be focusing on. Right. Those are the things, right? Yeah. So let's start with the field of view and go over that real quickly. Sure. So I'm an endodontist. I don't practice anymore. But when I did, if I had a CBCT, I'd be looking at something like a five by five, right? Absolutely. Something fairly focused. And with that, I'm going to get greater voxel detail. So clarify that so we understand when they're talking about field of view and voxel detail, how those two are part and parcel of each other. Absolutely. When you're looking at voxels, I liken it to the pixel. It's like a three-dimensional pixel. What is the smallest unit that you can, as you say, go slice by slice in? When you get to bigger field of views, the voxel gets larger too because there's a little bit less clarity when you get to the larger dimensions. So everyone's going to tell you their voxel based on the 5x5, which is generally now termed as the endoscan. And when you do a 5x5 in a modern machine, we're talking on the level of like 7 microns, like 0.07 something. It's very, very, very small. What you would hear with these machines, if someone would come up and say, oh, ours is, a couple years ago, ours is 0.875, you know, that's our voxel. Well, not when you scan them at an 8x8, then it's 0.3, you know. And so what you really want to know is, what is the voxel relevant to what I'm going to be scanning? And certainly as an endodontist, you really care about the tightest voxel at a 5x5. But generally... I take my scans at full field of view because I'm doing full arch implants and maybe even planning for zygomatic implants. And so I care to make sure that at the larger field of view, I don't lose quality. Because of course, the salesperson is going to tell you the best voxel possible. I want to know kind of what's the worst voxel possible when I'm actually going to be reading it. Absolutely. And tell us about that. That first visit, why you like to go with a full scan and what are we up to now? Are we looking at like 17 by 12? Is that something? That seems to be the limit that I think anyone in general dentistry ever needs. Anything above that, we're talking about frontal sinus, top of the cranium. That's OMFS, you know, maybe doing large. traumas or large surgeries, orthonathics and whatnot, a 12 by 10 will get you just about everything you could possibly need to do implant surgery outside of the zygoma, which is probably when you get to get the 12 by 17. And so for me, you know, there was some studies that came out and it was a periodontal study. you know, you're an endodontist, I'm a general dentist, so we can both rag on periodontist. But, you know, the study was showing what's the smallest voxel where you can actually detect accurately a vertical defect around the tooth. And they determined that 0.2 was kind of the, that was the turning point. Anything better than 0.2, you could still detect. Anything worse, it got a little bit harder. But there was minimal. advantage to having a 0.07 if you're talking about perio defects, which in my mind is kind of relates to implant surgery. I don't need to necessarily see the mesibucle 2 when I'm planning an all-in-4. But it's good to know, depending on the scope of your practice, you know, what it is you're looking for. So anything better than 0.2 is what I look for. So my 12x10s and my 12x17 scans are shot at a 0.2 voxels. So I can still see a lot of fine detail in these cases. My first CT was an 8x8, and I quickly realized that that was not enough to do anything related to the sinus. One of the first things most implantologists learn is sinus grafting after they learn their first initial training because more than half the implants end up being in the posterior maxilla. People lose teeth up there all the time. And what comes into play? Well, of course, the sinus. And you take the first course, and then the guy or the gal says, in order to accurately diagnose and treatment plan sinus lifting, you have to see the osteo. So you have to see the osteomeatal complex, which is at the superior. posterior medial wall, all the way in the top back inside corner. And an 8x8 is not going to capture that. You're going to see the bottom half of the sinus, and you can guess if the sinus is healthy. But what you might not see is a polyp or some inflammation at the osteomedial complex, which could then... kind of doom your sinus graft because if there's no ability for the sinus to clear itself, you can get these big infections that can lead to very, very horrible things. So one of the things you'll notice when you start reading things like what dental boards are talking about and standard of care is that anything to do with the sinus, you need to see the top of the sinus. Well, that's at least a 12 by 10. So I had quickly shot myself in the foot in a sense by I was now, I had limited myself by choosing a smaller field of view out of fear because the fear was if I shoot it, if I take the radiograph, I have to read it. And I think you're spot on there. I think a lot of dentists feel that if they take a film, a 3D image, and it has tons of information beyond what they feel comfortable with, they feel like they're responsible for any pathology that's in that area because they had the opportunity to detect it. at an early stage, and they didn't. But as you said in your webinar, and I agree, instead of worrying about what you're missing, learn how to read the image. There's educational resources that could teach you very well how to read the image. And of course, you're doing the patient a great service to catch something early. So having said that, it would make sense to me to purchase a CBCT machine that you can grow into, not knowing what you're going to be doing in the future. Right, right. I love that you said grow into it, because that's actually been my my latest turn of phrase is you know with with when action came out with the new optima which was i was speaking about on the webinar it unlocked the 12 by 17 field of view which previously they had capped at 12 by 10 or 10 by 12 however you want to say it and now when you buy the optima machine it starts at 10 by 12 and if you unlock like unlocking tesla tesla auto driving or whatever you can just pay a fee and it unlocks it now you have 12 by 17 so what's what's nice about that is you don't have to pay for it if you're not going to use it but you're also not locking yourself into a machine that may become obsolete in five years you know because here's the thing if you would ask me five years ago if i'd ever be considering doing cheekbone implants i would have said get lost you're crazy and Five years is not a long time for a machine that costs you $50,000 to $100,000. It's something you have to kind of be forward thinking, but it's hard to think that far ahead because five years in dentistry is a long time, especially for a younger doctor. So when you do your first implant, do you think, I'm never going to do immediate implants, or I'm never going to do this, or you don't even know. So I do like the idea to be able to grow into a machine, but certainly if your comfort level is the 8x8, the dentition, then just make sure that your staff shoots an 8x8 when you're seeing a new patient. It is a little tongue-in-cheek to say just learn how to read the CT. I do think for some reason there's this disconnect or this fear from 2D to 3D where we're all very comfortable reading panoramic radiographs. All of the pathology that's in a panoramic radiograph also shows up. in a 3D CBCT. As a matter of fact, it's easier to find in a CT. So you're just as liable for everything in that pano. But I think a lot of people just kind of can glance at the pano and they know if something looks funny. That's going to happen with a CT too. Once you get used to the machine and reading through three dimensions, you'll pretty quickly pick up what's normal versus abnormal. And if in the meantime, in that first couple months, you want to have a radiologist or a team of radiologists read each CT for you for $90 or something like that. that for a pathology review, that's something you could bake in to the cost, you know, if you choose to charge your patients, which is a whole different conversation. Yeah, no, no, that's a very good point. What would be the best way to become more proficient in reading these images outside of the typical 8x8 area? You know, it was not easy. When I first got it, you would get some training from... um whatever the ct company was at the time but it would be usually from the technician who was just showing you how to use the software i found some really good videos through online webinars like a viva webinar like you could have there's some radiologists who do travel the circuit and you might see them at conferences and they'll show you kind of the general ins and outs um textbooks you know there aren't very many obvious choices like when it comes to implant training you know oh you go to one of these three places so you have to kind of you have to go look for it you have to seek it out Um, I've read I don't know how many thousands of CTs now, so I do forget how second nature that's become. But I do have a course where we talk about CT review, and I do it with Acteon generally. But, yeah, there's a couple great webinars out there. Like I said, look for people at conferences. Yeah, and Dr. Azevedo, who is pretty well known, he has an online course. We're actually going to be working with him and putting an online course up. That's coming soon. at Viva. So you can actually purchase that course through Viva at vivalearning.com. It's not up yet, but it will be in a couple of months. So getting back on track to what you really need when you're making the purchasing decision for a CBCT machine, it's interesting because Action, who's a leader in all of this, focuses on three basic principles, software, size, and simplicity. Does that align with what you are proposing as three key components to keep top of mind when purchasing a CBCT? yeah i think the thing that people don't know they need until they have the ct which was my experience was something very user-friendly because you know the machine shoots a beam of radiation and then you can read it but how do you read it what's the software that allows you to ping back and forth and look through it that's probably the most important thing so something that is easy to use user-friendly the ui makes sense um you know i used to do a lot of stuff in blue sky bio which is a very powerful software but boy oh boy It takes like an engineering degree to really understand what you're looking at. It certainly isn't good enough to show a patient. So nowadays you have these beautiful softwares like AIS 3D that comes with Action. You can put that on a big screen in front of a patient and they can read the x-ray with you. What has that done for you as far as case acceptance? Here's what it does, especially if you're a younger doctor, is it immediately gives you credence because the patient is... kind of diagnosing along with you. And when you can showcase and you bring in STL overlays, you know, scans that you did on the patient's mouth and overlaid under their CT, plan the implant, show a little crown. You can, I, what I tell patients is I've just done the surgery digitally. All I have to do now is do that in your mouth, and I even have this little thing that will be 3D printed that will help me do exactly what we just did. And you get pretty fast at it. I can do that in a matter of minutes. And the patient kind of goes, wow, A, this doctor knows what they're talking about. B, they have the highest tech super software. So I'm very confident that this is a cutting-edge office. And they can say, wow, I need this, and this looks very simple. And I can see as well. And then you talk about, besides implants, like if you show somebody an endodontic lesion, and you and you're scrolling through and you see see these see these teeth how tight the bone appears to be there's no gap around it then you kind of scroll into the one that's bad they can their eyes will go oh my gosh you know like oh i see it And so there's a lot of that with the CBCT. And I think, you know, going back to the panoramic being a little bit harder to read and maybe our liability is a little bit fuzzy. It's at the same time, don't we want to find all the pathology? That is the goal. Yes, that is the goal. We don't want to hide behind the fact that we couldn't find it. And how many times have we taken... I mean, someone comes in, Doc, I have a toothache on the upper right. I don't know where. Everything in the mouth looks okay. PA's useless because the zygomatic's arches in the way. Pano, useless. You got the hard palate. The CT will show you which root it is. with with 100 clarity right and how to do the root canal and everything else and so you don't want to limit yourself and anymore with the price of these machines i mean when i bought the eight by eight machine it was 125 000 and now you can get a 12 by 17 for half that what used to cost for a panoramic machine which everyone had to have right so when someone is starting to practice or buying a new practice to me The CT, and obviously I'm biased because I've used these for 10 years, is a necessary piece of equipment. I couldn't practice without it, even if I wasn't doing implant surgery. I mean, the amount of pathology you find for endolesions or fractured teeth or for orthodontic treatment planning, it's amazing. And just showing the patient, even if there was no pathology, if the patient is a super healthy patient, just showing their skull on the TV in front of them will have them talking about your office for probably the next three hours. Then they'll forget all about you. No, it's very impressive. You know, it's a fantastic way for you to showcase the high tech in your office directly to the patient where they can see it, get it, and kind of realize what's going on. And you'll see so much more treatment to do. So the cost for me was an afterthought. And I think our listeners, Dr. Vorholt, will be very surprised when they hear what you charge your patients for 3D imaging using the CT. Tell us about that. I have never charged for a CT in my career, and I've been doing CTs for 10 years. I have found so many more productible treatment plans through a CT that I otherwise would not have found. than I would have ever made in trying to charge $300 for a scan and having the majority of people say no or opt out or what have you. And I know some people will say, well, we charge $300 for the scan, and if the patient moves forward with an implant, we deduct that. Why are we putting this limiting factor? You've already got the monthly bill. You're just paying for the electricity that runs the machine. Scan everybody within... you know, within reason, you know, I'm not going to scan my three-year-old, but any new patient, I would get a full dentition scan because I want to see everything. So you're saying that if you charged for a full scan on a new patient and you told them that it was going to be $300, they would say, no thanks? in some cases it's almost never covered by insurance right so a lot of times it's you either have this very high new patient appointment cost which is going to rub some people the wrong way maybe they won't even schedule or if you decide let me do my normal fmx and pano or what have you and then hey by the way mr jones you're missing a tooth on 14. i'd like to take a 3d x-ray so we can diagnose and see if you need an implant well that's 350 well mr jones hasn't cared about that missing tooth for you know 15 years but if you already had the ct and you can show him look at the sinus here you see how this tooth starting to drift you can see i've already planned the implant here in my office five minutes ago here's the surgery there's no barrier we're just automatically talking about replacing that tooth so given the fact that you're not charging for the scan um what's the time commitment on your side for getting the image up on the screen possibly with a digital wax up of the missing tooth perhaps with the implant placed in the bone digitally? What does all that take as far as your time? And apparently it's worth it because you've been doing it for free for 10 years, so you're obviously getting high case acceptance. I think so, and for two reasons. One, like we talked about before, it shows the high-tech ability of your office and your staff and yourself. And two, I think they can see the passion when I'm talking about it and spinning their head around and all that kind of stuff. You brought up an interesting point, though, because there's a time required to do this. I was at Chicago Midwinter where I met your son, and I was hanging out at the Action booth, and I started racing. the other technicians there to see how long it would take me from a fresh scan to import the internal scan design an implant wax up build a surgical guide and export the surgical guide and i did it in two minutes and 12 seconds and i am probably the fastest in the west when it comes to that software and that's using the acteon software that the native cbct viewer yeah the viewer that has built-in tools that you can you can opt in to have the guided stuff and so 10 minutes is a very reasonable amount of time to do all of that however 10 minutes. A lot of dentists listening to this are going, I don't get 10 minutes. Not between hygiene checks and doing everything else. So what's really cool that I'm excited about is the integration of a lot of AI tools that's starting to come out into the CT. And so the latest version of AIS 3D, which is what they call their software that's attached to the... It was called 5.4, and it introduced the first round of, I'm sure, countless rounds of AI integration. And some of them include things that you would consider pretty standard, like the panoramic curve generation and bringing an internal scanner. So let's say you have a prime scan and you want to export the STL into your CT. You hit one button. wait 15 seconds, and it's automatically aligned. It stitches right over the CT scan. Exactly. No more trying to go in there and say, oh, this point matches that point. So let me ask you this question. It would be much more interesting for a dentist to offer the CT scan for free if they didn't have to put any time into it, meaning a staff member could be trained to take the CT scan, do the panoramic curve, align that up, take the intraoral scan, stitch it over the ct scan do the digital wax up on the missing tooth and even possibly place the implant in the bone digitally and then when you walk in all you got to do is sell it and then you didn't put it dream yeah you didn't put any time absolutely so this is so you're what you're talking about you're on the cusp this is what's coming up so yes they can do that they can take the scan they can do the panoramic curve they can bring in the interval scan i've seen the beta for the wax up stuff and i've seen the beta for the implant plan it's not there yet but it will be because as everyone listening to this knows ai is exploding very quickly and it's the perfect it's the perfect use of ai because or machine learning if we want to get specific because they can look at a thousand implant plans ten thousand implant plans and the machine can learn without us even telling it why and where and how big and how long and what type and all this kind of stuff that is ideal so i don't see in the next two years it being ridiculous at all to say hey by the way i place bio horizons so that's locked in and they hit a button and it finds the fact that there's missing 14 it does a wax that does your inventory does your inventory for you it does your inventory it tells you exactly what they just plant size and then Wouldn't it be so nice, like you said, you walk into a hygiene exam, the patient maybe has watched this AI do all of this on the TV above their head. You walk in, the hygienist, he or she says, hey, we talked to Mr. Jones today about number 14. The AI programming kind of spit out what I think. Can you check the plan? You look at it and go, I'm going to change this size, this angle, but yeah, this is really good. I mean, it's there. They'll be clawing at your lab coat. They'll be, yeah, I mean, they'll be like grabbing you, taking their wallet out, saying, when can we start? Yeah, it's unbelievable. And even if they don't, it's taking none of your time. But we're not quite there yet. Okay. No, not yet. Not on that, but it's coming. I'm sure it's coming. And then on top of that, surgical guide design will be AI for sure. And my fastest in the West will be a useless skill. Yes, I think at some point it'll become you walk in, you show them the plan, you tweak the plan and hit go and it makes a guide and you 3D print it and you're ready to go. And with any more 3D printers anymore, you could have that ready in an hour. and do the surgery in a side room in 10 minutes. Before we spoke today, I was doing a surgery the hour before. I had reached out to you and I said, I have a surgery at 1.30, our calls at 2.30, I think we'll be okay. Patient was seated at 1.45, I was done at 2.00. And it was a simple, it was a guided placement of number 14 healed site. So speaking of surgical guides, I know you've used bone-borne guides and you've used a lot of guides in your time doing implants. I assume it's especially necessary for the all-on-fours working on these edentulous arches. And there's a lot of debate in that field with the full arch stuff. And I host a podcast called the full arch podcast where we've talked about this before, guided versus non-guided. And I don't do a lot of guides in full arch. There's still a lot of flexibility outside of guides. And anymore now by incorporating the digital workflow, you actually, without the physical surgical guide, you can do quite a bit. You can certainly pre-planning on the CT is a huge benefit. AIS 3D has a really nice library of every... implant brand I've ever heard of, plus hundreds more I've never heard of. And they also have the abutments. And so not only can I plan my BioHorizons implant in site number four, I can also attach the 30 degree multi-unit and change the timing in the software and make sure that I like that alignment. And the nice thing is the software basically tells you what your inventory is for that procedure. Your staff could bag it all up, bring it into the operatory, and it's sitting there waiting for you when you sit down and start working. You just don't want to change it. My staff love it. You don't want to change it on the fly, though. Well, I change it on the fly all the time because that's just who I am. But they have this really nice implant report that gets generated. So at the end of your implant... you know, planning on the CT, you hit this one button, it generates this PDF and there's probably six or seven pages. It has a little pano picture with the implants and each implant has an individual page, but it has an inventory list. And if you've gone ahead and chosen the implant and the abutment and all that kind of stuff, my staff then just, I print that out a week before surgery and they have a packing list essentially for what they need to set out for the surgery. And so that is a nice little tool that I've kind of taken it, you know, taken for granted, to be honest, until you just mentioned that. What you're saying, Dr. Vorholt, certainly underscores the importance of purchasing a machine that has really good software. And up until recently, you almost had to go with a third-party software because these machines didn't have the kind of software that they have now, like in the Action unit. Yeah, and that was the big issue. And for years, it was like that. I mean, I had a Serona machine when I first started, and I still exported it to a third-party software to do anything outside of it. Is that a big deal, taking that DICOM? It's not a big deal until you realize how easy it would be without it because you just get so used to it. I got used to basically showing the patient the CT in the room enough for them to say yes, and then I would go back to my office, export it, and start all over because I had to have it somewhere else. So it's always nice to have stuff streamlined all in one software. And it's an extremely robust software in the back end of it too and the model editing that's built in. And I've never had surgical guides that fit as... securely as I have since I've been designing them in this software. You mentioned the bone-borne guides, the ones that actually screw into the bone. They have one of the AI tools, so the Pano and the iOS tool, that's cool, but they have a bone segmentation tool. And for any surgeons out there, or 3D printers for that matter, the rendering we spoke about earlier, how cool it is and how neat it looks, almost like you could hold it, but you couldn't. It's not a file. It's just a software algorithm spitting out some image. With the bone segmentation tool, it actually does convert the DICOM file set into a digital physical file, an STL that you can manipulate. You can edit the file. You can export the file and 3D print the file. And so in my surgeries, rather than necessarily having guides, I will often edit the maxilla or the mandible, let's say, and plan my alveoloplasty. and digitally extract the teeth and the bone I'm going to remove and print that. And now I have a model that's not covered in blood and attached to someone who's, you know, upset with me that I can constantly refer to during the surgery. And then if you wanted to go ahead and make those bone board guides, you have the file built in. Now, what's cool about that is that if you didn't realize that, that used to cost you about $80 per arch and take about three days from a lab. When I was at Implant Pathway and we were teaching the sinus course, we taught a lateral sinus grafting course. to segment. That's what they call that segment out the maxilla on the first patient for every attendee. And it was $75 to get the maxilla. We get it back in two days and we print it. Well, now with the new AIS 5.4 release that has the AI tools, it takes about half a minute and you have the maxilla done. for free so right but with 75 in two days i now get in you know less than a minute for free and you can then manipulate it 3d print it and so for there's really no excuse you know i tell i tell i tell dentists all the time that i teach like what's the one technology i need to get you have to get a 3d printer so the fit on those bone born guides created by the ai bone segmenter that's part of the software for the action cbct they fit very well it's amazing i the first time i got the software beta the first thing i did is i segmented maxilla printed a guide not to do not to use it but just to test the fit and i have this video where unedited just said, okay, here it is. And I had the case was flapped open, the teeth were out. It just, it snapped in. And, you know, the bone is like a fingerprint. Like no one's, it only fits one way. It either fits or it doesn't. There's really no ability for slop. And so I was very, very impressed. And I've used it multiple times since then. And typically you don't work surgically through the guide. You flap the tissue first, do your pilot drill, and then place those pins in to make sure everything's working the way you expect it to. Yes, you would raise a full thickness flap to get the gingiva out of the way. You have to be really good at that and comfortable to expose the bone the way it needs to be exposed. And then when the guide seats, you're correct, there's kind of pin sleeves on the outside that you use, usually a pilot drill or some sort. And then you would take a pin and kind of tap it in with a little mallet. And then you can pretty much pick the patient up by this thing. And then there's usually often different pieces that then attach to that foundation guide, we call it. So like a stackable version of a guide. guide would be you pin that in that's the foundation now you do your alveoloplasty to that level and now something else kind of overlays and snaps on top of that that has your implant guides maybe even you pre-print the the PMMA teeth that snaps onto it so there's there's a whole workflow that I honestly don't do very often because of the some of the digital stuff I do now kind of made that obsolete but you can do all of that now with AI generated segmented bone way less time, almost no money. That's the stuff that I think is, it was a little overlooked because when they announced it and I got the beta, I said, oh my gosh, you guys didn't tell me you could do this. And the techs I was talking to at Action, they didn't realize how big of a deal that was. You're sitting in the operatory, in the clinical side. So we talked about software as one of the main criteria for making that purchase decision of a CBCT. But practice flow is also very important. In other words, getting that machine to work in that practice. where there's room for it and it fits into the flow of things practically i practiced in santa barbara california and as anyone knows california real estate is is quite uh hard to get a hold of in size everything's a little bit smaller kind of like practicing in new york city i imagine and so the practice that i took over was an older gp practice that we just took the space but they didn't even have a panoramic machine So where do you fit these large machines in an office that's already a thousand square feet and they're using every square inch? Well, we had an old closet that had like a washer dryer in it. We tore that down. We were able to fit the Action machine because it's one of the few wall mounted CBCTs, extremely low profile, extremely easy to fit into previously done spaces. Or if you're in a market where you can't get a lot of space. it doesn't take up hardly any space at all. And so it was funny when you're looking at the dental town, like magazines from the last decade and they'd have the practice spotlights, right? And you'd see these, these brand new gorgeous Taj Mahal practices. And inevitably they would have this like 15 by 15 glassed off room with a CT in the middle. It's just like, you know, for me, every time I had a practice, I built one in Ohio and I've practiced, you know, space is where you make money. I don't need. empty space around a machine that a i'm not even charging for it so i'd rather have an extra two operatories so the optima based on its footprint is ideal for smaller spaces absolutely absolutely and it's still are still six feet tall it articulates all the way up and down standing or sitting but it's wall mounted so you don't have to have all of this space on the floor it's like i said it's in it's around the corner where a small closet used to be in my office And it's amazing that it just kind of fits in. So I meet a lot of younger doctors who are looking at purchasing a practice. And usually they're purchases from someone who's retiring, maybe someone in the boomer generation that may have never had a pan. And they have to be able to retrofit something like this in there. And this is a great option. So let's get to that third criteria, diagnostic quality. And that obviously goes along with voxel detail. Absolutely. Okay, so that is one of the three things that a dentist should look at. So it's software capabilities, practice flow, which is what we just talked about, and then diagnostic quality. What's something that should be top of mind for a dentist looking to make that purchase? I think it's practical. practical accuracy like like we talked about as an endodontist you you actually would very much care about the the tightest voxel on a five by five but from a more practical standpoint let's just make sure it's 0.2 or better and my 12 by 10 is at 0.2 i have some slides in the webinar if people go back and watch that showcase some amazingly micro anatomy that i was able to see in the ct and then i have photos of day of surgery. And it's amazing the kind of little nuances you can still see at a point too. So just make sure it's practically good enough for you to get a diagnostic. And that's true of most. Yeah, and the standpoint of five by five, which that would be what I would be interested in as an endodontist, I think the optimum is somewhere around... according to what I've read, 0.0875. It's actually gotten better now. It's 0.0825, which is, I mean, we're talking, now we're really talking about splitting hairs. Yeah, I don't know. Maybe that allows you. Can you detect that with the human eye, that kind of detail difference? I personally can't. Maybe you as an endodontist could. Well, according to Bruno Azevedo, who's an endodontist now, he just finished his endo program, actually. He was a board certified, he still is a board certified radiologist, but AI has taken over. reading x-rays so he just didn't see a huge future in this so he went to endo school anyway got a graduate right near where I went I went to Penn he went to Einstein which is in Philly and uh he says and I talk to him all the time he's in Austin Texas so I get to hang out with him once in a while he's a great guy in his opinion and based on what he's uh written about and published he could detect vertical root fractures every time with CBCT if there's a vertical root fracture on a tooth he'll find it using cbct so yeah that's part of his course but that's it's really really exciting stuff so we talked about the three things that we should really be keeping top of mind software and it seems like the native software from the Optima is a really phenomenal package. We talked about practice flow, and obviously that has to do with footprint and workflow as far as just space. And then the diagnostic quality, of course, is very important. So as we get to the bottom of this podcast, what do you see the future like in the area of CBCT, 3D imaging, AI, everything we've talked about today? Where do you see all this going in, I don't know, two to five years? I think we've touched on it a lot today, which is AI. It has to be artificial intelligence and machine learning and the ability for it to take over more and more of the monotonous side of the imaging, whether it's the treatment planning. I've even seen tools that will spit out pathology or even connect to your chart and pre-chart the missing teeth and all that kind of stuff. It's an exploding industry inside everywhere and especially dentistry. So I think that's what I'm really excited for. I'm a really big proponent, like I mentioned earlier, for 3D printing too, which only continues to get better and better and faster and faster. But AI, I think, is going to be the big needle mover in the next three to five years. Do you see this technology, as AI becomes a bigger part of it, motivating dentists or driving dentists that typically would not do implants to do them? That's a good question. Implants are interesting because it's one thing to... plan them on a CT and have a really beautiful picture and make it obvious like, oh, this is, I can fit this in there. It's another thing to physically, it's still a very physically demanding technique sensitive surgery. Whereas even with the guided stuff, because like I teach a whole course on guided surgery and a big half day of it is what happens when the guide doesn't work, you know, because guides sometimes don't fit or the patient can't tolerate the guide or you want to change your mind mid surgery. And so implants are still going to take a certain type of person who wants to get bloody a little bit and they're comfortable doing that but certainly i do know quite a few surgeons or i may call them general dentists who who will trickle in some more easy implants because they do feel more confident now that there's guided software and and guided kits have generally gotten a lot more streamlined as well from all the implant manufacturers and so i don't know that someone would who doesn't have any predilection to do implants right now would necessarily get a ct and go i'm ready because i think it's something that you either feel comfortable with or not um but i think if you are placing implants and you don't like your ct or you're using a pano and a prayer absolutely you need to have a ct so just curious dr vorholt are you just doing implants now i mean are there any cases where you actually do uh arch rehabilitation the old-fashioned way with you know bridges and pontics and so forth or are you strictly doing implant cases? I do anything with implant related. So whether that's bone grafting for pre-implant therapy, or I will do the final restoration if the patient comes directly to me, but I also do referral cases. And, you know, I tell the story that I was a GP. I had a private practice, did everything for seven years. After a couple of years, what I noticed is I would look ahead in the schedule, like you're probably not supposed to, and just kind of get an idea. And I would only get excited for the stuff that was coming up that had to do with implants. So, oh, next Thursday I have an implant. I would just look forward to that. So I just kind of thought, let me just lean into that because I have to do this for the next 30, 40 years probably. I should probably lean into what kind of tickles my fancy. But yeah, I think that's a big part of it. In my practice, it's funny actually, to this morning, I had a patient come in to do an implant on number 10. And we had done some grafting on her before. And she's a really sweet woman who left me a really awesome Google review the first time I treated her. And so I've always liked her. We just get along really well. And she's been kind of bouncing around different clinics in California trying to get some treatment done because she's got some toothaches. And it's one of those like she goes to like a safety net clinic, for instance. They can only do one thing that day, you know. And so I said, you know, I pulled teeth. Like I definitely pulled teeth. Oh, I thought you just did implants. I do implants and anything around implants. So today we pulled three teeth that were going. bat on her, did the one implant. And I did a filling on number six. It was a class six filling. Those were one of those rare cusp tip fillings, right? That took you longer than the implant. I felt confident enough to do an incisal chip on number six. Using adhesive dentistry. Using adhesive. I know. I said, do we have all this stuff? We have etch, bond. What order does it go in? I can't remember. Is it bond, then etch, etch, then bond. And so I said, this is the first filling I've done in five years. freak you out, but I think I can handle it. I think it's like riding a bike. Now I can't say I only do implants because apparently I've now done a filling again. And you're even considering doing zygomatic implants. We've talked about that. This is my year for zygomatic implants. I'm taking some courses. I've taken some before. I'm taking some more surgical hands-on courses this year. So that's kind of the end boss for implant surgery as a GP. I mean, there's really not much more you can actually do outside of zygomatic. So I'm 12 years out of dental school. Never thought I'd do it. five years ago is when I went all implants and I still feel like I have a lot to learn. I still look up to colleagues who I think are just amazing and hopefully I can get to that level. And so one thing I've realized, you know, when we talk about 10 years ago or eight years ago, when I started to get that, Oh, I like doing implants, that, that feeling that in my GP world, that's the only thing I looked forward to. I started leaning so heavily into it and I still feel like I'm not, I'm still out of my depth and over my skis sometimes. And so. the beautiful thing about dentistry is you can be an inch wide and a mile deep, you know, or you can be the super GP jack of all trades where you're, you know, an inch deep and a mile wide and you can be successful in either way of those. And so I think I just happened to find a passion in this one. very, very small niche, which I've learned is a lot larger than I thought it was. You know, now there's just so much to learn. So yeah, I think take away from that what you will, but that's within my experience is that leaning into what actually made me passionate has led to all these things that you've mentioned I've done. And before we wrap it up, Dr. Vorholt, tell us about your podcast. Yeah, the podcast is called The Full Arch Podcast, and don't feel like you have to be a full arch surgeon to listen to it. We talk mostly all things implants, but we go from the wide range. Our most recent podcast, we're on mental health and as it pertains to doing these larger cases all the way to the nitty-gritty clinical stuff and economics and marketing, anything around full arch implants. And we do some CE courses attached to that podcast as well about twice a year. We'll do some intro to all the next courses meant for people who have never done it and are maybe just... starting to think about doing it. So yeah, check out the Flourish podcast. Anywhere you listen to podcasts, we're on there. Awesome. Very good. Thank you so much, Dr. Vorholt, for your insight. It was great talking with you and we definitely want to have you on the show again. Absolutely. Thank you, Phil. It's been a pleasure.