From Scan to Smile: Full Arch Rehab in the Digital Era

If it's collapsed, fine. You can actually take intraoral scans even in a collapsed VDO, but the bite needs to be taken in a CR record, period. If you don't have that, then anything you do from here on out, don't listen to the rest of this podcast because it's not going to make any sense to you. You have to have the intraoral scan in a CR position. You don't have to necessarily have the VDO corrected, but you have to have the scan in a CR position. Welcome to the Phil Klein Dental Podcast. Today, we'll be talking to a dentist who knows a lot about full arch rehabilitation. He's a young, ambitious dentist who has taken full advantage of digital technology, which has brought him predictable success with his full arch rehab cases. His practice is fully digital, and he absolutely loves practicing in this fast-evolving digital revolution. His name is Dr. Danny Domingue, a general dentist practicing in Lafayette, Louisiana, dedicated to implant dentistry. Dr. Domingue, it's a pleasure to have you on the show. Phil, thanks for having me. So you do a lot of full arch rehabilitation in your practice, and you've been doing these kinds of big cases for quite some time now. So to begin this episode, tell us about the digital workflow that your office employs and how it benefits you and your staff. Full arch rehabilitation has been around for a long period of time, right? We've known workflows. all analog on how to rehabilitate a patient there numerous appointments and at some point it's like what is the the return on investment you know obviously it's a big procedure and everybody wants to do those but they're so difficult to get the patient in multiple multiple multiple times for trying or all that kind of stuff to verify passivity mount your models they're labor intensive digital dentistry has made it so much easier for the clinician to provide a better service to their patient, less number of appointments, more predictability for their final product. So as technology has increased, it's enabled the dentist to provide a higher level of care to the patients. So in those cases where patients come in, where their teeth are really generally hopeless, they're worn down, fractured, there's gum disease, there's decay, and you know as soon as you look in the mouth that Most of these teeth should be removed. You have a whole nother level of confidence using the digital tools that you have today to do a full mouth rehab and doing it quickly compared to the past. What is your main message to the patient when you're thinking of full mouth rehab? We can actually get you into full mouth rehab so much better, faster than doing anything else. It'll save you some money. Why don't we look at that option? Once I've changed my practice from the analog world into the digital world, it completely changed everything I do, changed my mindset. The work that I was getting back from my lab was incredible. Just so much better, so much superior to what I was doing. Back in the day when I was delivering finals to patients, when I put them in, I was like, man, this is the best. This is the absolute best. Now, five years later, when I go back and look at those cases, even five years I'm looking at those cases, I'm thinking, wow. how much digital dentistry has changed for the patients. And we've gotten so much better results. So we've learned so much in the past five, 10 years on, you know, FP1 design, surgical guide design, being able to restore a patient with clinical dentistry. So in my practice, I take teeth out, place implants, take all my digital measurements that day. Patient leaves, go home, they're sedated. They want to go home, sleep for the rest of the day. They come back the next day while they're awake, alert. I put the temporaries in. There's no pain. I don't need to get them numb. They can bite down on their back teeth, and I can visualize their smile, maybe equilibrate their bite if their bite's off just a little bit, but fine-tune the aesthetics of their case and let them walk out the door with a really, really good set of provisionals day one. This is within a 24-hour period after extraction of multiple teeth. Yeah, so they come in for the surgery, let's say Monday. Tuesday, they leave my office with a full set of perfect teeth. And they're in those temporaries for three months. Now, that gives my implants the ability to heal, but it also gives the patient the ability to try out these teeth, right? And so when they're trying out their teeth, they're just, you know, the aesthetics, phonetics, and function. Can I chew real well with them? Do I have any issues? Is my speech perfect? And do I like the way they look? Typically, what we'll see is patients come back after, you know, we check them through the three month period. They come back in three months. They have minor adjustments. Hey, this is, you know, I don't want my canines sharp. We make all those changes. We scan. So we go back and we stay in the digital world. We scan everything, send it back to the lab for another set of provisionals or we go to finals. It just kind of depends on the case. So you scan the provisionals in your hand or in the mouth? In the mouth. Yeah, so we try to keep everything intraoral as possible. So that begs the question, what intraoral scanner do you use? What type of provisionals are you using? Are you using ceramic resin printing? Are you milling in PMMA? What type of digital workflows are you using for those? Then you kind of get into the weeds with digital trends of which scanner, how are you meshing them, what lab do you use, all those kind of things. I'll tell you, intraoral scanner. The newest one that's come on the market, I think that's revelation in implant dentistry is the new Shining Elite because it has photogrammetry with it. For the price point, you can't beat it. So let me just jump in here for a second just to tell our audience what photogrammetry is. And by the way, it's spelled photo, G-R-A-M-M-E-T-R-Y, photogrammetry. It creates an accurate mapping of where the implants are positioned in the mouth. And then, of course, the intraoral scanner is playing a vital role in recording the soft tissue details. So when you combine those two into one system, it creates a digital master model for the lab that includes both implant and soft tissue geometry. So I have one. I have it for a couple months now. That's the one I've been using for my photogrammetry. So it has intraoral scanning. So you can scan the upper and the lower and your bite and do the photogrammetry all in one thing. When you send the digital file off to the lab, and I use LA Dental Implant Lab or Louisiana Dental Implant Lab, when you send that file off to the lab, they have the patient's bite photogrammetry already done. They call it intraoral photogrammetry. Everything's mounted and ready to go. So the lab, all they have to do is finalize the wax up, convert the wax up into a 3D printable or millable file, and you're done. It's easy for the clinician. The other thing is whenever you get into photogrammetry, into your practice, there's a learning curve, right? So there's a learning curve for the dentist. There's a learning curve for the staff. I use other forms of photogrammetry. The other form of photogrammetry that I use, it's so difficult. It's even hard to train a dentist to use it, right? So the nice part about this, and I know I'm pumping the Shining Elite right now, but it's brand new to the market. So it's a hot topic. But that particular scanner is delegated. to my staff. They scan the whole entire patient. So just for an example, we had a patient scheduled for two hours and it was the first time we used the Shining Elite. First time we used the Shining Elite, we actually finished the scan in an hour and the patient was out the door. So, and I didn't really realize this because I wasn't in the room, but the girl that scans for her name's Rosa, she came to my office. She's like, that was so much easier, so much faster for me and the patient. to scan and do the photogrammetries record appointment. And that's when it kind of clicked. It's like, well, it used to be taking all my time when I have to walk out and do all the alignment for the staff. But if it's that simple, this really is a game changer. What kind of cases do you recommend? a dentist to start on when it comes to full arch rehab. In the past, I've heard many times that using intraoral scanners on the mandible is a lot more challenging than the maxilla. Would you suggest doing a full arch maxillary rehab with existing teeth on the lower first, just to get started with this? Yeah, that's a good question because you don't have – the palatal arch, if the patient's healed, not during the surgical visit, but you have to have something to align to. So in the palate, for the maxilla, you have the rugae, right? And you can use those rugae. If you're not getting the patient numb, you're not distending them, you're not making incisions or anything like that, but you can use the rugae to stitch your pre-op and your intermediary scans and your post-op scan all together because that's the one unchanged position, right? So in the mandible, you don't have that. You got the retromolar pad, though. You got the retromolar pad, but it's sometimes so far back there, you don't have any implants or anything back there, right? And so you're getting all this extra scanned out, and sometimes that can lead to inaccuracies of scans or things like that. So people have come out with fiduciary markers. uh aim screw which is a fiducial marker you can use at the midline that's a really cool tool um you know if you go to la dental implant lab.com they actually have a single fiducial marker to level and align the whole mandibular art right and the head of it is a multi-unit abutment interface so i know um There is a guy, Isaac Tiawall, that's working with Shining right now, and they're actually making it like an AI function where you can use that multi-nabump interface for the fiducial marker. You can use that and scan it. When you scan your lower arch, you can use it as a fiducial marker, and you can also use it as a photogrammetry marker at the same time. So it kind of serves both purposes. It'll level align your lower arch and stitch back with a fiducial marker, but it'll also use it as a photogrammetry peg. Freaking uncool. Nobody else is doing that. Yeah, that's really cool. Dr. Tawil, T-A-W-I-L, I think. Yeah, I know Dr. Tawil. He's a super smart guy. Yeah, smart guy. And he has an implant institute. And I think he has a location in Mexico, or he used to. Teaches a lot of people how to do implants. Yeah, he's always in a different country here. Yeah, that's true. Yeah, no, he's very innovative guy. And he's very knowledgeable, as you are. So take us through the major steps, real top view of the full arch rehab from the perspective of how you use your digital equipment in the software. Yeah, from the initial surgery visit? Yeah, start from the patient sits down, they've got this mess of an arch, top and bottom. A lot of teeth are broken down. You're pretty much seeing it very quickly that you need full mouth extraction on this patient, whatever's left of their teeth. And so you're looking at full mouth rehab. Talk to us about how you use that digital equipment and software to move this patient through the case. And as you say, they're in their provisionals in 24 hours. So Phil, this is a really good question because I get this question all the time. I'll get a question of, hey, this patient has really bad dentition. Everything's failing. And I'll get a close up. photo of their, their teeth. And I want to do full arch implant dentistry. Can you help me design surgical guides for this patient? So there's a couple of things that we need to like stop and think about. Yes. Patient has bone. They have the money. Implants will be the best option for them. Okay. Where do we go from here? Right? So, so the first thing into this is number one, VDO, vertical dimension inclusion. Is it collapsed or is it, or is it stable? If it's stable, good. Take your integral scans at that stable position. If it's not, if it's collapsed, fine. You can actually take intraoral scans even in a collapsed VDO, but the bite needs to be taken in a CR record, period. If you don't have that, then anything you do from here on out, don't listen to the rest of this podcast because it's not going to make any sense to you. You have to have the intraoral scan in a CR position. You don't have to necessarily have the VDO corrected, but you have to have the scan in a CR position. If you capture CR, okay, and you need to open up the byte three millimeters, that's not a big deal. You just write on your lab script, open up the byte three millimeters. Now, the lab knows, the lab that I work with that I mentioned earlier in the podcast, they virtually mount everything on a penitent articulator before they start the case. And as a lab script goes on, it says open byte three millimeters, easy. They just open the byte three millimeters and then incisal edge position, right? Because that's going to drive the aesthetics of the case. You can only get the incisal edge position from facial photos, right? Facial photos, retracted, and facial photos, smile. Why do I say retracted? Well, most people that have bad teeth don't want to smile, and so they're not, right? But you need that lip at the highest lip margin. So smile as big as you can, smile as big as you can, smile as big as you can, and they're usually not going to give you right. But if you could get a retracted smile and stitch that along, then you have wherever there's – now, let's say they don't have 8, 9. Let's say they don't have 6 through 11. Well, you're going to have to use a posterior teeth to wax up to the front. And then they can determine the incisal edge position. So there's still a work around it, right? And this is just talking about dentate patients. It's a little bit different for a digitalist patients, right? So then that will drive this. The incisal edge position of maxillary will drive the aesthetics of the case. Then you ask them for an aesthetic wax up. Once you get that aesthetic wax up from the lab, that's when you start the case. That's when you start planning your implant positions for the case. And that'll drive FP1, FP2, or FP3, depending on how much you open up that patient's bite. And then after that, the case is easy, right? It really becomes super simple from that point on. And that's the easiest. If people could just re-listen over that last three minutes over and over and over again, it'll decrease the number of questions that we ask ourselves when patients come in. So let's talk about the cases that are completely edentulous. What are we facing here? Dentate is different from a dentureless. So a dentureless patient, obviously they have to have some teeth. If they come out without dentures or anything, you need to have a reference. So let's just say they have dentures and they're terrible. At least you have something for them to go with. I would reline those upper and lower dentures, reline them in the patient's mouth, try to get the incisal leg position at a decent point, and take those small photos there. You can actually... scan the upper and lower dentures and digitize them. Then there's a video, it's called a dual scan protocol online under Corey Glenn's YouTube. Dual scan protocol, Corey Glenn, watch the YouTube video. Basically it just shows you how to scan the dentures in the patient's mouth with them biting down on the dentures that are relined. Then you take them out of the patient's mouth and scan them individually. and re-import those back in. And then that will set up your case. Then you send that out for a digital wax. So I'll reline the patient's mouth to know that they're seated. But I actually, once they're relined, we'll have them bite down into bite registration material to hold that bite. I'll take them out of the patient's mouth. I'll scan the upper in my hand, scan the lower in my hand, and then I'll put them back into occlusion based on the bite reference. And then I'll scan them outside the patient's mouth, right? So for dentures, again, it's a little bit different. And then the surgery is a little bit different because you don't have any hard references for those. You're basically going to be using the dentures that you utilize for the wax up to reverse engineer those back to the patient's mouth after you've placed your implant. So there's a whole workflow, a whole learning for that. I'm not going to be able to get all that through on the podcast. So let me ask you this. As far as dental school goes, you look like a pretty young guy. I know the audience can't see you because we're doing audio only. When did you graduate dental school? I graduated in 2007 from dental school. Then I did a three -year postgraduate residency. year general practice residency at two year implantology fellowship at brookdale hospital in brooklyn new york which is in east brownsville how much digital dentistry did you get in dental school zero zero so 2007 that was okay 17 years ago 18 almost well 18 years ago what about after that your post doctor at work did you get the digital experience there or did you pick up all this knowledge on workflow after all of your formal education including postdoc school where you got it at continuing education programs? Just curious. My first introduction into digital dentistry was scanning with a blue cam CERAC and milling out an Emacs crown. And I thought that was revolutionary. It was revolutionary, but I was like, even still, that workflow wasn't. fluid i mean it was fluid and it was great at the time but it wasn't perfect it wasn't until like 2012 when i bought a three-shaped scanner in fact it was the first three-shaped scanner in the state of louisiana and i started scanning my implant cases and that in 2012 so 12 years ago that was like revolutionary to me because all you have to do is scan a scan body scan the soft tissue sit off the lab and you get a custom abutment and final crown and that changed the game for me i never took another pvs impression since 2012 it that's that's completely changed my world and so you know fast forward today we have multiple uh scanners in our office i think five inch oral scanners are all they all serve a purpose they're all great so all of your models now are 3d printed in the office yeah so yes we 3d print all of our models yeah um we 3d print all models we 3d print provisional sometimes we mill our uh or provisionals if we need to. The efficiency that you've seen over the last 10 years has been a game changer for you. You probably never envisioned being able to do these kinds of cases in such a short window, right? Which is tremendous for the patient. You know, it's funny because when I was graduating dental school, the talk was, if you go into private practice, what are you looking for to buy into a private practice? You know, people were saying, you know, I need the guy to make at least, you know, produce. practice a certain amount of money per year or I need this guy to just do cosmetic dentistry because that's all I'm going to focus my practice on or some people were saying if the guy doesn't have digital x-rays I'm not going to join his practice you know it's kind of like because that guy's so far in the past and that was just 18 years I guess that's transpired I'd take the dental students from lsu school of dentistry to mexico every once a year we do some mission work in puebla mexico and it's just about a week But it's kind of funny to hear them talk now. So the dental students nowadays are saying, well, if I go into private practice, I really want the dentist to have an intraoral scanner before I go into practice. They're all expecting intraoral scanning to be a fluid part of most general dentist practices. And why would it not be? What do you say to dentists who have been doing things traditionally, shall we say, analog dentistry their entire career, maybe their late 50s, early 60s? Should they even embark on this? new type of, I shouldn't say new, it's been around a long time. Should they be even starting the digital workflow, even from the standpoint of exiting and having, like you mentioned, something to sell to someone else? What's your thought on that? So I do have friends that, you know, they have AOL.com email addresses and they're like, you know, that's not for me. They have a really hard time checking their email. They're not tech savvy in their 60s or mid 60s, but I do have a, there's a population of mid 60s that. are into this. They love their computer savvy, their tech savvy. Buying intraoral scanners, it's re-energized them. They love it and they're seeing the future of it and it's getting them excited about dentistry again. The best thing you can do, I think anybody, if you're starting out and you want to get into the digital world, buy an intraoral scanner, period. That's the first thing you should do. If you want to spend a little bit more and do a little bit more, buy a 3D printer. You know, start 3D printing your model, wax steps, things like that for your practice. Like that's the trend is intraoral scanner, 3D printer. And then from there, that will completely change the way you practice dentistry, period. You don't even have to be implant dentistry. Yeah. And there's a lot of choices out there. I know you like shining 3D. Is that something you would recommend to somebody just getting into this? You know, I get that question all the time because there's a lot of people in the market. And right now, I'm... still going back to the shining intraoral scanner for what you're buying. So there was one girl that I went to dental school with. I haven't spoken in 18 years. She emailed me and she said, hey, I'm getting into the intraoral scanning. I don't know which one to buy. The Elite is really for full arch rehab. I don't really do a lot. I probably do one to two arches a year. So I really don't want it for that. And I emailed her back and I said, you know, still for the price point and what this thing offers, it's still an incredible scanner. for the price. And it's really the best one that I can think of. You know, even if she doesn't do interwarled photogrammetry, but once or twice a year, it's still worth the cost to me to buy that scanner. Now, if you're doing a lot of arches, it's a no-brainer. The Shining, for my practice and for my friends, I mean, I think it's the fastest growing and selling interwarled scanner right now. Yeah, and they have a suite of products that make it cost-effective. And Dr. Tawil, who I know personally, he's a... Brilliant. Like we talked about him earlier, really knows his stuff. And he's gotten involved with this company. I think he might be clinical director now, but he's been a great mentor of implant dentistry and oral surgery, instruments to preserve the bone, which is so critical when you're putting an implant in right after an extraction. Atraumatic extractions is what he calls it. He's a really well-respected individual who has been using shining 3D stuff. To wrap up this podcast, tell us. In your experience with all you've done in the last 20 years, or in close to 20 years of practicing, and boy, you did graduate at a good time, Dr. Domingue, to be able to have the background of analog dentistry in dental school and then get into the digital world, whereas the next generation of dentists may never know what the analog dentistry world is, which I think could be a disadvantage in some ways. But all the older guys say that. But based on your experience, what do you see down the road? What would you like to see technology -wise to even bring more efficiencies to what you're already doing with your bigger cases and your simple implants? Yeah, that's a really, really good question. The future is AI for sure. And where is it going to help us out to become better clinicians? There are certain things that can help us out and drive this for us. And a lot of those tools are coming out for free. Digital wax ups for arches, things like that, that would really help us fine tune our cases. If you're in a practice, you're a general dentist and you're running a practice, you know, you got hygiene checks, you got payroll, you got insurance, you got questions from your staff, you got patients coming in. It's almost like a rat reel. you know, that never ends and you get pulled in so many directions and it's, it's very unusual lifestyle. I love it. I feed off of it. I think it's the best career. I love the energy of that atmosphere as technology increases a little bit more AI features built in and really, you know, hopefully to drive the cost down for patients, but also to get the best result possible for those patients. Right. So. taking out some of the human error in these, in these cases, it'd be really nice if we could have like a, a feature for internal scanning. Like I said earlier, Dennis get all caught up in like, what am I, what am I going to do next? Like, so, so shining, they have the facial scanner and they have. the intro scanner and in their software you can actually you know scan your upper and lower arch and then switch that back into the facial scan right and then you can export that and take your dicom data and stitch all those together and you can then plan your case but if there's a way to a way to have like an ai feature to you know digitally wax up, I think they're actually coming out with this pretty soon, but a digital wax up for the upper and lower arches and the correct bite pattern, then the dentist can select their implants and where they want to place those. That would be a huge help. Technically, what's going on right now is that you can actually send the patient to the laboratory virtually, right? With that facial scan and the double arch scan. They've got the patient's face and head right there. You know, actually, I do that. And I also, I export the DICOM data. And when I lecture, I talk about this, but I export the DICOMs as well. So I convert the DICOMs to STLs. And so when I export, I export the upper and lower jaw stitched to the upper and lower intraoral scans, stitched to the facial scans. So when the lab gets it, and I'm saying open up the bite, they open up the bite based on the face with the jaws and the intraoral scans all together. Now, that's important. important only really for uh fp1 cases those are the you know that's what i like to use them for fp1 if you're reducing a lot of bone and trying to go fp3 it's not that beneficial but but for fp1 that's really a a great service it's limitless it's infinite with ai i mean who could predict what it's going to be like five years from now five years ago i i don't know if you predicted clearly what you're doing now uh that's how fast things are moving and Some dentists feel intimidated by it, like you said, if they have an AOL account. Not to offend anybody that has an AOL account, we understand. I think at this point, we're starting to see that the digital workflow is becoming standard of care. And for those practices that don't embrace it, eventually we'll be left behind. Dr. Domingue, thank you very much for your input. Great discussion. Lots of detail on the... Full Arch Rehabilitation. We appreciate everything you've talked about and we look forward to having you on future shows. Thank you, buddy. Appreciate your time.