Increasing Efficiency by Adopting a Digital Workflow with Dr. Naif Sinada, DMD, MS

Announcer: Ladies and gentlemen, this is the Dental Up podcast, brought to you by Keating Dental Lab, a full service award-winning dental laboratory. Each week you’ll learn tips and techniques from real world dentists, bringing you in depth interviews, motivating stories, current events, and sports. Here’s your special host, the general manager of Keating Dental Lab, Bob Brandon.

Bob Brandon: Hey, everyone, Bob Brandon here. Thanks for joining us for another episode of the Dental Up podcast. Our guest this week completed his undergraduate studies at the University of Iowa, and then went on to begin his dental career at Midwestern University College of Dental Medicine in Arizona. He then completed a maxillofacial prosthetics and oral oncology fellowship at the prestigious MD Anderson Cancer Center in Texas. Currently practicing full mouth rehabilitative dentistry in Fayetteville, Arkansas, please welcome our guest today, Doctor Naif Sinada. How are you, Doctor Sinada?

Dr. Sinada: I’m good, I’m good. Thank you for having me on.

Bob Brandon: Well, it’s great to have you on the Dental Up podcast. I know you’re a busy man, so let’s get right down to it. Why did you get into dentistry and at what point did you think, I want to be a dentist?

Dr. Sinada: People ask me that all the time, mainly like dental students, kind of what was your motivation, and it really wasn’t like a particular moment that made me think, this is when I want to be a dentist. Kind of like we were just talking about a little off the air there, my older brother is a prosthodontist, and my older sister is a pediatric dentist. When I first started college I was thinking I wanted to go into medicine, and health care, and then was slowly getting persuaded by my siblings to look into dentistry.

Dr. Sinada: When I shadowed my brother, that’s sort of all I knew, is prosthodontics, and then got into dentistry and kind of got exposed to all these different fields. It was like, oh, whoa, there’s so much more to dentistry than just prosth, but over time it kind of slowly tailored into that. Going back in high school and in college, I started shadowing some physicians, and then realized while they are making difference, and they are practicing health care, it’s just the model wasn’t something that I really wanted to follow, in the sense that they really just sat in their room. Not to discount our physician colleagues, but they really just kind of sat in their rooms, and the nurses and the physician assistants kind of took care of everything, and then they didn’t really have much hands on with patients.

Dr. Sinada: That’s kind of where I started looking for something where I could actually have way more interaction with patients than the typical general medicine model.

Bob Brandon: Definitely. Did you make these sorts of observations and discoveries while you were in college, or was this younger?

Dr. Sinada: It was definitely in college. It was between that and partying, and getting like a 2.0 GPA.

Bob Brandon: Oh, come on.

Dr. Sinada: Yeah, it was definitely in college when I started doing that. No, I’ll be honest with you. My GPA was garbage in college. It was really my [SATs 00:03:12] that got me in. It was a slow process, and I don’t think I was mature enough in high school to be able to make those decisions. I know some people like in my class, and in my dental class too, that were way more astute in terms of shadowing and kind of had their head on straight. It really wasn’t until my third of fourth year of college that I really had to buckle down and be serious about getting into dental school.

Dr. Sinada: I ended up doing a Master’s in public health for two years after school.

Bob Brandon: Excellent.

Dr. Sinada: That’s kind of … That helped me a lot in terms of narrowing my focus down, and then just kind of getting into school too.

Bob Brandon: Where did you ultimately choose to attend dental school? Then was your MPH, was that at the same institution or was that at a different location?

Dr. Sinada: No. I went to … My undergraduate college training was at the University of Iowa. Go Hawks.

Bob Brandon: Yeah.

Dr. Sinada: Yeah, and I did my MPH there as well. I did my dental school at the best dental school in the world. You’re probably familiar with it. It’s called Midwestern University in Arizona. Woot woot! Yeah, no, when I was applying to dental schools, I just kind of looked at the map. This is really embarrassing, it’s not even scientific at all, but I kind of looked at the map, and looked at some latitudes, and I was like, you know what, anything south of this I’m okay with, ’cause I had lived in Iowa at the time for 10 plus years, and I had just had it with the winters. I was like, you know what, I’m moving south for dental school, and then just happened to interview at Midwestern and fell in love with it.

Bob Brandon: I [crosstalk 00:04:55]-

Dr. Sinada: Then kind of the rest is history from there.

Bob Brandon: I understand that completely. I used to live in Boston and it snowed like three feet on April Fool’s Day one year, and I was like, man, I gotta move south. I gotta move south.

Dr. Sinada: [crosstalk 00:05:10], okay. No thank you.

Bob Brandon: I completely understand.

Dr. Sinada: Yes, right?

Bob Brandon: Tell me a little bit about your dental school experience. How big was the class, was it all on site? Did you get to do any fun off location rotations? Did you do any-

Dr. Sinada: Dental school I think for me was a little bit different, and for our class was a little bit different than the average dental student around the country. The dental landscape is obviously changing now, and I say that because I’ve been to … I did most of my training … I never trained in one area for more than one program, so I went from Arizona to New York, to Maryland, to Texas, so I feel like I got a good healthy view from a bunch of different dental schools. I think what was different about our dental school, was that one, it was run by a bunch of general dentists, and there really wasn’t a specialist mentality as it is at a lot of other dental schools, where the dental schools are run by the specialist, and the deans are specialists, and then they kind of look out for the specialty program.

Dr. Sinada: Having said that, the dental students do get a lot of experience in their undergrad training than most other dental programs, which is really cool, but also kind of scary, knowing what I was doing then. I was like, oh man, I was doing stuff that I had no idea what I was doing, or should have been doing. Having said that, it gives you perspective to what your comfort levels are, because you will always have faculty there watching over you. We were doing … I mean, a lot of the dental schools at the time, things have changed a lot since I’ve graduated.

Dr. Sinada: When I was in dental school, CEREC and E4D were kind of like in the heat of competing for-

Bob Brandon: Sure, I remember now.

Dr. Sinada: -the single tooth, same day dentistry kind of stuff. At our school, it just happened to be team E4D. It was kind of like a battle to get dental students to adopt the technology, which is weird because now I’ve heard that at the school, that for every five impressions, one of them has to be a conventional impression, or something along those lines. For every like 10 impressions that you make, one or two of them have to be conventional impressions, which is the opposite of when I was there. It was forcing people to get digital impressions, but now they’re almost like forcing people to learn the conventional way. You know?

Bob Brandon: Well, you need to understand both methods and the skill set in order to become a successful clinician, because we have many doctors that have a digital impressioning system, but there’s just certain teeth, certain patients that you can’t scan accurately. The tried and true method of margin isolation, and a physical impression, we get those cases every month from our digital customers.

Dr. Sinada: Yeah, no, I know, 100%. As a prosthodontist, that’s kind of how they teach you to learn the analog ways, because if we face it, all the technology that we have is based on analog technique. Digital, all it is is just kind of changing the medium. It’s not changing the foundation or the principles, so you do have to know the principles to begin with. Having said that, the office I’m in right now is we’re all completely digital with our entire workflow.

Bob Brandon: Excellent.

Dr. Sinada: You don’t need to hang on to the old stuff to move forward.

Bob Brandon: Tell me about your office, and your decision to go digital, which system you went with, and sort of the pros and cons of that decision, now that you’re past that point?

Dr. Sinada: Okay, sure. Just to give you a little bit of background, so I did my dental school training, and then I did a GPR. Then after my GPR I did prosthodontic training at University of Maryland, and then I did a maxillofacial cancer fellowship at MD Anderson in Houston. That’s a really niche kind of care level that I kind of put myself into. I just happen to fall into a practice in Fayetteville, Arkansas, Ozark Prosthodontics, and we are a prosthodontic office. We have our own lab in house. There’s three prosthodontists here, and we have two master ceramists in house. We have an oral design master ceramist, and then another master ceramist who manages all our fixed cases.

Dr. Sinada: We don’t do any removable. Everything we do is fixed, and we manage all of our own cases in house. Having said that, you can imagine, the word prosthodontist is kind of synonymous with high overhead, and having your own lab in house is also high overhead,-

Bob Brandon: Yes, it is.

Dr. Sinada: -so you really have to be really, really, really efficient. Any business person will always tell you, having your own lab is not a smart business, but as a prosthodontist, and as a dentist in general, we are always wanting to be in control of our every aspect of what we do, and it’s just nice to have that aspect within your office. That means … The reason I bring that up is because having said all that, you really have to be insanely efficient with your workflows, and with everything else.

Dr. Sinada: The way that this office sees it, is that there’s no other way to be masterly efficient, aside from utilizing digital workflows.

Bob Brandon: Absolutely.

Dr. Sinada: We are … Yeah, yeah. We are digital from acquisition to the CAD, to the CAM, to milling, to printing, to everything. We’ve digitized the entire process.

Bob Brandon: Tell me a little bit about the components of your digital system. Which acquisition unit did you guys purchase, and which milling and printing systems are you currently using?

Dr. Sinada: Okay. What we do, all we do in the office is only full arch, or full mouth implant rehabilitation, or complex crown and bridge rehabilitation. We basically only do full mouth. Listen to my recommendations, having said that, that knowing that what we do is full mouth. It won’t work for everybody, but for what we do it just works perfectly. In terms of acquisition, we use the TRIOS 3Shape. For a scanner, we have two scanners here, we typically when a patient comes in we’ll get preliminary scans with our TRIOS. For radiographs and CTs have a Prexion CT scanner, but then we also use the Zirkonzahn Face Hunter workflow, where the patient comes in, and gets a digital facebow. We have scans of their teeth.

Dr. Sinada: They get a digital facebow, and a scan of their face. Then their face gets merged in with their digital scans. If you want to move the [incisor ledge 00:12:20], or if you want to move the occlusal plane, or if you want to move an entire arch, you can kind of see exactly where it would fit within their face, digitally, before you do anything, versus having to make wax rims, mount, and remount, and check [inaudible 00:12:34], and check midlines, etc … We’ve gotten the Zirkonzahn workflow from the Face Hunter to the scanning. We also have a Zirkonzahn M1 mill, and a Zirkonzahn M4 mill.

Dr. Sinada: Our M1 mill is basically just a digital mill. It mills out our zirconia for us. It’s a dry mill. Then we have an M4 where we mill out our models. We mill surgical guides if we need to, but most of all we mill our temporaries out of PMMA [inaudible 00:13:08].

Bob Brandon: The M4 is basically for your resin based products?

Dr. Sinada: That’s exactly right, yeah. Currently we’re using it for wet milling, but if we would have been recording this in two weeks, we’re looking at getting our carbon printer finally, which is super exciting.

Bob Brandon: We have one.

Dr. Sinada: I think that’s … Yeah, I know.

Bob Brandon: We’re soon-

Dr. Sinada: I need to talk to you off the air about troubles and tribulations.

Bob Brandon: Absolutely, will do. Yes, will do.

Dr. Sinada: It’s super, super exciting. I think, and I’m sure you agree, I think the future right now, CNC and milling is kind of where it’s at, in terms of accuracy, but I think the future is exactly what you guys are doing in your lab, with the carbon and with additive, versus subtractive technique. It just makes more sense.

Bob Brandon: [crosstalk 00:13:59]. So much faster.

Dr. Sinada: The more- Yeah, it’s so much faster. It makes more sense in terms of production, but moreover I think it’s just the fact that all the industries are kind of heading that direction, bowing, investing so much into there, and with all these different companies investing into the production line, that it’s just going to make our material so much better.

Bob Brandon: Oh, absolutely. I mean, we’ve only owned the carbon for less than a year, and we’ve already seen significant advances in the materials that they’re offering us. Yeah, I mean, I’m very excited what we’re going to be able to offer our customers. You’re doing it all on site, but yeah, the products are really … Right now I think there is a limit on them, but it’s going to have limitless applications for us in the very near future.

Dr. Sinada: 100%, 100%. I mean, the other cool part that excites me about this stuff, is that it’s, for example, I do a lot of maxillofacial prosthetics, and so if patient is missing anything from the head and neck, I make the replacements. Right now I’m doing it all analog, so if a patient’s missing a nose, I have to actually make them a silicone nose with my hands, but with this carbon printer, you can print silicone. You can print all sorts of different materials, and make it realistic, and make it efficient, and make it productive. That’s just so cool.

Bob Brandon: Yeah, the 3D bio printing is just, it’s unbelievable what can be accomplished these days. We have so many scientists, and universities, and companies investing in this technology, that it will definitely improve the final result, but also make things easier on yourself, and hopefully on your patients too, on getting these replacement parts.

Dr. Sinada: Yeah, oh 100%. Are you guys printing your own temporaries now too or are you sticking mostly to mill?

Bob Brandon: We are currently milling provisionals, but the printed temporaries, the printed essentially like wax ups, that’s coming on board very soon here for us.

Dr. Sinada: Yeah, yeah. Just like you said, a year ago, half of the stuff that was out there was not out there before. I really think we’re living like the golden era of dentistry. I say that because I was talking to the same Oklahoma people about it, and Doctor Schillingburg, who’s like one of the godfathers of prosthodontic principles, was from Oklahoma. I talked to a dentist about this, and he was saying, “You know, when I went to school …” He’s an older dentist kind of nearing retirement, and he was saying, “When I went to school, Schillingburg was kind of representing the golden era of prosthodontics.” We’re seeing all these new principles, and studies are coming out about resistance, and retention form, and da da da.

Dr. Sinada: Most recently being on social media and on Instagram, he’s felt like this reinvigoration of seeing new dentists, and being revitalized into his career, and buying these new … He bought new scanners, and bought new printers, and kind of just felt like this new reinvigoration of his career, and was like, man, I almost feel bad that I’m going to have to retire soon. I think that’s because we’re in the golden era right now. Just like we talked about, five years ago the digital scene was completely different than what it is now.

Bob Brandon: Oh, definitely.

Dr. Sinada: Let alone even six months ago.

Bob Brandon: I’m sure you’re seeing that on your zirconia side for the M1 mill, the materials that are available now with Zirkonzahn and other manufacturers, I mean, those materials are evolving every month. It’s fantastic.

Dr. Sinada: 100%, 100%. I think that the people that … I always tell people whenever I go for any lecture event, I always tell them that wherever you are, if you haven’t visited your local lab, or you haven’t visited the lab that you send your stuff to, then you’re really missing out, because the people that are on the forefront of all this stuff are not the dentists. It’s people like you, ’cause you guys are the ones who are, whether you like it or not, beta testing. You’re the ones who are making our life easier. All we do is send it out and get something back, but it’s you guys that are kind of having to be behind the scenes making it all work. When new stuff comes out, you’re the first to be exposed to it.

Bob Brandon: Yep. Then we’ve learned. We’ve been bitten by a couple of purchases and systems, but we’ve learned what works for our own internal workflow, and for our customers. We try to make our purchasing decisions, obviously as any company would, we try to make our purchasing decisions in line with our customer expectations and desires.

Dr. Sinada: Sure, sure. Well, but that kind of speaks to the kind of lab that you guys are. You have to be ahead of the bell cure in order to be … It’s a fine balance from being at the bleeding edge versus the leading edge, and I think once you find that sweet spot of adopting new technology, that’s when your business, or your practice, or your lab can really take off.

Bob Brandon: Sure, absolutely.

Dr. Sinada: Go ahead.

Bob Brandon: Did your lab technicians on site, did they provide input into you and your partners in the office? Did they-

Dr. Sinada: How the office started was the owner right now, Doctor McNeel has been here since 1993 I think, ’94. He’s been here for a long time, and then kind of slowly grew this office to what it is today. The lab techs that we have definitely give their input, but here’s how it kind of runs. It’s not so much of a lab management. We have ceramists, and two ceramists, they get 100% creative freedom into what they provide for us. One of them is Lou [Cosigallo 00:20:08], who is a oral design member. If you’re not familiar with oral design, it’s kind of for the listeners, it’s kind of like an exclusive club of-

Bob Brandon: It’s top of the line, yeah.

Dr. Sinada: Yeah, top of the line ceramist. It’s very fortunate to have this guy in here with us, but having said that, they’re artists. What you and I would be happy to deliver 10 days of the week, he would kind of take it back 9 times out of 10. You’re very fortunate to have people like that in your office to work with them, but you also have to be cautious of over creativity, if that makes sense. The reason I say that is, how our office works is, let’s say we’re doing a failing dentition and we’re converting them into a complete implant rehabilitation. Let’s say six or eight implants on the top, or even four implants, whatever. Typically, we’ll get them through their beginning scans, we’ll get scans, we’ll get records, we’ll get pictures, everything else that we need.

Dr. Sinada: Then convert them. I’ll do the surgery, and upstairs they’ll plan the prosthesis. I’ll essentially get them to the temporary phase. Once I’m … That beginning part from the beginning appointment, to the temporary phase, I have as much control as possible in those phases. I’ll tell my patients, I’m giving you from zero to 75%. That remaining 25% is in the hands of the ceramist. In the sense that the prototypes that I will send you up to them with, is going to be a prototype that I would feel comfortable cementing or delivering permanently, but they’re going to get the artistic freedom to take you from that 75% to 100%. That’s kind of the most input that they get, is in those final stages of really dialing it in and making ceramics just kind of pop, and making them life like.

Dr. Sinada: In that sense that’s kind of the control that they get, and they love having that freedom, but it’s also a balance.

Bob Brandon: Absolutely. Walk me through a little bit when you’re doing your pre-op scans, and your cone beam. How is the integration and the file transfer? How is that meshing, and then the execution for the surgical guides? How are those steps time wise, and file integration-

Dr. Sinada: Awesome.

Bob Brandon: -if there’s any conversions? Okay. Which software are you using for that?

Dr. Sinada: We use two main softwares really, two or three main softwares. Again, let’s see that same scenario of somebody coming in with a failing dentition, and their final treatment plan is to have let’s say six implants on the maxillary, and six implants on the bottom. What we would do is get their original scans from TRIOS, or from a 3Shape, and then put them in a master folder of all the STL scans. Once they’re done, they’re converted into STL scans and put into a folder. We have some dental students that work with us. They’re pre-dental students. One of them’s starting dental school next year, but they essentially help us with all these conversion process.

Dr. Sinada: ‘Cause if anybody’s tried to plan their own cases digitally, they know that one of the hardest things isn’t so much … Well, planning is hard, but one of the hardest things is just going through the motions of clicking file, open file, find this file, move it into that folder. What we’ve done is we have these dental students who work with us, and also we have live staff that do this, but a lot of times the dental students will go through those motions and kind of create the files and the workflows for us. Once they have the scans and the STLs or their initial scans are put into a folder, we’ll open up Blue Sky Bio, which is a free software from Blue Sky Plan, free software from Blue Sky Bio.

Dr. Sinada: They will import the CT scan from our CT machine, and then they’ll also merge that CT scan with the STL of the patient. Now we have a record of their intra oral mouth with a record of their CT scan. They will start the planning based on my prescription. They’ll just kind of put in arbitrary implants into kind of semi good locations, but like I said, that’s kind of one of the hardest parts is just finding the file, and the click, and the uploading. By the time that I get to that file, I have an open Blue Sky Plan file that has my CT in, my intra oral scans merged, and I have a rough placement of how ever many implants I’ve put into my prescription.

Dr. Sinada: Then all I do at that point is take each implant, tweak it at 360 degrees, and move it into the right location. We put that case on hold. At that point, we take that case, put it into Zirkonzahn, and we start our planning, or we start our wax ups. Our wax ups are first based on the implant location potentially, but more often based on my prescription, on how the teeth should be prosthetically. Finally, we’ll tweak the implant location in Blue Sky, and merge our wax ups into that whole folder. At the end of the planning we have a CT scan, merged with intra oral data, merged with the wax ups, and merged with the implant locations, all in one.

Bob Brandon: The wax up-

Dr. Sinada: That way whenever … And the wax up, yep, merged into the implant.

Bob Brandon: The wax up you’re referring to, that is a purely digital wax up at this point in time. Is that-

Dr. Sinada: 100%, yes. Call it a wax up, but should call it more a proposal than a prototype. The digital proposal is merged with the intra oral scan, and the implants ideally are coming out of good locations into the proposal.

Bob Brandon: In terms of Blue Sky Plan and implant compatibility, are you using Blue Sky implants or using another manufacturer?

Dr. Sinada: No, I use Nobel Biocare for virtually all my implant placements. In the Blue Sky Plan software you’re able to put the different manufacturers in there, so I just use their Nobel compatible ones. Really as long as it’s within the same dimensions relatively, as long as the height of the platform is the right length, it should work out fine. At that point, once we’re at that stage and we have all those, then we’ll generate a guide, and then we’ll either print the guide or mill the guide, but mostly we’re printing our guides on a [inaudible 00:27:01] printer. Lately we’ve been doing 50 and 50, either milling the guide centers Zirkonzahn, or printing them.

Dr. Sinada: Then they’re ready for me that day. What I’ll have the day of surgery, I’ll have a printed model of their pre-op scan. That’s mounted. I’ll have a printed model of my diagnostic proposal, or my wax up, but it’s all been done digitally and that’s also mounted. Then I’ll also have a surgical guide and I’ll have a temporary shell ready to go for that day of surgery.

Bob Brandon: That’s fantastic. Is there any issues or problems you’ve encountered on surgical guide construction, using the Nobel implants? Has it been seamless? Are you incorporating metal drill stops into the guides?

Dr. Sinada: That’s a really good question. That’s something we’re actually we’re constantly changing our workflows on. The reason I say that is, so the typical workflow for a guided surgery with Nobel is to have a sleeve within the resin. It’s a metal sleeve that goes into the resin of the guide, and that way whenever you’re driving your sleeve, or whenever you’re driving your burs into your osteotomy, you’re not driving acrylic or a toxic resin into the osteotomy. Well, more and more research is showing that actually PMMA is not going to cause that much harm into the osteotomy, and then by the time you’re putting the implant in, it’s not a … Let me put it this way, when I was doing my training for cancer fellowships, head and neck surgeons would laugh at us when we were talking about having a sterile environment in the mouth.

Dr. Sinada: It’s like dude, the mouth is the butt hole of the body. Like, there’s nothing sterile about it. We would have neurosurgeons opening the skull and putting literally acrylic templates to kind of close up the skull, and pouring PMMA on to the brain. It’s a good thing, but we kind of take ourselves a little bit too seriously as dentists sometimes. Having said that, we’ve changed our protocol lately to have our surgical guide not have any metal sleeves in them. Whenever we mill our surgical guides, we mill them just with a round circle, and that inner diameter of that round circle is the same as the inner diameter of the metal sleeve that should be in there.

Bob Brandon: Okay, makes sense.

Dr. Sinada: That way when you put the key into the guide, it just kind of guides through, and it’s still protecting the body from the harmless acrylic.

Bob Brandon: Two extra [crosstalk 00:29:57] precautions.

Dr. Sinada: So everyone can sleep better at night.

Bob Brandon: Yes. Excellent. What is the general I guess time to complete one of these cases? I know it’s obviously patient dependent on a lot of them, but from treatment plan acceptance to delivery of new teeth, and the final prosthesis I’m envisioning it’s a screw retained monolithic zirconia?

Dr. Sinada: Yeah. It’s a … I’ll preface by saying that-

Bob Brandon: Probably not [crosstalk 00:30:35].

Dr. Sinada: -95% of what we do here at the office is zirconia, just because that’s kind of what we’ve tailored our workflows into. Whether people like to admit it or not, you kind of do what is most efficient for you, as long as it’s within the patient’s best interest. Having said that, most of our stuff that we do is high end dentistry. If we’re doing full arches, I’ll plan as many implants as I need to plan. Typically, it’ll be a six to eight implant rehabilitation on either arch, and it’ll be a cut back, a digitally cut back zirconia restoration, where Luke and [Kit 00:31:11], our ceramists, are adding facial veneers of [inaudible 00:31:19].

Bob Brandon: Do they primarily layer the interiors or bicuspids forward? Or do they do the [crosstalk 00:31:26]-

Dr. Sinada: You’re going to laugh, especially because you’re allowed. They do the entire arch.

Bob Brandon: Well, I could imagine [crosstalk 00:31:32].

Dr. Sinada: Yeah, I tell them, “Just do the front six. I don’t care.” To them it matters. I mean, they’re also staining the linguals, they’re staining inner proximate stuff that no one else would see but them, but that’s just kind of their modus of operation.

Bob Brandon: It’s their art, yes.

Dr. Sinada: It’s their art. You kind of have to approach that delicately by, you don’t want to discount somebody’s art, and not make them feel valued, but at the same time you want, going home, like dude, let’s just be done. They’re truly one of the best in the world that what they do. Typically, our cases take around 12 months to complete. That’s kind of the hardest thing about practicing in this workflow. It’s not so much because … In this day and age people are looking for the immediate, for the quick. In dentistry, that translates to immediate loading, that translates to all on four, and there’s nothing wrong with those protocols. They’re awesome protocols and they work great, and the literature’s there to support it, but with the type of dentistry that we’re doing, I immediate load frequently, but more often than not we are doing staged extractions, where we keep teeth during the transitional phase, and then convert provisionals into implants.

Dr. Sinada: What most people don’t realize is that the biggest change that people will get isn’t usually from the temporary to the final. The biggest change that people get is at appointment number one, at that surgery appointment. Where they go from their original teeth to their new 10. If you’re doing this kind of full arch dentistry, I would challenge you to kind of go back and consider the patients that you’ve done, and gauge their reactions from the time that they first went from their original non restorable dentition to the first time that they got temps. Gauge that reaction versus the reaction they went from their temp to their final. I’m willing to bet there’s been more often than not where some people might even ask for their temps back, because they’ve gotten used to the bite.

Dr. Sinada: They’ve gotten used to the look or something just feels off with this final. The reason I say that is because whether you’re doing a staged approach, or whether you’re doing an immediate loading approach, the biggest change for them is that first temporary or it’s that first transformation. However long you take in those temporaries, it’s not really a marketing practice builder for the patient. It’s more so getting them out of your office and a practice management kind of thing. Most of the time for us we’re doing stuff staged to give the changes to go through multiple prototypes if we need to, and it gives our ceramists kind of a little bit more freedom with having the ability to move teeth at different stages, when they need to.

Bob Brandon: Definitely. After the last tooth is extracted, the last implant is healed and you’re on your last stage provisional, do you then re-scan the patient’s mouth? Is that your blueprint then for your zirconia prosthesis?

Dr. Sinada: Yeah, that’s awesome perspective. That is where we talked about earlier where now we’re at that 75% or that 80%, and that’s where the ceramist upstairs kind of can start to shine. At that stage, once they are in that final prototype, or close to the final prototype, I will take them through Zirkonzahn Face Hunter, and they will get scanned. First they’ll get scanned intra orally on their temps, for occlusion, they’ll get the temps in occlusion. We’ll also get a relationship of the implants in that same occlusion, and then we’ll take them into Zirkonzahn Face Hunter and scan their face in relationship to those temps.

Dr. Sinada: At that point they have the final ability to really move teeth, change midlines, change [inaudible 00:35:42] if needed, based on the location of their face, and based on their new smile, ’cause lots of times you’ll have a patient in the beginning come in and animate for you, and give you a smile, and it’s rarely ever the same smile that you get when you finally deliver and they’re happy.

Bob Brandon: True.

Dr. Sinada: I always will try to Face Hunter again, because that’s going to be their new smile. I can’t tell you how many “low, moderate smile lines” have turned into high smile lines by the time treatment is done.

Bob Brandon: Yep, absolutely. It’s hard to gauge where their muscle position is going to take their lip line, once they see teeth in their own mouth again. [crosstalk 00:36:20].

Dr. Sinada: Exactly. Because they’ve lived their life so guarded for so long.

Bob Brandon: Exactly. Well, Doctor Sinada, I think that we could turn this into probably three or four different episodes. There’s so much information and content.

Dr. Sinada: Oh, easily.

Bob Brandon: I thank you for your time, but I would like to have a follow up with you.

Dr. Sinada: Oh, sure. Would love that.

Bob Brandon: Maybe it’s two months or three months, and we can bring in some of the additional topics that you are doing in your office, that we were unable to hit on today, if that’s okay with you.

Dr. Sinada: Yeah. I would love that.

Bob Brandon: What I’d like to do though, just for the remaining couple of minutes, I’d like to maybe if you could just give … The question is going to be, what advice can you give some of our newer dentists that are just starting out today?

Dr. Sinada: You know, there’s so much advice I could give. Typically I bet the first gut reaction is something along with student loans, just because that’s a sexy topic. Right? That’s what people want to hear. How do I get rid of these loans. I would just say I’m not going to give you advice about the loans, because there’s people out there that are way smarter than you and me, that are good with money. Utilize those people. The reason I say that is dentists love to be the dentist, the hygienist, the front desk, the janitor, the receptionist. Dentists love to kind of do everything. At some point in your career you’ll realize that delegating to the appropriate people is probably one of the smartest moves or career decisions, or business acumen that you will learn will be one of the most valuable things for you, because the more you can spend doing dentistry, the more productive you’ll be.

Dr. Sinada: Take that perspective in financial planning too. Don’t be hesitant to hire somebody that is good with financial planning, or find somebody that will manage your money, or find somebody that will manage your debt. That’s my spiel about financial planning. I think more so don’t let it weigh over you, in the sense that appreciate where you are at all times, and kind of realize that right now, just like we talked about, we’re in the golden age of dentistry. I remember graduating dental school and feeling so overwhelmed with how much student debt I was getting into, people saying that jobs are hard to find, da da da, but I really wish that the message was more drilled into us that guys, you are literally living through a renaissance of dentistry.

Dr. Sinada: Things are changing in front of our eyes. What I’ve taught in my digital courses a year ago is completely stone age now. Things are just changing at a rapid pace, and that is probably the most exciting thing about the career that you’re in.

Bob Brandon: So true.

Dr. Sinada: If you compare it to finance, or if you compare it to accounting, or anatomy, that’s not changing.

Bob Brandon: Very [crosstalk 00:39:30].

Dr. Sinada: If you’re in a career that’s constantly changing, and you can reinvent yourself, you can reinvent your career and it will be a rewarding career regardless, if you’re in something that is that fulfilling to so many people.

Bob Brandon: Well, that is excellent advice. Again, Doctor Sinada, I appreciate your time. Thank you so much for enlightening our Dental Up listeners. I look forward to speaking with you again in a continuation episode in the very near future.

Dr. Sinada: Awesome. I would love that. Thanks again for having me. It’s been really fun.

Announcer: Thanks for joining us on the Dental Up podcast show this week. Make sure to follow us on Facebook, Instagram, and Twitter, or search the Dental Up podcast on iTunes for our weekly feed. Don’t forget to visit KeatingDentalLab.com/promo for exclusive offers. Keating Dental Lab is a full service dental laboratory, and we’re nationwide. We’d love for you to send us a case so we can show you the Keating difference. If you digged what you heard, please leave a review on iTunes, and we’ll be back next week.