Dentistry Uncensored with Howard Farran

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Dr. Frank Lauciello graduated from the State University of New York at Buffalo (SUNY), School of Dental Medicine in 1969 and completed his Prosthodontic training at the Buffalo VA Medical Center.  He is a Clinical Associate Professor in the Restorative Department at SUNY at Buffalo and was director of the Veterans Administration Advanced Prosthodontic Program from 1973-1998 and Chief of the Dental Service from 1996-1998.  He is presently Director of Removable Prosthodontics Research, Development, & Education for Ivoclar Vivadent, Amherst, NY and Director of the Implant Esthetic Center of Excellence in Sarasota, Florida.  

Dr. Lauciello is a Diplomate of the American Board of Prosthodontics and has authored 25+ articles including several chapters of textbooks.  He is actively involved in dental research and new product development

40 Crimson Lane

Elma, NY 14059

(716) 691-2239

frank.lauciello@ivoclarvivadent.com

Howard: It is a huge honor today to be with a idol of mine for decades. You're the lead- When I think of the lead prosthodontist at Buffalo, the lead prosthodontist of Ivoclar, for thirty years, I think of you. You've been teaching me prosthodontistic information for three decades, so thank you for that.

Frank: Thank you.

Howard: First of all, I want to start off with seriously twenty-eight years ago, my three uncles, not one of them had a tooth in their head when they got out of high school, growing up in [inaudible 00:00:48], just wait until it hurt, and then you took them to the dentist, they pulled it. They all three lost all their teeth before they got out high school, and when I got out of school in '87, I thought those days were just disappearing rapidly, and I thought, if you were to ask me when was 24 and walked out of school to today, I would've guessed dentures would be gone by now.

Frank: I agree.

Howard: My god, they're still growing and growing and growing and growing and growing and growing. Some of it's poverty. Some of it's, the world's a big place, 7 billion people, only a billion people kind of live like us. 3 billion people live off 3 dollars a day, and they're told not to drink the well water because it's got cholera in it, they might die. Their leaders are telling them to drink soda, because soda might have cavities, rot your teeth, and make your fat, obese, and diabetic, but you're not going to die. Are you surprised that dentures are still going strong 30 years- How long have you been a prosthodontist?

Frank: Your kind words were probably because I've been one of the more survivors of dentistry, been around for a long time. 40 plus years in dentistry.

Howard: 40 years, and you're still better looking and have more hair than me. If I would've been a prosthodontist, would I have had more hair than a general dentist?

Frank: Wish it was that easy. I enjoyed your comments, though, and again, thank you for the comments, kind words and certainly my privilege and honor to be working with you and talking to you at this moment. The demographics of the patients have changed, somewhat unexpected, personally as well. If I look back 20, 30 years ago I would've thought removable was going to be a thing of the past in the near future, certainly by now I thought it would be a dissemity. A lot of contributing factors that I personally wasn't aware of. We're living longer, which is obviously good thing. We're tipping the scales with the elderly in our demographic population, so I think if you look at the statistics, in 1900, maybe 4% of the population was over age 65, now I think we're projected around 22-24% of the population over 65. If you think of the numbers, you got a large, we live longer, so there's a lot of people over the age of 65, and now the population growth on top of that. 

We have a significant bubble of population over age 65, so all the preventive dentistry in the world catches up to individuals through disease or whatever it might be. At a certain age, you're going to be more prone to tooth loss, like it or not. We're living longer and we're enjoying good life, and it kind of brings up the kind of the interest in individuals that we're looking at that are quite different than they were, the removable patient, I think we stereotype in our mind, someone who didn't take care of their teeth, and they're not really interested in looking good or feeling well because they lost their teeth in the first place anyway. 

That stereotype sometimes still resounds, but it's somewhat unfair, because what I see in our denture population, there's a very concerned group of individuals that are looking to us as professionals to provide them care that will make them certainly appear, look better, look as good as they can, to function. They want to stay in society. They want to go to a big restaurant, so a rather demanding group of individuals that are well read, well informed, and know the right questions to ask, and they're seeking better care. It's kind of incumbent upon us as professionals to learn more to provide that level of care. It is a significant shift. The numbers are there. We got 30 plus million patients who are already dentulated.

Howard: In the United States?

Frank: In the United States. Those are the same individuals who are starting to seek implant treatment, which brings them back to the dentist to have that type of, making of a denture. They're concerned about aesthetics, et cetera, brings them into the office more, because the loss of vertical things, they want to reestablish their appearance, so the 30 million not only are already dentulated, but they're seeking care at a more rapid rate than they used to. My grandfather type of individual would've been satisfied with the same denture until they pass away, whereas individuals now understand the importance of replacing a prosthesis to maintain their facial characteristics and things. It's an educated patient, for the most part, that I think brings them back to the office more often and again just pure numbers. The removable has not gone away. I represent a company that makes denture teeth and we're losing a significant growth in denture teeth sales. I don't think it's all from other companies who are doing quite well, but I think there is a significant growth in the removable market which we're seeing.

Howard: What are the things that you've been a big part of or your company? When I got out of school, coffee was free. In Kansas, you could get a cup of coffee at any gas station, a pot of coffee, a little Styrofoam cup, maybe- I never paid a penny for coffee, and I thought coffee was just cheap and free. Then a man from Starbucks came out and said "You know what, coffee is no cost, it's free, anywhere in Kansas, any diner or any gas station, but there is a market for people that will pay $5 for a chocolate mocha something whatever and Starbucks." 

I was actually shocked when I saw Starbucks. I didn't see it coming. I didn't think that some day people would pay $5 for a cup of coffee, and I think when I was in dental school, denture teeth were just cheap, grammatic, white. It was all low cost. They were just acrylic teeth, simple. Now, you've kind of been part of saying "Well there's room for a Mercedes-Benz, Ferrari, Audi teeth" and you and we're sitting right here behind them. Talk about the BlueLine and the Phoneras and I would reckon out of the 5 thousand people that would be watching this, I bet maybe half of them don't know about it. Tell the evolution, as a prosthodontist, how BlueLine came about, then after BlueLine, why Phoneras? Why did you need two fancy teeth?

Frank: BlueLine was a, kind of a gathering of information on the North American sector in particular. I kind of look at the BlueLine tooth as the ideal denture system for a dental school. Our target was to Americanize the way the teeth are selected and the occlusal schemes to be more acceptable to the North American dental schools. BlueLine was a, kind of a experiment in the sense of tooth organization, occlusal schemes, that we felt would be more popular and it was very successful for us. It remains to be very successful. It's a tooth form that's, chemistry-wise, it's a double-crossed linked acrylic. It's on par with the premium poly methyl methacrylate based denture tooth as far as we can go with that particular chemistry. It's got the wear resistance, the aesthetics, about all we could really achieve with the PMMA chemistry.

The Phoneras was a next in line, and I think we released that about three or four years ago, and that's composite resin tooth, and major difference in tooth chemistry. The wear characteristic and especially the aesthetics are far different than a poly methyl methacrylate based chemistry. In composite resins, we do this all the time, in restorative dentistry, and the appearance is obviously quite good. It has a nice chameleon effect and blends in with the other teeth and et cetera, and the Phoneras teeth and that chemistry is very similar, based on the same as a restorative chemistry. The aesthetics far exceeds what we're able to achieve with a poly methyl methacrylate. The intrinsic shading of the teeth so that it just bounces, it just pops at you when you look at it in the patient's mouth, quite a bit different than your traditional tooth. 

Again, that was in a response, not that it's going to be for everybody, or in demand for every individual, but for those patients looking to have a, demanding to have a better quality denture tooth that's something that looks more natural, I think the Phoneras is a great response to their demand, and to have that degree of development. I don't know if it'll stop there. I'd like to think that we could constantly improve. Again, constantly trying to meet the demands of the patient. We've done that in all ceramic. That's been such a, talked about, and again it's patient demand. They're looking to have the veneers and whatever it might be to- Dentistry's become somewhat elective in that regard, as far as aesthetic dentistry, and they're looking for a higher quality material, and the same for removable patients.

I'm going to correct myself just a wee bit. If I kind of look at the big picture, we got certainly patients looking to have an improved performance in aesthetics and et cetera, and you kind of eluded to the coffee, and some will pay $5 and some are still looking for the nickel coffee. Of course we get a population of patients that may not, that maybe they desire but they can't certainly afford that level of care that might be for somebody else who's able to. We certainly have that population of edentulism that probably needs to be serviced as well. 

We have to be somewhat innovative in that end of the spectrum as well to provide, you know, get quality service, I'm not sure how to put it, but at discount techniques, so that we're fully able to provide good care for a lot of people that maybe still need those types of services. It's quite a diverse population. That group has grown as well, I think with the influx of immigration kind of touched on that a little bit and et cetera, that a lot of these individuals from third worlds are coming into the states and they are going to require dentistry that we thought we were maybe a little-

Howard: You're saying the BlueLine was a PMMA a poly methyl methacrylate. That kind of maxed out at the properties then. Then you're saying the Phoneras, which I think phonetics, was kind of a resin composite, like a helium molar denture ceramic, more resin based. Will the next generation be porcelain like an Emax, or- Back in the day, there was porcelain teeth thirty years ago. Talk about porcelain teeth.

Frank: We are one of the few manufacturers that do have a complete of line of porcelain teeth as well. That's part of our candulor tooth, so we have a pretty significant tooth portfolio that even covers porcelain teeth. Porcelain teeth are probably the least popular tooth chemistry. They're beautiful teeth, but there's a bonding issue. They've got to be held in mechanically, so there's some undesirable characteristic to the porcelain tooth, and they're difficult to adjust and et cetera, so probably-

Howard: Is it the clocking, too?

Frank: If the verticals impinged upon or whatever, the patients may experience the sound that they find distasteful, so there's some patient negatives.

Howard: We'll talk about that. You're in prosthodontics, so if they're clocking they're teeth, do you think the verticals off?

Frank: Typically. Typically we're infringing of the freeway space is what's difficult.

Howard: Can you just talk about that real quick, about how do you- What's your go-to to get a vertical? What's your go-to to avoid that? Is that, as a dentist, as a 52 year old dentist, when I'm at the Waffle House, and I can figure out the waitress has a denture, the first thing that I come to is I hear it. I hear the clocking.

Frank: That could be part of it. Howard Paine was my mentor, and I copied his slide that he used to always show. It was kind of a picture and the title said "Vertical Dimension, Exercise, and Judgement" and it really is a judgement, because you and I, we judge it probably slightly differently. It's just what you- It's not a pinpoint location, thank God, because we'd quite always be wrong 90% of the time then, but it's a judgement call in an edentulist patient, that you try to strive. It's common sense to some degree. I observe the patient. I try to make a judgement based on a whole host of things. 

One, let's say they wore dentures, let's say they been an edentulist for a long time and they haven't wore a replacement. They're going to have a challenge. With that type of patient, I'd probably reduce their vertical slightly, because it gives them a little more freeway space, more chance to adapt to a prosthesis. Let's say I have an elderly patient that is challenged, and has wore dentures for 20 years, now the denture vertical has significantly wore down. That would be an individual I may not want to try to restore fully, not at one time anyway, back to a more normal vertical for them, because they probably won't be able to tolerate it. We have to transitionalize certain individuals. 

Vertical dimension, it's a process, it's a judgement, it's more of a visualization than I can actually pinpoint to a objective technique of determining it. It's in the eyes of the beholder, and I sometimes will talk to a group of dentists, and I say "Don't discount the auxiliary personnel that you have in the office, because they may be better perceptually than you in the ability to look at a person and check their vertical. They're sometimes quite good as an auxiliary to look and-"

Howard: I want to ask you another question about the teeth specifically, because over the years, it seems like, I've read a lot of times that the patients are most happy was zero degree flat plain teeth, and a lot of dentists with fully [inaudible 00:17:11] have been talking about 33 degree teeth and 9 point occlusion, so is 33 degree teeth and 9 point occlusion for a dentist thing, does the patient want 0 degree, what's the answer? What degree inclined teeth do you like?

Frank: It's very little science. I'd be hard pressed to point to articles that could really support my particular viewpoint on it, but it kind of goes back to some common sense. Edentulism is such that dentures are resting on soft tissues, so we have to be, unless you're implying supportive, they're relatively unstable. To put an excessive amount of cusp angle on a tooth for an edentulist patient is probably doing a disservice, because it's going to cause movement of the denture bases. A more shallow cusp inclination, I think, is appropriate for eduentulist patients, just because their foundations just can't support steep cusp incline. 10 degrees, 15 degrees, somewhere in that range, I think is probably an appropriate angulation to maximize them. 

More important that, or as important as that, is what we call the occlusal scheme referred to as lingualized occlusion. I'm somewhat prejudice on that, because Howard Paine, again, one of my mentors, was one of the founders of that concept of occlusion, but it made sense. It's a very simplified occlusal scheme that's somewhat, I think, universal, where you have a cusp upper tooth, a relatively steep cusp upper tooth, opposing a shallow cusp lower tooth. There's a lot of good things about that. The upper cusp tooth is going to be more aesthetic, because in your premolar region, it's going to have an aesthetic appearance to it. However, on the lower, which is the basis for cusp inclines, the lower cusp being somewhat shallow, it allows for a little easier movement and stability of the denture basis. It's a little more complex than that, because the lower occlusion is relatively uncomplicated. It's not a specific intercuspal relationship. It's more of a trough on the lower, so it gives a little more forgiveness in the occusal scheme. 

It's different than natural dentation. I think lingualized occlusion, to me, is the most aesthetic and probably the most functional, simplified approach to dentures' function and aesthetics that we could provide. Flat teeth, as a rule, on a personal note, I think are not as aesthetic, especially flat upper teeth, I believe as a real eye catcher to me. I'm not a real fan of flat occlusion, nor do I think a patient is. I think it's like two tongue blades coming together trying to penetrate food, where lingualized occlusion I think has better chance of penetrating the food and also another factor of the lingualized occlusion, it allows the food to escape off the occlusal table, where anatomic teeth tend to trap the food on the occlusal table, so the lingualized occlusion tends to free that up and allow your food to fall through the slipway so to speak, because there's no tight inner cuspation to trap the food. 

Again, just kind of a biomechanical feature of lingualized occlusion. It's that kind of a universal taste, tone, and another factor with the lingualized occlusion, it supports the upper cheek, because the upper buckle cusp is somewhat discluded, it's not in contact, it supports the upper cheek and prevents cheek biting. That's, I think, a major factor in our edentulist elderly population. They tend to really bite their cheeks quite commonly.

Howard: You're saying lingualized occlusion and 10 to 15 degrees? If someone said exactly, what would you say? Lingualized occlusion, what degree?

Frank: We do make a tooth that's specifically designed for lingualized occlusion. In the BlueLine, it's called Ortholingual, and in the Phoneras line, it's called Phoneras lingual, and that actually has a 15 degree working side cusp, and actually a 20 degree balancing cusp.

Howard: Blueline is what? Then Phoneras is Phoneraslingual.

Frank: Phoneras lingual. 

Howard: Blueline is?

Frank: It's the Ortholingual.

Howard: Do you remember a student named Sam Dominic?

Frank: Sam Dominic.

Howard: Who went to Buffalo.

Frank: I don't remember.

Howard: You taught him in Phoenix. He makes the best dentures I've ever seen, and so I don't know if I should credit Sam Dominic, or you.

Frank: I'd say credit him.

Howard: Great, so then I want to ask you, the next question is, you see techniques where dentists are trying to do a denture in three appointments, you see a lot of them teach a technique, five appointments. To make a good quality BlueLine, Phoneras denture, how many appointments should a denture be?

Frank: That's the one thing I never trapped myself into-

Howard: You're trapped, right now.

Frank: I won't let myself.

Howard: I'm not going to let you go.

Frank: My standard lecture on removable, I break it down into appointments, but I always explain "I do this as a matter of organization to show you kind of what gets done in a clinical appointment and how it gets transferred to the laboratory." I look at number of appointments as almost a personal thing. I was at the VA Hospital for a number of years, and I used to enjoy doing what I referred to as an all day denture. I did a patient, several patients, and we do all the procedures up to the insertion all in one day. Is it a one appointment denture, or is it multiple appointments in one day? I'm not even sure what to call it. Number of appointments is variable according to the clinician and his experience and his ability to treat. 

I think what's somewhat of a travesty in a sense, in some of the techniques that I've seen more recently put out there, they tend to use a shortcut in the sense trying to eliminate one of the appointments, and that appointment being the preliminary impression so that you can make a custom tray and then make final impression using a custom tray. They try to shortcut that appointment, and a clinician, or suggest that the clinician uses a thermoplastic tray, which is somewhat mold-able, and you can get a little bit closer than a stock tray, but I see clinicians struggle with that technique. I'm really not an advocate of trying to eliminate that particular appointment based on the fact, I think it just makes a much longer appointment and I think the results are compromised. In the effort to try to eliminate an appointment, I think they've created a monster. I think still the traditional technique of utilizing a custom tray is probably still in the best interest of the clinician to take a better impression.

Howard: You recommend a full set of edentulist trays, or do you use a custom tray?

Frank: I think you could get that custom try a variety of ways. A patient may have an existing denture, which most times they do, and I think duplication of the existing denture is a great way to go.

Howard: Explain your, how do you duplicate an existing denture? I feel like, is, that downtown no dentists should ever have to practice solo again. I just know some dentist is driving to work an hour away, and he's thinking, so I'm trying to guess their questions. How do you duplicate a denture?

Frank: Two ways to look at it. One is to actually duplicate the denture. There's these little devices called the Lang, L-a-n-g, Duplicator, pretty simple little hinge device that you can put some alginate in while the patient's in the chair, and literally duplicate their denture in alginate and then pour in some autopolymerized resin and just make a duplicate of their denture. [crosstalk 00:26:07]. Just a tray resin, or a clear resin, doesn't, just a polymer, mix it up and soup-

Howard: That's what you meant by Lang?

Frank: Lang, yeah.

Howard: Where's Lang at?

Frank: I can't say, but it's certainly easy to find on the web.

Howard: L-a-n-g?

Frank: L-a-n-g duplicator, and they also sell the acrylic, the resin to-

Howard: Then you wouldn't have to- You'd fill it up with alginate, duplicate it, and then you'd use that for a custom tray.

Frank: That could be their custom tray.

Howard: What would you take the impression with as a custom tray?

Frank: A variety of, depending on techniques and experiences of a clinician, there could be thermoplastic materials to border mold with, the compound, people shutter when I say that word, but there's-

Howard: Do you still like compound?

Frank: I like a variation of it, it's called Iso, I believe GM makes it, but it's a compound-like stick, thermoplastic. It's a lot nicer to work with than the old-

Howard: GM makes it?

Frank: GC.

Howard: I was going to say, General Motors? GC. It stands for General Chemicals.

Frank: I believe so.

Howard: In Japan and America, GCC. General Chemicals Company.

Frank: There's some upgrading in the thermosticks but that's probably the nicest one I've worked with. Washing, I'm still an old guy, so I still like my old rubber bases, but some of the new innovations with polyvinyl has been vastly improved. We have a product called Virtual, which is a polyvinyl impression material, but just recently, we somewhat stumbled upon it. We have a Virtual XD, which stands for extra definition. To me, personally, it stands for extra density. I wish we would've named it that, because it does have more density to it. It stands up and it's more stack-able. It does make a fairly good edentulist impression material, so I kind of gotten off on my rubber base and I'm kind of on my XD-

Howard: Now you've talked about, you definitely want to do a custom tray. What would you make the custom tray out of? Would you make that here or would you send it to a lab?

Frank: That could be done in the office pretty easily. I'd say a duplication of the denture could be done in the laboratory or certainly in the dental office. I didn't complete that story of denture duplication, because the other-

Howard: Finish it up.

Frank: The other technique that's pretty, in fact I just said it this morning. I took a patient's denture, and I filled it with a laboratory putty. I soaked that putty and pulled that out and took the patient's denture and took some autopolymerized tray material, and made a custom tray. That took me, personally, a couple of minutes, to do that particular procedure, five minutes for it to light cure, but it's actually physical working time just a couple of minutes to make a custom tray based off of the patient's existing denture. Another very simple technique that any dental system can be taught pretty quickly to do. 

I don't like taking impressions in a patient's existing denture because that old denture is gold. You don't want to modify, touch it, because God forbid, at the end of the day, sometimes things hit the fan, and the patient looks at you, "Doc, I know you tried real hard, but just give me my old denture and I want to go on my way." I don't want to be guilty of touching that old denture. It's still sacred to that particular patient, so duplicating it is a safer way to go. One way or the other, a complete duplication of denture or duplication of the internal part of the denture to make a custom tray, two very nice techniques to utilize. 

Without that, to get a preliminary impression, we have irreversible hydrocolloid. The system that I like best to do that type of impression is called Accu-Dent. Accu-Dent is unique because it has a light body and a tray body material, so you can inject a lighter body in the patient's mouth, capturing a lot of the anatomical landmarks, and then the tray material's got more thixotropic quality to it, so it picks up the light body and it's just a two-phase alginate system, I think is excellent for edentulist patient in particular, to take good preliminary impressions. 

In lieu of that, we also have thermoplastic trays, which are good. It's where you could take it and melt it or put it in hot water, and you can manipulate them to get a little bit closer to that particular arch warm, and then take a polyvinyl impression, maybe like a monophase polyvinyl material, and to take a preliminary impression that way. Not a final impression, but you can use it to take a reasonably good preliminary impression. I'm partial to a hydrocolloid preliminary impression, because it picks up better tissue detail than polyvinyl can, because it's more hydrophilic, but those are different techniques of getting that preliminary impression. Make the custom tray and then proceed to the next appointment. 

I do want us- Maybe this is a good segway, because this, that's underlooked. Taking the impression is the foundation. Without that, we could talk occlusion. We could talk denture base. We could talk the digital denture. We could talk all the wonderful things that's happening in the dentistry. It's all for naught, if we don't have at least a reasonably good impression, because digital dentistry is really a computer, and we got to put data into this computer. Good data, good denture. Garbage in, garbage out. Having some help to the clinician to take better impressions is key. 

Again, today, this morning, I took impressions using a custom tray that I fabricated as a digital custom tray. I took preliminary impressions. They were scanned, and on a big screen, I was able to outline and I could read my muscle attachments, I could read so much better on a big, blown up screen of this scan of my impression. I could rotate it in the 3-dimensional, unbelievably more accurate. I made an outline for custom trays. I tried my custom trays in this morning and they were exquisite. They were better than I could ever do by hand manipulation. I look at that as an advancement in dentistry, using the digital technology.

Howard: When you got out of prosthodontics school four years ago, did you ever think you'd be doing that-

Frank: No.

Howard: Four years ago?

Frank: Never in a million years. I experienced it all, I saw the early fix was a crown that fit like a sock on a rooster. I never thought they would ever get improved and this become the standard.

Howard: I'm going to hold you down for details. Talk exactly what you were doing on this digital dentistry. What were you scanning it with? Where you were you sending it? I'm in Phoenix, Arizona. There's a lab up there, was it AvaDent?

Frank: AvaDent.

Howard: AvaDent. When we got out of school, there was no digital denture. Talk about digital denture, but name specifics. Who's doing this? What technology?

Frank: Digital dentistry is touched almost all phases of dentistry. Removable's really the last vestige that really hasn't been utilizing the digital process. AvaDent is a company that was much relevant years they've been in existence, but they've explored digital dentistry for removable. It made some very good inroads in that particular technology. Their process is, and I won't speak for them, but what I understand, it's more of a centralized service, where the dentist deals directly, primarily directly with the center to have a denture fabricated. 

I've even recently announced that we're in the digital denture arena as well. Our business mold of operation is typically through dental laboratories, and we pride ourselves in systems. We're introducing a digital denture system for dental laboratories, so the double laboratory would have the capability of doing all the procedures from the scanning to the computer design to the computer fabrication of making the denture in the individual dental laboratories, which I think personally has a lot of merit, because the technician is a terrific partner to the dentist, especially in removable because there's so much subjectivity in removable that it's nice to have a good technical partner to help guide through that process, and by virtually eliminating that technical involvement, I think, is probably not the way I would want to go. I want to include the technician as our partner. This system is particularly designed for that.

Howard: You are optically scanning it, with what?

Frank: I take an impression, and it can be an impression from a duplicate denture. It could be, whatever preliminary technique that you would employ, that is going to be scanned, and we use a three shape scanner.

Howard: It makes three shapes?

Frank: Three shapes?

Howard: Where are they added?

Frank: I believe Michigan, but I'm not really familiar with their- I know we sell three shape scanners as part of the package, but I'm not actually sure where they're-

Howard: As part of the package with your denture-

Frank: With this system.

Howard: Is it CAD/CAM?

Frank: Mm-hmm (affirmative). It's the whole CAD/CAM process. The Weilend is the center that-

Howard: With a V or W?

Frank: W. Weilend.

Howard: Say it again.

Frank: Weilend.

Howard: But it's spelled with a W.

Frank: Spelled with a W.

Howard: But you pronounce it with a V?

Frank: Right.

Howard: Okay, so that's why I'm confused. It's spelled with W, and pronounced with a V.

Frank: Right.

Howard: Weilend?

Frank: Weilend.

Howard: What is that? Is it a German pronunciation?

Frank: It's a German pronunciation.

Howard: Do Germans pronounce most w's like a V?

Frank: Yes.

Howard: Really?

Frank: I'm a little better at Italian than I am German, but Weilend is the sister company to get this digital denture process. We've teamed together, the two companies, to do sort of a separate company with the milling machines and things, but they've kind of supported this operation to develop a system, a digital denture system, so the design and the milling is Weilend, and three shape, again not part of our company, but we incorporate through scanning process, so that we can really complete off the system. The design software obviously is Ivoclar, and that's and add-on software to the three shape. All that part, I don't yet have a lot of detailed information.

Howard: You can use a three shape [inaudible 00:38:35].

Frank: Yeah, it's a scanner. The closest software upgrade that makes it unique to removable.

Howard: I thought the neatest thing with the milling, though, for myself, is I just assumed that if you're milling a denture that all the acrylic would just gum up in the [inaudible 00:38:48], but they're actually able to figure out a way, what they ionized it or something?

Frank: The actual miller, milling machine that complements this is the select mill that we use for crown bridge, but it has what's called an ion. It's the select ion. Quite ingeniously, it reduces the charge of the particles and collects it. It's dramatic, the difference with the machine and without it. It's not only dentures. We do an awful lot of milling for temporary crown bridge. Any poly methyl-any resin based material the ion machine is excellent for, so this is, I think, a real advancement in-

Howard: I want to switch gears, or did you still want to do the steps of your denture- Finish the steps of your denture.

Frank: We, just what I just did. We took preliminary impressions. We scanned it, and then after it's scanned, it takes a couple minutes to scan and then it's up on the screen, and if the clinician has the access to the software upgrade, which I think most clinicians are going to be able to scan in their office. I think I've seen that growing pretty immensely.

Howard: Because of SEREC, because that's scanning it.

Frank: Right.

Howard: That's probably the most common scanner.

Frank: I think that's probably the most common, but I think having a scanner in the office is the most common place.

Howard: You would agree that the most common scanner is probably SEREC, because they've got 13, 14 thousand-

Frank: I'm seeing extra oral scanning.

Howard: Extra oral?

Frank: Extra oral meaning the intake to scan an impression.

Howard: Can you scan that with a SEREC?

Frank: It would be much too time consuming, because it's-

Howard: You need a extra oral scanner?

Frank: Right.

Howard: What would be the most, the three shape, is that the most common?

Frank: It is.

Howard: Are there any other ones then?

Frank: There are, I'm not familiar with all the different names, but there's-

Howard: Three shape is the market that you're-

Frank: There's scanners where you could scan the entire impression in one shot, optimal pictures of the impression. That type of scanner, I think will be more and more commonplace in dental offices, because it allows the clinician to scan the impression very easily and not take the risk of sending that impression to a laboratory to be poured or to be scanned. I think then it's electronic file, that can then be send to the laboratory.

Howard: I cringe at this for six months of the year, it's 100-110, then you take an impression, you put in a box, you put in on the pack of a UPS truck, and you can't believe that they're saying "The inside of the back of a UPS truck is 140 degrees" because-

Frank: I just opened a new box of isocompound material, and it was all melted. Somewhere in transit it hit some high temperatures, so you don't really have control over-

Howard: What do you think of the world cup mixers in the Qatar.

Frank: I think it's ideal.

Howard: 120 degrees, what a great place to have a soccer game. 120 degrees.

Frank: I can't imagine being a spectator, much less a player in that. Again, the scanning process, what it does, it opens up a completely different world in removable because what you can do as a clinician is with a reasonable knowledge base of anatomy, knowing how to outline my custom tray, makes all the difference in the quality of the next impression. When I tried my digitalized milled denture basis, which can also be printed by the way, printed or milled, it's done through design and read beyond what you would do in conventional terms. Your impression tray with a reasonable preliminary impression, boy your light years ahead by next clinical appointment, which is to take a vinyl impression, which is the foundation of everything from that point forward. 

My point about what I make with that is digitalization is not only- We think of digital dentures, well the mills, and its the machine, and it does a marvelous job of milling and putting the teeth in. It's like a miracle in itself, that part of it, but on the clinician, how does it help me? What's in it for me? How do I provide better care to my patient, more efficient, more productive? The clinician's got to ask that question. It's nice. It's really fun to watch this mill and all that, but clinically, I don't care what you do over there, what is it to help me on this end? That's why I'm most interested in the clinical applications where digital dentistry could help me clinically. It goes beyond just the preliminary impression. We got devices and methods to mill in custom rims on the denture basis, instead of the traditional rims, they're custom rims. 

They could also be fitted with very precise tracing devices, so it's not a pre-manufactured, not so quality-oriented tracing devices. They're pinpoint, incredibly stable devices that we can mill into our rims. That's helping me clinically. I did a job record again, this morning, on my patient, and I complimented the fact that I did an intra-oral tracing in probably 10 seconds, if not less, and I got to pinpoint very accurate tracing, because my bases were so stable and the devices that I clamped in were really incredible. That helped me. That was digital dentistry helping me clinically capture what I think is a very challenging appointment, a centered-relation jaw record. It helped me, so I achieved benefit from the digital process today in being able to do better dentistry for my patient, more efficient and so unexcited. 

Now, I will say this as well. Digital dentistry has hit removable. There's no going back. It's here to stay. It's the better, more innovative, more- It'll change the world in which we know in removable prosthodontics for the better, and it's just going to be kind of exciting to see all- I mean, everything's on the table. It's just going to grow in the innovation part of it. That part I'm pleased to see that I'm still here, still involved in dentistry, where I can help maybe shape that process and contribute to it at the very least, and for that part, I couldn't be more excited.

Howard: You're a grandpa?

Frank: I sure am.

Howard: So am I. What would you say if one of the people listening to this broadcast is a junior or senior in dental school, and they're saying "Should I be"- You're a prosthodontist as well, and I recognized, especially in the American Dental Association, there's some kid listening to this right now saying "Should I just go out and join dentistry or should I go and become a prosthodontist?" What would you tell that person?

Frank: I guess on a personal note, I can't imagine not specializing, personally, in prosthodontics. It's been my hobby. It's part of my life, and I certainly made the right choice for myself as an individual. Why I made it, I think, I just so loved the challenge of diagnostics, the diagnostic part of dentistry, and I was exposed, fortunately, to a couple of good prosthodontists who I always admired their ability to quarterback the big treatments and to really kind of see, understand the perio, the endo. It kind of quarterbacked the entire treatment. I think your- That's, I mean, as opposed to, I guess, an endodontist, who's kind of tunnel-visioned into what they have to be, into that type of work, and I kind of like the bigger picture, the more larger, the more challenges on that end of it. That's what makes it excited and kind of thrilled. 

I think prosthodontics is the, perhaps, especially if you want to know why, the answer's behind- I did a face bow. Why did I do a face bow? What did it for me? What's the science behind it? If you have that kind of curiosity, that specialty is kind of a natural area for you to maybe achieve. A lot of things have gone on in prosthodontics that has been implant dentistry and aesthetic dentistry. That's kind of the foundation of prosthodontics, so if you wanted to really learn more about that, and to have a higher level of achievement in those areas on a restorical side, I think prosthodontics is a great specialty in high demand, by the way, in high demand at this particular time.

Howard: Would you say high demand if you don't surgically place the implants? I see prosthodontics who say, "I start placing the implants and I don't get any referral from periodontists and are all surgeons." Then other ones say, "Be a prosthodontist, but don't place implants until you get all these referrals from periodontists." If some kid was going into prost. school, would you say learn to place implants or not?

Frank: Yes, in fact it's incumbent upon the prosthodontic program to develop some reasonable level of competence in surgical placement. Now, when you take that information and that knowledge base and go into a private practice, I think there's, you have to certainly analyze your environment and referral base and et cetera. If you are in a particular community where your the one to place the implants because of that particular community, then you have the capability, certainly within your comfort level, to place implants. If you don't place implants, I think you're in a better position to guide the process through another party, so you'd be able to understand. If you don't- To have the competence to know how to place them and then try to communicate that, I think it's going to give you an edge in providing the right information necessary to the surgeon then.

Howard: I've only got you for 10 more minutes. This has been the fastest interview I've ever done. The reality is that 94-96 times out of 100 a crown is done, it's done one unit at a time. A lot of dentists are thinking, "Is it okay to do a sideless preliminary triple tray for a single unit if I'm using a lab?", which is still the majority. Sirona's probably only in maybe 10, 12, 13% of the offices. Is a sideless preliminary triple tray okay? Where do you cross the line to where you say "No, I'm a prosthodontist. You need full arch impressions?" Where do you cross the line to say, "I need a face bow transfer?" Answer those three.

Frank: Oh gosh, all individual type questions based on the clinical event at that particular time. Obviously triple trays done correctly, in other words, if you have a triple tray, hopefully you use one that's rigid, because one of the dangers, two dangers to the trays like that, one is obviously if it's flexible and you have the patient close down into it, and when they release, if it's flexible, it's going to distort. It could look perfectly fine-

Howard: What's your favorite quadrant tray, metal or disposable plastic?

Frank: Metal, at least or rigidly plastic design.

Howard: Do you prefer the metal just 'cause it's rigid?

Frank: Yeah.

Howard: Some people say, "Well, if it's a metal tray, to bite in there, their bite will change."

Frank: Obviously cost is second part of the bit, to answer that question, is that you don't want to interfere with the occlusion, so you got to make sure it's placement clears where the occlusion is going to be. Rigidity, base it on rigidity, and base it on- Make sure that you don't interfere with the occlusion. Those are the two factors, and certainly the third factor I guess would be don't exceed expectations. For single unit's one thing. Going into two or three units, I question whether you'd want to use that type of tray system.

Howard: Come on, four years prosthodontist, grandpa, just tell them. Two units-

Frank: Use a custom tray, or at least a-

Howard: Full arched.

Frank: Full arched tray.

Howard: You're for using simplest custom tray. Do you prefer custom tray for two units?

Frank: No, I don't. [crosstalk 00:52:37] At least a full arched tray.

Howard: You say one unit, you can do a tray. You like to be rigid, not too rigid to where it interfere their bite, got to make sure they can bite. If it's a flimsy plastic tray, and when they bite down they distort that tray, and they open back up it's going to distort back, there goes your impression. Then you're saying full arched tray for two units, more.

Frank: Anything more than that.

Howard: Anything more than that. What about face bow?

Frank: Face bow is, to me, somewhat controversial. We have, what I think, are better systems that I think gather, more easily gather, probably more accurate, practical information that we need. What does a face bow do? If I, I can throw the definition. It's a caliper-like device that captures the maxillary relationship in three planes. I can throw all that out. What does that mean clinically? It means basically that you're capturing the upper jaw in relationship to kind of where we think the jaw spins, opens and closes. We're kind of capturing that distance, that opening and closing access and putting that on the articulator. How important is that? It's somewhat important, but we do the same with an average-value method of mounting probably. In other words, we're not that different. There's a relatively close average, Doctor Kois has done some research on that. I think his figures around 104 millimeters is pretty darn close to average, and that average doesn't-

Howard: 104 millimeters from-

Frank: From the spin point, the hinge access point, to the [inaudible 00:54:27], that approximately distance doesn't vary a whole lot. 90% of us fall within this-

Howard: 104 millimeters.

Frank: 104 millimeter range, at least 105 to- 100 millimeters to 105 millimeters, somewhere in that range. Probably a average value system could work very well, and maybe even do more for us, because the more important to the clinical aspect, most important is the patient's aesthetic plane, and transfer that to the instrumentation so that the prosthesis, when it comes back, is an aesthetic commodity, and not ka-ka. I think that's probably as important, if not more important, of this transfer. We got wonderful transferring devices. 

I just did one this morning, again, with our digital dentures. We have a device that very accurately records the patient's aesthetic plane, and also the occlusal plane, what we call Camper's plane. It's so much easier than a traditional face bow, and I think much more accurate. I think there's other techniques and Kois, John Kois has got his Kois Analyzer, which does similar- It's kind of like the stick bite, glorified stick bite technique, where you could transfer that information, and I truly do think that's more valid information than the opening and closing access, which could be also guesstimated with a good, average mounting system, I think within a clinical acceptability. I'm thinking there's other devices that are probably going to be replacing face bows. That's just my personal speculation.

Howard: Is Kois not, John Kois, not using face bows?

Frank: Right.

Howard: He's not using them?

Frank: No. He uses that analyzer.

Howard: I look at your formats. Can you explain the Kois Analyzer? He's a legend. Can you go into a little more detail about that? Where's my timer?

Frank: We have, I think John's selling his to Panadent.

Howard: Panadent, what's Panadent?

Frank: An articulator system. I think that's what-

Howard: Panadent, P-a-n-a-d-e-n-t dot com?

Frank: Right. We also have an articulator called the Stratos Articulator, Ivoclar does. The Stratos or the Panadent both have devices that accept the Kois Analyzer, so we have a little table that fits onto our articulator that then accepts the transfer, that registration that you would use the Kois Analyzer. It really, it's kind of a Fox Plane, kind of a glorified Fox Plane, where you have a little registration material that's added to it, and you kind of level it to where you think is a good aesthetic plane of the patient, and then that information is transferred to the articulator so that the articulator will mount the cast so that the occlusal plane is parallel to the tabletop, so when the technician fabricates the restoration, it goes back in in an acceptable, aesthetically acceptable plane.

Howard: One of the problems I believe about removable dentures and all that stuff is, if I need two or three crowns a day, and I need five or six fillings a day, I just get really good at it, because I do it every day, but if you only do a denture once a month, it's sometimes hard to reach critical mass. I've always missed, I'm throwing you under a bus right now, I've always wished you would do an online curriculum on dental, because the online CE is, like University of Phoenix online. Our online CE just passed half a million views. The reason is 'cause a lot of times, they say "I can't afford, I don't want to close up my office for a day. I also-" so that might cost them four thousand. Then, on the CE, it's a lot easier to listen to it in hour segments, instead of signing up to listen to eight hours to where at 3 o'clock in the afternoon you're falling asleep. Would you ever be up for, as your lying on TV, on podcast?

Frank: How can I say no you Howard?

Howard: I would love it, because what you do, you make it sound so easy, but it's hard for a lot of reasons, and the biggest reason is you only need one a month, and the second reason is this is all you've done for four decades and these kids, they've been out there 5, 10 years, and I would love to have-

Frank: I appreciate that so much, and I think the innovations that are coming forward with the digitalization is making that easier to teach, easier to practice, easier for the clinicians. I'm all about that. Removable is such a incredibly challenging subjective procedure. The more we can kind of objectively define it and help with the help of this digitalization process, I think it's going to help clinicians who, as you said, they're not going to do this every day, but if they have a nice package of armor material, that's relatively simple to understand and easy to comply, and then using the digitalization process to help guide through it more easily, they'll enjoy it more. They'll get better, more success, and everyone enjoys success.

Howard: I can't believe we're out of time. It's been an hour and I think a big takeaway is that digital dentures are here, and it's not going to go away.

Frank: No.

Howard: The genie's out of the bottle.

Frank: It's out of the bottle.

Howard: Of five thousand people listening to you, someday they'll log onto Dentaltown and you'll show them how to do this online.

Frank: My pleasure.

Howard: It'd be an honor. Thank you, seriously, on behalf of all your students you educate at Buffalo, leading this for forty years really. You're an amazing man, and you're a legend in my eyes, and thank you so much for an hour with me.

Frank: Thank you.