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Digital Smile Design

My guest this week is Dr. Christian Coachman and we'll be talking about Digital Smile Design.

Speaker 1: [00:00:03] You need to first design the smile. You need to design where you want to be even before knowing how to get there. First set design where you want to be. What is the ideal position of the upper teeth, bone and gum in relationship with the face? Not in relationship with whatever is in the mouth. [00:00:22][19.4]

Speaker 2: [00:00:27] Welcome to Dental Digest. Listen, dentistry is rapidly changing and this podcast exists so you can have real time updates to changes in delight occasion research and technology. Dr. Christine Curtin, the founder and CEO of the Digital Smile Design Company. Former president of the Brazilian Academy of Historic Dentistry in Global Phenomenon is back this week. In this episode, you're going to learn about how to incorporate dentistry and true planning in esthetic dentistry. You'll learn what you can be doing differently in your treatment plan and why you should take a basically general approach to your cases. All right, let's jump in. [00:01:03][35.9]

Speaker 3: [00:01:04] Welcome to Dental Digest. This is a podcast devoted to. [00:01:07][3.6]

Speaker 1: [00:01:08] Following evidence based. [00:01:08][0.9]

Speaker 3: [00:01:09] Dental literature. Here's your host, Dr. Melissa Seibert. [00:01:11][2.7]

Speaker 1: [00:01:12] She's a dentist currently practicing in the Air Force. With that being said, nothing contained within this podcast is intended to be reflective or endorsed by the U.S. Air Force. [00:01:21][8.3]

Speaker 2: [00:01:21] Today's podcast is sponsored by Legwork. Your one stop shop for tracking, retaining and delivering patient happiness attract new patients with digital ads, then convert them into lifelong customers through a dental website that integrates with your office phones and patient engagement software. Keep your seats filled with happy patients using tools like tool texting and automated reminders as a dental digest listener. You can get your first six for no pay at legwork icon slash dental digest. And so talk to us also about your implementation of tooth libraries. Can you tell us a bit about that? [00:02:02][40.2]

Speaker 1: [00:02:02] This is another concept that we were able to help spread that I think it's a revolution in restorative dentistry. You know, I was able to to learn back in 2011, 12 from one of my mentors in Brazil, an amazing dentist technician. That was the first one to bring this idea of using natural teeth as your guide to manufacture restorations. Of course, natural teeth were always the inspiration. So we as technicians, we were studying natural teeth to try to reproduce with our own hands, either with wax or with ceramics, and building their morphology with our own hands inspired by the natural morphology. And this teacher, Dr. Paolo Chernoff, he came with the idea, you know, why should we try? To replicate nature with our own hands if we can literally copy nature 100% with scanners. And when he first said that to me, it was so clear. You know, that's obvious in the future. At that time, two dozen, 11, 12, I was thinking in the future, we're not going to shape deep with our own hands because it makes no sense. We going to scan natural teeth and we can scan anybody that has beautiful dentition and save these scams into the libraries of our software. And when I'm digitally waxing up your case instead of designing with my own hands, I'm going to copy and paste the natural morphology of the most beautiful teeth on Earth. And then I'm going to design your mockups, design your provisionals, and design your final restorations with that. The only thing that needs to be done here is to understand that if you want to use natural libraries in your software and they look amazing because they're natural to keep that beauty in the patient's real mouth, you need to accept the principle and the concept of monolithic restorations because you need to milk or you need to treat the restoration. And if you touch the surface or you cut back to layer on top of it, you're back to scratch your back into your own morphology. So the natural library concept comes hand-in-hand with the monolithic restoration concept, and these two concepts together are allowing so many dentists and technicians to finally do beautiful natural work without having to be a michaelangelo of dentistry. [00:04:45][162.4]

Speaker 2: [00:04:46] Help me understand a little bit. Is this something that you did? Are you a part of creating these libraries, or is this a technology that you advocate for implementing? I'm sorry. You have to pardon my ignorance. I'm not quite as familiar with this. [00:04:57][10.8]

Speaker 1: [00:04:58] So we were the first ones to develop digital 3D libraries and do diagnostic wax in 3D with natural libraries and then design CAD cam restorations with natural libraries, mill these restorations and places in the mouth. So this is what we call the complete digital natural restorative workflow. Okay. Inspired by this initial idea from Dr. Paolo Garneau. That was the first one to mention something like that. We were the first ones to then bring this to the digital world and make it restored. The first two patients back in 2014 with this complete digital workflow with natural libraries. [00:05:43][45.3]

Speaker 2: [00:05:44] What ceramic materials do you advocate for using when you're trying to design beautiful interior restorations? Do you like lithium de silicate zirconia feldspar? They porcelain. What do you like? [00:05:54][10.3]

Speaker 1: [00:05:55] I like all of them. I like all of them. And the key is beautiful. Natural morphology. Beautiful natural morphology makes every material looks beautiful. We can't beat nature. It makes no sense. So it's amazing, you know, when you use natural libraries and then you manufacture these with natural libraries, they come out of the machine really looking beautiful because it's a copy paste of a natural tooth, you know? So all the materials will work fine. We work a lot with Legion Basilica, we work a lot with film spectacle. So just to emphasize, we do 100% related and we do 100% digital. Everything we do is digital and monolithic with natural libraries. We do hundreds and hundreds of anti restorations every month, and that's how we do all of them. Of course that if we are trying case in the business models and it doesn't look good, we're going to do everything we can to save the case too. So the patience problem and make the modifications that make them happy. And if we need to touch with our own hands and and save the case, we will. So that's one point. But we always do everything digital and most of the times we don't have to really modify them too much with our own lens because they come out of the machine already looking good. So these interior monolithic restorations we usually do with Emacs or Empress multicolor blocks, we also do translucent zirconia. They work fine. We also do hybrid materials, composite blocks. They all look beautiful as well. So it's a matter of mature selection for any biological, functional reason and value selection. How do you pick the right materials to give the value that you want? [00:07:54][118.7]

Speaker 2: [00:07:54] One of the things that is such a challenge for dentists and oftentimes overlooked, but this is invaluable. Is shade selection in with your background? How would you recommend Dennis communicate Shade to the lab? Some Dennis would say that they actually have the patient go to the lab and then the lab technician themselves is doing the shade matching. But that's just so rarely practical because oftentimes the lab might be even in the different country. So what information should a Dennis be gathering to effectively communicate shade to the lab? [00:08:22][27.7]

Speaker 1: [00:08:23] So we need to we probably should divide this topic into are we talking about cases with one or just the few restorations that you need to match remaining dental of the remaining dentition? So a single central, central lateral, you know, lateral pane. So the case is where you have everything natural and a few restorations that you need to match. This has a complete different protocol than the cases that you're doing, the full smile, right? The cases that you're doing, the full smile. The challenge here, as I mentioned, is value. You need to you want to pick the right event. Okay. You're not matching anything. You just don't want the full set to be too great or too great. You want the right then. Okay, so value communication depends on experience. You need to understand the color of the remaining track, the color that the patient wants, and how much space for the restoration. These three these are the three pieces of information that your technician needs to know to select the material for the right value. Right. So about the color is the right value. So you take a picture with the shade guides and the tooth perhaps, or the something simple. Sent to the lab. You tell the lab what is the final color value that the patient wants? Sent to the lab and in the software, the lab already knows the clearance, so we need to do the math. As we say, initial color, final color and clearance. Now, a good technician and good lab. By doing several cases, hundreds of cases, they're going to become good on understanding the combination of these three factors. What block should they pick to generate the value that the patient's patient want on full set? If you're talking about single restorations to match to natural teeth, then of course the color matching becomes a little bit more challenging. The shape is not the challenge anymore because as you scan the patient, you can use the natural remaining to even just flip to the other side and make the perfect morphology so it becomes, you know, how tricky the color is. If the color of the natural and tissue remaining tissue is not that complex, you can still solve with monolithic restorations, and labs are becoming better and better on matching monolithic restorations to match the tissue. If you see that the natural incision over patient does have very unique internal characterizations. This is one of the few situations where. Cutting back and layering ceramics. Old school is still necessary. And for that, this is the situation where top technicians usually want to see the patient life. But as you said, is very unrealistic for 90% of the dentists. So, again, what you need to do is just. There are some very simple photography protocols that you can use to generate these images to send to the lab to help the lab increase the chances of magic. What I used to do was to then to have the doctor try in before finishing the crown in a certain phase, maybe with two bakes and one final bake to be done, and then make some pictures to understand how close I am. To allow me to fix. To fine tune. The final layering to make the ideal match. [00:12:17][234.4]

Speaker 2: [00:12:18] Would you advocate for the use of polarized light and gray cards? Is that effective? [00:12:23][4.8]

Speaker 1: [00:12:23] Yeah. People or people? I would say we love to complicate our lives and people like to create new things to just create something. So the polarized photo and it's something beautiful for lectures. I never used it and I was able to match single central without it. You take a very good photo. Normal photo with some tricks to make the light place in the light in a way that you don't have the reflection. So you see the characteristics of the teeth. For a single central if if it is, of course, a full mouth, then it's completely useless. But if you're doing a single central, the polarized photo may allow you to see a little bit better the inner structures of the tooth and allow you to kind of inspire you on the build up to match that. But if you take a very good picture without the polarized filter, I was always able to to see as well what I needed. But yeah, it's possible for single centrals when the natural two is very complex. Maybe it can add some value. The green card is a way to calibrate, to calibrate the color of the camera, to allow, you know, then you can use some people developed techniques on Photoshop that you can kind of define the value in the Chroma on the hue of the restoration through some numbers in the Photoshop. And then they try to link these numbers to the ceramic system saying that if it's Photoshop, whatever, number, X, Y, Z, you go to the ceramic and you mix this and this and this, then this file that you get that same color. Honestly speaking, it's just too complicated. And I can tell you that the best ceramics in the world, at the end of the day, they're using their experience. They're looking at the picture and only the experience by doing dozens, hundreds of times these type of cases to allow you to understand which powders to use in the amount that needs to be used, with the mixture that needs to be used, that this single central case is still today, 21st century. They are still done in a very old school way. You know, it is still an art. It's still an art. [00:14:56][152.9]

Speaker 2: [00:14:57] What are these techniques with light that you're referencing? [00:14:59][2.1]

Speaker 1: [00:15:00] So, for example, the the traditional flash, you know, the dentist use the ring flash, you know, it generates a straight and strong light. And that's the worse to see things, right? So usually you can see better when the light is not straight is lateral and when the light is not strong is soft. So direct light straight is not ideal. Lateral indirect light is good. So utilizing an arm for your flashes and moving the flashes, a ray from the lens, moving the flashes backwards and putting a bouncer to bounce the light or using certain filters. These are techniques that every artistic technician, artistic dentist has been using for 15 years, you know, to take beautiful pictures of the tissue. The two tricks is indirect and lateral light. [00:16:04][63.6]

Speaker 2: [00:16:05] So the question that I've been dying to ask you about as well is how are you using keynote and PowerPoint for digital smile design? This is something that you're renowned for. And it's it's very interesting. [00:16:15][10.9]

Speaker 1: [00:16:16] This is what we call the vintage. The yes, the there was the how I started. Right. How the whole. So what happened was that, as I mentioned, lecturing was a passion. So in 2004 five, I started to learn PowerPoint and then keener to put lectures again. And I would finish a nice case and I would say, okay, this is a cool case for a lecture. Fantastic. Let me get grabbed in the documentation and let me put a lecture together about this case. As I was putting the lecture together about the case, firstly I started to identify mistakes that we did on the treatment. Second, I realized that I was learning more about the case when I was building the lecture. Then when I was starting to plan the case. Unfortunately, it was too late because the case was already finished. So when I started to realize was inside Keynote and PowerPoint, you have so many tools and so many tricks that you can play with the images, with the possible manipulations of these images, with placing lines and references and doing drawings. So I was doing all these drawings and guidelines to try to explain to my public, to my audience, how good I was. And instead, I was identified. The mistakes that I did. Right. So I, of course, said to myself, I need to start using these tricks, not at the end to put a lecture together, but at the beginning to make better decisions to treatment plan, to not make these mistakes. So in 2006 seven, I started to use little by little. I started first to demand from my clients dentists to send me facial pictures of their patients, not only intraoral pictures, but also facial pictures. And I started to develop a protocol on how to bring these facial pictures to the slide and transformed PowerPoint and keynote into a dental software. And every day learning a new trick. You know, ways to analyze sizes and shapes and measure harmony and balance and arrangement, facial integration and all the principles that we learn from oral facial norms and denture principles, and so full of measured principles and automatic principles. All these principles that helps you. Design is mine only with the phase I started to bring into into PowerPoint and Keynote. Little by little, it became a protocol I started to use in every single case, and then people started to see it and think, This is very cool. Can you teach me? And then I started to show it to colleagues and friends and then small groups and then little courses and then bigger courses than courses all over the world. And that's how the whole thing started. Of course, that today. Today things changed because at that time there was no 3D software. All I had was 2D PowerPoint keynote. And then from that 2D, I developed a technique that also exploded all over on how to make measurements and guides in PowerPoint keynote and then translate to the stone model to guide to wax it. So it was what I called a facially driven, handmade wax set, and that was the big a big hit until 2014. Or that was my main way to work until 14, when we moved completely in three into 3D. And now everything is inside the 3D software. But but we still use PowerPoint Keynote as the digital chart of the patient and everything we do in the 3D software, those three screens and video recordings that I mentioned to you, everything goes inside PowerPoint and Keynote and PowerPoint. The keynote is where we organize the digital information of the patient and what we use to present to the patient. [00:20:24][247.9]

Speaker 2: [00:20:25] I think it's funny that you say that this is vintage, because for many dummies this is still very cutting edge. And I think this technique is phenomenal because, listen, investing in some of this technology is very, very expensive. And this is such a great way for people to get their feet wet and get started. So would you make this actionable? Can you help us understand how are you doing this? Are you actually tracing the design of the teeth on keynote? Would you explain this a little more? [00:20:50][25.1]

Speaker 1: [00:20:51] So in Europe, I call it vintage. Of course, we work with 3D technology nowadays, and 3D technology is becoming very popular and very democratic. And of course, everybody is going to go there. But we still have hundreds, even thousands of doctors utilizing this vintage way, and that is very useful and very efficient. And people are doing better dentistry because of that. And I get messages every day from people saying, look, I didn't have the time or the opportunity to jump into 3D, blah, blah, blah. I know this is the future, but I'm very grateful that I have these tools that I can do for free and I can do it myself and I can communicate better with my lab. And my lab doesn't have any technology. We are in the countryside of India, you know, in the middle of Brazil. And all we have is this and it's helping us to do better. So I am very proud of this. And I think that you need to do whatever you can with whatever you have to do the best you can. And that is fantastic. So we still have online the videos that people can access for free on YouTube, on our YouTube channel of how to do the vintage DST, 2D facial analysis, 2D small design on Keynote and PowerPoint. Then the digital ruler that we invented that you place into the slide that you can calibrate and make the measurements between where you are and where you want to be. So let's say you put the patient's picture in that slide, you grab the templates you put over, you design the smile in 2D. So, you know, you see where the patient is. So let's say there's a chef and there's a cat and the teeth are small. You draw the ideal smile on top based on the face. So you have all the lines, the facial midline smile, curved tooth proportion, inter dental proportion, gingival fulfilling position. So what we call the smile frame that we developed, the ten steps of the smile frame that we used. So today on 3D, the same 2D or 3D, the smile frame process, ten steps. So use those ten steps on the 2D. So now what you see very clear is where you are and where you want to be. So let's say the incisal edge is here and the midline is here, and you want them in light to be there and the incisors to be there. So what you do is you take the digital ruler, you match the measurement, so you calibrate the ruler and then you measure, for example, that on the cervical of the tooth you need to shift the midline one millimeter, and on the incisal you need to shift 1.5. And that will fix the shift and the cat. And that on the incisal edge, on the distal corner, you want to lengthen half a millimeter and the medial 1.5 millimeters. So you have those measurements, you start making the measurements, you go to your model, you take a. Caliper. You start making the measurements tomorrow with the pencil and you start throwing the wax on top of it, guided by these measurements, and you can use the barrier probes in the wax to measure the thickness of the wax. You know, you melt the wax and you put the burial probe and you start guiding the volumes and the position of the wax midline in size of large volumes, gingival margins proportions. And your handmade wax can actually look very like your 2D drawings on PowerPoint. Of course, you need to know how to use PowerPoint or keynote, and you need to be a very good waxer. There's no magic here. You need to be a very good wax. If you have those two skills, you'll watch the video on YouTube on how to do it. And you can start tomorrow and you're going to have quite a lot of problems in terms of the misplacement of the midline, the size of add your own proportions and even beautiful lines and all these things. [00:24:47][236.1]

Speaker 2: [00:24:48] No, I think this is such a cool innovation and I love that because again, Denis, I might not have access to some of these technologies. This is a great way for them to get started. So why should Denis why should their treatment plans be facially driven? Denis Of the highest echelon in dentistry, this is something that they advocate for. But oftentimes, unfortunately, the default when it comes to treatment planning is we're just thinking of disease control, starting with posterior teeth in the mouth. But why do we need to start with the smile first? [00:25:13][25.4]

Speaker 1: [00:25:14] So this is all about what we learned. You know, this is not something that we at DSD invented. We we what we do is to translate into the digital world, the beautiful, beautiful things that we learn from mentors like Rick Rowley, John Kois, Frank Sfeir, Bill Robbins, Jeff Rouse, Peter Dawson, Jack. She's just come one year. You know, they they all they all talk about the same thing, facially driven treatment planning, facial generated treatment plans. What does that mean? It means that you need to design a smile first before you plan the treatment. It's like an architect. First you design the project and after you engineer how to make that project possible. And even though it's pretty obvious, unfortunately in dentistry, too many people invert those things. They start treatment, planning the solutions. And then in the middle of the process, they say, Oh, this is more or less where we're going to end and let's hope for the best. You know, if if you think like an engineer, if you think like an architect, it's pretty obvious. Start with the end in mind. As Peter Dutton said, if you know where you want to go, it's easier to get there. Period. What it means, you know where you want to go. It means you need to first design the small. You need to design where you want to be even before knowing how to get there. First set design where you want to be. What is the ideal position of the upper teeth, bone and gum in relationship with the face? Not in relationship with whatever is in the mouth. Because that will change. May change, and you probably want to change many other things. So you cannot treatment plan based on whatever is in the mouth. You need to treatment plan based on the face and nowadays face and every face. And these are the two guidelines to let you know where the upper teeth should be for ideal facial harmony and ideal and weight. So when you know where you want to be in treating the teeth, bone and gum, this is where you want to be. Now you need to compare where you want to be and where you are and understand the discrepancies. And then you need to ask yourself, what is the treatment plan? And that's only then that you need to use your skills and the specialty skills of your team members to start understanding. This is the ideal outcome we want. This is where we want to be. Is it possible? Do we really want to offer this to the patient? Is this realistic? How challenging it is? How much time do we need? You know, does the patient want to go through this process? And many times, of course, the ideal project is not feasible. It's not possible. It's not realistic financially, maybe to too much time the patient doesn't want for any reason. Many times the ideal is not possible, and only then you adapt the ideal to something that you think is more realistic. But as we say, give ideal a chance. Give the face a chance, give the airway a chance. Start from ideal reverse engineer the treatment plan, start from smile design and then build your treatment plan. [00:28:47][213.6]

Speaker 2: [00:28:48] Would you almost say that this is analogous to dentures? You know, some of the greatest minds when it comes to treatment planning correlated to dentures. They say, you know, when we're selling denture teeth, what are we starting with or starting with? Where do we want eight and nine to go once we know that we know everything else? And it's perhaps the same way with Smile Design. Perhaps fewer dentists are doing dentures today, but we can't forsake these principles 100%. [00:29:10][21.8]

Speaker 1: [00:29:13] This is exactly what we say. The only dentists that are treatment planning properly always are the ones treating full evangelist's patients and why their treatment planning? Ideally, always not because they're better, but because they have no other option. There's nothing in them up so they cannot treatment plan based on whatever is in the mouth. The only thing they have is the face. So they need to start from the face and then they design over the wax rim. They design where the teeth should be first. Then one of the gun should be first. And then they look at that and say, okay. This is what we're going to do. This is where we're going to place the influence we need to cut the budget. We need to raise the interface. We need to grab. We need to do the after after they set up the T. So this is because, you know, naturally, when you're treating a dangerous patients, you have to think the right way and you need to start outside in. Now, if the patient has teeth and an existing bite, you need to think exactly the same way by allowing yourself to ignore the existing bite for a moment. Ignore the existing teeth for a moment, look at the face, look at the enemy, and envision and plan the ideal and then build a plan. [00:30:38][85.1]

Speaker 2: [00:30:38] Dr. Coachman, it has been just incredible to have you on. What message would you like to leave us with? What closing thoughts do you have? [00:30:45][6.6]

Speaker 1: [00:30:46] I would say, you know, congratulations to all for picking this amazing profession. There's no better moment in the history of dentistry to be a dentist than the moment we live nowadays. It is definitely the most exciting moment. Of course, the world is going through tough moments, but dentistry showed amazing resilience and we were able to see for the last two years how important dentistry is, how vital what we do is for people, and how strong is our business. Even on super tough moments like the ones we left. So I think we are just very, very lucky to be in the dental business mainly, also because we are just discovering the real power of what we do. I think that the next decade will be the decade, hopefully that dentistry will play the role that dentistry deserves in the medical field. We're going to we're going to enter. This position of really going way beyond just treating decays and doing cute smiles. And we're going to discover the depth of what we do in terms of systemic connection, biological importance, the impact on breathing energy and sleep quality related to dentistry, the relationship between function and posture that impact on people's life emotionally. Even more so, all of these topics that are starting to be explored now will show the world the importance of dentistry in people's well-being. So it's just amazing to be in this moment in time, inside a profession that is reinventing itself. [00:32:44][117.7]

Speaker 2: [00:32:45] And you provide a lot of educational resources. If they want to learn more from you, where can they go? [00:32:49][4.8]

Speaker 1: [00:32:50] So the best way first is to go to our website. Our website has a lot of information, digital smile, design dot com, digital smile designed icon courses, and you're going to see our main course. The entry course is called DACA residency. That is the residency is a three day course where explain we explain the full concept. It's a three day course that we do in this year. We're going to do in Miami and Las Vegas. This residency, of course, social media. I'm very, very active on Instagram. Chris Coachman or Digital Smile Design, both accounts. We share a lot of content, a lot of insights, tips and tricks. So if you follow us on Instagram, you're going to get a lot of information. And also we talk about the courses as well. So I think these are the two ways to interact with me personally and with my team. [00:33:47][56.9]

Speaker 2: [00:33:51] Pay raise, believe it or not, ratings for this podcast on Apple Podcasts app actually really matter. So if you like this show and it's helpful to you, would you please be sure to leave a rating and subscribe on the Apple Podcast app? And as always, please send a direct message on podcast and screen, which is done on that is podcast. All right. I'll see you next week. [00:33:51][0.0]

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