Protrusive Dental Podcast by Jaz Gulati

July 03, 2025 Digital Articulators Explained with Seth Atkins – PDP230

We use articulators to help ‘mimic’ our patient’s jaw movements, to ultimately do less adjustments/revisions in the future.

But are digital articulators there yet? Or is analog king?

Or is digital dentistry just flashy tech with no real-world benefits?

Can a virtual articulator truly match the movements of your patient’s jaw?

Is a CBCT really better than a facebow—and WHEN should you use which?

In this cutting-edge episode with Dr. Seth Atkins, we dive into the world of digital articulation—exploring how tools like virtual articulators, CBCT alignment, and 3D-printed provisionals are transforming clinical workflows.

You’ll learn how to combine analog wisdom with digital precision, improve lab communication, and make full-mouth rehabs more predictable and efficient than ever.

From mounting accuracy to motion capture, this episode is your ultimate guide to articulating smarter in the digital age.

https://www.youtube.com/watch?v=fT31Ecf_kDo

Watch PDP230 on YouTube

Protrusive Dental Pearl: Always send your lab the color version of your digital scan — the PLY file — not just the STL. STL shows shape, but PLY shows color — like markings and tissue detail. Ask your lab: “Are you seeing color, or do you need the PLY?”

Better scans = better results

Need to Read it? Check out the Full Episode Transcript below!

Key Takeaways:

Digital methods can enhance accuracy and patient outcomes → but only when used intentionally.

Understanding both analog and digital techniques is crucial → they complement each other, not compete.

Mentorship plays a significant role in advancing dental education → experience accelerates clinical confidence.

Digital workflows can significantly reduce chair time → and improve patient comfort in the process.

The integration of CBCT with digital workflows enhances diagnostics → giving clearer insight into static and functional relationships.

Digital provisionals offer a cost-effective and efficient solution → saving time, money, and frustration for both dentist and patient.

Axiography is essential for capturing patient motion accurately → because real movement matters more than assumptions.

Highlights of the Episode:

00:00 Introduction

04:00 Protrusive Dental Pearl

05:32 Interview with Dr. Seth Atkins and his Journey into Digital Dentistry

08:06 The Evolution of Digital Articulation

13:38 Digital Workflow and Mentorship

20:01 Accuracy and Efficiency in Digital Dentistry

22:32 Static and Dynamic Relations in Digital Dentistry

31:01 Interjection 1

36:05 Practical Guidelines on Integrating CBCT

37:15 Interjection 2

40:59 Clinical Observations in Dental Rehabilitation

42:29 Interjection 3

45:21 Introduction to Axiography

46:40 Advancements in Digital Dentistry

49:33 3D Printing in Dental Practice

53:31 Motion Tracking on Digital Articulators

57:30 Cost Efficiency of Digital Tools

01:01:10 Alternatives to CBCT

01:05:52 Involvement with AES and Future Plans

Check out the study mentioned: “Comparison of the accuracy of a cone beam computed tomography-based virtual mounting technique with that of the conventional mounting technique using facebow”

🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES).

🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”

📍 February 18–19, 2026 · Chicago, Illinois
Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond.”

If you loved this episode, be sure to watch Basics of 3D Printing, Milling and Digital Dentistry – PDP224

#PDPMainEpisodes #OcclusionTMDandSplints

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C – Maintenance and development of knowledge and skill within clinical practice.

AGD Subject Code: 610 – Fixed Prosthodontics – Emerging techniques and technology

Aim: To provide a comprehensive understanding of how digital articulators can enhance clinical workflows, improve occlusal precision, and minimize restorative complications through accurate static and dynamic articulation.

Dentists will be able to:

Differentiate between analog and digital articulation methods, including their benefits and limitations.

Apply digital workflows to provisional restorations, improving efficiency, patient experience, and predictability.

Recognize cost-saving and diagnostic advantages of digital design in restorative and full-arch treatment planning.

Click below for full episode transcript:

Teaser: I got into some of the digital things initially, more for selfish reasons. The key there is not necessarily digital for the sake of digital. It's how well can we do analog?

Teaser:
Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing?

Yes, and the reason I say that is I think it’s the correct answer for both. Yes, bad and good.

Are you at any point picking up your analog facebow and then working on analog articulators to wax up, or have you got to a point now whereby the trust and the faith you have in your digital workflow means that you can do it fully digitally?

The biggest thing that a lot of people don’t understand is-

Jaz’s Introduction:
Analog versus Digital. Are we there yet? How on earth does a digital articulator work and what’s the point? And are there any real advantages to the digital workflow other than it looking cool and pretty on the screen? Can it help you be more efficient, more accurate, more predictable?

We’re gonna cover all those things with our guest today, Dr. Seth Atkins. I tell you, this guy is a wiz. He’s part of the organizing committee of the AES, that’s American Equilibration Society, and this is part of the AES takeover. We are promoting the AES 2026 conference, which has got some of the biggest names in occlusion, comprehensive dentistry and TMD over two days in Chicago.

The date is 18th and 19th of February, 2026, and it’s called the Evolution of the Oral Physician. The lineup, I tell you, is absolutely phenomenal, and also it’s a privilege to be one of the speakers alongside Mahmoud Ibrahim. We have the 8:00 AM slot on Thursday 19th of February, so it’d be great to see as many of you there as possible.

Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Let’s talk about digital articulators. Now, let’s go back to basics for our students and younger colleagues. The whole point of an articulator is that we can mimic the patient on the table because we can’t take the patient home with us and design the restoration in the mouth.

And then fit it the next day. We have always needed a way to mimic the patient, mimic their head, mimic their movements, mimic their bite so that we can work on the benchtop. So the analog way was to use a face bow and then feed that face bow into something like a semi adjustable articulator. Now what you see on the articulator, this analog articulate in front of you, we’re hoping is somewhat representative of your actual real patient, so that when you design the cuspal inclines of the molar, let’s say that you are restoring that when you put it in the mouth.

And the patient then moves left and right, it happens, so in the same way as it did on the articulator. The ultimate benefit of that is less adjustments, more accuracy, and ensuring that the design that you intended actually works in the patient’s mouth. Now, when you talk about comprehensive dentistry and doing more units, doing full mouth cases, you can appreciate how important it is to replicate the patient.

And let me tell you, this episode is all about digital. We are moving away from analog facebow and analog articulators. Now you’ll see how Seth explains why we can never probably be fully a hundred percent digital in these big cases because the final stages still need to be analog because our patient, when we fit the crown in the mouth. That’s an analog process, so we still need some analog knowledge, but how can we harness the power of digital articulators?

It’s a very exciting, very geeky episode, and I put a few interjections in there to help make it as tangible as possible so that our younger colleagues, our students, can also follow along. That’s always the mission of this podcast.

I asked Seth how we are now transferring the patient to the digital articulator. So like I said, in the analog world, we use a face bow and we talk about the role of face bow, but then how do we actually now use a digital face bow, if you like, and then how do we ensure that the movements are as close as possible on the digital articulator?

Dental Pearl
The Protrusive Dental Pearl is one that was given to me by Dr. John Cranham. As you know, I attended his lecture recently in Copenhagen, all about occlusion, cosmetics and digital. And what he’s doing with digital is amazing. Just like Seth, the top tip that can help your lab technician is as well as when you send over the STL files to your lab, what they don’t get is the color.

Very often the lab software, all they get is like the digital stone models. They don’t get to see the color models, they don’t get to see if there’s any ink on the teeth, i.e. articulating paper marks. And sometimes when it’s clear when you’re looking at a color scan. What’s gingiva and what’s tooth?

Sometimes when you’re looking at it on stone, it’s difficult to tell. So the tip is to also ensure that they can see the color version of the model many times. This is with a .ply file. That’s a .ply file. So our scans are STL files. The color overlaying is a PLY file. So ask your lab, hey, are you seeing what I’m seeing?

Are you seeing color? Or do I need to send you the PLY file? If anything, if it’s one thing that this tip allows you to do or encourage you to do is to have that conversation with your technician. Anytime we can have more of a conversation with our lab techs about our workflows, we are benefiting. We are growing because we depend so much on our lab techs.

So my friends, get in touch with your lab. Ask about the PLY file. Do they have it already or do they need it? Because it can help them, it can give them additional data. Make sure you check out the link below to learn more from Dr. John Cranham and of course, how you can come to AES 2026. I’ll put all the links there. Let’s now join the main episode and I’ll catch you in the outro.

Main Episode:
Dr. Seth Atkins, welcome to the Protrusive Dental Podcast. Thanks for being up at this time in the US, whereabouts, since you’re in Texas, right?

[Seth]
Yes, sir. That’s correct.

[Jaz]
Well, it’s great to have you, my friend. I saw you, two years ago now at the AES. A wonderful presentation. You are a real whiz. You are a, I’m sure you get called all the time. You’re a real whiz with the whole digital stuff. And we’re excited to learn from you today. But Seth, I wanna start with more about you, my friend. Tell us about you as a dentist, a family man, a practice owner, your digital enthusiasm.

[Seth]
Absolutely. Yeah. I mean, honestly I got into some of the digital things initially more for selfish reasons. I practiced South of Dallas, Texas, about 30 minutes, and when I took over the practice, I guess 2013 or so, my kids were six and four. And we were blessed in the sense that the practice got busy.

Things took off quickly, which was good. But the last thing I wanted to be doing was working up patients after hours. And during the day, you’re seeing patients, it’s hard to have time to do it. And yeah, I’d bring my wax at home, wax at the house. My wife would get mad so I’d make a mess. All these things.

And it was tough to do, after the kids went to bed. And so originally I started looking at things really more just, how could I do this more efficiently? What can I do to streamline some of these things to make it easier to be more present with my family, hang out with the kids, and do all the things you wanna do as a father and a parent in those scenarios on it.

And it kind of occurred to me that it’s a lot easier to do a lot of this on the computer. I can have a laptop at home, I can wax up on the screen, I can combine the photography, do all the things that we want to do digitally, and it’s a lot easier. You don’t have to carry the stuff back and forth, it expedites that quite a bit.

And you kind of quickly learn, you gain a lot in efficiency in doing it. Not only cost-wise, but time-wise. And for me, that was huge, initially. Was lucky in the sense that I started scanning back in ’07, ’08, like as soon as I got out of dental school. And so I’ve had a long time learning the scans and the pitfalls and pros and cons, but it took me a good seven, eight years before I realized we’re not really doing anything with the scans.

And we’ve reached this tipping point where I think the majority of clinicians are now scanning finally. But you really don’t get the return on the technology and the leverage you’ve got digitally until you start to do something with that data. And that was where-

[Jaz]
More than just printing the models. The next step, the next level like you did, but you did it so early. I mean, back then, were you a little bit like worried like, am am I doing the right thing? Am I sacrificing accuracy? Were you a little bit concerned at that point?

[Seth]
Well, yeah, for sure. I mean, that’s always a concern, right? Even all the literature early on it was, digital is not as good. Analog has been the standard and over the last 10 to 15 years, we’ve seen that change dramatically. We’ve got a number of systematic reviews now showing digital is at least as accurate in some cases, especially on the articulation side, some other things.

It’s the best representation of the patient by far. And that’s kind of been, I think the paradigm shift for many people is depending upon where you get your training, when you were trained, all those things. We’ve got some, maybe, I don’t wanna use the word bias, but legacy concepts that permeate.

And we’ve always gotta be critical in reevaluating what is the current state, where are we at? And because the point of digital is not just to go digital. ‘Cause at the end of the day, everything digital ends up analog, right? ‘Cause we’ve gotta go back to the patient’s mouth. So the key there is not necessarily digital for the sake of digital, it’s how well can we do analog?

And what’s kind of ironic with that is we’re reaching the point that digital, at least in certain arenas, does analog better than analog. And that’s kind of spot where your mind kinda goes, wait a minute, what’s going on? Like, where are we at with this? And I think that’s really the take home on all of it is, some of the things we looked at with the articulation, things were meant more to bridge the gap because you had this fear, right?

If I went digital, how can I go back home? Am I stuck? How do I get out of the pool if I jump in the deep end? And the reality is, I think we’ve got the capability now to seamlessly go back and forth between analog and digital. And that gets rid of a lot of the hurdles for people.

Because if you can go back home to what you’re used to at any point in the process, it makes it easier to try something. The nice thing with digital in a lot of ways is that once you’ve got the technology, it really doesn’t cost you much to try something. It’s kinda like a video game, right? I grew up as a kid playing games and if you’re gonna go fight the Bosch, you save the game right before you go fight them.

So if you screw it up, you just turn it off, turn it back on, you’re right back where you were. And that’s the same thing with digital. If you wanna print something or design something and you’re at a spot where you’re kind of sketchy, if this is gonna work, save it and you try it. If it doesn’t work, you reevaluate. Go back and, you know, go back to the other methodologies on it.

[Jaz]
So Seth, I was at a lecture by John Cranham in Copenhagen just last week, and it was about the cosmetic occlusion workflow and then how much of what he’s doing is digital like you, and he made an interesting point, which is very relevant to what you are saying about, okay, you can still go back to analog.

But an interesting observation that John made is that nowadays with the new grads coming through, because they never got to or they don’t get to go and wax things up and mount an articulator. He was worried that when they go straight to digital, that they be missing out a huge chunk in education. They may be missing out in terms of the why or the foundations of it.

But actually, he concluded that it’s not really a disadvantage at all because they get the concepts through digitally and for them they kind of bypass the whole analog and that’s not necessarily a weakness. What do you think about that? Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing?

[Seth]
Yes, and the reason I say that is I think it’s the correct answer for both. Yes. Bad and good. For a couple reasons with it. I think understanding where we came from is important because it lets us, from a chronology perspective see how things evolved. It also gives us the capability to evaluate is something new really better or is it just new?

And I think if we don’t have that lens of being able to go back and reference that, that can be a problem. And then the other half of that I would answer is right now, except for a very, very small percentage of people, analog is how we do articulation. And if you don’t understand how we do things, the analog with the facebow, the articulator programming and it’s relative strengths and weaknesses, it doesn’t allow you to manage the miss and handle that instrument appropriately.

And when I say that, ’cause we’ve always used the analog articulation and it was the best that we had, but it’s not a exact representation of the patient. And so if we don’t have the capability to be absolutely accurate, we need to understand and try to control our misses. And that was basically the strategy with how we program the articulator, how check bites work, even just all of those things with the analog instrument.

And to understand that basis and where that came from, I think you’ve gotta have a little bit of the analog side of things. Now, fast forward 20 years when the technology is different, and we may have digital axiography and all these things being more ubiquitous, it may be a different ballgame because I think that’s the big debate that we look at now, is instead of resigning ourselves to a certain level of inaccuracy, can we shrink that error and make it where we’re really shooting to hit the bullseye as opposed to just being on one side of the dartboard or the other.

And I think that’s really the next evolution and where things are going, but that’s also where things are developing currently. Maybe the state of the art is how do we handle that? How do we think differently? How do we design differently? How do we really try to build that in to be more efficient chairside doing it.

[Jaz]
Well, you mentioned axiography and so from my younger colleagues. I’m gonna just get you to define that in a moment. But just one part of your journey, which I’d just love to know is two part actually. The role of mentors in you uptaking digital and really going for it.

And also your source of education and comprehensive, because not every dentist is gonna think about going home and waxing up, right? It’s really you enter the stage of comprehensive dentistry. So tell us about your background in becoming a more comprehensive dentist and the role of mentorship that you may or may not have had when you were moving digital.

[Seth]
Absolutely. I mean, failure is a great motivator, right? And you get out and you see something and it doesn’t work, and you try to figure out why. And initially my goal for going more comprehensive was I didn’t like redoing things, and you don’t like disappointing patients, and you wanna try to give people the best that you can.

And then, we realize when you graduate, the education’s kinda lacking in a sense. I don’t mean that to be despairing, but just they don’t have enough time in three or four years to cram in just even the basics, let alone trying to figure out bigger, comprehensive things.

So I started going down the road initially of figuring out, there’s a lot I don’t know, and where do I start? So I went down, ideally a comprehensive pathway. I started with Spear kind of going through that continuum on it. In looking at it, going back, just the basic training, that’s where you started looking at the bigger picture.

How do I need to understand joints? And I don’t know how the education is over there on the UK, but we spend maybe two hours talking about joints in dental school. It’s abysmal. And they just basically tell you if you suspect intracapsular issue refer, and when you start looking at patients, especially the ones that need restoration, the chances of having some issues at the joint level go up tremendously.

Because in my experience, people with healthy joints structurally intact, joints, good anatomy, barring a couple of exceptions, really don’t thrash their teeth. And so we’ve got stability on the back end of the system, more on the posterior determinants that nobody talks about. And so, starting to understand failure, you look at, a Monday morning situation, you go to the office and patients fracture the distal lingual cusp of a lower second molar.

You see the big wear facet, you see the cupping, your brain’s looking occlusally. Like, we have some issues here. We may not have vertical at the joint. Like we want all these things. And that’s the one that’s the frustration coming out, right? Your new grad clinician, you prepped the tooth, get everything ready.

A team member comes back, I’ve got no room, I can’t make a temporary. And you know you did the reduction, you checked everything out, it’s like, what the heck? And you go back and reduce some more and you’re still outta room. You do some more and you’re still outta room. And now you’re thinking, do I need to talk to this patient about endo?

What are we looking at? Because we’re running outta space to reduce. And these are all conversations that I would much rather have on the front end of the system or the front end than an excuse on the back. And so it was just the school of hard knocks a lot of ways trying to figure out, okay, why did I not catch this earlier?

What can I do to try to make that better? And that’s what kind of got me started on it. And then the digital side was more initially from the scanning, just the practice builder. Just nobody likes impressions from the patient perspective. And so it was initially kind of a builder to say, all right, we can get you in and we can do the diagnostics and we can take the mold or whatever we need to do and not have to have that analog experience in doing it.

And with that, that was probably my initial motivation to try to figure it out is if more patients are able to say, yes, we can help more people do more things, grow the office, all the good parts that come around that. But early on, scanning was tough. I mean, it really wasn’t accurate. At times, depending on when you did it, we didn’t understand the limitations of what the machines can and can’t do.

And sometimes we’re trying to fit a round peg in a square hole in the sense that, that’s not the right modality to fix the problem that we’re going after. And I think even today, that’s where a lot of people run into issues, is we listen to the reps and who’s selling the scanners and oh yeah, you can do everything with it.

There’s no limitations. And then you quickly find out it doesn’t always work like you want. And there wasn’t really a support system to help people troubleshoot that. You know, when I started doing a lot of the digital stuff, there was no manual in any of it. So we try something, I would go to lab groups and look at their forums and ask questions.

And sometimes in Dentaltown may have it or just honestly Googling it, trying it, trying to figure out something that did it. And my background in college, I was initially electrical engineering and computer science. So I like technology, I like all these things.

[Jaz]
It all makes sense now. Every podcast with a guest, I have a a click moment where they mention something in their journey and it’s just like, oh, that’s why he’s into this. That was your click moment for me.

[Seth]
Okay. Yeah. And I got to third, fourth year university and I really liked interacting with people. I didn’t wanna write code behind a computer all day. And my younger brother who’s an oral surgeon, we were, nobody in our family was in healthcare. And my dad was like, well, what do you think you wanna do? He kind of thought dentistry or medicine, and he’s all right, well go volunteer in a bunch of offices during the summers, just sweep floors, pick up trash, just watch and see what you think you wanna gravitate to.

So we went to all the different kinds of offices we could find, and dentistry kind of clicked for both of us. Just different specialties in doing it. But when you look at it, you see how things work and you see the workflows and you see the inefficiencies. And that’s when it kind of started putting together, at least in my head.

Okay, some of these digital things offer an opportunity and if we can implement them correctly and kind of put together a framework that allows us to do that predictably, I think that’s when it really takes off. And I think that’s what you started to really see the last five to 10 years is a lot of the wrinkles that get worked out.

People have beat their head against the wall, figuring out the initial hurdles, and then that makes life easier for everybody else. If you’re willing to share and say, here’s how we did it, this is what I would avoid. How do we move forward with something in a framework that’s much easier to implement on it?

And that’s really kind of what got me into it, is I was willing to play with things and check it out initially, and that allowed me to have the experience to share it with other people. Okay. If I was starting today, here’s how we do this. Where would I implement, what would I pick, what order, kind of all those things to make that a much less of a headache, putting it in and actually a benefit for the practice.

[Jaz]
Well, as we evolve this discussion now, I think the first thing I wanna know from you is, are you fully digital now? Let’s say you have a wear case. Are you at any point picking up your analog facebow and then working on analog articulators to wax up? Or have you got to a point now whereby the trust and the faith you have in your digital workflow, it means that you can do it fully digitally?

[Seth]
Fully digitally for I’d say 99% of it. Now, we’ve got some capabilities now where we bring the mounted models based off the CBCT positioning on an analog instrument, but that’s mainly for the lab to finish the final restorations. And you know, because like I said, the whole point of digital is to go analog.

So we’ve gotta go back at some point. And that was one of the main hiccups is you’ve got these unmounted models and you could check contacts and things, but when they wanna do the final finishing, if they stain and glaze and all the little hand touches that they put on, we really didn’t have a good way to evaluate all that.

And that’s where, we came up with the jigs and the ability to basically add attachments to the printed models that precisely replicate the position on the analog instrument that we had on the digital instrument. And that gives us a number of options we didn’t have in the past.

So now predominantly for the lab to check, but early on before we had the trust, it was more to give us the capability to go back and forth when we need to. And the biggest thing that a lot of people don’t understand is whether you’re taking an analog impression or sending a digital scan at a lab, you’re probably digital either way. And the reason I say that is what is the lab doing? They’re scanning your model, the models that they make, virtually designing and waxing everything and then bringing that to you at the end of the day.

And so, that was kind of initially the knock on digital was, it’s not accurate, all these things. And then people didn’t realize you’re digital regardless. You just don’t know it yet because it’s such a small percentage of labs now that are hand waxing, hand investing, doing all those things. And they realize the efficiencies that we gain doing it a long time ago, and they’re doing it at scale because they’ve got more restorations, more clients, they see more things that we’re gonna see as individual clinicians on a daily basis.

And then the next reason that we did that predominantly was, if you send your scan to the lab or you’re just sending impressions in a facebow with no check bites, ask the lab how they’re programming your articulator. And if you don’t know the answer to that question, I think it’s a worthwhile.

Path to go down. Because the reality is we’re giving the labs many times, part of what they need. We can give them some information to help with the static relation. But when you do an articulation, there’s two types. So you have your static, which is your relation, the maxilla to the hinge axis, but you also have your dynamic relation.

That’s your programming on it. And before we had the digital axiography, the patient motion, the mod jaws, that kind of thing, we didn’t really have any good ways to derive the programming values for the dynamic side with a digital scan. They had some programs.

[Jaz]
So, to clarify, talking about the condylar guidance on the articulator and-

[Seth]
Correct. Because you think with analog instrument, you take check bites, right? Take your protrusive bites or your lateral check bites. When we had our mounted model, you would put those check bytes on and that’s how you program the po, the back end of the articulator doing it digitally. And my argument is the most compelling reason to go digital, quite frankly, is the virtual articulator because it’s got many more or much more capability to replicate patient anatomy than the analog.

But what was simultaneously, I think is potentially its biggest strength was also initially the biggest weakness. And that the virtual articulator was great, but you had no way to program it. And because of that, it wasn’t really useful. And for a long time, even with the design softwares, ExoCAD three shape, those kind of things, labs weren’t even buying the articulation module. They would just have it purely as a clap clap type scenario because they didn’t have a way to program.

And the reality with that is, and when I started looking at the softwares kind of playing with all this stuff, I quickly realized we need to know what the inputs are and what it’s capable of as clinicians, because it’s really more designed for us in the lab. Once you realize that, and I said, oh, if I give you X, Y, and Z to my technician, they can execute at a much higher level because we’re giving them better input.

And that was really what kind of started me thinking, okay, how do we drive these values? How do we give the lab what they need to execute at the highest level possible? And once that happens, you start to collaborate more. You realize some of the synergies and the software, your collaboration on design goes up to another level.

Because we’re no longer like taking snapshots and emailing pictures. They can send me the entire scene file, I can go through the software, change the wax up, manipulate it, do all these things in real time, and it’s much more efficient and it gives me the capability to visualize the case much more efficiently on it.

You know, because really with digital, the advantage lies in twofolds. Computers are very good at aligning things and they’re also give us the capability to combine different records that aren’t able to do that we can’t do in the analog world. So that’s why you can stitch like your CT to your intraoral scans, to your face scans, your photography, and it gives us the capability to layer the patient from a diagnostic perspective.

And that’s something that analog, you can’t take a pano, combine it with your CT or your articulator. They’re all different media and because of that, we lack the ability to cross over.

[Jaz]
That’s what excites me the most, Seth, I mean, just that stack is just phenomenal. I’m not there yet, but in my journey, that’s what excites me the most. The fact that the capability to layer, just like you said is phenomenal. What I wanna draw now is some, some ideas for those most dentists who may be listening right now are probably analog, right? For this part. They may be scanning, but when they have a comprehensive case and they wanna do kind of a wax up, they’ll then be getting their face bow out.

And the ultimate goal is to try and get the movements that you see on the screen to be somewhat identical is a strong word, but similar to the real movements that you have in the mouth. We all know the TMJ is the best articulator, but when the mandible, the digital mandible moves to the left, it moves in the same way that the patient’s mandible moves.

So now that you’re using a digital workflow, please explain, instead of using a analog facebow or an ear bow, what are we using to capture the relationship of the maxilla to the condyle? How are we doing that digitally so that we can actually, get represented cans and whatnot on the digital articulator?

[Seth]
Sure. Well, and there’s a couple different ways to accomplish that. When we talk about, you know, ’cause you’re asking about static relation there, which is gonna be the first part of the articulation, the mounting side. And when we talk about static relation, it comes in two flavors. We’ve got an anatomic relation, which is purely relating condyles to the hinge axis.

Then many times we’ve got an aesthetic relation, which is relating things to the horizon, and those are both important because they allow us to do different things. The patient, if you’re trying to get the instrument to mimic the patient anatomy as best you can, you ideally want an anatomical relation, right?

Because we want to get things as close as possible to the anatomy. But with their technicians, many times we send ’em a scan and that’s all they see. They don’t really know where the horizon is, they don’t know where the cant is. We’ve gotta give them more information to capture that and that’s where the aesthetic relation comes in.

You know, Dr. Kois did a lot of work with the Kois boat and it’s not necessarily, it’s an average value relation anatomically, but what it does to do is correct the cants so that you can wax in a way that gives us aesthetic results that are coherent with facial anatomy and what we’re looking at from that perspective.

Interjection:
Hello again guys. Another interjection for this episode, Kois Bow. What is Kois Bow? It’s named after the legend, John Kois. And I try to like find some visuals or clips for those who are watching. Obviously for those who are listening, I’ll make sure you can follow along. But I have to tell you that the video I found is like it needs an update.

Maybe I didn’t look properly, but the video is from John Kois and it’s like from a long time ago, and we know it was uploaded 12 years ago, but it looks like it’s from a lot longer. And it literally looks like someone is doing like a facebow transfer or a facebow recording on what someone who looks like John Travolta basically.

And that’s what I’m seeing at the moment. And so essentially, you know that fox’s guide plane we used to use for like dentures, right? Complete dentures. You get that fox’s guide plane, make sure the cant is good. You look from the front and then you check the occlusal plane from the side.

Well, it kind of is what a Kois Bow is like. It’s actually properly called the Kois’ Dento-Facial Analyzer. And you don’t need like a traditional face bow if you’re using this. But the real advantage of this is that how it prioritizes the aesthetics, because you’re looking from the front, you’re making sure it’s all level with the eyes and you’re looking from the back and you can use an aesthetic plane.

So you truly are using the aesthetic relation rather than the anatomic relation. And now in combination with the Kois reference classes, the Kois group are really taking this to the next level. So this led the ideal of using the aesthetic reference back to the episode.

[Seth]
We did that with the ear bow for a long time. And we’ve got a lot of literature with the regular face bow that on a good day it’s gonna get us within five millimeters of the true hinge axis, which sounds like, okay, we’re pretty close in doing it. But now that we’ve got this digital data and more things at our disposal, many times now we’re using a CT initially to do that hinge access relation and it makes sense.

‘Cause you know, the facebow, the whole point’s to capture the maxilla relative to the condyles. If you have a CT of adequate volume, you’ve got the condyles, you’ve got the maxilla. If you take that scan in a seated position, all the anatomy is there that you need for the relation. So how I’m doing that today in the digital side, if we’re not doing axiography, and I’ll kind of get off on the nuance of that in a second.

You’re aligning an intraoral scan to your CBCT, and then once you do that in the software, you can move them as one cohesive unit. So then I’m overlaying that on the virtual articulator and you just position the condyles of the patient over the articulator condyles, rotate it till you- intraoral planes parallel to the upper member. You’ve got all the information you need done with it related now that’s gonna give you.

[Jaz]
That’s the ultimate then. Using the CBCT to use, essentially got the skull of the patient, the maxilla, and you are manipulating the articulator relative to that. And you can see the condyles. There’s no guesswork. That’s amazing. And so that is, would you say the most accurate, is that what the evidence is saying as well?

[Seth]
So we’ve got literature now. There’s a paper that was just released that was interesting. They were comparing clinicians and they were given a multiple trials, I think it was 15 times for each clinician and they, versus an analog facebow positioning it.

On a reference model and then translating that to the analog instrument and then doing the same thing with the CT and aligning the scans and transitioning. Once they did it, they scanned the final mountings on both and overlaid all of them to get an idea of how repeatable is each one, and also how close to the hinge axis of the analog of the reference instrument.

The final results were. And what they found is they confirmed with the ear bow still five millimeters, it was like 5.2 millimeters plus or minus two. What was interesting is that you had better repeatability and closer to the actual anatomy doing it with the ct. So they found that the rare, there was only two and a half millimeters plus or tip minus a little.

So they cut the variance from the hinge axis in half doing it on the digital side already. And I’ve got that article. I can’t remember if it’s pre-press or it was just published in JPD, but it’s interesting ’cause we’ve already cut our error in half. Just going through that method with it.

It’s also something that’s easier to store because you don’t have to worry about, if you take your facebow records, some people don’t wanna mount it in office, they wanna send it to the lab. It gets beat up, distorted in the process, the wax melts. I mean, any of the things that go into potential sources of air and doing it.

And that’s one of the other nice parts on the digital side is record storage becomes much easier. That record on the CT, if we align, it’s gonna be equally as accurate 10 years from now as it is right now. And not that you would need it that far down the road, but it gives us the capability to keep things on hand, replicate things with a higher level of accuracy.

And it makes that aspect from the maintenance side much easier to do. And so CT, if I’m on that respect, I think already is cutting the air in half. Now I know sometimes you can’t get the CT and then there’s concerns on your radiographic exposure, things like that. And many times if I have a reason to get it, that’s where I’m using that as well as kind of an ancillary benefit. But the other part we talked about was the patient motion, and you’ve got ways that you can do the articulation now that don’t require-

[Jaz]
Before we get to the articulation, ’cause I’m really enjoying this bit on the static relationship. You raise an interesting point there about the radiation, right? So I think where I’m getting from you is that if the sole reason for the CBCT is to help you align it on the digital articulator, then that’s probably unjustifiable or justifiable. But if you’re also applying some implants, you might as well just get a bigger field of, you get the condyles in and for that sake, a little bit more radiation. You’re getting a better programming. Can you just give us some clear guidelines on what you are practicing?

[Seth]
Sure. Well, let me maybe backtrack just a little for reference. So, we talked about allowing the CT, the intraoral scan in overlaying that on the virtual instrument. And the virtual instrument is a carbon copy of the analog.

Everything is identical. Same programming inputs, same dimensions. They move the same if you have models in the same positions with the same programming. So in a sense, interchangeable in that regard. And when I started overlaying scans of patients on the instruments, you very quickly realize they don’t match very well.

And that was kind of a light bulb moment for me. If you look at the semi adjustable instrument, at most, every intercondylar distance is set at 110 millimeters and you start to unpack where did that number even come from?

Interjection:
Hey guys, it’s Jaz with interjection number two. semi-adjustable articulators, okay. Briefly, right, that 110 millimeter value is from like one condyle on the articulator to the other, condyle on the articulator. And this is where some inaccuracy comes from. ‘Cause you know, if you look at the average person, fine, they might be close enough. But we have a huge variation, lots big heads, small heads.

And so this is a source of error and just getting very primitive for the function of a semi adjustable articulator is that its purpose is to replicate the mouth. So when you’re doing a wax up on the articulator and they transfer it to the mouth, we hope that because you use an articulator to create the jaw movements, that it will be similar in the mouth, therefore, least adjustments as possible.

But we all know the best articulator is the TMJ. And now obviously this episode’s all about digital articulators, which will eventually fully replace these physical articulators. But when you understand things like this fixed distance of 110 millimeters, or the fact that in a semi adjustment articulator you can change the condylar guidance angle to help improve your accuracy, these are some things that we should know about analog articulators. Back to the episode.

[Seth]
It was kind of an artifact originally on the Lee panographs that were courting elements on those back when they were doing the old school fully adjustables were at 110 millimeters. So when they moved it over to try to make the analog instrument match the patient tracings, they put the condylar heads at the same width so that they could make sure the movements were one-to-one in doing it.

What’s interesting is you start looking at actual patient anatomy. Nobody’s at 110, and I’m talking even at the lateral poles. Generally, if I’m doing my virtual articulations for splints and things, I’ll measure from the midpoint of each condyle ’cause I think that’s kind of probably the middle of the road.

If you take in a heat map of activity with lateral and rotational movements, it’s probably somewhere in the middle. But even then, on a lot of patients that need restoration, the articulator at 110, they’re at 75, 80, 82. And you start thinking, okay, you got 30 millimeters of shift. When you start to model that digitally, it’s interesting.

So you can take a model on an articulator. Have the 1/1oth intercondylar distance and if you’re measuring the distance from each condyle to like midpoint between the maxillary centrals, changing the intercondylar distance to correct it to let’s just say from 110 to 80 will shift that link to the central seven or eight millimeters on each side.

And so what initially got me looking a lot of this is, yeah, I’ve got a practice that we’ve got a fairly heavy joint based diagnostic component to it. And so I see a lot of patients with compromised joint anatomy and invariably we make these patients appliances at times to see if we can change the load at the joint level to facilitate adaptation and healing as best as we can before ruling out surgical intervention, those kind of things.

And I would go through the same process in every patient, take your ear bow, facebow, get everything done, have a splint made. And sometimes the splints were 20, 30 minutes easy for like a flat plane group function appliance. Other times it was an hour and a half and I’m like, what’s the difference why are some of these so much faster than others and you start trying to investigate that.

‘Cause initially you think, okay, the lab screwed it up. I’m gonna do it all myself. Started making ’em myself. Same thing, same variability. It wasn’t until I started overlaying these scans on the articulator and comparing the patient anatomy to our instrument that I realized some match better than others.

Some are more average than others. And the patients that were a better match to the analog instrument, the adjustment times were lower. The ones that varied more, we were working with poor data on the input, which is makes perfect sense while the output doesn’t match. And we see the same thing clinically.

There’s times, you’re doing a rehab and you insert it and you’ve got minimal adjustments, and then you’ve got the other, where it looks great on the analog instrument or the articulator, but you go to the mouth and the guidance isn’t right and you’ve gotta go in and grind a bunch of things. And we’re getting a more compelling body of literature that there’s not a single restorative material on the planet that benefits from adjustment.

[Jaz]
That’s very true.

[Seth]
And with zirconia especially, if you sue on them, had some date, literature out that the minute you touch it with a bur, if we don’t refire it, we’re losing 50% of the strength. Then they probably, if we’re not firing it to heal ’em and maybe 1% of people are re firing everything after adjustment.

It just doesn’t make sense from a practicality perspective. So all these benefits that we’re seeing with zirconia being the strongest material and all these things, you take half the strength away, we’re below Emax immediately. And you start wondering, okay, maybe that’s why we’re seeing some failures in certain places we didn’t expect.

And there’s a number of factors that play into that. But the take home there was many patients don’t match our instrument. And especially the ones that I see that need more comprehensive restoration, when the joints aren’t structurally intact, the growth gets to be altered and you lack projection.

They end up being class two. It’s the same difference in orthodontic practice. 80% of ortho patients are class two. And the reason is the back end’s not growing like it should, which leads to compromises on the tooth position, on the front end of the system.

Interjection:
Hello, Protruserati. Jaz here with some injections, right? So this episode, because it’s about occlusion, because it’s about our articulators, we need some interjections just to make sure everything’s really tangible. So the point Seth is making here is that many class two patients, class two, meaning, large overjet classically in a class two div one.

But if you think about the causes of a skeletal class two, well, it’s either that the maxilla is too big or it’s the mandible that’s too small. That will create you a class two skeletal pattern. And so what Seth is saying, and he is totally right, is that the main cause of class two is that the mandible is too small.

Not necessarily that the maxim is too big, but the mandible is too small, it’s too set back. It is retrognathic in nature. It’s smaller and set back in nature. And, and the final distinction here is he said poor posterior growth. And what he is referring to is the condylar growth and the health of the TMJs.

So someone who does a really good job of talking about this is Dr. Jim McKee. Jim’s a previous guest on the podcast, Jim McKee, came on the podcast before, talked about piper classification, but he’s brilliant at talking about this stuff. And essentially if you have a destruction in your TMJ, in your growth years, during childhood, during teenage years, then that condyle and that posterior mandible will not develop normally.

If that doesn’t develop normally, then that will contribute to a class two because it’ll make your mandible deficient. So just making that important distinction. Once again, if you’re enjoying these and these are helpful, please comment, let me know. The last few times I’ve done this, everyone’s been saying good things generally, and so we’re kind of keeping it in the podcast, but there’s still time to say, no Jaz, this is not good, so you gotta let me know. Back to the ep.

[Seth]
My wheel spinning on that was, okay, how do we make things better match the patient? Because at the end of the day, that’s the goal. Legacy concepts, if you look at how we did things, it was more about making our patient fit an analog instrument. It’s a fine point, but instead of making the instrument fit the patient, we are making the patient fit the instrument and trying to control where the screw up was.

And I think that’s where I was kind of alluding earlier that I think is the biggest difference we’re going to see is we’re switching the order now. We’re actually truly trying to make what we’re doing digitally truly match the patient as opposed to forcing them into a box that they may or may not conform to.

[Jaz]
So with the digital articulator, then that intercondylar distance, can you just simply just plus, plus, plus minus, minus, minus, and change that seamlessly?

[Seth]
So on some, yes. Some programs, yes. Some you can. Others you gotta be a little more adventurous and maybe go into the code and tweak it. Like ExoCAD does it let you do it off the rack. But there are ways to go about it, but the digital axiography side overcomes that limitation as well.

[Jaz]
So tell us, what is axiography tell us the definition. What is axiography?

[Seth]
Sure. Yeah. So initially in the analog world, it came from the fully adjustable articulators where they would go in and they had an apparatus that went on the face that attached to the lower jaw.

And as it moved, it made physical tracings on paper, on recording elements. And that’s how they use that to program the analog instrument. They would use that to find a hinge axis and you could actually change all the parameters on the D5A Denar and some of the old, fully adjustable articulators.

And it was a great way to match the patient as best we could, but it was cumbersome. It took a lot of time and it a lot of effort. And what they found was most people weren’t gonna do it. So we started going then to semi adjustable where you only have a few things to input, but you try to manage the miss so that the analog instrument is designed to, as a general rule, be flatter than the patient’s anatomy.

And that’s a benefit, right? Because if the instrument’s flatter as we grind everything in the accessory, cus pipes are shorter. So when you go to the mouth, you have a steeper disclusion, you don’t have interferences. And that works great if we’re trying to execute canine guidance where you only need to have one plane steeper than the others and things come apart.

But when we start having to do these progressive group functions and other things where patients may need more support at a joint level, it gets a lot harder to accomplish. So what we started looking at on the digital side is we’ve got ways now to capture all that data much more seamlessly. And these would be like Zebris or Mod Jaw or the different, you know, digital axiography or sometimes term patient motion that you see.

And what it really is, honestly, it’s a high speed camera that sits in front of the patient. There’s reflectors that are fiducials that get attached to the lower arch. And as the patient moves, the camera’s just purely articulating and capturing those movements at very high resolution relative to a tiara they wear that gives you the reflectors for that upper arch.

And once you have this data, it can be brought in seamlessly into your design software, like ExoCAD or 3Shape, and it comes in fully mounted. The articulator gives you programming, so you’ve got all your programming already done. And where it overcomes the analog, the virtual limitations is you actually have the movement on the screen.

So I can take you through protrusive closest speaking space, left and right, para function. You can even have the patient chew and eat and masticate. And what you start to see is, articulators mainly on the bench work inside out. You start it static and you go into discursive this way. Where the form really meets function is when patients chew.

They’re not starting in and going out. They’re coming out on return stroke in, and there’s a lot more variability and a different dynamic to that than we’re used to thinking about. And because of that, that’s just data we weren’t able to capture ’cause you can’t replicate on analog instrument, any of that.

Where we now, when we start to see it digitally, one of my preferred workflows now in any case is we virtually wax the case up ahead of time. We go to prep. And when we’re doing our provisionals, I’m not relining provisionals or doing shells or doing full arches anymore, we’re virtually combining our definitive prep scans with the virtual wax up and 3D printing.

The provisional is fully contoured. So everything is two year definitive margins. There’s no reline. It allows us to do like full arches of single units now, which is huge for hygiene staging. It makes life so much easier ’cause now you know, if you’ve got a full arch maxillary restoration or provisional.

The worst call you get is Ms. Jones calls one of ’em chipped. Okay? Which, where? Where did it break? What do we gotta do? There’s nothing more inefficient to try to patch or take off a full arch provisional. Doing it as individual units is massive because now which one chipped number five. I can have number five reprinted before the patient gets the office.

The characterization is done. We verify that the scan was accurate initially when we did it. So I mean, I hardly even have to see the patient. We can go in. Assistant can see the provisional, make sure everything’s good. I’ll come in, double check the bite, figure out what went wrong. And it’s just a huge time savings doing it.

[Jaz]
And these 3D printed provisionals are like a temp bond, placed in. Is that how you’re doing it, like temporary cement and then you are giving some time for adaptation and checking whether you are happy that the patient’s TMJ is articulating as you planned for everything in the design stage?

[Seth]
Yeah. Generally, I like Duralon for the 3D printed provisionals just because I think I’ve had better success with that, but just from a long-term maintenance perspective on it. But exactly that. And it gives you the capability to one, verify everything, right? Especially on the aesthetic side.

Do we like the tooth form? Do we like the shape, do we, is function what we want it to be? And even though you can plan everything digitally, I feel very to very high level. The patient articulator is always the final judge. And because of that, I still always want to give them some time to evaluate and check and make sure we’re on a path that we like.

I also like it from a phasing perspective because, I mean, that’s the biggest issue that we see a lot of times is, if a patient is of more modest means, affording a full arch at once can be very tough. And so it gives us the capability to phase cases differently. So as opposed to, let’s just say they’re in an insurance environment, they can do two crowns a year.

We can initially get the case stable with the 3D printed provisionals, get everything where we wanted as individual units. Well you’ve already got a fully designed crown, you’ve already got your master scan, your margins are done, everything’s done. I don’t need to bring that patient back in to prep and press two crowns a year.

I can send those to the lab, have them turn it to our definitive material, bring the patient in, pop those two off, put the provisional, their definitives on a ceramic. They’re not having to come back to the office to repress, they’re not having to do any of those things. So now my chairside efficiency goes dramatically in doing it.

I also like it because it’s easier to maintain those patients ’cause if you wanted to maintain a phase a case over two or three years. If you’re doing it splinted, you worry about hygiene, you worry about can they get in there to clean all the different things. As well as, two years is a long time to trust any provision without something going wrong.

And going in and remaking a full arch provisional could be three, four hours by the time you get it off, clean it up, have everything redone. Now it’s literal 20 minute visits ’cause you know, individual, which unit broke you can accommodate for all that. And the next objection or question that sometimes gets asked is, well what if they wear change over time?

Well if that happens, you just bring the patient in and re-scan for the occlusal changes. The lab can combine that seamlessly without having to redo all the other parts. And you can adapt very quickly to anything that happens when you do it. And that’s probably, honestly my best part of doing this digital now is I really don’t, it’s taken a lot of the stress off full arch provisionals, bigger case temporization, and even the stress on my body doing it.

‘Cause now a lot of times we’ll do in demand design with my lab technician. So if I’m gonna prep the maxillary arch at eight, I may tell them to definitive scan by 10:30 or 11. I send the scan off, the wax ups done. I can go have a coffee, hang out, take a break. My designer will virtually combine the two 30, 40 minutes later, all the files go to my inbox, drop ’em on the printer.

It’s a 15 minute print, 20 minutes to characterize, which I can have my team do that in the back and I’ll come back 30, 40 minutes later to see all of ’em when we do it. And so, huge difference. And you could go see another patient if you wanted to. I prefer to sit and take a break and I don’t, prepping is tough.

And it, and to me, if you want an argument on why to go digital doing it, that’s it. I mean, it’s huge and not that you yet necessarily have to start at the full arch level. Take the scenario where a patient comes in, they chomp down number 19 and shattered existing crown. So you’ve got no crown, new patient, no matrix.

And that’s always a time consuming deal, right? Because you’ve gotta figure out, okay, did I put a stainless steel crown on and take a matrix? How do I get something to make a provisional crown for this patient? Well do it digitally. Get everything prepped, get everything where you want it. Pack your core, take your definitive scan.

You can virtually wax the tooth up in two minutes, put it on the printer like the Midas now from SprintRay, you know, seven minute print and then five minutes post-processing and you’re ready to go. I mean huge efficiency perspective.

[Jaz]
I mean this concept of putting your cord in and scanning for the definitive has so many advantages. Like you said, I mean, I guess there was a phase where people might have been doing the rough prep, then putting temps on it and then going back and refining it. I mean, what a service to our patients, not only just time, but comfort. This whole digital workload you described really is fantastic. But one thing we touched on was yes, getting the static right, and then we touched on axiography, and you mentioned about motion collection.

But in terms of actually the articulation, what are you currently using? You described all these, I mean, are you using a module at the moment? How can we make sure that when you put it on the digital articulator, yes, you’ve got your CBCT and the condyle and you’ve lined that all up to give you sort the best idea.

You’ve got the cancel correct, but now the actual motion, what metrics are you using or what can we be recording chair side to make sure that the kind of checks that we have so that when you move the mandible on the screen, it’s like the patient moves.

[Seth]
So two ways of looking at it, one is we try to match the patient precisely, and that’s where I think you’ve gotta have the digital ay side of it, just because there’s no way to capture those movements, mod jaw, debris, any of those that allow you to capture.

The other is we get the better static relation using the CT. So we’ve got a better initial starting position, but we still have to use analog check bites. That’s the only other way to derive those values. And the way that we would do that is we’ve gotta get the model in the identical position on the analog and the virtual instrument.

So if I’m not using Mod Jaw on these scenarios, what I would do is take my CT, align that to the analog instrument and my project, a few years ago I was working with AD two, which is an articulator company. It actually came out of AES. it was maybe four or five years ago at AES and I was taking a break walking through the vendors and Dave who owns AD 2, was at the booth.

I saw he had a jig in the back. It was kind of, one of the jigs for putting a printed model on an analog instrument. It was kind of more akin to what Dr. Kois and them were doing with their analog jig, with their average value jigs that they had. And we started talking shop a little bit and I said, if you figured out how to position the jig coordinates, where it loads relative to the virtual instrument as opposed to the model.

And that was what I was working with ’cause initially I like ExoCAD for doing a lot of this, but ExoCAD has a different global coordinate positioning system than 3Shape does. Where 3Shape positions, everything relative to your scan. ExoCAD has a global positioning relative just to that reference.

And that sounds like we’re off in the weeds, but the significance of that is I was able to encode the positioning of a virtual attachment in ExoCAD. Not relative to the scan, but relative to the articulator. So when you add this virtual attachment, it loads in the same position relative to the virtual instrument, not the model.

So the benefit of that is when you use the CT to position the model, the attachment loads relative to the articulator. So as long as they intersect, when we print those as one unit, it puts it in the identical position on the analog instrument with the same jig.

[Jaz]
So you don’t need to get the mounting stone and that kind of stuff, right?

[Seth]
No, never that. Exactly. And what that allows you to do is, we talked earlier, we have the same programming, same dimensions, same instruments. If the models are the same in both, I can now take my check bites on the analog instrument. So take your protrusive bites, take your lateral bites program, the analog, and I can plug those values directly back into the digital.

So now we’ve got the dynamic movement programmed without having to guess. The downside to that is we’re still resigned to the same miss, right? Because the analog instrument can’t precisely replicate the movements. So we’re gonna have accurate programming on the analog to give us the flatter movements, the things we’re desiring, but it’s not going to be the highest level of replication of the patient.

And so, depending on where you’re at in the process and the adoption, and to be clear, yeah, if somebody was asking me today, what order do I get these things in? The motion side is the absolute last thing you need. You need to be scanning, you need to be comfortable with the software, you need to be 3D printing all those things.

Because if you don’t have those tools in your tool belt. You can’t really take advantage of what the motion offers in that scenario audit. So from that perspective, that would be where I would tell you to start is if you’ve got a scanner, you’ve got one of the more expensive pieces of the puzzle, but you need to get comfortable with software because the software is what’s going to allow you to manipulate the data and actually do something with it that’s productive, both from an efficiency and an ROI perspective.

Because when you send to the lab, you really don’t gain much. But when you’ve got the software in-house, if you wanna 3D print the provisional, that’s where you gain the time on. And the other deal I didn’t even talk about is 3D printing than the provisionals is less expensive than using bisacryl.

[Jaz]
Oh wow. I didn’t know that.

[Seth]
Which is huge. Yeah. The average bisacryl in the US is about a 1.50, a provisional. I can print them, if you’re using, depending on the resin, it’s usually 60 to 75 cents per. So you’re already cutting your cost by more than half.

[Jaz]
Something that’s stronger and better fit and all those advantages for something that’s way less that, I didn’t know that. That’s amazing.

[Seth]
And that’s where you start to actually pay for the digital stuff, right? ‘Cause when you buy a scanner, the rep’s always saying you’re gonna save $20,000 of poly vinyl. Well, yes, but over five years. And they don’t tell you the monthly fee on the scanners and the maintenance.

And what if things break when you’re just scanning, you’re really neutral at best in terms of the financial side of things. But when you start doing provisionals, okay, now we’re saving 75 cents to a dollar every time we print one. You do a splint, a digital splint from a labs 150 to $200.

It costs you $7 to print a model is $4 to print, which sounds okay. It’s cheaper on its own than doing mounting stone and all the others. But now when you’re doing a wax up. A wax up in the US is 50 to $75 a unit virtually, it costs me $4 just to print the model for the stent. And so a 10 unit wax up, 700 versus four.

It doesn’t take you long to actually start to pay for all the technology you wanna bring into practice. And that’s something that many times isn’t talked about because as clinicians we’re always looking at what’s best for the patient. But the reality is we have to run a business because if we can’t be profitable, we can’t pay our team and pay our staff and do what we need to do to learn the things we need to learn to handle our and take care of patients.

And that’s something that isn’t touched on very often. Or I guess it’s, I would say it’s more rare that usually when you bring in something new, you’re doing it at an expense for a clinical benefit, right? So I’m gonna be more accurate doing this, but it’s hard to make it truly cash flow and make a good business decision.

And I think that’s where digital really has the potential to differentiate itself, is you can bring in all these technologies and all these synergies come in and you actually have a way to make it a good business decision. In addition to enhancing your clinical outcomes, and that’s where I think it’s special in that regard.

[Jaz]
And for many of us, Seth, think of how much fun you can have, right? Think it’s the intersection of technology and dentistry. I mean, you could stand, you can see from how you speak about it and your presentation at AES man, like. For, many people, right? This may not be their cup of tea ’cause they just hate it.

They very much love the analog world. They hate anything digital, I get it. But for most of us, we actually embrace this. We went to scanning because of the problems it solves and patients love it. They love when they can move their models around. And then when you’re able to give them that level of service that you’re describing, and then the amount of fun you can have with it as well, it makes our job so much more satisfying, so much more rewarding.

So I think that alone has a huge benefit and always, always gotta keep learning, right? If you keep it fresh, keep your mind stimulated, then that’s another wonderful reason to look into digital. Last question before we just talk about how we can learn more about the AES and the exciting things coming up with AES 2026 is for those of us who don’t, I mean, we’ve got a CBCT at our practice, but many clinicians around the world don’t have access to CBCT.

I’ve seen whereby a good way to perhaps replicate the static detail, the cants and whatnot is aligning the digital articulator with the patient’s photos. So using that as a tool for the lab, can you describe that workflow, whether you think that is the second best or is there anything else that is perhaps inexpensive and something that we can use to get digitize the patient without using face scanning? Without using CBCT?

[Seth]
I mean, photos give an opportunity right now, the problem with the photo side is it’s two dimensional. And so if you’re using a straight on and a side photo to try to do it, you can get some idea of it. But there’s some wobble in the system on it. In those scenarios I would tell you go with the analog facebow and used the traditional method to do it ’cause that’s inexpensive, easy to do.

And we can then digitize that and work off that framework very easily doing it. And so that’s the other way to look at doing it is, you can take measurements off the analogs and plug those into the digital and use that for your positioning and you’re going to be probably as good as the photos, if not better doing it for sure.

[Jaz]
So essentially just so I’ve got the workflow right, it’s as an alternative to the photos, it’s doing everything as we usually do, face bow mounted and articulator at your desired bite. And then how are we getting the articulated models? Is it by scanning the positions or just taking like ruler measurements and then plugging those into the software?

[Seth]
You can do both. So, if your lab has a lab scanner, you can send that mount to model to the lab. They can easily digitize the articulator and that allows for the alignment of it. The other way to do it would be, and that’s actually how like one of my favorite splint programs is a program called D3 Tool or D3 Splint. It was written by a dentist who also was a coder, or he also did commercial software design. And I like it from that scenario because he understands what we’re doing as clinicians, but it’s also very intuitive and it’s dirt cheap.

I think it’s 600 US one time fee and you own it. But in that program, there’s arrows that you can drag and draw, and it basically has three measurements ’cause to position something in space, you need an X, Y, and a Z coordinate. And it’s a measurement from each condyle to the central point between the centrals and an angular measurement from the infraorbital through the condyle down.

So you’ve got right condyle to central point, left condyle to central point and an angle. Well, that gives you your three coordinates. So all I would do if I wanted to do that virtual articulation, you can use a ruler. So measure, just put that face bow record on the analog instrument. You don’t have to pour a model, you don’t have to do any of that.

And just take a linear measurement condyle to there, condyle to there, and use a protractor. Between those that you can put in the digital splint program and immediately go in and do your virtually articulated splint. Now you have a little wobble for the can and there’s some finer points that you can do to tweak that, but you’re gonna be much closer than you otherwise would’ve been arbitrarily throwing that in.

And so that’s kind of the very easy, low cost MacGyver way to get there doing it. But there’s other methods that you can do that obviously increase complexity going down, but that would give you a starting point. For sure. And I would tell you that’s a great place to learn to trust it is make two splints, have one done, starting it with better values at on the input and have one, do it done as average and start to see where’s the difference in doing it.

And that was really kind of one of the nice things digitally is when it only costs me six or seven bucks to make a splint, I can do multiple proposals. Same thing with wax-ups. Usually having three or four aesthetic proposals is cost prohibitive ’cause it costs you too much to the lab. Well doing it now with virtual libraries and only costing $4 to print the difference, you can actually have so much more flexibility and it lets us see, have the patient see these proposals ahead of time. There’s less guesswork. More likely they’re gonna be happy with the initials which is less time remaking, less time starting over, just everything gets more efficient in that scenario.

[Jaz]
I think the thing to emphasize here for those listening is what Seth has done is because of the fact that it doesn’t cost much more to change a few variables and print it, you’ve been able to test and test and test, what if you change this?

What if you change that? And really your workflows now a representation of all those near misses and failures, which were inexpensive failures because you were able to make that adjustment, spend 10 minutes to print it again and get it corrected. And what a service to your patients. So that again, is a huge advantage of digital there.

Tell us about your involvement with AES, Seth. How did you get involved with AES? You’re on the squad of AES in terms of organization. What role do you have with AES and how did you come into that and what have we got in store for AES 2026?

[Seth]
Awesome. Yeah. I had a couple cocktails one evening and started talking up in one of the suites after the meeting. And the next thing I knew, I woke up the next morning and was gonna be involved in planning the 26 program, which sounds funny, but that’s kind of how thing it goes down occasionally. And it’s been a great opportunity. Jim McKee was the one who originally got me involved with the organization on it and had never planned a program before.

So first time coming in as a program chair doing all that. Yeah, I would’ve been blessed. The fantastic co-chair Liz Turner, who is awesome. And she and I were kind of charged with executing the vision for the current president’s meeting, which is Bobby Supple. And Bobby is very much an occlusion nerd.

He’s very much tech scan digital guy. So he was trying to put together a meeting that would bring a lot of these concepts together. And one of the nicest things about AES for those who aren’t familiar is they make it a point of trying to bring different vantage points into the same room and letting ’em talk it out.

Which this panel discussions and things where the point is to let everybody see what’s out there and then try to figure out what you believe is the best truth going forward on. And so for 26, we’re looking at a lot of different things. There’s a very heavy digital component, but we have a lot of sympathetics and airway and all the different things coming together that are problems for us clinically today.

So we have, example Jeff Rouse is coming in and looking at the etiology of wear patterns and maybe he is gonna look at, is it more of a global thing as opposed to a toothpaste level deal. We’ve got Tracey Nguyen, talking about airway on it as well. We’ve got Mark Piper, Nick Yiannios talking about the roles of Sympathetics, how they play a role, ’cause the sympathetic nervous system I’m finding in my practice is something that makes a huge difference in a lot of cases, but it’s something we were never taught to look at.

Alter alterations and sympathetic tone. How do you diagnose it? How do you figure out if that is part of the problem? And I’ll use an example. We have these patients that maybe have an asymmetric response to procedure pain wise. So you go in, you think, man, the tooth popped right out. It shouldn’t be a problem, and I’m hurting the next day.

And three days later, they’re hurting, and a week later they’re hurting. And then they don’t look like they have a dry socket. You can’t figure out what is going on. Well, you start looking at these patients and the apnea patients and the airway patients and people who have systemic inflammatory diseases, their sympathetics are cranked up all the time.

And we start looking at substance P and pain response. And they’re just, they respond differently. And I had a patient where I was curious that they had increased sympathetic tone and we were taking out two teeth, 18 and lower second molars bilaterally. And there’s diagnostic nerve blocks you can do to kind of turn off the sympathetics to see if they play a role.

We do that a lot for the joints. But so outta curiosity, I told the patient what we were doing and I was gonna do this block on one side and not do the block on the other. Taking out both teeth, same teeth, symmetric, same side, the two, the side where we block the sympathetics, uneventful, healing, no problem at all.

The side that we didn’t had that asymmetric pain response, it hurts dry socket, I can’t get it to go away. All the things. And at that point, my mind was like, there’s a piece to the puzzle we’re missing here. And I think that’s what Mark and Nick are gonna really focus on is maybe a different way of seeing the same patient and using that to factor in our diagnostics, our discussion, our treatment planning, setting expectations for where we’re gonna go. We’ve got Lukasz Lassman coming in who I think was on the podcast last week?

[Jaz]
Just yeah, just yesterday was published.

[Seth]
Insanely smart guy. And he’s looking at vertical dimension and how we alter it. Maybe some of the conceptions and misconceptions we may have on the literature and what that supports. He’s even gonna look at the role of the sympathetics and how does that play in? There’s a lot of things that tie in. I think at the end of the day, it’s going to be a very interesting meeting and it’s a fantastic time to come check out the whole dental world in terms of the States is in Chicago at that time.

There’s eight or nine other meetings going, you have lab day, all the things. It’s a cool way to come spend a few days when it’s cold in the middle of February. Not much else to do.

[Jaz]
You know what, it wasn’t so bad that when I came two years ago, the weather was actually really good, but I know it can be very variable. But what a beautiful city. What a beautiful city. Chicago and honestly like, what you guys are, are bringing together all these top level clinicians is phenomenal. So I’m just wanna champion the event you guys are running. And so it’s been a great pleasure to host yourself, Jeff Rouse, Liz, Lukasz in terms, and Dania Tamimi. We recently published our episodes-

[Seth]
Oh, I forgot Danny. Yeah.

[Jaz]
And so, so many superstars and so many learning points. So I really encourage you all, if you’re able to come Feb 2026, make it the conference that you attend. Seth, thanks so much. Your hard work and organization so far. But the best is yet to come.

The hard work is yet to come still. But for now, we want to just spread the good word and honestly keep up the amazing work you’re doing in the digital side. Like, my mind is blown in terms of the possibilities. And may you continue to be, this super nerd in a nice way possible.

Like honestly, you are. You’re very clear, you’re very passionate and really intelligent. So, thanks so much for the good work you do. And I appreciate your time today on the podcast.

[Seth]
Absolutely. I enjoyed the visit. Thank you very much.

Jaz’s Outro:
Well, there we have it. Guys, thank you so much for listening all the way to the end. Hope you enjoyed the injections, but my goodness, Seth is some sort of wizard. I appreciate him very much for allowing us to use his slides during this presentation. But don’t worry for the audio listeners on Spotify and Apple, you didn’t miss out because the whole conversation happened without any visuals.

It was just to enhance what we’re doing. Now if you’d like to get CE, this episode is very much eligible. There was plenty of juice in this one. Protrusive Education is indeed a PACE approved education provider. The episode is eligible for one hour of CPD or one CE credit. Head over to our app Protrusive Guidance.

It’s also home to the nicest and geekiest community of dentists in the world. Click on this episode in the all episodes and CPD section, answer the quiz. And if you get 80% Mari from Team Protrusive, our CPD Queen will send you your certificate. You’ve done all the hard work, you’ve listened. You might as well get that certificate.

We’ve crossed the threshold recently so that now if you tally up all the CPD and CE available and Protrusive Guidance, it’s less than a dollar. So imagine getting a CE certificate for this episode for less than a dollar. There is so much good stuff on there, and just the network and the community that’s on Protrusive is absolutely amazing.

We’ve somehow attracted the nicest and geekiest people in the world. Head over to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate to get a free trial to make sure that you are happy with the education that’s on there. As always, thank you to Team Protrusive for their hard work in putting this together for the visuals of premium notes and to ensure that the mission of making dentistry tangible is totally accomplished.

Thanks again, my dear friends, I’ll catch you same time, same place next week. Bye for now.

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