665: Treatment Planning & Digital Are Not the Same Thing! – Dr. Jeff Rouse

If you're new in the digital space, there's one thing you should know: digital smile design and treatment planning are not the same thing! To explain how they're different and why the confusion is one of his biggest pet peeves, Kirk Behrendt brings back Dr. Jeff Rouse from Spear Education with advice for using digital and analog in your treatment planning process. Analog isn't outdated just yet! To learn why the best dentists still use analog, listen to Episode 665 of The Best Practices Show!

Episode Resources:

• Join Dr. Rouse on Facebook
• Follow Dr. Rouse on Instagram:
  
• Subscribe to The Best Practices Show podcast 
• Join ACT’s To The Top Study Club 
• See ACT’s Live Events Schedule
• Get The Best Practices Magazine for free! 
• Write a review on iTunes

Links Mentioned in This Episode:

Register for Facially Generated Treatment Planning at Spear Education (December 2-4, 2023): https://campus.speareducation.com/workshops/facially-generated-treatment-planning/details/syllabus

Main Takeaways:

Understand the difference between treatment planning and digital design.

Digital still has some limitations for certain kinds of cases.

Smile design software is not a treatment planning tool.

Don't go fully digital until you master analog.

Using software can lead you to overtreat.

Quotes:

“I love the idea behind [digital] of creating a motivational mock-up. So, when DSD or Dr. Christian [Coachman] talks about doing that, I think that's perfect. I absolutely agree with the whole concept of being able to motivate a patient to continue on and create the desire to do dentistry. Got it. The problem comes when you believe that is treatment planning — because it's not. It’s a motivational mock-up to get people interested in doing something, but it tells you nothing about how to actually do the dentistry.” (5:13—6:01)

“Digital designing doesn't show you how to treatment plan the case. It simply is a way of giving an illusion to a patient to create a desire to act, but it doesn't treatment plan the case. In fact, I would argue, in some cases, it actually does quite a bit of harm because unless you're skilled at treatment planning, you don't know what can and can't be accomplished. You just simply pick out the perfect place for a smile, and it doesn't matter if the teeth are going to actually work with that final smile at all, and it ends up creating the need for more dentistry, some dentistry that doesn't really need to be done. There are tons of problems because people conflate one with the other, treatment planning with smile design.” (7:20—8:20)

“Treatment planning is, if you start in the Spear world, figuring out where the incisal edge of the central incisor belongs in a three-dimensional plane. So, it's not only in a vertical, horizontal fashion but also in an AP fashion. So, you have to figure out exactly where it belongs, and then you work your way around the rest of the arch. That is where the teeth belong. Treatment planning is, how do I actually get the teeth into that position and, more importantly, in the Global Diagnosis system, how do I get the gingival architecture into the position that it needs to be for me to actually accomplish the dentistry that I'm describing? So, that could be, ‘Everything is fine. It works perfectly. Let's rock and roll. All we need to do is make the teeth prettier than what they are. They just have a bunch of restorations in them.’ Unfortunately, the majority of the cases that people are using smile design concepts on are cases with significant amount of wear, significant amount of erosion, teeth that are malpositioned, teeth that are twisted, turned, or something is off in the totality of the smile. Well, in those cases, the gingival architecture is off, the positioning of the tooth is off — everything is off. And so, you have to, in treatment planning, figure out how I can get the teeth and the gingiva to work within this framework or idea of where the perfect smile is.” (9:05—10:42)

“Smile design, on the other hand [of treatment planning], simply limits it to, ‘Let me show you a pretty picture of where the teeth would look better on you.’ It has nothing to do with the reality of the case behind what you've drawn. It's just, ‘This is where the teeth would look really good, and here's a model of a tooth that would look pretty on this particular patient.’ That's great. I love it. But I love it for what it's intended for, which is selling the patient on the design. Unfortunately, when you confuse it and call that treatment planning, then you run into real problems with the overall case.” (11:07—11:52)

“You have to learn how to treatment plan to make [the design] software work to your advantage. If you don't know how to treatment plan, you will get frustrated by that software because it's going to require you to do more dentistry than your patient base probably can do, because most people that are doing this don't have a lot of patients that can do full-mouth rehabilitation — that's me included. I don't have a lot of people walking through the door all the time that say, ‘Design the most perfect smile for me.’ And, by the way, now that you've designed the smile, all the teeth are in the wrong location, which means I have to do the lower teeth as well to get the function that I'm after. I don't have a lot of those people, and design software would lead you to believe that that's the treatment plan.” (13:13—14:14)

“At the current moment, digital has some limitations that if you want to do [certain] types of cases, you've either got to be very invested in expensive software and very time-consuming effort in order to transfer information correctly to your virtual articulator — which, I found very few people do. Now, the ones that do it, that's great. But the majority of practices are not invested that deeply into digital. They scan for a crown. They scan for a nightguard. They may print the nightguard in the office. They may make casts in the office. They may store digital files in the office. But they're not so invested in the case so as to have the ability to put a virtual facebow to it and a face on it. And so, if the patient is canted like in the case that I was referencing, if you try to send that off to the laboratory, or even something as simple as send it to Invisalign or some sort of orthodontic system — I mean, if they're canted and you level that cant virtually, your wax-up is going to be completely off. Your orthodontic movement is going to be completely off. Everything is going to be off. And so, the idea that a facebow is gone, to me, it has not reached that point in time.” (17:25—19:03)

“While I have a 3Shape scanner in my office, I choose not to use it because I can get things done more efficiently by simply staying in the analog world at this point in time.” (19:09—19:22)

“It is very limiting to throw everything into the digital world unless you're really willing to live in that world completely.” (19:43—19:51)

“It's amazing, some of the things that they're able to accomplish [with digital], and workarounds and such when I say, ‘Well, this is a problem.’ ‘No, I can do it this way, that way, or the other.’ I think it's phenomenal that they can do it. That's just not the regular dentist. Too many of the regular dentists give up on analog because they . . . I don't know why, honestly. I think they want to seem progressive, but it just makes their life harder.” (20:22—20:50)

“If I was a young dentist today, I would do everything in my power to get really, really good at analog with a little smattering of digital. But remember, digital — I can do everything analog. I can do everything. I can exit my practice having never practiced digitally and be just fine. It's just learning to work within that world. And, by the way, I would note that . . . for the most part, if you put together all the big names in dentistry right now and said, ‘Tell me how they practice,’ they're analog.” (22:38—23:25)

“Anybody that you're like, ‘Oh, yeah. They're really good,’ when it comes right down to the difficult cases, they're all analog. Bigger cases, cases that are off somehow, all the hard cases they do, they're always doing it in analog. So, if that's true — which, I know it is — why do you think that you have to be digital just to keep up with people?” (23:31—24:02)

“If I was a new dentist and going out and trying to get continuing education, I would go somewhere and learn how to do things in an analog fashion. Learn how to make a facebow. Learn what an articulator does. Learn how to use stone on an articulator. Learn the proper way of doing all these things. If you want to print a cast, that's fine. But the cast doesn't, today, have the detail that stone does. It's not even close. A printed cast is not close to a stone cast, and there are reviews all the time in the literature to tell us that. So, are there cool things that can be done digitally? Yes. But with the background of analog and knowing how to work analog, you know what the deficiencies are as well to digital. So, you can then pick out the strengths of the digital and use it. That's how I work with it in my practice, is when I have something that I know digital does really well, that's when I use it. When I know there's something that analog does better, that's when I use it.” (24:32—25:42)

“So long as a young dentist is going into the smile design world knowing that that's not treatment planning, that it’s a way of motivating a patient — if all they do is say, ‘This is a motivational mock-up,’ that's what I get from it, then it's a wonderful tool.” (26:11—26:32)

“The frustration a young dentist is going to get [with digital smile design] is they're going to look at it and go, ‘Now, what do I do? How do I actually make this happen?’ If you don't have a background in treatment planning, you are going to do crown lengthening to mimic the gingival contours on the mock-up. And if a tooth is in the wrong place, you're going to cut the bejesus out of the tooth in order to make it happen, or you're going to not cut so aggressively and you're going to have to warp your crowns around, which won't mimic the mock-up anymore. So, if you want to get digital smile design, go learn how to treatment plan so that you know how to actually make it happen and marry those two technologies, or marry the technology of smile design with the intelligence of treatment planning so that they can work the way they're supposed to work, which is to the benefit of the patient, and that you're not just crowning or veneering everything you see there, that you actually get their teeth in the right location, you get the tissue in the right location, but you do it the correct way. You don't force the case once you get to that point in time because you know what needs to be done.” (26:51—28:15)

“Some of the best dentists in the world don't actually treatment plan very well. They do really beautiful dentistry, but their treatment planning is not that well done.” (28:50—29:00)

“I honestly do understand what digital can do for you and the benefits that digital can have for you. And the way I understand that is I know how to do analog, and I know what analog can do better than digital — because this discussion a few years ago would be completely different. Three, four, five years ago, digital couldn't do a lot of the things that it can today. And so, I trust it more than I would have in the past. In the smile design world, it's always been the same problem, though, since its introduction. People are taking it as a treatment planning tool, and it absolutely is not — and it's never been marketed as that. It's always been marketed as a way of creating a vision for the patient as to what can be done so that you get this motivational mock-up.” (33:33—34:26)

“All the people involved, from Christian [Coachman] on out to all the other different people that have done this and are talking about it, never say, ‘This is how you treatment plan the case,’ by somehow magically making the teeth go to that spot. They always say it's much more in-depth than that. Now that you know where you want the teeth, you have to figure out how to get them there and get them there correctly. But people miss that over, and over, and over again, and they think that learning the treatment plan is old-school, and the old way, and we need to do digital, and in order to be up to date, you've got to show digital. And that's not right. That's simply incorrect. They are two completely different issues, and there will never be a digital version of how to treatment plan. It will never exist because it's a way of thinking. Maybe AI can someday treatment plan for us. But it isn't now, and it's not for the foreseeable future because there are too many different variables that are involved at the present time.” (34:28—35:41)

Snippets:

0:00 Introduction.

2:14 The problem with digital.

8:46 Treatment planning and smile design, defined.

11:53 The problem with design software.

15:54 Don't give up on analog.

20:51 The best dentists still use analog.

28:17 Things dentists get wrong.

29:59 Have a systematic approach to treatment planning.

32:57 Last thoughts.

35:44 About Dr. Rouse’s Facially Generated Treatment Planning course.

Dr. Jeff Rouse Bio:

Dr. Jeff Rouse is recognized as a pioneer in the field of airway prosthodontics — the impact that a compromised airway has on the stomatognathic system. Along with fellow Spear Resident Faculty member, Dr. Greggory Kinzer, he developed the "Seattle Protocol" to recognize, control, and direct resolution of airway distress in a restorative dental practice.

After graduating from dental school in San Antonio, Dr. Rouse completed a two-year general practice residency at the University of Connecticut Health Science Center. He practiced family dentistry for 12 years before returning to school to earn his specialty certificate in prosthodontics from The University of Texas Health Science Center at San Antonio in 2004. He is a member of the American Academy of Restorative Dentistry and American College of Prosthodontists, and past president of the Southwest Academy of Restorative Dentistry.

Dr. Rouse maintains a private practice in San Antonio, Texas, and practices with Dr. Kinzer and Dr. Frank Spear in Seattle. He is also an adjunct assistant professor in the Department of Prosthodontics at The University of Texas Health Science Center at San Antonio. Among his dental accolades, he has written numerous journal articles, including a portion of the “Annual Review of Selected Dental Literature” published each summer in the Journal of Prosthetic Dentistry. Most recently, he co-wrote a textbook by Quintessence titled, Global Diagnosis: A New Vision of Dental Diagnosis and Treatment Planning.