Engineering Excellence in Dentistry: Dr. Sven Bone on Innovation and Mastery: Part 1

Just to update you guys , I guess it was maybe the weekend before last , the weekend before that everything blurs together , but I attended the first annual ORCA symposium in Las Vegas , which had a really , really impressive lineup of speakers , and one of them is here with us today , dr Sven Bone .

He got up on stage and you know there were so many different lecturers there that came from a variety

of backgrounds and spoke to so many different things , and it was really an incredible conference . I really enjoyed it . But Dr Bone got up there First of all coolest name in dentistry , I'm just going to go ahead and put that out there and he got into some really , really interesting concepts . We're going to get into them today .

You know including , I mean , dr Bone is bringing a whole lot of experience from a background in physics that we'll talk about .

He has his own lab , he's a prosthodontist , he also does surgery , he does full arch , all these wonderful things that we talk about and I got to talking with him after the symposium about some of the things we spoke about and we got into some really cool topics that I just thought would be amazing for the show , and he's been gracious enough to come on .

So , Dr Sven , thank you so much for coming on .

Yeah , sure , sure , yeah , well , I mean I think that's all the better and really , when you know we argue that when people go about learning this , learning the process first and then kind of working your way backward is really the appropriate way to do it , because the difference between just being able to say you did this and doing this well really goes down to

those types of fundamentals . So I'm really really happy to have you on here and I know you can go deep on that kind of stuff , yeah totally , I think you know , and if we look in the literature you know the number .

But the prosth side sometimes that's where things can get really kind of challenging .

as an undergraduate and so I did . And in that time I you know physics majors have to get minors in mathematics in order to get a degree , and so I was kind of I ended up . At the time , you know , a big revolution was happening in biology and I became really interested in kind of the biology and and and kind of the biology side .

So I took a few biology classes and , um , one of my lab partners was going to be a dentist . And so , uh , you know cause I asked him , I was like , what are you going to do , johnny ? He goes , I'm going to be a dentist . And so I'd never thought of that before , never once .

And and I started looking into it and then I realized like , wow , dentistry is a beautiful combination of medicine , it's art and engineering really mechanics , yeah and so so I was like , wow , this could be a really good avenue for me .

so so I uh ended up , uh , so I ended up taking more pre-med type classes and decided to go on and finish a degree in mathematics . And so I have two undergraduate degrees , one's in physics , the other one's in mathematics , with more of an applied side .

So so basically , it's trying to solve real world , real world problems , like how do we model these sophisticated mechanical problems ? And and also I mean just I took a graduate course in in it was it was called like I think it was biologic , biological mathematics and biology , or something like that .

I ended up modeling the calcium fluxes , like the voltages through the heart through the cardiac muscle and also I remember modeling insulin release in the beta cells in the pancreas , so really kind of complex , fun stuff . And so I finished that up and then I applied to dental school and I got accepted to . I think it was there's no dental school in Montana .

I got accepted to . I think it was there's no dental school in Montana . So I got accepted to I believe it was Tufts and Boston and UOP and I think Creighton , nice yeah .

And I , when I was in dental school , I knew that there was more complexity involved with , like full mouth rehabilitations and large like restorative like procedures .

So I decided to work for one year after dental school back in Montana , and I encountered some cases that I knew were complex and I didn't feel like I was as prepared as I wanted to be , and so I decided to move on to PROS and I applied to PROS programs and got accepted to Carolina and then Baylor , and so I decided to go to Baylor for my PROS .

I was reading a whole bunch of like Carl Sagan and you know um astronomical stuff and um , I found out pretty quickly you do have to be able to do math to do physics . And that was that was kind of the problem , that that was what was in my way , um . So , uh , yeah , I was .

I stood no chance of being contributory to that field , um , but fortunately I did . I did have a , uh , you know , a mind for biology and things like that and working with my hands and physics kind of had a very roundabout way of sorry . Dentistry had a roundabout way of finding me , but but yeah , that's fantastic .

So you went to a prost residency at Baylor and you know you've ended up in Bozeman , so kind of you know what was that journey out of prost residency into dentistry ? Did you go directly into private practice or what ? What was that like ?

So I wanted I knew my compass always pointed back to um , I knew I wanted to go back to Southwest Montana , so it's always felt like home for me and and so so I I just kind of packed up and it was time for me to head on out , and so I came out here and worked , uh , I commuted and worked in uh , a couple of private practices and then , uh , when a

space came available , I I started my own practice .

You find what you really are interested in and that's what

you're going to end up doing , you know , and so so at first I was did more general dentistry and then now it's . It's pretty much implant based .

I mean , basically we do a lot of lab work is part of the requirement , and so I somewhat missed that .

And then also I was really excited about the transformation that the lab industry has gone through , and so I wanted to , I really wanted to dive deep into that , and so I started the bone dental lab , mainly for just my own curiosity , my own desire to control the , I think , really control the the the whole process for my patients , because the , you know ,

understanding from A to Z is very important to minimize your risks .

I do have like an all digital workflow for my full arch now , and so the lab can do a lot of heavy lifting for me , um , but thankfully I there was a time before that for me where , um , I did have an in-house lab and a lab technician that would do all my conversions , and we had a week where I had , um , three double arches and , um , he , um , his

father was sick in Israel and he wanted to go back and spend some time with him .

I was like , of course , you know you have to go do that , and so I had to do my own conversions for a week , and that's when I learned you know how good and bad of a surgeon that I was , you know because I figured out what needed to be done in order to simplify that conversion process and by even just like the third conversion that I did that week , I

was significantly better and giving my tech a lot better of a time when he came back to do my conversion . So I definitely learned that live , just starting with the end in mind and working your way backward .

Everybody has to be on the same page If you want to have the most amount , the greatest amount of success and the minimal amount of risk is that everybody's kind of like mind melded together yeah , you know for sure gotta be reading the same sheet of music .

Um , and then we , locally , you know we'll , we have , uh , in the past we've gone out and done records and do the whole like , basically do the whole thing . Oh cool , yeah , Okay , and so uh . But you know Montana is a big state and so drive in three hours , you know it can be challenging .

Has that kind of experience of building out the lab then kind of taught you more , as you know a prosthodontist like what does that development really look like ?

It's , I think you know , for me , because I do all the CAD designs and stuff for my patients . I tend to get a little lazy with communication with the lab , but I can't under emphasize how critical that is .

You know , as far as , like , how your relationships are with your other , with the people you work with , how your relationships are with with your other , with the people you work with . Like , how well do you communicate with them and how clear is your from the clinical perspective ? How clearly can you describe what you , what you intend the outcome to be ?

Because the more information you can communicate with the people that are , you know , fabricating these things , um , the the the better . I think , like I tell my patients , I don't want any surprises and so that's what we write . That's why we kind of go through a lot of that , why I'm very systematic about things yeah , that makes sense .

You know what are the different stages they work with and things like that . But there's a lot of questions I think dentists don't know to ask , right In terms of , like , how they actually make their prosthetics . Um , you know different , not not even just turnaround times , but just like , what is their quality control ?

Like , um , you know , how many designers do they have on the team ? How experienced are they ? What you know , how , how has everything ? You know , uh , what are the different departments look like and how has all that flow ?

And I and I'm curious about you know , with you having such a direct relationship with your lab and them making that final product from start to finish has that kind of taught you some things that dentists might need to be a little bit more discerning about when they're looking at different labs ?

I came , I kind of like came out of the womb , you know , out of a prost residency right , knowing kind of like , like just having that beaten into my head as far as how you , you know , of a prost residency right knowing kind of like like just having that beaten into my head as far as how you , you know take records and and things and I think that

standardization and record record taking is massive , um , yeah , as far as like getting a reducing the entropy or chaos that's in the , in all the the information that that the laboratories receive , and and so I think that , uh , so one is portraits or face scans , um , and then the other one is shades you know , standard shade selection with photos , and then some

sort of job relationship record . You know treatment position , and so , on the clinician side , their responsibility is to determine the treatment position and then also , you know , be able to provide enough data so that the technician can reproduce the patient in their like in front of the screen .

And , and that's the goal and that's what I do with all my patients on . So that's helped me on the clinical side and then on the on the laboratory side , on the manufacturing side , they to , um , absolutely understand their materials . Uh , on the cad design part , uh , it's a little chaos out there .

We'll probably get into that yeah , oh yeah , let's do it right and and on the and on the manufacturing , like tool changes , uh things like that . Like all the little details to keep your uh systems uh . Like that , like all the little details to keep your uh systems uh .

Like machining , like what kind of validation and verification are you doing for your machining ?

He made parts for Boeing Gulfstream and that was like my summer job was working a CNC machine and learning about , you know , quality control and tolerances and you know the human error that can be involved in those manufacturing processes .

And then , on top of that , before I got into dental school , part of the things that I was doing to build out my resume was working at a dental lab .

So I worked in the CAD game department for a lab and the number one thing that got drilled into me before I ever learned how to do any type of dentistry was shit in , shit out right , like if the record's bad , their product's going to be bad .

And you know , dennis had this idea that somehow , you know , given it's almost like that scene and the really cliche scene in movies where they they zoom into a very , you know , poorly resolved image and then they they resolve it more and somehow it's higher quality after they zoom in , dennis think that labs can do that yeah yeah the , the born , or like the

satellite . Yeah , that's not how data works yeah , yeah , exactly so somehow it's , it's not it longer . Yeah , we're just trying to minimize the loss of accuracy , but somehow we're supposed to create it . But those have really gotten me a better appreciation for what it takes to have high quality records and result in a high quality product .

And generally , as hard as a lab's job is , it's a lot easier when that data is accurate and when it's good and it makes the lab , it makes the doctor feel a lot better when things work well . But that's only if they did the records correctly . You can't create accuracy , so

but yeah , no , that's , that's really good . So you've got the , obviously your prosthodontic practice , you got the dental lab , and then I also learned a little bit about what you're doing with your smart mouth technologies company .

Yeah , so I started a I I I just kind of , I think , just having my background and like a technical background and then also having a clinical background , I think I'm particularly good at kind of teasing out like some fundamental problems , that that where I think we need improvement .

And so I started a engineering I guess that would be a tech company really and and I I have about five engineers on staff and we essentially we have a bunch of projects that we're working on , and so the .

I think one of the biggest first projects that we're working on is a web application called Will it Break , and that's a finite element analysis for dental prosthetics , and essentially what it does is it tests designs . So what we want to know , and I think what is really important for designers to know is are their designs set up for failure from the beginning ?

And so the you you know we have a bunch of rules of thumb , right , you know , cathedrals were built on rules of thumb , but structural engineers don't use rules of thumb anymore to build , you know , uh , skyscrapers and buildings , and you're right , you know that kind of stuff , so we use um . Basically we want .

Our goal is to increase the engineering rigor into this space and make it more sophisticated .

interpretation . So what finite element analysis is is it's basically a numerical , uh , salute , it's a numerical computational method for solving incredibly complex equations .

And and these , when you take a structure or or like , let's say , a full arch , and you , uh , and let's say , a patient bites on it , or let's say they grab some beef jerky and bites down right on that distal cantilever , so what happens is a very complex tensor field is created in that structure , in that full arch , and it what it does is is that that

field describes how that force is experienced , I guess , by this , this , uh , by this full , by this prosthesis , and . And so finite element analysis is a numerical method of breaking that , um , breaking that full arch into tiny little chunks .

And the reason why that finite element method works is because computers are very , very good at basics , summing up a bunch of little solutions together . And essentially what it does , the output is stress , so it calculates this very complex tensor field that that is created and strain in the in , in the prosthesis , so so so the interpretation of that .

And you can also tack on a failure theory . So so there's theories about a material has , you know , ultimate tensile strength and things like that we can describe those little teeny elements and sum them up and and , and we can apply a failure theory to it and the output is essentially . Here's where .

Uh , usually the output is in in a heat map , and the heat if you've ever seen this before , you'll see it in some of the dental literature too . The heat map tells you where the stresses are and then , depending on the material , you can somewhat figure out where it's likely to fail .

Part of your presentation was just like an A and B of like which one is going to break , and it's just kind of everyone's just being intuitive about it . You're not seeing a heat map or anything and it was very counterintuitive and you kind of talked about the multifactorial processes and stuff like that . But back to my question .

So something I'm very curious about and I hear this talked about without a whole lot of really substantial argument . It's just kind of , you know it's hand-waving for the most part . So , you know , something we've seen in the past several years is the proliferation of direct to multi-unit design , as opposed to using tie bases in these restorations .

Through finite element analysis , have you been able to make any conclusions about stress points between those different systems and what's better set up for success long term ?

However , there's a phenomenon called tolerance , stacking . So so , when you add a lot of things together and you're trying to to get them all to fit together , you , you compounding inaccuracy , yeah , you compound your error , and so , uh , I think theoretically , uh , direct to MUA is doable .

I think there's some , there's some fundamental problems with that as well , um , but I think both are are doable , and I don't believe I can answer that question Okay .

I have definitely seen that chip . Yeah , oh yeah , that's set up for that yeah for sure .

It's typically you know somebody with like a high school diploma or something like that . It doesn't necessarily mean that they don't know anything about . You know mechanics , but the odds are they don't yeah Right . Mechanics , but the odds are they don't yeah Right .

And so I think it's on that side of things , on the design side , there's a lot more emphasis on you know , does it look like teeth ? And that's important , but at the same time it's got to work , you know .

I think , back towards more like we , we , we absolutely know like fractures and prosthetic complications are extremely inefficient part of in our industry , like , like right now , prosthetic complications and stuff are huge efficient inefficiency that needs to be , addressed For sure .

Is it more so going to be , you know , a design aspect or some some aspect of how that's been configured , or is it going to be more on the fabrication side of things how well lab handles zirconia and centers it , you know so on and so forth .

It's multiple , multiple variables , like , come into this equation , and so so I think the I think there's not one silver bullet here to to to go that's going to solve every , all the problems , um , but I think we , we kind of , you know , I , I know that on the design side , um , you know we're , we're very focused on getting a very nice , valid tool for

designers to use to help them design better , you know , as far as improving the structural predictability of their , of their um processes , um , and and , and I think , on the lab , on the manufacturing side , um , you know there's , there's other things that need to be done as well . Okay , okay , fair enough ?

I I'm kind of um , I'm really curious about what we're going to find , like I'm yeah , no , I mean I'm really interested in , yeah , and how you know and and and what , what we're gonna see from the design side , and we're're also , you know , we're also embarking on mechanical testing as well , for about you know , you know validation .

Yeah , yeah , you should do , but it's , it's very difficult for us to really quantify those things .

That's the , that's the , the future , that's what's going to happen , and , and you know , and , and and so I think we're going to see less polarization , um , as as we get more data , um and so .

So we're kind of in the , you know , we're in more of a speculation kind of landscape right now because we just don't have the tools , we don't , you know , and and I , I think , I think that's the key the goal is to is to get as far away from that as we can .

ask me you know what's going to be , you know the best restorative material for you know any given case , you know the safest thing to say is , oh , it's multifactorial , right . But you know , really , the answer that people will have is entirely dependent on who they've been talking to . You know their own experience and who they've been talking to .

But both of those things are inherently biased , right ? You know , some people just swear by monolithic zirconia . It's God's gift to earth , it's , it's fantastic . Other people will tell you the modulus of elasticity is way off and you get saucer defects around implants and all these things . Some people will say you have to have a titanium substructure .

Other people say , oh well , then the superstructure is going to be thinner and more prone to fracture or something . We're all just kind of , you know , shooting in the dark . So I'm very interested to see what comes up from that .

I think we need more resolution on that patient that's sitting in the chair before while we're making these decisions about , okay , what , how am I going to design this prosthesis and how and what you know as far as the implant , the surgical plan and things like that .

But I think , like bite force , just one , I mean a little old lady I think I said this in my talk . You know , a big , massive cantilever totally broke any kind of rule of thumb , but that one is going to do fine because it's in a different environment .

We're all different and so you know , a middle-aged male that bruxes is going to be entirely different than a little old lady that's , you know , eating mush all day , you know . Yeah , I mean , it's just totally different environment and so we really need to step away from from these . We kind of need to evolve past like get , get through this .

You know , period of , and , and , and and throw down our , our rules of thumb , and , and start using more sophisticated tools to make these decisions .

But , you know , still that's not really enough to inform every decision you make for each patient .

Something that I really enjoyed from Dr Sonata , who went , and you know , of course , he was talking about his FP1 cases and had some beautiful documentation and everything , but one of the things that really , you know , I left with was he was just talking about the FMA angle and how he assessed his cases and you know I was aware of that , but you know he was

like I can look at a patient and I can tell how big of a problem they're really going to be for me from an occlusal standpoint in terms of the bite forces Just off of that .

But FMA is a , it really is a very , it is a useful , you know , a tool or a diagnostic aid and a treatment planning aid , but again , it is just an aid , right , of course , and I think that we're even going to get better , like you know what I mean , with more data , like as far as , like , hey , bite , force , things like that .

I mean , uh , even just knowing how they chew is a really important thing , right . If you're , you're might be concerned about some you know structural , uh integrity issue on the left side , but they never even chew over there , right . So , like , just knowing how they function is extremely important . We don't even really measure for that .

possibilities , and then how much ? Load , could that be ?

Um , do you really need to do that ? Right ? And we're not necessarily making an informed decision , we're just going off again that . Do you really need to do that , right ? We're not necessarily making an informed decision . We're just going off again that rule of thumb , and that's affecting how the patient is being treated .

It's affecting what you're doing as a surgeon , um , so that's that's kind of an uninformed decision , um , so , yeah , I think we we stand to gain , you know , uh , a lot of advancement in terms of you know how we take care of people and what we're able to do .

So we start filling in inputs in all those buckets and we start figuring out okay , given all this input , what should I do ? How am I going to treat this patient ? And then what's the outcome going to be ? And I think it's really important , I think , to get to mastery , I think it's really critical to make those models one very diverse , like complex .

So you have lots of inputs and you're analyzing lots of different data points , and then I think it's also really critical is to harvest as much experience or much knowledge as you can from your experience points .

So every case is an opportunity to make , to enhance those internal models , and so I think the clinicians that reach mastery I'm not saying I'm a master by any means , but I think all of us are , or most of us should be , on that path Like how do I get , how do I really get you know good at this and and I think that's the the kind of the pathway

because you know experience , you can kind of rinse and repeat , uh , the kind of robotically right . Uh and and I think your job as a clinician is to is to really um grow in your sophistication as rapidly as you can .

Like a lot of dentists , they take all those different models that you just mentioned and they form a certain formula for their practice and they , like you said , rinse and repeat day in , day out .

And you know , sometimes as long as the office is doing well , you know you get this idea that , like you're doing something , you're doing something right and you're doing it the best and other people should be doing it that way too .

And you know you're not necessarily committing yourself to excellence that way , because you're looking at different surrogate markers that aren't necessarily , you know , tied to . You know what is the end product , what have you provided for the patient , what's really going to be the best long-term ?

And you know one thing about full arch is you know we are measuring our success on kind of a monthly basis . Right , it's just , how much did the office do ? How many arches did you do Not ? You know , did the thing that you did today is ? Did you do not ? You know did , did the thing that you did today . Is that going to last the patient 25 years ?

And we have no idea . But maybe if we had some data we could have a better idea .

screwed in , they're probably right , and that's that's not enough .

And and I think I think that's that's like a um I I think that's so important to to get to a place where you , where we all want to be , you know yeah , and it's it's easy to to kind of rinse and repeat . Oh the patient's happy . You know I must do a great job .

But yeah , but no issues , right right but it's when , because when you have a , when you , when you have that like mentality as far as , like I'm really going to , you know , analyze all of my outputs or all my outcomes , then when you get into a tough one , that's when , that's what's going to save you .

But I do think that they are , but inherently it's very complicated and so sometimes we get bit .