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AUDIO - HSP#186 - Christian Coachman
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VIDEO - HSP #186 - Christian Coachman
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Learn Dr. Coachman's digital workflow, and why he teaches dentists how to speak 'patient'.
Dr. Christian Coachman graduated in Dental Technology in 1995 and in Dentistry at the University of São Paulo/Brazil in 2002. He is a member of the Brazilian and American Academy of Esthetic Dentistry.
Moreover, Dr. Coachman attended the Ceramic Specialization Program at the Ceramoart Training Center, where he also became an instructor.
In 2004, Dr. Coachman was invited by Dr. Goldstein, Garber, and Salama, of Team Atlanta, to become Head Ceramist of their laboratory, a position he held for over 4 years.
Dr. Coachman worked with many leading dentists around the world as Dr Van Dooren (Belgium), Gurel (Turkey), Fradeani (Italy), Bichacho (Israel), Ricci (Italy) and Calamita (Brazil).
Currently works at his family Dental Clinic in Sao Paulo-Brasil, together with his father, uncle and brother. Also works as a consultant for Dental companies and offices, developing products and implementing concepts and has lectured and published internationally in the fields of esthetic dentistry, dental photography, oral rehabilitation, dental ceramics and implants.
He is the developer of techniques as the Pink Hybrid Implant Restoration, the Digital Smile Design and the Virtual Lab concepts.
www.digitalsmiledesign.com
info@digitalsmiledesign.com
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Our hands-on Digital Smile Design World Tour is coming to the U.S.!
Las Vegas, December 11th-13th
link:
https://worldtour.digitalsmiledesign.com/usa
Howard Farran: It is a huge, unbelievably, amazing honor to be interviewing probably the number one, most legendary cosmetic dentist in the world. He lives in Brazil. I’m podcast interviewing him in Morocco where it’s 6:00 pm. It’s 10:00 am here in Phoenix. I have heard dentists speak of you like a cosmetic god in so many countries. I can’t even count it. You’re just the man. You started out as a lab tech, which really explains a lot of your success, because you started out on the other end as a certified dental lab technician, and then you became a dentist. Now, you’re merging it together with technology to where a dentist can transfer more information about the face to the models. Did I say that correctly?
Christian Coachman: Amazingly well. You were able to summarize the whole thing in few words. Yes, I’m a dentist, but I consider myself a dental technician still even though I went to dental school. I never worked as conventional clinician. I was always involved with the prosthetic part of the work and maybe, yes, this dual combination helped me to develop the concept that we’ve been talking about for the last two years.
Howard Farran: Does that help-
Christian Coachman: First of all, I just want to thank you for your introduction. It was probably one of the best and the most exciting introduction, so I’m very honored to be here speaking with you. Yeah, it’s a pleasure.
Howard Farran: You’re either in your dental office or you’re in the airplane lecturing. I look at your speaking schedule, I almost passed out from exhaustion just looking at your schedule. How many countries have you lectured in?
Christian Coachman: On the last seven years, we did 190 cities, I think, 70 countries. It’s like an average of 180 days on stage per year, so it’s every other day.
Howard Farran: Every other day. Is that what attributes to your good, charming looks, is living an airplane, eating airplane food why you’re so handsome? If I doubled my speaking schedule, would I be less short, fat and bald? I think we should start with … You’re talking about 7,000 dentist probably, 80% of them are probably US, but explain to them the Digital Smile Design concept. Explain to them, they want to hear it from you. How would you explain this?
Christian Coachman: Okay. I’ll try to explain in few words. Digital Smile Design, DSD concept is a concept that I start to work on nine years ago. Basically, it was something that I was doing for myself to technically help me become a better technician and deliver work that would require less adjustments in the mouth by the dentist. That was my main goal. I can summarize DSD with four main goals. We want, through this concept, become better smile designers, or that means integrate smile with faces in a better way with less struggling, less inside the mouth, saving time inside the mouth or that means planning better outside the mouth to design things better on the lab, so it when it goes to the mouth, it’s aesthetically ready in harmony with the face, that’s the first goal.
Second goal is to create a communication protocol that allows better interdisciplinary treatment planning, a better communication among specialist, dentist technician through what we call the Synchronous Online Communication Process that allows us to be on our iPhone, on our tablets, on our laptops constantly, 24/7 connected with the team, and without having to call people on the phone, or schedule meetings, or going and driving back and forth. We can be connected and treatment planning our case is beautifully through this communication protocol. The third goal is what we call the Emotional Dentistry Approach. It’s to help dentists to improve their skills with communication with the patient; how to improve the perceived value of the treatment, how to make patients understand how special the dental treatment can be, increase the emotional link between the patient and the product that we are trying to sell, the dental treatment, and give value to the smile transformation, how important confident smile can be to improve your lifestyle, your quality of living, and your health, your profession. Everything can be improved by a confident smile.
The final goal of the DSD concept is to implement a workflow through software that helps us to become more precise, more predictable, more efficient, sharpening the treatments, reducing the number of appointments and being more predictable between the initial project all the way to the final outcome of the case through a series of interdisciplinary software that we developed that integrates CAD/CAM with digital orthodontics, digital orthognathic-guided surgery, everything based on this initial 3D facially-guided a smile project. That’s basically the summary of that.
Howard Farran: How does a dentist adapt this? Obviously, the dentist has to be doing this, that the lab and the dentist, both have to be doing this. What do you have to purchase? Is it mostly just purchase computer software or …
Christian Coachman: Basically, that’s a couple of options, but you can implement the DSD comps without purchasing absolutely nothing, without having to change nothing the way you do dentistry. We usually show the concept. You have to understand the concept, the philosophy behind it. You have to enjoy this; the philosophy, and then there’s a couple ways to implement it. On the courses that we give, we usually show people how to implement DSD on a complete analog path, so bringing this concept into the analog world and the conventional way of doing things, and you can do that in a very nice way. Another option is to integrate the concept into software that the dentist technician already have. Of course everything is based on teamwork, so it something that dentist and technician have to understand and share; the concept and the goals of this concept.
We also have of course all the software that we personally developed that people can also, as an option, buy it and do everything themselves, or they can use existing software like let’s say CEREC or Invisalign or NobelClinician. These software that out there can be used and you can link the concept inside these existing software. Finally, very recently, since we realize that dentist really, even the ones that really loved the concept, they were struggling with implementing, going back Monday after the course to their clinics and saying, “I want to do this. I really see the impact of this.” They were struggling with the learning curve and implementation, training their staff and all these. We started an online service that we call, “The Virtual Lab,” where the dentist and the technician, as a team, they can outsource all the pieces that they don’t want to do themselves. There’s plenty of options on how to implement DSD if you think the concept will help you.
Howard Farran: Dentaltown now has 202,000 dentists from 206 countries. We put up 350 courses and they’ve been viewed over half a million times. I would give anything for you to put an online CE course on Dentaltown that you would be complete enough where they could watch this and get it implemented and going. Then, you wouldn’t have to fly to many cities.
Christian Coachman: That’s our goal actually. This December, for us, is going to be a very important month, because we’re going to end the world tour, and after seven years, we’re going to stop with this craziness of travelling, otherwise, I’m going to kill myself.
Howard Farran: Your world tour’s been seven years?
Christian Coachman: Seven years, and I would say the last three years with the more official, the DSD official world tour on the last three years, but the seven years that we’ve been giving this course all over the world. It has been growing and then becoming more organized, supported by important companies and now, recently, the last two years in a partnership with Quintessence, so it’s something that became very solid and professionalized. We are ending this December, the world tour and next year, we’re going to only have our DSD centers that will be longer programs more intense, we call it, “The DSD Residency,” or the, “Digital Dentistry Residency,” that we are starting next year, so longer programs more in that into Smile Design Digital Dentistry and interdisciplinary treatment planning.
Now, our centers will be only in São Paulo, Miami, Madrid and Abu Dhabi. I hope I’ll be travelling only mainly to these four places. We count on the web to spread, to start sharing this content with everybody that cannot come to our courses. Your idea is exactly what we are thinking at this moment; how we’re going to create this partnerships with online educational platforms to start sharing the concept in all corners of the world.
Howard Farran: Do you remember in São Paul, Brazil, the Aesthetica 2000 Conference with 4,000 dentists?
Christian Coachman: Yes.
Howard Farran: Do you remember that? That’s the largest lecture I ever got invited. Larry Rosenthal from New York was there. São Paulo is one of the most amazing cities on earth. The different ethnic sections, there’s a section that’s all German, and the restaurants are all German. Then another part of the town, you think you’re in Tokyo. How many people live in São Paulo? Is it 30 million?
Christian Coachman: It’s 20 plus million.
Howard Farran: Twenty plus million?
Christian Coachman: Twenty something.
Howard Farran: Wow. What a city you live in. You’re going to focus on São Paulo, Miami, Madrid, Spain, Abu Dhabi?
Christian Coachman: Yes.
Howard Farran: I’ve always noticed that everybody from Central and South America, their favorite American city is Miami, no doubt about it. Is that one of your favorite American city?
Christian Coachman: It is one of my favorite cities. I think, half of Miami now are Brazilians. They invaded Miami. Probably it’s more Latin city than many Latin cities. We all feel at home, Central America, South America, we all feel at home in Miami for sure have many friends over there. The weather is always beautiful. People like to travel there mainly. I love New York as well, but we believe that having the center in Miami, people from Central America, from Europe, it’s nice, easy. The airport is very good. You can fly everywhere. It’s in a strategic decision besides the fact that we know we will enjoy life in Miami as well.
Howard Farran: Yeah. New York’s a little brutal in the winter; December, January, February. I also want to point out a very interesting [inaudible 00:12:59]. I’ve lectured in Brazil half dozen times is your dad is a dentist, your uncle’s a dentist. It seems like in Brazil, nobody is an individual dentist. There’s either half a dozen dentists in their pedigree or there’s none. Do you notice that?
Christian Coachman: Yes. It’s a family business in Brazil. Yeah, first of all, Brazil has more than 200,000 dentists. We have more dentists in Brazil than US, it’s crazy, even though the population is half. We have 130 dental schools, I believe. It’s crazy. It’s too much, too many dentists. Many of them are like that; family-oriented, father and son and goes on. We actually have a very unique tradition in dentistry, not only me and my brother, my sister-in-law, my uncle, two uncles and my father. Before us, my grandfather and three brothers and my great grandfather and two brothers, my great, great grandfather and a couple of brothers, and finally, my great, great, great grandfather also all dentists, so six generations nonstop.
Howard Farran: I know a dentist in Miami who has 18 dentists in her immediate family, 18 dentists.
Christian Coachman: Eighteen.
Howard Farran: Eighteen, just amazing.
Christian Coachman: This is a record.
Howard Farran: What are you doing? You said you’re professionalizing, you’re working with some companies. What companies are really getting behind your program and your technologies?
Christian Coachman: We are very happy to see that, first of all, that we were able to grow the concept until this point without having to commit with any kind of company and what we say we were able until now to do commercial-free education. Every course, we have this opportunity to really speak about any kind of system, even though we had the opportunity to do business specifically with this and not talk about that. We preferred to stay open and talk about everything. I think that generated a very nice credibility and people can feel that honest message on stage. At this point, we are very proud to see that many companies and many institutions are now approaching us on the last year trying to bring DSD into their philosophy, into their workflow from very well-known universities in US.
We started to work with DSD at NYU, at Taft, at Harvard, at LSU, at other institutions and universities, in Europe as well and South America, teaching centers like … I’m lecturing with John Kois, an amazing honor. He wants to know a little bit more about DSD, and Peter Dawson Institute as well. Now, companies like Noble, Invisalign, they all want to somehow incorporate DSD to their workflow. For us, it’s just amazing to see that the concept is making sense to these big corporations, big associations showing that the concept is very solid and it works.
Howard Farran: You started out as a certified dental technician, then you became a dentist. What do you think of, in your lifetime, how CAD/CAM is trying to do more of the dental laboratory technician work? Can you be an elite cosmetic dentist like yourself with a CAD/CAM or do you prefer a human making your restorations?
Christian Coachman: Before I answer that, I just forgot about mentioning the three main corporate partners that we have nowadays. The Seattle Study Club, that is our long term partners and for us, gives a lot of credibility having the Seattle Study Club on board and being able to utilize DSD as part of their super strong interdisciplinary philosophy. DentalXP, my friends from Atlanta where I worked for five years, and we’ve been sharing knowledge and they’ve been supporting DSD. As I mentioned before, Quintessence, probably one of the most well-known dental publishing companies that had been supporting our DSD world tours since two years. These are three amazing partners.
Regarding your question, yet, we have this initial impression that digital dentistry is for average quality work, and handmade is high quality work. We don’t agree with that, and you can see on other areas how this was a paradigm shift even on, for example, architecture 20 years ago, everybody was drawing everything with their own hands. Nowadays, it’s all about software and machines. This doesn’t take the quality and the artistry of the process. We know that through technology, just to give you an example, we can copy nature perfectly through scanning technology. There’s no reason why we should struggle that much to try to copy nature with our own hands, and I’m talking about wax-ups and ceramics and indirect restorations. It doesn’t make sense.
If we can just scan nature and have a perfect copy of nature, why would we try to copy with our own hands if we can scan and have it perfectly in our library, in our software and design smiles with this beautiful, natural, morphology in texture. Nowadays, we can scan a young person with beautiful dentition and rehabilitate the father with the same morphology and the genetic information that you’re getting from the son. Things like this are possible nowadays through technology. Every time you have to finish things with your hands, you are increasing the risk of bringing stakes and having to rely on a lot of training to be able to do with your own hands. The basic, what we always say is that digital dentistry will make good dentist and good technicians become even better. Digital dentistry will not save the ones that are still doing bad dentistry. It’s not the solution for everything. It’s just an amazing tool to make the good ones become even better.
Howard Farran: My whole goal back in 1998 and I saw the internet come out is, to try to help come up so that no dentist would ever have to practice solo again. I’m always trying to guess what my dentists are asking or thinking as they’re listening to this podcast. Sirona just merged with Dentsply, that’s one now the largest dental companies in the world. They have CEREC. Planmeca at Helsinki Finland bought the E4D at Dallas, Texas. Now, there’s a Korean just selling a model. Is CAD/CAM, CAD/CAM CAD/CAM? What are those do you like more than the others? Are they all pretty much the same technology? What are your thoughts there?
Christian Coachman: We have nowadays several CAD/CAM systems that are really amazing. They all evolved, improved beautiful scanners, great software and great milling machines. Milling machines are nowadays able to mill and capture all the details of nature, so this kind of technology is definitely a reality. I see very small difference between the systems. Most of them are very good. They all work very well. It’s just slight implants. They all work, it’s just a matter of you going through the process of the learning curve of that specific system. What we see is that the systems were … They had a couple of problems, of challenges that they were not focusing.
Corporations, they didn’t have this vision about the reality of the dentist. They were making more and more sophisticated equipment and not thinking about simple issues that the dentist was facing. What we see is that a lot of the technology that is bought by dentist is underutilized, because of this implementation problem. Another problem is the fact that most of the CAD/CAMs were not developed to be facial analyzer software and were not developed to be diagnostic or design software. They were developed to make final restorations. That’s a waste of technology. We can use this beautiful technology to actually start the process of analyzing the patient’s face, integrating face with teeth and lips and gum, and understanding better the 3D position of the teeth and the gum according to that face, and then utilize the 3D software to actually do digital waxup, the starting point of every dental treatment, every restorative dental treatment can be done nowadays on 3D technology.
That’s why a couple of years ago, we’ve been talking to companies and the bigger they get, the slower they get, the more bureaucratic and tougher they get to implement new ideas. They have their own strategy. They’re making a lot of money. They don’t want to change things just because a couple of crazy guys are saying this or that. At one point, we gave up on trying to change these systems and we started to develop our own line of software that nowadays, I can say is the only system that is interdisciplinary, that means one software is orthognathic, ortho CAD/CAM, restorative, design, face and guided surgery in one platform.
You can move teeth. You can place implants. You can move the jaw. You can add a wax up. You can change the abatement, everything together back and forth, because that’s the way the treatment plan happens. It’s not like fragmented. It’s also the only system that brings the face over each one of these specialties and allows the dentist to have a whole vision of this facially-guided treatment plan. Through this process, you can generate communication interdisciplinary what we call, “Dental brainstorm.” It’s beautiful to look at a case with these 3D software and make decisions, make better decisions by improving your visualization through digital 3D software.
Howard Farran: You know, Christian, one of the things I’ve noticed the most from when I got out of school in 1987 at age 24, not at 2015 when I’m 53, it seemed like back in the day at ’87 when cosmetic dentist who would say, “I’m a cosmetic dentist,” they would straighten all the teeth by filing all the teeth now for crowns. Now, I almost believe and I want to see if you agree with this, I almost believe, you’ve mentioned in this line that to really be an elite cosmetic dentist, would you say you have to be involved with the orthodontics? Is it so much enamel saved by unraveling the teeth, whereas in the ‘80s, you just unravel them with a burn, filed on other teeth. Would you say that you have to be in the orthodontics at some level if you want to be an elite cosmetic dentist?
Christian Coachman: Perfectly said. I agree 110%. For us, there’s no restorative dentistry without ortho. Even though I’m not an orthodontist, I would say that half of the DSD course, we’re talking about orthodontics. Suddenly, it became almost like an ortho course. We are talking about minimum evasive dentistry. We’re talking about ideal design, and you have to talk about the integration between restorative and orthodontics, something that for many years was like two different worlds and very tough communication, very difficult communication. This was one of the strongest links from the beginning on the DSD communication protocol; how restorative dentist can create visual images to communicate better with orthodontist and to guide the movement of the teeth from a restorative perspective and how orthodontist can explain orthodontics to their patients through visual communication to increase case acceptance of orthodontics, as we know, it’s something difficult.
The patient is always saying, “Oh, I don’t want to do ortho. I don’t want to do ortho.” We started to work a lot on how to help the orthodontist engage their patients and explain and educate the patient about the advantages of doing ortho procedure pre-restorative and improving the final outcome, saving a lot of structure, being more conservative through this process. I agree completely and that’s why I mentioned about the software. Our restorative software is also an ortho software, so it has to be one thing. When you’re designing the final outcome of restorations, according to their face, guided by their face, you’re going to immediately see the discrepancy between the ideal position of the teeth according the face and the actual position of the teeth. This discrepancy usually can be better fixed by moving the teeth and then restoring the teeth, instead of just aggressively prepping or harming the final design by a wrong tooth position.
Howard Farran: One of the first things I learned in cosmetic dentistry back in, I think, ’84 was that, one of my teachers at University of Missouri, he told me, he could tell how old a person was on TV by how much teeth he’s had. If it was a man, he was showing two, three millimeters of teeth, he was in his 20’s, 30’s. He said, by the time they showed no teeth, they are 50. By the time they were 80, they only showed lower teeth and you could see lower gum tissue. My question is, if gravity is pulling the whole face down, gravity is pulling all your skin and face down while you’re wearing an erosion and abrading the teeth shorter, so how do you account for length and need of teeth and then the other big question on that was how would that affect occlusion? How do you piece all that together?
Christian Coachman: We can reduce a little bit that this look by lengthening the upper teeth, but we need to follow first basic rules of proportion. We cannot just lengthen totally teeth, because they’re going to look very weird. The other problem is that when people smile, even when you get older, in certain movement, the lip will still go up, so you’re going to see the relationship between the gum line and the incisor edge, aggressively, because it’s going to look bad. On the other hand, you also have to take in consideration function occlusion of course, and there’s also a basic rule that the more you lengthen the incisor, the more steep you create the bite, the more stretch you generate on the anterior teeth. We don’t want to do that and aggressively, because we’re going to either hurt the TMJ or we’re going to break our restorations.
We need to follow certain occlusal principles. One of the things that we can do is if we want to lengthen teeth without change in the occlusion is you need to lengthen the teeth by bringing them out as well. When you bring them out and you make them longer, you can keep the same path, the same inclination and you can, in a safe way, make teeth longer. The other option is to increase the vertical, open the bite, so then you have to restore the posteriors, but this is a very used technique. You open the bite, open space, restore the posteriors and gives room to make the anterior longer again. The other option is to do orthodontics as well. In my opinion, getting old and getting a little bit away from the perfect beauty is not a problem at all. This is something that the media is aggressive on selling.
Howard Farran: Dr. Coachman, when you’re an elite cosmetic dentist like yourself, where do you draw the line between using a CAD/CAM monolithic block versus saying, “No, I need to go back to the human stack feldspathic porcelain? Can you do all that you do, veneers, everything anterior on a gorgeous person with a monolithic block?
Christian Coachman: Yeah, that’s a very important question. That’s a very good question. This is exactly what we are, at the point that we are right now. The first consideration here is that even though I’ve been talking about digital dentistry teaching and giving courses and the digital smile design concept is all about digital. I have to say that I’m not a digital freak or somebody that was always digital. Actually, I’m not a digital expert, not even a digital expert. I know the minimum digital information to actually do what I have to do in my work. For me, as a technician for 20 years, I’ve been stacking porcelain and I’ve been doing wax ups. This was my main job for 20 years. That’s what I loved to do. This is how I was paying all my bills. For me, the change, accepting these changes was not easy as well.
We know that change is never comfortable. We tend to stay on our comfort zone, and everything that comes that is new, sometimes, we tend to say, “No, that’s not so good. I’m going to keep doing what I’m doing.” I think that’s the way we should think, but at a certain point, we need to be open for these changes, because this is not going to go back. This is not going to stop. This wave is going to just move forward, and that’s the way it is. Digital dentistry is here to stay and we have to be open, because that’s the future. We also believed that the future is monolithic restorations.
Coming back to your question, monolithic restoration is definitely the future for many reasons. You remove interfaces between different materials. That is always a challenge. It creates weak spots, fractures, chipping and it creates challenges. We want to get rid of the interfaces. We want to work with monolithic restorations on the anterior area as well. That’s definitely the future. The question is, “What is the quality that we have right now?” Another advantage of monolithic restorations is the predictability of the design. Since we are designing everything beautifully and precisely on the computer, we want this design to be followed precisely during the whole process.
My dream as a technician was always to have an initial wax up that is identical to the markup, that is identical to the provision, that is identical to the final restoration. Identical not only in shape, but also in texture, also in vertical dimension, also in occlusion, everything without having to suffer on each phase of the treatment like we always did on conventional prosthesis. Every time we would build the ceramics, it doesn’t matter how beautiful the provisional was, you’re starting from scratch and things are never identical and you have to readjust everything again and again and again. If we can work with monolithic restorations, we can keep that predictability on shape and function.
Now, when it comes to quality, the companies are developing beautiful blocks and ingots. We have amazing feldspathic blocks. We have multi-colored blocks. We have blocks with more fluorescence, blocks that have more chrome on the cervical, more translucency towards the incisor edge. I have to tell you, if you take these high- quality blocks, feldspathic, beautiful blocks, multi-colored blocks, and you put on the software, and then you copy perfectly nature by utilizing natural morphology and natural texture, it’s very tough to beat. It’s very tough to beat that combination already on the stage we are. What we see is that monolithic restorations, if they are properly done, they can solve 60% minimum, 60% of our daily cases that we do in a super high-end quality level. Level that we will not say, “If I would stack ceramic, it would be better.” No. This will only improve.
If we are now already substituting 60%, 70% of our restorations with monolithic CAD/CAM restorations, in the future, this quality will improve and we will be able to substitute more and more and more. Now, which are the cases that nowadays we still have to stack and build porcelain? We still have to do handmade buildups on cases where the structure has tough colors to hide, where you have difference on sub straights, on colors beneath the restoration, where you want to do ultrathin restorations, we still have to do it on a conventional way with refractories or platinum foils. When we want to do partial veneers for examples, or when the preps have very weird shapes that the scanning technology still has problem creating the fit. If we want to go ultrathin, if we have challenges on matching colors or single restorations, we still have to do the old school handmade restorations. For the rest, we already achieved a quality that we believe it’s very nice, straight from the machine, stained and glazed if necessary, straight to the mouth.
Howard Farran: Just for the young kids, you said something very succinct, but some of the younger kids might have missed it were, one of the importance of a monolithic block, you’re saying, is when you have two substances together where they join, that’s a weak spot. Historically, going back two decades, we saw this problem, we saw with art glass, Tardis vectors. Do you remember those where they were …
Christian Coachman: Yes.
Howard Farran: Explain that history lesson to make the point of why monolithic is better.
Christian Coachman: As I learned from a couple of experienced mentors, dentists, they always said, “Interphases are always a challenge.” When you have ceramic over metal, we know that this is a very reliable interface. It has been used for more than 50 years, but it’s still a challenge. You have to master the way you treat the materials to make them get together the best way possible. Usually, when they failed, they fail on the interface. The interphase between composite and enamel, between composite and ceramics, between different types of composites when you were doing Tardis vectors and bonding fibers into composites on top and trying to do … The challenge was always, we need a very strong material that usually is the base that doesn’t have aesthetic qualities. Then on top, we need to put a beautiful material that is weak, but over this bottom, both together will create the perfect combination like a tooth, denting enamel type of idea.
The problem is that we cannot replicate nature perfectly like you have denting enamel combination, and we see that having a solid block of material is the best way to avoid these challenges. When you build over zirconia, we know that the weak spot is between the ceramic and the zirconia. People say zirconia is super strong, but that is not the issue. The issues that zirconia doesn’t look good so you have to layer something on top and then you curve your back into the same problems you had in the past. When they come up with translucent zirconias that you don’t need to layer on top, that’s definitely a modern solution. As zirconia gets more beautiful and you can design bridges with this monolithic material, then I believe this is a modern solution for dentistry. E.max lithium disilacate is a modern solution, because you can do beautiful restorations in one block of material and has strength and aesthetics together. Dentistry is still evolving on that area, but we believe that we already have beautiful materials that in a monolithic way can give us the aesthetics that we want and remove us from the interfaces.
Howard Farran: What are your favorite blocks? What company blocks are your favorite? Do you have different favorite blocks for the anterior teeth versus the posterior teeth?
Christian Coachman: I’ve been working with Ivoclar for many years. I’m a big fan of e.max. We know the limitations. We know aesthetically many people struggle with e.max. We were able to learn through the process like everything, you need a learning curve. There’s no magic. I like the blocks for the anteriors now, that ones that are feldspathic, natural common ceramic block. Usually, what we do is we use e.max blocks on the posterior area for single crowns. Empress CAD multi blocks, the ones with multi-colored blocks, on the anterior area. These are the ones we have more experience. Now, these has beautiful blocks-
Howard Farran: What’s the name of the last block, that multi-colored block?
Christian Coachman: Empress CAD.
Howard Farran: Empress CAD. Okay.
Christian Coachman: Empress CAD.
Howard Farran: You use that on anteriors.
Christian Coachman: Yeah. That’s the one that we use the most for anteriors.
Howard Farran: Is that anterior crowns or also an anterior veneer?
Christian Coachman: You can do crowns and veneers. Of course, I mentioned that you have the limitation or thickness from the milling system that you have to mill something point four, and we know that nowadays, we can do beautiful veneers point two, and sometimes even go down to point one with old school refractory or platinum foils. This is still, when we want to go down to these prepless ultrathin veneers, we still have to do it in a conventional way.
Howard Farran: What do you think of prepless veneers? If you did 100 upper 10 veneer cases on 100 gorgeous people, what percent of them would be prepless and what percent of those would be CAD/CAM versus laboratory manufactured?
Christian Coachman: Prepless would be less than 1%. 100% prepless, I don’t … What we call prepless is actually almost no prep. We don’t believe in prepless veneers totally for 99% of the cases mainly because when you do prepless veneers, even if you’re building the teeth out and making them longer, so theoretically you have room to do a prepless veneer, the problem is not on the buccla, is not on the incisor. The problem is in the interproximal area. That’s a very tricky area for veneers that usually technicians, they struggle, because there’s not enough room to wrap around the teeth and create a nice interproximal morphology. We know that to make beautiful teeth, we need to create the interproximal design to make them look elegant, and to make them look natural.
Usually, when you do prepless, you don’t have the interproximal space. You have to go around those corners and the veneers will look chubby and square and the contact point will look too long, and you’re not going to have that little neck, that little concavity that you have on beautiful natural dentition. Usually, when the case is prepless, actually it’s almost prepless, and we do prep a little bit interproximally. If you have a case that you can build buccally , you can build incisorly and you have diastemas all over, and you have path of insertion as well, and you don’t have sharp angles, then you can do prepless.
Howard Farran: By the way, I’m just amazed, how did you learn perfect English being born and raised in São Paulo, Brazil, because you should be speaking Portuguese? How many languages do you speak?
Christian Coachman: I speak-
Howard Farran: How many languages can you lecture in?
Christian Coachman: I lecture in three languages, basically Portuguese, Spanish and English. My English is, I think, it’s okay. It’s better when it’s talking about dentistry. We’ve been talking about dentistry-
Howard Farran: It’s perfect English. I’m just saying, you are a genius in so many ways. I want to ask you. I think you’re a special person, because like you say, you’re a certified dental technician and a dentist. If you put on your certified dental technician hat, would you rather receive an impression for a single crown on a molar? Would you rather receive an impression like Vinyl Polysiloxane or Polyether, or would you rather have a digital scan command, for you? What would you rather work with?
Christian Coachman: Nowadays for simple cases, the digital scan. When you do a digital workflow on this type of restoration, you skip so many steps and you avoid so much distortion that you reduce a lot the problems. If you think about the conventional way of doing, how many little things can happen can go wrong? How many little distortions you add on top of the other, so at the end you end up having a problem? You can have distortion on the impression. You can have distortion removing an impression. You can have distortion pulling the model. You can have distortion setting the stone model, removing the model, cutting the model, trimming the model, wetting the model with different humidity and temperature, and then trimming the dye and then chipping the dye, and then abrasion on the dye, waxing, spacers.
Everything is very critical. When you scan digitally and you jump into a software and you design a crown or inlay only on a table top whatever on a digital, you just remove 15 or 20 things that could go wrong. It’s obvious that this is something that is here to help us and definitely dentist should be using digital impression for sure, because this is something that is already profitable. It’s already feasible. It’s already technically an advantage.
Howard Farran: I personally feel that’s why Dentsply just bought Sirona, because Dentsply is an older company selling hundreds of millions of dollar of impression materials, and they didn’t really have a digital strategy or plan. Now, by merging of equals with Sirona, now they have a complete digital plan and strategy for the future. I think that was their strategy, it’s like, “We’re behind the curve on digital.” Is there any oral impression scanners that you like or prefer? You think some are better than others? What do you use?
Christian Coachman: I work with several dentists, so we work with several different scanners. We still use bench. I think bench scanners are still something very important, because the intraoral scanners didn’t solve … That they don’t solve all the problems. For single units, it’s perfect. For initial diagnostic models, it’s okay. When you’re doing bridges that goes around the curve, you cannot scan yet intra-orally. You still need precise impressions when you are doing bigger cases and then scanning these models on a lab scanner. When it comes to intraoral scanner, we know many of them are very nice, the ones from CEREC that you just mentioned, the Omnicam and then from 3Shape, it’s very good scanner. True Definition, very good scanner. These are basically the ones that the guys I’m working with, they use the most.
Howard Farran: What about the one from 3M?
Christian Coachman: I heard it’s very good. I don’t have experience with that one. I never had much basic-
Howard Farran: I want to ask you another question. You just said when a bridge is going around the corner, when you’re trying to do elite cosmetic work and someone’s missing an anterior tooth, do you personally feel you can make that more beautiful with and old fashion bridge, or do you try to attempt placing an anterior implant? What do you think is harder to make beautiful? I’ll give you the problem; missing one anterior tooth. You could do anything. Would you rather say, “I’m going to place an implant and I can make that look perfect,” or would you say, “No, if aesthetics is the chief concern, I’m going to with the bridge”?
Christian Coachman: Okay, that’s another good one. First thing that we see happening is that, two sentences that I love that I heard recently. First is that, “Implants are amazing for people that already don’t have teeth.” Second thing that I heard from Iñaki Gamborena, one of the best implant bar restorative guys that I know, he said, “The more I know about implants, the more I like natural teeth.” We know that implants are amazing, yes, but there’s the limitations and we are learning with experience now with cases 20 plus years in the mouth. We see that there’s many issues involved with implants. That’s one point. For me, always since the beginning, the challenge is not even the teeth. The challenge is the gum.
Making teeth look natural is, it’s done. It’s over. We know how to do that. that’s not anymore something that, “Oh, it’s a huge challenge.” Thousands and millions of technicians all over the world are super well trained to make teeth look like teeth. Now, the gum is definitely the problem. That’s probably the only remaining aesthetic challenge that dentistry didn’t find the solutions for it yet. When you have a missing papilla in between teeth, you are in trouble, because there’s not many things you can do to regain three dimensionally a papilla in between two adjacent missing teeth. When you lose this pink architecture, you are in trouble.
Even time we look at a case, even if it’s a single implant case, we know that if the soft tissue is an issue and the pink aesthetics is creating a problem, we know that by placing implant, by doing a surgery, we will only make this problem bigger. It doesn’t matter how good the surgeon is. You increase the chances of soft tissue shrinking and the crown’s restorations will look worst. Yes, not placing an implant and doing a pontic, you have a better chance of making pink look better, as people know that. Working with a pontic is easier than working with an implant restoration when it comes to soft tissue management.
If we see that the soft tissue is tricky, I definitely prefer to improve soft tissue, graft the area and not place an implant and place a three unit bridge. That’s an option that is growing back. It’s coming back to our table. Now, if you have a very good surgeon that knows very well how to work with these anterior cases, with all the tricks and details that you need, it’s a paleoartist. These guys doing these anterior single implants, they are like artists on this science. If you have one of those working with you, yes, we have amazing cases, single implants cases that we can do, but we keep that in mind that every time you place an implant, there is that percentage of shrinkage that you’re going to lose soft tissue architecture that can generate a problem that will make the technicians struggle to develop a shape that looks natural.
Howard Farran: I think it’s amazing. The smartest dentists you talk to, like yourself, they’re never extremist. They’re never all implant, all bridge. I think it’s a human error, especially young minds have where they’re extremist. They think, “Left, right. Up, down. Yes, no.” Older people and wiser people, everything’s in moderation. There’s indications for this. There’s indications for that. Nothing is simple. I’m at the end. I want to switch gears completely, because so many dentists look up to you from so many continents. Do you think amalgam is extinct? You’re in Brazil, there’s 200,000 dentists in Brazil. There’s 150,000 dentists in the United States. The North and South America, the western hemisphere has a billion people. Is there a place where amalgam within those one billion people, or do you think it’s just done?
Christian Coachman: I think, you know, there’s no place for amalgam for the ideal dentistry, no place for amalgam. When you go to certain areas in Brazil for example, everything is possible. Whatever you have that can fill a hole is a good idea, because you have to do something. The dentistry that we know, the dentistry that we are talking about, the dentistry that we see on meetings, the guys that we know, the small world of dentistry that we think it’s huge, is actually maybe 3% of dentistry, 5% maybe. This is the dentistry that we know.
Now, there’s 95% below us in areas that don’t have absolutely nothing, and we know that amalgam works and it’s a very democratic material that allows dentist to improve people’s live by fixing their problems. I’m not a specialist on this topic, but I think again, we cannot be radical. Until companies develop materials that are so cheap or cheap enough that they can go into third world countries in the middle of nowhere and help billions of people with this kind of restorations, if you give me an amalgam, I would definitely use it on these kind of people, because it solves the problem.
Howard Farran: One last macroeconomic question, is water fluoridation popular in São Paulo and Rio and Brasilia or is that not community water fluoration where they just fluoride the water to 0.7 part per million? Do they do that in São Paulo?
Christian Coachman: What is the name of the-
Howard Farran: Community water fluoridation. Do they adjust the fluoride levels in the drinking water to-
Christian Coachman: Oh, fluoridation. Yeah, in Brazil, we have that. Yeah, we have that in Brazil. Yeah.
Howard Farran: Is it very popular? Do the people accept it or is it controversial?
Christian Coachman: It’s always been there. People don’t even talk about it. Everybody knows. People see it as a good thing.
Howard Farran: Because in the United States, one out of four Americans are very much against and three out of four accept it. About 71% of the towns in the United States have it. My last question, just for a macro-historical, since you have grandfather’s dads, you have a long line of dentist, do you see dental disease in Brazil going up from increase sugar consumption of, say, Coke or Pepsi? Does your grandfather say and your dad says, “Kevin, there’s more disease now because of diet changes and drinking sugar”? Does he say, “It’s about the same and … Where is dental decay at in Brazil now in 2015 as opposed to 50 years ago?
Christian Coachman: That’s a good question. I am sure there are some science and research giving solid numbers on that, but my feeling is that, yes, diet … We have a diet issue. Even Brazil, it’s becoming a chubbier country and a lot of sugar, but at the same time, I see communities that didn’t have any kind of instruction, having instruction to clean. It’s a balance there. I believe that’s the reason why we don’t see any major increase or decrease of decays. Again, in Brazil, you have class A and that’s people definitely have men much less than in the past. For example, my kids, they don’t have. I had almost nothing. My dad, even though his father was a dentist, he had a lot. His father, even though his grandfather was a dentist, had even more and lost teeth.
We see that the educated people are definitely having better teeth and preserving better their teeth, but if you go to the very poor communities, where sugar is more accessible now, you’re going down. You have two different worlds. Now, several strategies bringing education to these pour communities, now you see poor people brushing their teeth and that is helping as well. I don’t know exactly the numbers, but definitely on class A, it’s getting better and I believe on the lower levels, it’s balance in between more sugar for sure, but more education, dental education as well. That’s what I see.
Howard Farran: My final question has nothing to do with dentistry. The World Cup was in Brazil. That was an amazing … I was glued to the TV for so long, and what are your-
Christian Coachman: You really want to talk about?
Howard Farran: One of your training centers is in Abu Dhabi, isn’t that where the World Cup is next?
Christian Coachman: The next World Cup is in … Actually, the next one is Russia.
Howard Farran: The next one’s in Russia.
Christian Coachman: The next one in Russia in ’18 and the following is actually in Qatar, if I’m not wrong, not in the Emirates.
Howard Farran: Okay, Qatar.
Christian Coachman: In Qatar in 2022 under heat of, I don’t know, 60, maybe 110 Fahrenheit.
Howard Farran: Well, I felt like I lived in Brazil during the whole World Cup. That was just an amazing, exciting time.
Christian Coachman: It’s a lot of fun.
Howard Farran: Hey, again, I think this might have been the greatest interview I’ve ever done, really. You’re a legend. You’re a rock star. Congratulations on your world tour, and I hope someday, you would grace us by putting a course on your Digital Smile Design on Dentaltown. I think that would really explain it to a lot of people, but thank you so much for your time. Say ‘hello’ to Morocco for me, and thank you again.
Christian Coachman: Howard, thank you. Thank you and your team so much. I think that what you guys are doing is amazing. This philosophy of sharing and bringing information and exchanging information with as much people as possible. This is our philosophy as well. I hope, one day, we can talk live, in person and exchange more information and get to know each other more. It was really fun to be here with you and the interview was actually very cool for me as well. Yeah, definitely, let’s talk about how can we share contents with you guys, and I’m totally open for whatever idea you guys have on how to bring this information to the whole world.
Howard Farran: All right. Well, you definitely left dentistry better than when you found it. On that note, I’ll probably see you … I’ll see in Miami sometime.
Christian Coachman: Perfect. I’ll look for you.
Howard Farran: Okay, bye-bye.
Christian Coachman: Ciao.