Why & How I Keep an AOX “Arch Log”

One of the best pieces of All-On-X advice I ever received had nothing to do with surgical technique.

Before completing my very first arch, I was told by a friend and mentor, 

“Matt, you’re starting from scratch. Keep track of everything you do. Write down in a notebook each arch you complete and any notes about the case that you can learn from. And always keep track of what doesn’t work or fails”. 

I’m sure he had told this to many surgeons. 

But I actually took this message to heart. 

Since the very first full arch surgery I completed, I have kept an “Arch Log”.

I have recorded each and every arch that was performed, the date of the surgery, and how many implants were placed. I have also kept track of implant failures and made notes about why I presumed they failed. This has helped me immensely to spot trends and to learn from my mistakes. 

I will always be grateful to my mentor for this simple, but amazing piece of advice. I am likely one of very few surgeons who has actually tracked all of this information, with personal surgical notes, from the very first arch ever cut. This has been invaluable. 

So how does this help you?

I first want to highlight why I think an AOX case log is important and the benefits it provides. 

Second, I want to show you the super simple method I use to create and track my Arch Log, in hopes that you can easily implement this in your daily routine as well.

Why I Keep an AOX Arch Log

1. I want to track my implant failures. 

In my opinion, the most important reason I keep an AOX case log is to track my implant failures. I want to know exactly how many of my implants are failing to integrate, as well as when/if implants are failing after the integration period.

Both of these data points are incredibly valuable in understanding what is and isn’t working for you surgically. 

In general, an AOX surgeon should strive to have a failure rate of ~ 2% or less. I can tell you on any given day what my failure rate is down to the tenth of a percentage point, for any time period since the start of my AOX career. 

It amazes me how many surgeons have absolutely no clue. In reality they don’t know if they are doing great as an AOX surgeon or very poorly. Most just assume they are doing great. You should know exactly what your failure rate is. 

This is especially true if you run your own practice. You should see the failure rate trend and calculate this into your overhead. Based on your numbers, you will have “x”%  of implants fail. Therefore, you should build that into your surgical and prosthetic overhead. If you don’t know that number, that’s simply poor business planning. 

2. I want to spot trends related to why implants are failing. 

In reality, the true value in the point above, is the ability to deduce why the implants are failing in the first place.

If you don’t even know which implants are failing, or how many are failing, you will never be able to put together the puzzle pieces as to why this is occurring. 

If you track your failures, and write notes as to why you think those implants failed – you will see trends.

The key is to keep detailed notes regarding each failure, so that when you look back you have insight into that specific case. 

I have changed the way I practice in certain scenarios based on reviews of my data, and have subsequently noticed a decrease in implant failures based on those surgical adjustments. 

3. I want to know how many implants I actually place per arch. 

In my practice I normally place 4 or 6 implants per arch, depending on what the case dictates. Part of this decision process as to when and why I place 6 implants is based on a review of cases that were similar and had either success or failures with the traditional 4 implant distribution.

I find that there are three principle benefits to tracking how many implants are placed per arch: 

• I can limit subjecting my patient to unnecessary surgery when I am able to see over time that a traditional 4 implant distribution has clearly been adequate. 
• I can decrease implant failures when I know that additional implant support, as in a 6 implant configuration, is needed based on my case log history.
• I can decrease my practice overhead by both avoiding placing unnecessary implants, as well as strategically placing additional implants when indicated to decrease the failure rate.  

As a side note, if you track this data, many of you will realize that the 5th midline implant you are placing is most likely a waste of time and money…

4. I want to know where I stand in terms of volume and experience as an AOX surgeon. 

Knowing how many arches I have completed provides me a level of mental confidence in tackling difficult cases. It is also just fun to track and see the number grow. The “Arch Count” still drives  and inspires me today.

As was taught to me, I also feel that an “AOX expert” is created at around 1000 arches. Knowing where you are in relation to this level of experience is highly motivating. 

And let’s be honest, I guess this is also just a polite way of saying bragging rights. But this is also one of my pet peeves in the AOX space, and one I am very cognizant about. I know exactly how many arches I have done. Not one more, not one less. 

I have talked to many surgeons who drastically, drastically over-inflate how many arches they have done. I’m going to assume and hope it is unintentional, as most surgeons don’t keep track of their arches and want to give themselves the benefit of the doubt. 

One surgeon even said he had done a few thousand arches and had only been working at an AOX center for slightly over a year. That would be roughly 150 arches or more a month. Don’t be like this…

If you’re gonna talk about your arches, you should actually know an accurate number of how many you have done.

And if the surgeon you are talking to doesn’t actually keep track, in my experience, a good rule of thumb is to divide the proposed arch count by two 😬.

5. I want to know how many arches I did that month, so I know what I should receive in payment from my practice. 

I do not own my own practice. My paycheck is directly tied to how many full arch surgeries are completed. This is typical of full arch practices. As you can imagine, I know exactly how many arches were completed each month and exactly what my paycheck should be that month. 

I have had a number of surgeons over the years tell me, “I think my paycheck might be off”. And my response is always the same, “What do you mean you think? Don’t you know how many arches you did?”

This should never be an issue. If you work at an AOX center, you should always know how many surgeries you completed each month, so that you can ensure your pay is accurate. 

(For the record, both AOX practices I have worked for have always paid me accurately and on time. But I have heard this comment from other surgeons/practices). 

The Super Simple Method I Use to Create & Track My AOX Arch Log

Ok, are you ready for the grand reveal of the elaborate, intricate system I use to keep track of my AOX Arch Log?

It’s a super simple… iPhone note. 

Since my first surgery, I have kept an AOX Arch Log on my iPhone in the  “notes” section. 

Here’s Why I Like This Method:

1. It’s super simple. After my surgeries that day, I take out my phone and update my log. It literally takes 30 seconds. I did not want to use a desktop based system that required me to log in or sit down at a keyboard. I’m always on the go, and I knew if it wasn’t quick and efficient, I wouldn’t do it. 

2. iCloud backup. My Arch Log is backed up to the cloud. I have years of information on this log – I want to ensure it is backed up automatically. 

3. External drive backup. It is easy to access the note on my Mac and carry out an external drive backup (which I do). 

4. It’s always with me. My phone is always with me. This makes recording the data incredibly easy and efficient. Furthermore, if I ever want to look back at a case, check a previous failure, or even check my arches that month for my paycheck… It’s all right there with me. 

I’m sure many of you can come up with a much more sophisticated way to track your surgeries.

The point is, however, that there are a multitude of benefits to logging our AOX arches, and we all should be tracking them one way or another.

This is one simple way I record my AOX Arch Log, but you can create your own method that works for you. 

Here’s to knowing where we’ve been, where we’re at, and where we need to go. 

Matthew Krieger DMD

P.S.  A special thank you to my friend, colleague, and mentor, Dr. Pete Walters, for this invaluable piece of advice.