The Fixed Podcast

Maximizing Efficiency in Implant Dentistry: Part 1

June 10, 2024 • Fixed Podcast

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Unlock the secrets to efficient implant dentistry with actionable insights from Dr. Tyler Tolbert and Dr. Soren Paape. Discover how Dr. Paape completed an astounding double arch surgery in merely an hour and a half, using innovative techniques and the six-handed dentistry approach inspired by Dr. Matt Krieger. You’ll gain expert advice on maintaining surgical efficiency, transitioning to digital protocols, and documenting each step meticulously to enhance outcomes.

Explore the protocols and workflows that streamline denture and CT-driven full arch cases, emphasizing the use of pre-designed dentures for superior visualization and alignment. Navigate the complexities of using fiduciary markers versus segmenting CTs with our expert tips, and learn how thorough preparation and team coordination can make or break your surgical process. Dr. Paape also shares invaluable tips on pre-surgery planning and the six-handed approach to ensure everything runs like clockwork.

Get an in-depth look at the surgical protocols and anesthesia techniques that underpin successful dental procedures. From pre-operative photos to anesthesia administration and the surgical flap reflection techniques, we cover it all. Learn how to effectively use tools and methods for optimal visibility and efficiency, and follow detailed steps for preparing and executing osteotomies. This episode is packed with practical insights and personal preferences designed to elevate your practice in implant dentistry. Tune in to elevate your surgical precision and efficiency.

Speaker:

My name is Dr. Tyler Tolbert, and I'm Dr. Soren Paape, and you're listening to The Fix Podcast, your source for all things implant dentistry.

Tyler:

Hello, and welcome back to the first full episode of the fixed podcast. Maybe this is the first one. Maybe the pilot counts. I'm not entirely sure. But either way, we are super, super stoked to bring to you some real content, not just talking about the show, but just being the show. But we just wanted to start things off between me and Soren, because we have a lot of really cool things to share with you guys, and we were talking about what we wanted to talk about this evening, and And Sorin has just polished off a double arch that he posted on Instagram with his timestamps. And I can assure you that they are for real. He's not lying. Of a double arch that he was able to do in about an hour and a half from first injection all the way to the last bit of records. Now there's gonna be a whole lot of things that we have to break down for this in terms of how he's doing his surgery, the armamentarium, how he's working with his assistants, his six handed dentistry that was partially inspired by Dr. Matt Krieger. Our friend over aox surgery. com. We'll talk some more about him later on, hopefully have him on the show before too long here. But we're going to really break this down into the surgical techniques, the mindset behind everything, how to work on your speed what workflow looks like and exactly how Soren is doing these things. I'm doing it too. I just don't do it as well, Soren. So I'm hoping to learn a little bit

Soren:

Ha!

Tyler:

But anyway Dr. Soren Paape, welcome to your show.

Soren:

Hey guys, how's it going? So excited to be back on here again. Man, I, Tyler, I am, I'm just like pumped about this podcast. I keep, we we change, I'm sure you, the audience can tell we were definitely spending a lot of time on our production value. And we're really excited for like posting some Instagram reels, getting you guys excited, getting like little tidbits of information and then getting you excited for the upcoming episode. So that's our goal. Like I said, we're going to try to do bi weekly episodes. This Is our first full episode. Our second technically episode ish. Yep. Today's going to be all about efficiency. But yeah, so talking about the case I did today like I said, our last episode, I post. Every single case I do. Good, bad, ugly complications that occur. I'll post them. You'll get to see them today. My case was a double arch. I think there was maybe like 24, 25 teeth. I'm going to see if you're watching on YouTube here, I'm going to see if I can post the panel right now so you can get an idea of that panel. And then I'll also post my post op CT. So you can take a look at what the panel look like, what the post op CT look like. On my Instagram, I did post some times, I think in the future, what I'm planning on doing is I take photos throughout all of my cases and that's just for my personal records. Like I like having pictures of each surgery in case anybody down the line was like, this surgery wasn't up to par. I can say, yeah, it was. Show you the picture. But I might start posting like photos for the surgery with timestamps on them. So you guys can get a feel of what it's looking like for like time wise, like where I'm at in my surgeries. But yeah, today's surgery, we did first injection. Usually my patient shows up around seven 35, seven 40, and then CRNA brings it back, checks over all their medical history. And then I He checks over all my medical history. I make sure that that everything's all set. Good to go. And then we do he puts them to sleep today. We got started right around like eight 25 was my first injection. And then. So after the injection, we'll go through all of the stuff, like all the efficiencies, how I work through everything. But my last stitch was at I believe nine 50. So it was like an hour, 25 minutes. And then it took about 20 minutes to do all my records. This is something that we'll talk about later in the episodes, like what Tyler and I's digital protocol is we've transitioned a lot throughout doing these cases, what kind of works the best. And lately. Prior we were doing fiduciary markers and I feel like a lot of people are doing fiduciary markers for their digital cases. I was having a lot of issues with with just like maybe the scans weren't aligning or something. And I was having issues with patients, the bites being off when I got in there, plus it took me a while to get fiduciary markers and the retromolar pads. Sometimes it was like, Really quick other times like the their tissue would just be so thick back there And I would and sometimes my screws weren't long enough or I couldn't engage good bone You know a lot of times in that area where the retromotor pad is there's like a thin cortical layer and then very medullary Bone under it so like sometimes you engage that cortical bone, and then it just you just can't get Stability with those fiduciary markers. So

Tyler:

Yeah.

Soren:

there's different opinions out there lately. What I've been doing is essentially a protocol where I have my,

Tyler:

for a second? Just before we talk about the new protocol. So I do want to expound a little bit on some of the shortcomings of the fiduciary marker workflow, because that is like super, super common. It's what most people are doing when they first started doing digital. And, but I want to make sure everyone is on the same page about what that is. So when we're going digital. When you start a case, as opposed to an analog workflow where you already have pre fabricated dentures that are ultimately going to be converted into an all in one a temporary one, You don't have anything like that. You don't have a prefabricated prosthesis. So what your lab has is the scans that you've already sent them along with some photos that they stitched together. And so what you need is you need something that's going to look the same and be in the same position in the beginning of the surgery as it is in the very end of the surgery when you're taking your postoperative records and then That thing, whatever that fiduciary is it going to relate to everything that you did to stitch everything together? The pre op plan the pre op teeth, the pre op plan, now the post op surgery. And now the post op plan that merges is all together. So you have one thing that's consistent and on the uppers, this is fairly easy, somewhat consistent. I've had a few issues with it. Every now and then now I don't do it anymore, so I won't be getting any more issues, but you usually use palatal markers. So there's usually about seven, some of these screws are about seven millimeters. Most of them are around 12 millimeters. You thread this through a a printed marker. There's different bodies out there. The cheapest thing is just to have a little STL for a marker that has a hole in it that allows that screw to pass through. And then you print that. And then it's going to be printed like a dime model, resin, whatever. And then you're placing that in the patient. Up in the pallet, usually two, you can do three if you've got space for it. And then the lower you're putting the retromolar pads, just like Soren said, to start your surgery, you have to first place those, get them in place and get them super, super solid. So that even if you like tap on them with a mirror, they're not going anywhere. They need to stay in exactly the same place. No matter what's happening throughout the surgery, patients biting, moving around, you're using your instruments that those things need to be really solid and engage really nice bone and cortical bone. Issues can come about when there's really thick tissue, just like dr Paape mentioned when you have a retinol or pad that has really thick tissue, or even if you have a palate has some flabby tissue. Sometimes I see that from time to time, the screws aren't long enough or they just don't engage very strong bone. And if those markers are moving, they're practically useless on the lower. This is really tough. And you're having to do these scans before you even get started in your surgery. So you place these markers, this can take 15 minutes. If you're being efficient and then you have to actually take the scan, send it off to the lab, and then they then have to verify for you that stitches together with what they already had, that you didn't double scan something. If you do it and you double scan it, then you get started and it wasn't good. You're screwed. So a lot of things can come up with that. You're then having to try and scan in a bloody field or take like an alginate impression and scan the alginate. And then it's there's a lot of work involved with the foodie Sherry workflow. Yes. You can use some existing teeth. If there's some solid ones that you're not going to have issues working around during your surgery, but that does add a lot of extra steps. So Soren is going to talk a little bit about what we're doing now that helps circumvent that and makes digital a whole lot more intuitive and a lot more friendly for the patient. To people that may be a little bit more accustomed to to the analog workflow. I'm sorry, sir.

Soren:

no, absolutely. I'm glad that you stopped me there because, I forget that not everybody's doing digital protocols. And I think we actually talked about this last episode that sometimes we might. You know have to tail some things back because we're doing this every day So it just seems natural for us, but we do want this to be a podcast for everyone

Tyler:

Yes.

Soren:

So first, let me talk about through the three kind of main ways right now in digital dentistry that you can Do your cases? Obviously, this isn't digital. Not digital, but analog is the first one. And that's what Tyler and I started with. We've done hundreds of arches analog before getting into the digital workflow. Number two is a digital workflow with fiduciary markers. Tyler just said, we're looking for a way to relate the pre op to the post op scans. When you take all the teeth out, a lot of things change. So effectively, what they're doing is aligning those fiduciary markers. So that the scans can align together and they have a way to merge them for pre op and post op. The second digital way is actually setting, and this is what Tyler and I do now, we set the video ourselves. What does that mean? It means using the patient's existing denture or printing a new denture for that patient. And what you're effectively doing is, You're not putting any fiduciary markers in, you're doing your entire surgery, putting scan bodies in, and then you're taking a manual impression of the patient's arch on the top and bottom, and then setting them into a bite themselves. What this does is it creates you're getting that, the location of those scan bodies and you're aligning it to the the video of that patient that's set by the denture. And then you scan the upper three 60, the lower three 60, and then the bite together. This allows the lab to merge those pre op scans to that denture. And it aligns everything really well. And what I've found is I get way better bites. Also,

Tyler:

Yeah.

Soren:

I'm not dealing with. So like pitfalls with fiduciary markers, right? You're scanning in the mouth in a bloody field, or you're taking an impression, trying to get the fiduciary markers in the impression. And that's like just another thing that you need to get. So when you're doing an impression in the denture, effectively it's less things that you're trying to get an impression of and you can just scan the top, scan the bottom, scan the bite together, and then they can merge all that together. I like it a lot more. I find that it's much quicker and I find that my bites are a lot better and lastly there's one more thing I wanted to mention about it. But anyways, but the pitfalls of this are you do need a denture ahead of time. I use my, I, if a patient has a denture existing, I will use their denture. But if not, then I will use a denture that's pre designed. Did you have something Tyler?

Tyler:

Yeah, no, I think one additional pro, I don't know if it's what you were thinking of, but Is it allows you because you're using a denture and you're doing a wash in the mouth, you're able, and the lab is also able to physically see where those teeth are in relation to the face, in relation to That can't, and the relation of the dentures to each other. So let's say in the plan, things didn't really come together the way that we'd hope they would. And maybe you're like really class two or class three, you can take pictures and you can evaluate the case and say, Hey guys it didn't really line up that well, but I'd like where the uppers are. It's just a little bit too class two. Can we bring those lower teeth forward and that enables them to relate the soft tissue to the teeth in the position you captured, but also move from there as well. So it makes it much easier for them to adjust in the fiduciary workflow. Yeah, things may look like they've stitched together really well, but you're talking about these like little tiny markers across the entire mouth that you're hoping have stitched together well enough to where, you're going to take this one little point or maybe three, two to three, and then you're going to have all these teeth that are trying to stitch from there in accordance with the soft tissue and all that. And you're hoping that does it in such a way that's going to coincide with the lower. And a lot of times you get these crazy open bites. You get things crossed up with the denture workflow. Even if you don't capture a wonderful bite, a lot of times the lab can actually move those teeth a little bit and get a more predictable bite that way as well, even if you're not able to get that really good capture.

Soren:

Yeah, for sure. And then the last denture pro or the last like protocol for digital and I don't want to get too far in the digital weeds because it's like a whole episode in itself. This is an efficiency one, but we're just giving you a quick recap. So you can get an idea of this. But the last one is like segmenting CTs. So you can

Tyler:

Yeah.

Soren:

pre op CTs and post op CTs. And that protocol, you don't need fiduciary markers either. However, that is it take like a special protocol. Lab that knows how to do that and it also takes a lot longer for the lab. So for me, I'm trying to deliver the teeth same day. A lot of, you can do that with a CT protocol, but a lot of places that are doing alignment of pre op and post op CTs are doing next day deliveries. So it gives them a little more time for the lab.

Tyler:

Yeah, we actually did. We did a really good podcast with Dave O'Dowling on the full arch podcast about a CT driven workflow using those sort of hard relationship markers. And I think the new like segmark workflow is similar to that in a Go over a lot. If we did it on video and could do some screen share and stuff like that. So it's another reason this medium is going to make things like this a lot easier for people to understand. So I'm excited about that. Yeah. Yeah.

Soren:

thing now is just to jump into what my protocol is. And Tyler, if you want to jump in at any point and talk about maybe where you do things differently you're more than welcome to. But so let's talk about first like every single step that I do. So first thing is that I think is super important is making sure your team is set up and ready to go for the case. That means if in my office, I do everything six handed and I think that doing things six handed makes it much nicer for for your team to be passing instruments to you. You don't have to move. Basically I sit there, I look in the mouth and my goal is I don't look away from the mouth at all. My team is handing me instruments throughout the whole surgery. And I'm just focused on what I need to do next. And they know exactly what instrument I need next. They know what implant I'm placing. They know what their next step is supposed to be. Getting your team prepared and ready for the cases ahead of time. That might mean doing a couple of days of just teaching your team like going through what all the steps are with them. Just so they can be ready to hand that off to you. Another thing I do to prepare for the case is the Wednesday before my surgeries of the following week, I prep every single case. Today's a Tuesday, tomorrow's a Wednesday, I will prepare every case for the following week. What does that mean exactly? It means bring up my CT, plan all the implants, I write all the implants down for my assistants. I wrote all the multi units down for my assistants. I write any other thing that is needed. If they need, like when I was doing analog, it would be like tie cylinders how many healing caps I need just so they can then take those out, put them in a case pan and have every single case ready for the week. Following. Why is that beneficial? One, you're prepared for that case to, you never run into a situation where you're like, Oh my God, we're out of four by thirteens. What are we going to do? You want to be prepared for those cases and you don't want a day where, you're out of four by 13. So you have to use another implant just because you weren't prepared for that case. And I think that's definitely on the surgeon to have that ready to go. If you're like. All of a sudden using a five by 13 implant on a patient who doesn't really need it. That's your fault. You didn't plan the case correctly. You weren't prepared. The team wasn't prepared. Definitely have these things ready to go ahead of time.

Tyler:

And I'll say too, just on the inventory note I think the ritual of preparing all of your cases for the next week on the Wednesday is absolutely brilliant. But one thing that, we talk about when we get into, you know the art of freehand surgery and not doing, guided and having a really rigid plan, we do have plans. We do know. Usually 80, 90 percent confidence interval, what implant is going to go where, however, we do in addition to setting out our pans or bagging up the cases, what I do we also have a full stock of implants ready to go in case you do need to pivot, right? Like for a terrible or something like that, you might know that you usually place an 18 or a 20, but maybe just your angles a little bit different and now you need a 24. You got some on the side as well. So after those cases get set aside. You're also making sure that you have a full stock of implants and every single size has the appropriate number associated with that. So that you're always going to be ready. And it's good to actually have that in the operatory as well. So it's, you're like, okay, this one's not going to work. Let's swap out for this size. And then one of your systems can go and grab that. It doesn't create an interruption. You're not having to leave the room and go get something else or say, Oh crap, I wasn't ready for that.

Soren:

yeah, absolutely. I part of what I was getting into was after the, they set aside all those case pans with the implants.

Tyler:

Yeah.

Soren:

then do our implant order for the following week. So we're stocked. And the reason that's beneficial is then you always have implant sizes ready to go. You're ready for the next week. But if let's say you get a last minute case, a patient comes in consult, they're like, Hey, I want to do this tomorrow. We got the implants for it. We're always prepared to always have a full stock of implants and you can't always have a full stock unless you do your implant order after your prep for the week following.

Tyler:

Yeah

Soren:

so that's step one, biggest thing, be prepared, have your case ready, make sure your assistance already for the case, make sure you have all the implants, all the equipment, and then next it's setting up for the case. I would, I would really urge you guys to go on Matt Krueger's All on X pod or his website,

Tyler:

Yeah.

Soren:

alexsurgery. com. He's got pictures of his setup. He's got a great setup. He, and he talks about every single instrument, what he uses every single instrument for if I can, I'll see if I can post a picture here with like that setup and what he does, but I would just urge you to go on there. Cause he explains everything really well. So make sure your team is set up. That means having implant motors ready. They should be checking the water on the implant motor. These are conversations that I've had to have with my assistants throughout this journey is let's say I go to get my implant ready. And all of a sudden we're out of water already. And I'm like, guys, this stuff needs to be prepared ahead of time. Just check over everything. Think about it as if it's you're, we're going through the full case and all this stuff should be I have my implant motor settings set for one through five, so we just step up as we go through the procedure. And everything's prepared. Now, this isn't going to happen overnight. This is going to take a lot of cases to get this down with your team. But once you get it down, then I get asked on my Instagram all the time, like, how There's no way that you did a double arch an hour and a half. And it's once you have these things prepped, once you're ready to go, your team's ready, every single case should look the exact same every single time. And if you look at my Instagram and see my cases, they all it's hard to tell them apart. They're almost identical.

Tyler:

And I wanted to ask you this too, sorn, if someone were to watch you actually do the surgery, are you moving quickly?

Soren:

No

Tyler:

move fast and all that?

Soren:

I don't I'm very I think it would be more of a, it's like smooth. My team is very smooth. If you're in my op watching me, I don't think it looks like we're fast at all. It's just, everybody's handing you things at like the, it's it's just like a musical, right? Like a, yeah, it's just you're just, I'm getting handed things when I need them. My team knows exactly what to hand me when, and it's just smooth. What's the quote? It's like smooth is or it's smooth is slow. Slow is smooth and smooth is fast. That's what it is.

Tyler:

I like speed up and slow down, or slow down and speed up

Soren:

yeah. Yeah. But effectively what it's just saying if everything's in the right place, everything's ready to go. You might not. That's the difference between rushing and just having efficiency with the case. And that's the goal. I'm not trying to rush. I'm not trying to go fast in the surgery, but I do want everything to be prepared and ready for the case. And then you'll see holy cow, this is, I didn't arch in an hour. And then all of a sudden I'll be like, I didn't arch in 45 minutes. And you'll start to really speed up. So

Tyler:

If you want to see someone moving fast, you see someone that's like maybe not their first case, but after like maybe 10, 15, 20 cases, they start trying to move

Soren:

yes.

Tyler:

and they've rushed too much and they move on to something before they were done with the one thing. They're throwing instruments. It creates a mess. A slow surgeon, when you see a messy operatory table, when everything's just all over the place, the assistants aren't putting them back where they belong. They're, the doctor is physically like looking up and grabbing everything and then

Soren:

Yep.

Tyler:

stuff. That's what fast looks like is it actually very slow as far as the patient's concerned?

Soren:

And I think I think everybody goes through that a little bit, right?

Tyler:

In it. Everyone

Soren:

No, I'm sure when I

Tyler:

And

Soren:

I, my first intuition was Oh, maybe I just need to move faster. And then like you said, you're cutting your assistant off trying to grab instruments just to speed up. But then when you put them down, like you're not handing them back to the assistant and they're getting a loss. And then all of a sudden you're looking for five minutes for your molten iron and you're like, what, like, where did that go? Cause it's not in the place that it should be every time. But yeah, so those are, that's like. pre synopsis of what needs to happen before the surgery starts.

Tyler:

we talk just really quick about the six handed part? So who is there like a main assistant and then someone off to your side that's just like handing you other things? What are the roles? How do you

Soren:

Yeah. Yeah, absolutely. So my assistant to my left she's my lead assistant and she does all the suctioning. Okay. Like her goal, her job is suctioning reflection making sure that the surgical field, I can visualize everything. And I'll talk about some tips as I go through my steps, but making sure that I can see everything. There's no blood and everything is reflected correctly. That means using the right using the right retractors throughout the case, knowing what retractors I want to use when these things are really important. And that's what my lead assistant does. My lead assistant also will hand me off some instruments here and there. If My second assistant is, doing something else. If she's like loading an implant or something like that, and I need a molt nine, she'll hand that to me, but they mainly she's her. Job is to keep the surgical field clean, keep the surgical field so I can visualize everything going on during the surgery.

Tyler:

Okay.

Soren:

other assistant, her job is to hand me everything exactly when I need it. So what does that, it means instruments, retractors. It means handing, making sure my implant motor speed is set, making sure that the, she knows what implants I need when, and those are ready to go for the next case.

Tyler:

Okay.

Soren:

those are. their responsibilities and job duties. And as I walk through my step by step surgical protocol, you'll I'll walk through what they're doing.

Tyler:

Thank you.

Soren:

so let's get into it. This is probably what people want to hear, right? So first thing let's start with Like I said, every case I take pictures. So before the case starts upper, lower photo of the patient with their teeth in or if they're a denture list, what it looks like prior to the case starting. Then we use an O ringer. I put the O ringer in And then we start our anesthesia protocol, my, for my anesthesia protocol. And actually, this is something that I don't think a lot of doctors do that I do every single time. But my assistant is, we have two car peels going. My assistant's loading the second carpeel as I'm doing the first one. I do all my anesthesia the same way every single time. And then we My patients are under general, so I can, I get a little bit of fluctuation with this, but I do a lot of oral conscious cases too, and in general, this is how I do my anesthesia almost every time. It is, on the upper, I do 3 so that means a carposepto on upper right quad, carposepto upper left, carposepto upper right. Septo throughout the palate and then I do a carp of marking across the whole buckle and all these are deep injections These aren't I never I don't even touch and this may be controversial, but this is what I learned My oral surgeon told me I don't touch a blue tip. Every single case is a yellow tip. So it's a

Tyler:

Always.

Soren:

deep injection And I feel like a lot of people Especially when they're starting they don't do this and like halfway through the patient's hurting and it's like it's because you're not deep enough you know the

Tyler:

they're taking the blue tips and then they're bending them and they're just,

Soren:

Yeah, it's like barely getting in there and it's you're if you're doing good cases You should be reflecting everything up So and you need to go deep with your injections in order to get that point properly. But then marking across the buckle, marking across the palatal. These are all just, local infiltration, deep injections. And then for me, I'm going right to the bottom, getting everything numb down there too. For my lower it's opposite. And this is what I tell my assistant. So she knows on the lower it's three marking two septo. So I do a block with marking on the right block with marking on the left. Then I do local infiltration with marking across the buckle and lingual. Then. It's septo across carp, across the buckle, across the lingual of septo. Now, This is like a generalized anesthesia protocol. Yes, I'm hitting the PSA. I'm hitting the MSA, the ASA, these are all just me deep injection throughout the buckle. And I'm just hitting those, that anatomy as I'm going So that's all the septo all the marcaine, and when I'm injecting, my assistant is then placing the next carpule into the syringe and getting the next one ready to go. So it's just like a handoff, right? I take it, She hands it off. I hand it back to her next one, and I'm just going through all so I do my whole All my infiltrations like relatively quickly So once the patient's all numbed up then the next step is The reflection right so I have the o ringer in I like to I've had a lot of issues with the o ringer coming out and

Tyler:

Mhm.

Soren:

I've had a lot of issues with the o ringer coming out throughout the case, because I'm like moving things around so, I will suture the o ringer to the patient's mouth, and the way I do that is I just do a suture, I do a suture through the lip on the top, And it's like a big mattress suture. So up the lift lip back through tied off, same thing on the bottom. So they're both sutured in on the top and bottom of the lip. So now patients numb or isn't going to move. Now we're ready to jump into it. So my assistant's hand was handing me everything throughout that. She handed me the suture and they know next if there's teeth involved, my first step is large, straight. And this is, don't do every single thing I do to the T because everybody does things differently. Whatever you like to use grab that one. I prefer a large straight elevator I says it knows that hands me that with my Minnesota and I'm just elevating every single tooth now I Think I'm gonna I'm gonna go through this and then at the end I'll talk about what I've been recently doing But this is in general how I do most of my cases. I start with the top You then I go to the bottom. still able to do arch 45 minutes to an hour this way. However, lately I've been trying some other things that I'll talk about at the end, but this is my main protocol. So let's start with this. Large straight elevator elevate all the teeth on the top there until they're mobile. I really shoot to get those teeth mobile. If the teeth aren't mobile, Most likely you're picking up a handpiece down the line. My goal is to not pick up a handpiece at all to take these teeth out. Now, is that always, am I always able to do that? No, but the first step to doing that is getting the teeth mobile. So large, straight across the whole arch. Next, if there's molars, my assistant knows right away. The only four steps I use for upper molars is a one 50. Sure. You can use 88 R 88 L like there's a lot of different options. I use a one 50. So I grabbed the one 50, take out the molars, right? If a tooth breaks if a molar breaks, as you're going, don't sit there and start finagling with it, just leave it, move on. Next, my assistant note, I hand her at once. I get all the molars out, hand her that back. And they're sitting there right with, they've got a gauze in one hand and they're grabbing those teeth for me as I'm taking them out, because It's like one, you're just grabbing them, handing them, grab, hand, grab, hand next. They know my next four step is always an ash. I like an ash for my anterior teeth on the upper and lower. I can get really good leverage and I, and it's a rotational movement, right? You're grabbing and rotating. I'm rotating these teeth out. I'm not doing any buccal lingual rotation. Or back and forth at all. That's how you break teeth. If you rotate in a mesial distal direction. So if you think of an access, it's like this, how I take out all my anterior teeth and I almost never break off the anterior teeth. The one caveat to that is, those fricking like 25 millimeter canines, right? Like the crazy long canines. If I have a canine that I see, and I know that. If I grab it and it's that thing's not budging at all, I will come back to that. I'll grab everything else, come back to those canines. But in general, I am getting the canines out with that, the ash. So now we have all the teeth out. Let's say we have a couple

ty_2_05-28-2024_194310:

let's

Soren:

in

ty_2_05-28-2024_194310:

I got a question.

Soren:

go ahead.

ty_2_05-28-2024_194310:

So a lot of people would say you get a flap first. Can we talk about why you like to extract first and why that works better for you?

Soren:

Okay. So pros of flapping first, if you flap first, you get a good visualization of all the teeth. You can then take a surgical hand piece, cut and trough in between every single teeth trough a line of exactly where your reduction is. You can measure from the incisal edge of the teeth, mark your reduction there and then you can like. As you're taking the teeth out, take that buckle plate with it, and it's less reduction down the line. I think that's awesome. all aboard that train if that's what you like to do. I, for me, I find that a lot of times when I'm reflecting my flap, there, it's like sticking to the teeth, the keratinized tissue Holds onto those teeth, and it takes me way longer to flap. That's my personal opinion on that, and that's probably the main pro of it. of first, right?

ty_2_05-28-2024_194310:

Yeah.

Soren:

trough, you can make your line, you can measure everything. Now what are pros of teeth out first, you get such better visualization after you take those teeth out, you can see everything. And what I do is I. I will save a couple key teeth that I'll then go back, place in the sockets and still do that measurement. So usually that means a premolar on the upper right central incisor, premolar on the upper left. And I'll keep those three teeth. My assistant knows that she'll set them aside. She'll mark what tooth that is. And then I'll get to flapping. Another reason I like taking teeth out first is you can really like, if you know how much reduction you're doing, you can And when you're doing your your reflection, you can make your initial incision and kind of plan for where that reflection is going to go and so that means like cutting off all the papillas. A lot of times there's a lot of perio you can cut off, you can like cut where that perio is going to be. So I'll do my initial that's the next step, right? So after I get all teeth out I'm getting that 15 blade. I use a 15 blade every time and I'm flapping from the back of the tuberosity because I'm doing a pterygoid every time that I can from the back to porosity all the way to the front and I'm cutting chunks of tissue out that I think that I'm like later. I won't need because of my reduction. So that means on the front like with. Cutting one side of the papillas and then the other side of the papillas and then my next step my assistant knows is handing me the ronger and then I go through and I ronger off that tissue. That's that I've incised off. And then I should have. My incision line's done. And I also do a rate at the maxillary process, usually where the first molar is, I'll do a releasing incision. And I love releasing incisions there. I don't do a midline release, but I do a release on both sides. After that 15 blade goes to my assistant, she hands me a molt nine. I always reflect my palatal first, I go to the rate where the nasopalatine is, get my molten iron in there, reflect up, and then I scrape along the bone all the way to the tuberosity, and every I couldn't dink it at first, but now I can. Every time the whole thing just flaps like this. It's just like

ty_2_05-28-2024_194310:

Yeah.

Soren:

flap. And then I do the right side. I've been working on getting good with my left hand and

ty_2_05-28-2024_194310:

Huh.

Soren:

filet with my left hand. However,

ty_2_05-28-2024_194310:

Yeah.

Soren:

use my right. And I just we'll do like a rocking

ty_2_05-28-2024_194310:

Yeah. Yeah.

Soren:

and everything's flapped

ty_2_05-28-2024_194310:

Yeah. I do the three rocks, but I do both hands at the same time.

Soren:

Oh,

ty_2_05-28-2024_194310:

I'll take once I get in the front, I'll take two, I can take either two Minnesotas or like a Minnesota and a mole, and I'll just rock back with both hands at the same time. The whole thing's done. Yeah. I really like sliding along the pallet though. I think that's really cool. And that's what I do for the lingual flap on the lower. I know I'm getting ahead of it, but I freaking love that. It's one of the most satisfying things in the whole surgery. I look forward to it the whole time.

Soren:

If you do, yeah. If you do this slide, usually a lot of periosteum doesn't get attached and it's just

ty_2_05-28-2024_194310:

Yeah.

Soren:

so

ty_2_05-28-2024_194310:

Yeah.

Soren:

nice.

ty_2_05-28-2024_194310:

Cause, because if the periosteum won't come with it, it won't work.

Soren:

Exactly.

ty_2_05-28-2024_194310:

so if it worked, it's full, it's a full thickness flat. Yeah.

Soren:

percent.

ty_2_05-28-2024_194310:

Yeah.

Soren:

and then I do my distal releases. So I do distal release back behind the tube porosity. And then what I do is I take the, and I do the same way every time. I use the molt nine, the big spoon. And I will. Like peel off the keratinized tissue till I get to the midline. If you don't get the keratinized tissue peeled off first, then you will, that's how you rip and rip your

ty_2_05-28-2024_194310:

Yeah.

Soren:

So I get all the keratinized tissue off and then I hold, grab my Minnesota, hold it down and do gross reflection of all the periosteum. I'm telling you every single time my flap takes me a total of three minutes, mate, like Doing my initial incision and reflecting all the tissue back. I'm reflecting to the floor of the nose every single time. Is gone. If you reflect properly, you won't have problems with bleeding. The patients bleed from their periosteum if you're getting a lot of bleeding. And If

ty_2_05-28-2024_194310:

There are some,

Soren:

if the patient's like very periocompromised and,

ty_2_05-28-2024_194310:

yeah,

Soren:

some

ty_2_05-28-2024_194310:

perio and

Soren:

in

ty_2_05-28-2024_194310:

or something. Yeah.

Soren:

off of that bone, you're going to have a nice clean flap with minimal bleeding.

ty_2_05-28-2024_194310:

Yeah. Yeah.

Soren:

my next step is ronger, go through, clean up everything, get as much bone reduction done as I can with the ronger. And I'll do that by doing. In between the teeth, right? The frickle bone. I'll snip that first, go through, snip all the frickle bone. And then I turn my ranger to the side and I'll do a gross cut of the buckle bone, gross cut of the lingo bone. Now be careful here because this is when you can break off buckle plates. So I do this cautiously, but that's the next step every single time.

ty_2_05-28-2024_194310:

Yeah.

Soren:

and then we go,

ty_2_05-28-2024_194310:

Make sure you like squeeze hard on the ronjour so you actually

Soren:

snip,

ty_2_05-28-2024_194310:

Break the bone before you try to, before you try to roll it off, or it'll take more with it. Yeah

Soren:

take the buckle And that happens all the time.

ty_2_05-28-2024_194310:

That's me how I know Yeah,

Soren:

10 minutes in, maybe, and we've got all the teeth out, flap reflected, and a gross amount of the alveoloplasty done. Next step, my assistant. And they're handing me these instruments. My assistant hands me my straight hand piece. I've got a coarse barrel Meisinger burr on that straight hand piece. And she has the handpiece set 40, 000 RPMs. And I'm ready to roll on my alveoloplasty. I grabbed the straight. My assistant has the palatal side reflected back with her Minnesota. I grabbed my Minnesota and it's one clean all the way across. Cause if you have a good burr that is sharp. Like it should be cutting very well. Now let me go back before I jump into this quick. At this point, I and I just forgot this step. At this point, usually I'll grab the teeth, place them in the socket, mark where 15 millimeters is from the incisal edge of those teeth. So I have my line across and I know where I'm reducing to, but then I take that burr, reduce all the way straight line across the, I do the right side first and then on the left side. I'll do because I'm right handed. I'll do like a motion like this I'm just basically for the people listening to the podcast It's just on the right side you can do one clean, but then on the left It's like a couple strokes to get the bone off the left side. then evaluate it I look at the patient's eyes and I look at where the tragus line is and I make sure that my is like perfectly straight looking down from that. And then usually I'll go through and clean up a couple of areas that may be like every once in a while you like look at it and you're like, Oh, like I sloped a little bit buckle on the left side compared to the right.

ty_2_05-28-2024_194310:

yeah

Soren:

clean that all up. I, so then alveolus done next. Handed off to my assistant. She does a quick clip, takes the straight off, puts my contra angle in with the Ready to go. She changes the motor to 1200 RPMs. And then I'm ready to go for my osteotomies. I look, I take a quick peek over at my plan. I'm like, okay, my implants are coming out. I'd already got my 15 millimeters reduction done. My implants are coming out second pre molars on both sides, and they're coming out in between central and lateral. For my two anteriors. So then I take my pilot. I do. I do them all at once. So I do my upper right. I do my straights, my upper left, those front four are done. this is something that's going to be a little bit controversial to Patsy protocol, right? Patsy protocol believes in doing pterygoids first. I still do my front four first, just because I like getting my arch in and ready to go.

ty_2_05-28-2024_194310:

Secure the case. Yep.

Soren:

just to secure it. And then I know like where exits are going to be because I don't always do pterygoids. If I'm if my Is in a molar I don't need to do a pterygoid. I don't always do them, but I would say probably 90 percent of my cases now. I'm doing pterygoid cards on,

ty_2_05-28-2024_194310:

Yeah.