The Fixed Podcast

Maximizing Efficiency in Implant Dentistry: Part 2

June 24, 2024 • Fixed Podcast

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Ever wondered how to achieve optimal torque and stability in implant dentistry? Join us, Dr. Tyler Tolbert and Dr. Soren Paape, as we lead you through the intricate steps of implant placement, from selecting the right drill sizes to executing precise osteotomy adjustments. We delve into the specifics of pterygoid implants and explore the art of choosing and angling multi-unit abutments for flawless restorations. Our deep dive ensures you never settle for inadequate resistance, offering insights into achieving the perfect alignment and stability critical for successful outcomes.

Efficiency and precision are the cornerstones of effective surgical procedures. We emphasize the mantra "slow is smooth and smooth is fast," underscoring the importance of a well-coordinated surgical team. Discover how standardized systems and incremental improvements can drastically minimize complications and elevate patient care. We provide practical tips on honing surgical techniques, highlighting the collective expertise required to refine and streamline your practice for better results and smoother processes.

Finally, we tackle the complexities of full arch surgery, offering strategies to improve both efficiency and quality. Learn how to manage patient movement and utilize full-thickness mucoperiosteal flaps to reduce surgery time and risks. We break down advanced techniques for multi-unit implant placement, shedding light on how to avoid common pitfalls and achieve perfect prosthetic outcomes without over-reliance on guides. Plus, find out how you can get involved with the Fixed Podcast, giving us feedback and contributing your expertise to make our show even more interactive and valuable. Join us for an episode packed with actionable insights and expert advice to elevate your implant dentistry practice.

Speaker 1:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry I get my first four.

Speaker 2:

So my assistant's handing me pilot, then she's handing me 2.0, then she's handing me 2.3, then 2.6, and then it depends like what the bone density is of where I'm stopping there. But effectively every single time I'm just doing all four osteotomies super quick throughout. When I'm ready to go, she's like you're ready to place implants? I'm like yep, so then she has my and man. Almost every single case I'm doing I'm placing three, eight by 13, three, eight by 11 fives. So three by 13 is on my two posterior, three eight by 11, fives on my two anterior's my go-to.

Speaker 2:

Everybody has their own go-to but that's mine and I very rarely sway from that. The only times I sway from that is if I can't get torque with the three eight. Then sometimes I'll jump up to a four five. And the reason I like placing three eights is because usually I can get stability. Jumping up that 0.7 millimeters. It's like enough for me to regain some of that torque. If I get like halfway and I can tell oh no, this isn't going to work, I don't put the implant all the way in and increase the osteotomy size. I will like play work, take it out and then go to a five, five, oh, um, for my implant.

Speaker 1:

So those four implants are in this is such a no, I'm just gonna say it's such a like rookie, uh mistake. Is you to say it's such a rookie mistake? You're not really feeling a ton of resistance with the drill, but you still just place the one you're planning on and pray. If you don't feel that resistance, then maybe you go as far as starting to place the implant. If that torque isn't really starting to jump up.

Speaker 1:

You should really go ahead and kick up to another size, not just a half step but a whole step. For instance, if you're replacing a four and you didn't get a lot of stability and then you go to a four or five, you've only gone up half a step and the implant itself is actually bigger than its corresponding drill. So you've already widened the osteotomy so that next implant isn't going to be grabbing any more bone than the first one was. So you're going to have to skip it. But what Soren is saying is go ahead and do that Skip, get a feel for that haptic, get a feel, for if the implant's not going to work, go ahead and place that next size up. That gap from three, eight to four or five is a little bit better than just a half step, but it actually can work, so that I totally agree. I use three eights 95% of the time.

Speaker 2:

Yeah, yeah, but yeah. So all the implants are in then and I'm telling you like at this point, like we're usually probably like 25, 30 minutes in and we've got all the implants placed. Next step, we jump to pterygoid. So while when I'm placing my last implant, my assistant's sitting there with my long pilot drill and she grabs the long pilot, places it on. I do my pterygoids with the drill protocol. I have placed them with the osteotome protocol. I've taught a lot of doctors with the osteotome protocol. I know how to do both. I prefer the drill protocol personally.

Speaker 2:

So long pilot, do my right pterygoid, do my left, same thing. Switches them right, left, switches them right, left, and then we're placing Pterygoids are in. At this point it's 30, 35 minutes into the case, sometimes even less than that, right, if my cases are taking 45 minutes like, sometimes a little bit less than that. Next, my assistant's literally sitting there with a 17 degree multi-unit. I almost always place a 17 degree multi-unit on my pterygoids. So she hands me that. I check the angulation of both, then I grab she'll. She also will have the one two, my one two driver on my contra angle handpiece set at a 50, 20, so 50 rpms, 20 newton centimeters. Once I get the 17s where I want them, grab that handpiece, lock them in. They're both torqued, ready to go. Then I grab. Third, she hands me my two 30 degree multi-units. I place those.

Speaker 2:

I'm super anal at this point about my angulation. I do not want to be switching my multi-units when I'm going to finals. So I will get. I will take an extra, whatever it is, five, five minutes to get my angles all perfect. I want them all to come out of the central fossa if it's like a posterior tooth, or out of the central fossa If it's like a posterior tooth or right behind the incisal edge if it's an anterior tooth. So I'll spend a little bit of time to make sure everything's parallel. Everything looks like it's where I want it to be.

Speaker 2:

So thirties go on and then I torque them down both sides with that in that contra angle handpiece and then my straights go in. I rarely use 17s on my straights. I usually angle my osteotomies forward quite a bit and I want them right behind that in size of ledge. That just comes with practice. Sometimes you'll like, when you start you'll probably place some and you're like, oh, I gotta put a 17 on just to get the angle. That's fine, not a big deal. But once you have done hundreds of arches you'll know exactly where those implants should be. So all the multi-units are on, all the multi-units are torqued. Then we take all the multi-unit holders. Do you know what they're called? The metal pieces on top of the multi-units, the rods.

Speaker 1:

I just call them the carrying rods or whatever. Yeah, the carriers, but yeah, so take all those off, then my the carriers.

Speaker 2:

But yes, take all those off. Then my micron mapper photogrammetry scan bodies are going on. My assistant's over here setting up the micron mapper for me, while this one is helping me, she's handing off, I'm like handing her my driver. She's loading the next one while I'm taking, while I'm putting the other one on, um. So it's just that every like my assistants are constantly moving. While I'm moving right, I'm not sitting there grabbing each Micromapper scan body my assistant's handing me a driver with that Micromapper scan body on. And that's the difference. Right, like that.

Speaker 2:

There's so many doctors out there, me included, who, when you start, you're taking the scan body, placing it, grabbing the next one, trying to get it to engage in the one two screw, placing that one. No, I'm, they're handing me. I'm moving for my pterygoids. I always will put my user contra angle. Just my implant motor. I'm moving with a one two driver on it and I do it at a 50, I think 10 newton centimeters and I'll hold the micrometer, your handpiece, not back there with the patient bodies. If one of your, if you try to go quick on your multi-unit part and one of your multi-units is like crossing over the other one. Good luck getting that scan in 30 seconds, right, you're going to be sitting there trying to get that scan. You can't get it, then you got to take a scan. Yeah, you can't get it, then you got to take a scan buddy off and do two scans. Have your lab merge them together. Doing these little steps ahead of time and doing them correctly will save you time down the line. So, once you get the micro mapper, take all the micro mapper scan bodies off, put I use nobel white healing caps, put the nobel white healing on. I then use a five millimeter tissue punch that goes on my implant motor. You can get these anywhere, but I use a five millimeter grab that I tissue punch all of my implants to make sure that my flap's going to lay properly. After that, hand that to my assistant. They're handing me a suture and I'm doing two simple interrupted sutures in between every single, in between all of the scan bodies. So at this point I have all my records done. I have I shouldn't say all because you still need to take the impression at the end, but I have my photogrammetry done. I have my scan bodies on Everything's sutured. We're at the 30, like 30. Sometimes 45 minute mark hour, but rarely do my cases take in that time like it's all handing me stuff. Yeah, I get everything's on the top, we're not skipping a beat patient.

Speaker 2:

I like to set my patient up a little bit when I'm doing the lower patient sits up a little bit on the lower and then the bottom is the exact same way. My assistant immediately is handing me a large straight elevating all the teeth. Then I grab a 151 getting the molars out. I do use a cow horn on the lower molars if there's a lot of furcal bone, but then it's ash for all the anteriors, then laying my flap. Same thing I about at that first molar mark.

Speaker 2:

I'm doing my releases, I do my and motion across the lingual bone. It's one sliding mode, one on the other. I do my lingual first, then I reflect my releasing incision up and then peel that keratinized tissue forward and then release it all down. Now on the lower anterior, you're going to get a lot more periosteum attached there. At this point I will look at my patient and a lot of times like people, especially in the beginning, their lower alveoli will look like this It'll be canted.

Speaker 2:

I like to close my patient and look at the lower upper and that helps a lot for me visualizing. Okay, I know my upper was straight because I was looking straight down on it. If I close them, I can see where the discrepancy is on the lower and that helps me out a lot. Onto my lower alveoloplasty. And then, yep, patient, my assistant's got my pilot drill on my handpiece. Punch those front four in. If I'm doing straights in the back too, if they have enough bone, I do those as well.

Speaker 2:

And then I go through the whole sequence just like I did on the upper Suture that all up about an hour, 20 to an hour and 30 minutes in. When I get lower sutured, assistant hands me the upper denture, make sure it fits okay, make sure the midline looks good and everything. Do my impression on the upper while that's setting, if I have a good stop, grab the lower impression on the lower. And before I do the impression on the lower, I close them. Make sure that their bite looks good. Do the impression on the lower, grab the lower into the bite reg. Take the whole thing out, hand it to my assistant and I'm out of the op.

Speaker 1:

My assistant is our design. You prefer to use a bite reg and then scan outside the mouth as opposed to doing it in the mouth.

Speaker 2:

Yes, I do. Um, the reason why is because the assistant then has to scan upper, lower and then put them both in and maybe she doesn't know, like, where my bite was or I have to come back in the op, yeah, takes me 30 seconds to do a bite and then everything's out of the mouth.

Speaker 2:

My, my crna can wake my patient up while my assistant is doing the scans. That's why I prefer it. Got it, got it, got it, got it. So that was a lot in a short period of time, but I just wanted you guys to visualize like how, how you know what is, what are the steps, what's going on?

Speaker 2:

that's what's going on. I do it the same way every single time. My cases all look the same and that's not a bad thing. That's a good thing, like I want my cases all to be to look the same. I want someone to look at one and look at another and be like I think it's the same case. Essentially, my setups always setups always look the same. We do everything the same every single time and that's why I hear a lot of doctors knock on wood who are like oh, I'm having this medical complication or all these issues. We don't get those very often because our surgeries are efficient. They're in and out my, my assistant, my assistants know what they're doing. My CRNA knows what they're doing. If the patient's only asleep for an hour and a half, it's hard for them to lose a ton of blood in that period of time or to be under so long where they're getting like crazy fluctuations in their blood pressure.

Speaker 2:

A lot of times you get those issues because the patient isn't numb anymore. They're starting to feel the surgery, Blood pressure is going up, and that's when emergencies happen. They're starting to feel the surgery, Blood pressure is going up, and that's when emergencies happen. If you get your team locked in, it's super efficient. A lot of those complications that you see just won't occur. Also, like we said before, slow is smooth and smooth is fast. Making sure throughout the procedure you're doing everything correctly. You're not sitting there flying through your multi-units and all of a sudden all your implants look like they're like this right and not like straight. Then it's going to take you from that much longer.

Speaker 2:

Then all of a sudden you're going to get to seating your prosthetic and you've got a 40 degree divergence from one implant to another and it won't see it.

Speaker 2:

And then it's like I got to reprint the whole prosthetic like the doing it, do it right, do it slow at first, make sure that you do everything correctly and then, once you're doing these things correctly, you're doing them the same way. You'll start to see that it gets quicker and quicker and you won't fall over your feet as you're going through these cases and having to go back and fix problems that happened in the past. Ask me how I know I've done. I've made every mistake in the book. I've done it all and I am not saying that I learned this stuff without issues. I've probably made every mistake that you, as listening, have made times 10, but now we're to a point where I can do these in my sleep.

Speaker 2:

It's just assistant knows what they're doing. Both of them do. I can just, I'm just hanging out along for the ride. We're listening to good music in there. It's become something that previously, prior to a surgery, I you'd have a little bit of anxiety going into it. Now it's something that's fun and we've gotten there through a lot of practice, a lot of a lot of trying different techniques and that's.

Speaker 1:

You'll find your flow with your team, what works well for you, I think, something that I just really hope that people take away from this and there's some little nuances in what you talked about that I want to expound on a little bit, but just in broad strokes, what I want people to understand is that the least valuable thing you can take away from this is that Soren is fast. There's no point in knowing that or thinking that at all. What's important is Soren has systems, and these systems have been developed over time through very incremental change and just being absolutely obsessive about every single step and making it as efficient as possible, and a commitment to that. And it's not just him, it's his whole team and how they know and understand that surgery. And I'm sure that you just said you could do this in your sleep. I'm sure your team mentally could, like they could, walk through the entire surgery, everything you do, every instrument you use.

Speaker 1:

And if your team couldn't do that, either you know done a lot of surgeries with you or you're shooting from the hip in these things and they don't exactly understand what you do and they're just waiting on you to tell them what to do and in that little bit over the entire course of a surgery can add up to additional hours, like it's not just seconds. You can't think of every one little thing and just think, oh, that's only going to save a few seconds. All of it saves many seconds and every single step. There is time saving in everything that's done and over time. That's how you're cutting out an hour, two hours, right, like I would say. I don't. I can't really say for sure what's average. I've seen a lot of first timers. I've seen a lot of people who have done like a handful of arches. I would say in general, like a double is, like it's a whole, it can be a whole morning.

Speaker 2:

Yeah, like your average person, I would say four to five hours, two, two to five hours to two to three hours per arch is probably average.

Speaker 1:

Pretty average.

Speaker 2:

Yep, and if that's where you're at, there's nothing wrong with that at all. I know people who have been in surgery for eight hours on these cases, consistently. Like my CRNA works. There's a lot of offices in Denver that do this and my CRNA will come and be like man this case. Like I go there once a week and it's like eight hours for a double. Like I go there once a week and it's like eight hours for a double.

Speaker 2:

Yeah, and all I can think about is man, all the risks that patients in being asleep for freaking eight hours, that's just not. Yeah, that's not. Um, like good patient compliance is my opinion on that. It just means that you didn't take the time with your team to to get ready for these cases and your team doesn't know what they're doing, probably if they're in surgery for fricking eight hours, but I would say on average like two and a half hours per arch is pretty like normal yeah.

Speaker 1:

Yeah, yeah and, like you said, that is okay. But what I'll tell you too is like when you first start doing these and they're taking you two and a half hours to do an arch, it's really exhausting mentally and physically. I remember my first double was, the case turned out okay but I I was in shambles. I mean, I was like torn apart and it's not as fun like when you do like really long surgeries and you're having these sorts of complications with patients that are moving around so much that it's five minutes between each stitch because they're moving and they're ornery and they just want to go home and they're trying to talk and no one understands what they're saying. It's miserable for everybody. So, like these things, surgery will get better over time and more enjoyable and you reach this sort of zone of nirvana where things just go smoothly and everyone knows the drill and every surgery feels relatively the same and if you're really fast, all those sorts of complications and patient management issues they start to go away because they're directly proportional to how long you're taking. Also, in your post-ops you won't be so scared to see your patients because they're not going to be covered in bruises. They're not going to be miserable, they're not going to be swollen up like a balloon. I haven't seen anybody in my chair that was swollen up like a balloon and I can't even remember the last one that I saw and that was almost ordinary for, like my first few cases, because they were long and there was a lot more inflammation and I was tearing periosteum in my flaps. That causes a ton of inflammation and pain. If you do a full thickness mucoperiosteal flap, you're not going to run into that nearly as often. So all these things they really do improve outcomes.

Speaker 1:

This is not about being productive for the sake of money. Yes, you will. You can make more money and you can do more efficient surgeries. You can even do multiple surgeries in the same day. You could do double doubles, you can even do the triple double. Some people have been doing like you can do more than one or two hours a day. But also you're going to have better outcomes and the quality of your cases also gets better by following these protocols, because it's not about rushing through, it's not about beginning at time, it's about doing it efficiently and doing quality surgery. And the steps that are necessary to do that also happen to make you a little bit faster too. So making that commitment and really getting anal about it will, over time just like these little changes in your surgery, will cut off a bunch of time. These little changes that you make throughout the course of your career and all these surgeries that are now going faster and smoother and with less complication, will make your life better. It will make your practice stronger, it will make your patients happier. So it really is important. It's more than just speed, it's really just the overall quality of what you're doing in full arch.

Speaker 1:

But yeah, just to zone in on a few things that you were talking about, you explained everything beautifully and I really appreciate it. One thing is alveo. So there are a few things that I have picked up in how I A do the alveo but also evaluate the alveo. I find that my perceptual ability is fairly poor. Like I can look at an arch and think it's perfect and then I'll turn from the side. I'm like, oh, I totally missed that. So I had to get a little bit more routine about about how I actually evaluate my audio and how I do it in the first place. So, on the upper, I'm a big fan of doing half and half, so you're never going to.

Speaker 1:

I think it's pretty rare to just go all the way around the arch just like all the way back to front to back, like in one pass. I usually like to do things in approximately two passes, right. So in the very front, I'm looking at the interior, I'm determining what my reduction is going to look like. Standard is 15, but of course everything goes back to the high smile line. You want to look at that Duchenne smile, see where that lip is. Add two millimeters at least, if not three, and then that is going to be your measurement from the incisal edge. Super, super important point. I don't want to just gloss that over.

Speaker 1:

I start on, let's say, the left side. I don't even know what side I actually do first, but I start and just to the, if I'm doing the left side, I'm going just to. I'm biasing a little bit on the number nine side of the midline and I will take that coarse cylindrical Meisinger burr. That's a black stripe burr, super, super useful. I wouldn't use it in every single spot, but it is very aggressive, it eats bone. It's incredible.

Speaker 1:

I go down and do a depth cut, I get to where I want to go and then I'm fixating my eye, just how you talked about the establishing your yes, the tragus line. Thank you. I'm looking down that allotragus line and I'm fixating my gaze from where I first dip into the bone to get to where it needs to be and I am setting a mental plane and I'm not going gonna move my eyes. I'm gonna look right down this plane and I'm just gonna cut all the way back from that spot, keep that same depth and pull it all the way back and keep it flat. I don't wanna see. I'm fixing myself on this plane and I better not see any bone that comes up above that plane. If I'm looking at it dead on and I see some bone up there, I need to reduce that and I'm going to take it all the way back to the hemular notch. I'm going all the way back and you should be doing that even if you don't play pterygoids.

Speaker 1:

Do it every single time, make that routine and then you won't have to learn it later. You're going to do this every time. It makes your cases look cleaner, gives plenty of space for additional teeth. Do that routinely Once you have a really nice half of the mouth. Now you can do the other side and now it's easier because you're just matching. It is much easier to match one side to the other when one side is already done perfectly. If you're just reducing everything at one time and just trying to figure out the high spots, it's like playing whack-a-mole You're just hitting all the high spots and then you're hoping that everything ends up flat, and then your eyes are getting tired and then you look at your post-op and you're like that was not flat at all. Systematic about that, especially with the upper.

Speaker 2:

That's very useful and I'm always doing this. Yeah, two things tyler mentioned go all the way back past that, like to the back of the tuberosity. Super, nothing says a novice full arch surgeon. Then, like you have, your alveolo is like to that, first molar and then it's just a freaking huge divot there.

Speaker 1:

It's just artificial combinations. I see it all the time and I'm like man just go all the way back.

Speaker 2:

Finish your work.

Speaker 1:

Finish the job, make it look clean.

Speaker 2:

Your pano is going to look crappy if you don't do that. Really important, yep. There was one other thing, but continue on, I forgot it, yep.

Speaker 1:

So that's my course cut. I try to do that in one pass. That's usually my goal is one pass all the way back and then I'll swap. I like personally to swap to a finer grit just for polishing a little bit. Like I like to have really nice round edges. I just like how the flap adapts to like really round corners. You get less dehiscence and things like that. So I'll swap.

Speaker 1:

I really like in certain burr blocks. I think the affordable burr block has this one, the, the TFAP SPG collab has this one as well. It's like a tapered burr with a blue stripe. You can go in. It's very quick. You just go right down the line, angles of the bone after you've made this very flat shelf and you just round those off. I just like to do that. It looks cleaner. You can get any like residual periosteum or granulation tissue outlet that way as well, and then I just repeat the process on the other side and then for the lower.

Speaker 1:

Another thing that I learned from Matt Krieger is using the external oblique ridge to set how low you should be going in the posterior. So you're going all the way back and you're flapping well enough to so you can actually visualize the external oblique ridge. So I'm starting there and let's say I'm using my left hand, I dip it down, it's the upper. But in reverse, I start in the back, I dip it down to the external oblique ridge and then I actually just rotate my hand forward and I try and keep it fixated and I lock my wrist and rotate it all the way to the midline. So to try and do that in one pass and my proximity to the mental nerve as I pass over that should be about five to seven millimeters. I should be getting pretty close to it by following that external oblique ridge as I come to the interior. If there were some central, if the centrals were still there, I should see those sockets disappear. Now, granted, if that had extruded out or super erupted, that marker goes away.

Speaker 1:

But it's really nice to have a tripod of reference points, your distance from the crest of the ridge to the mental, as well as getting the central sockets eliminated, and just try to triangulate all that and make it really nice and flat. So, starting from the external oblique ridge, carrying it forward in one pass, and then I can switch hands and do it with my right hand, do the exact same thing or, if you like you can. This is about the only time I'm not at 12 o'clock I'll go in front of the patient and then you can go front to back that way as well and match the other side. It's just so much easier to make the sides match than do it all at one time, and generally I don't.

Speaker 1:

I used to worry a lot about under reducing the lower when I'm looking at those three markers, using the external big ridge and then getting rid of the central sockets. I have not had an issue of under reducing the lower. Jb Dental Lab might tell you. So that's just how I like to do the alveo and in terms of evaluating it, before you move on to the next thing, look from a bunch of different angles. Look from the side, maybe on the upper. You can even get a Fox plane if you want to and sit it up on the bone some people do that and you can see from the side. Did you parallel the triggers?

Speaker 2:

I like that a lot. I don't think I think that's a great thing to do I remember when I was cool, one thing I'd recommend doing that I've seen a lot of doctors do. The other route is over reduction. You can do over reduction and something I like to to do is when I place those teeth and mark my line at 15, i'll'll actually mark it at 13. And that gives me like.

Speaker 2:

You got to know your biases Right, so like 13, and then I make sure that I get rid of the whole line. But a lot of times cut down to there and then all of a sudden you're looking at it from different angles. You're like, oh, I need to reduce a little bit there. I need to reduce a little and then all of a sudden you can be at a point where you're placing your anterior implants and you're like, oh man, I'm like two millimeters in the nose and you don't want that Right I give fixed cases from doctors who have over reduced, and it's not fun.

Speaker 2:

It's a good point, um so yeah, just you know slow is smooth, fast, whatever the quote is. Just take your time on every single step, don't just blow through the alveoloplasty over reduce, fix it.

Speaker 1:

You're fixing it because then you're gonna have issues in the future. I'm really glad you say that, because I just know my biases. I'm a light-handed person. I tend to under reduce and so I had to mentally get a little bit more aggressive with my alveo to get the speed down. But there are definitely people that put way too much weight on it and just tear it up. In that case you use a finer grit burr, slow the hell hell down and make sure you're being careful.

Speaker 2:

I think that's a great thing. You said Know your biases and then take the steps accordingly. Like I said, we've been on all ends of the spectrum, so we're trying to give you tips for different biases. If you over-reduce, maybe make your line a little bit short. If you under-reduce make sure you add that line and actually cut to the line, if you under-reduce maybe every single time you cut until the front incisors are gone.

Speaker 2:

Know what issues you have and try to take things accordingly. Did you have anything else that you wanted to go over?

Speaker 1:

I would say incision design. So you definitely talked about that in terms of releases up the maxillary buttress on the upper, going all the way back. The other thing I want to ask you about is do you do straight line incision? So the concept of this is, as you're going, provided you have adequate care in ice tissue and ultimately that's the decider in a lot of this but instead of going circumferentially around the teeth and going like papillae, like through the papillae and actually tracing the papillae, do you just establish a straight line, a common denominator across all these papillae to give you that straight line decision?

Speaker 2:

almost every time on the upper it depends on the case, right? But yeah, like from tuberosity until I get to where those teeth are, and then I do one across the buckle, cutting off all those papillae, and then bilingual and then I go back with a ronger and just get all those papillae and then bilingual, and then I go back with the ranger and just get all those papillae. So it's nice and straight and everything will come. So it's nice and straight, but yeah, that's how I do it I got another one for.

Speaker 1:

We'll have two more, but I'm going to go to the one that I think is a little bit more important. First, because I'll probably forget the other one multi-unit timing and placement. So I think it's really important to be very routine about this. Your multi-unit placement at first. Can I remember when I first started I dreaded this part because timing the implant and getting it to come out in the right place, fiddling around with the multi-unit profiling bone and stuff like that it would slow me down so much. As far as the profiling bone and things, I think that has a lot to do with how you do your alveol, but also has a lot to do with how deep you place your implants and the profile of the multi-unit itself.

Speaker 1:

Not all systems were designed specifically for full arch, even though they may have multi-units. If they're really bulky, you're going to be profiling a lot more often. That's just an additional step and something you have to screw around with. Most of the full arch specific systems out there, like neodympt, I think megagen, and they have much slimmer multi units. Like you, you hold these up next to each other and there's there's obese ones and there's very sexy ones.

Speaker 1:

But once you're placing your multi-unit timing the implant on the upper generally and please, soren, your timing is wonderful. So if I'm wrong on any of these, let me know. I got cases tomorrow. So when you're timing your implants, always looking at the dot that indicates the flat side of the hex, so when I'm placing my pterygoids and my tilteds, I get that dot to point towards my midline. So I'm just visualizing where that midline is at.

Speaker 1:

Sometimes I'll actually turn my head and look at the implant that I'm timing directly and I get a dot to stare back at me from the midline and then as I get to the interior, those midlines just go straight back at me. They're not pointed at the midline necessarily and if you can get that to where you time it the same way every time, what happens is your multi-units. You're not even having to fiddle around to find the hex, it actually just drops right in. Like you can literally hold the multi-unit in the sort of angle correction you want it to have. You're going to be correcting 30 degrees this way and it's going to be correcting this way and you're going to have in that orientation. It'll drop right into the implant because you know that you've timed it the same way every single time. The more you do that, the faster you'll get and eventually you won't be fiddling around with multi-units. So much You'll know that it's timed correctly, that it's going to Every single one of those implants, is really important.

Speaker 2:

Yeah, for sure, take an implant and just spend the 60 bucks or whatever it is However, not 60, probably 100 bucks for your implant. And just take it out of the package and look where your multi-unit is coming out of that implant.

Speaker 1:

Yeah, so you can get an idea.

Speaker 2:

I need to angle my implant this way, so my multi-unit comes up here. This is where.

Speaker 1:

I totally agree with that. Can we also talk about and this is something you helped me a lot with I used to rely a lot on guides and multi-unit placement guides. I would always have that for the upper and use them for the lower. They weren't that great just because they don't always seat that well. But on the upper I would need to put that guide in to check where my multi-unit placement is. Recently I've not done it at all. I don't think I've done it in six months. How do you perfect your multi-unit timing? How are you always having such good prosthetic exit? What are your reference points? How are you doing that so predictably without having to compare a bunch of stuff and see the guide and all that?

Speaker 2:

yeah, absolutely for me. I, yeah. I don't use a guide at all because I'm like I said, I'm marking 15 millimeters, I know where my reduction is. And for for multi-units this is how I do it my upper multi-units all should be look, they all should be relatively parallel. They should all be flaring out buckly equally flared just a little bit.

Speaker 2:

I like to look at where um, I'm gonna probably finagle this terminology, but if you look at where your maxilla is flaring, your maxilla flares as it comes up where the teeth are. My multi-units almost match the flare of the maxilla.

Speaker 1:

That's what I'm looking at.

Speaker 2:

And so everything is flared. My anterior ones are flared a little bit forward and my number four and 13 are flared a little bit buckly, and then my posterior ones, my pterygoids, are flared like a little bit buckly and a little bit forward because I'm and the reason I like that some people like to place 30s, I like to play 17s because my assistants who are taking up my prostatex on and off, are able to find that easier when there's a little bit of a buckle flare.

Speaker 2:

What's nice about the Micromapper and not everybody has this luxury, though is that it actually tells you exactly what your divergences. I think the max divergence you can have is 40 degrees. My personal max is 35. I like 35. If it goes above 35, I'm changing my multi-unit because I don't want down to where there's a zirconia and all of a sudden being an issue where I can't see that zirconia, because the zirconia is much more rigid than your printed temp or your analog temp, or whatever you're using.

Speaker 2:

So that's my upper on the lower. Now I just know looking at it, but very similar, less of a flare on the lower, just a slight flare, everything parallel. I like to close them on the lower when they are in there and I want them to hit like just inside of where those where those uppers are or just where the upper teeth would be. So I close them usually and that's how I do my lower multi great placements, but when you? Start. Don't do that when you start, use a guide like use a guy, yeah.

Speaker 1:

Yeah, I don't know until like your first hundred arches, and then you'll know okay, I know exactly where this is coming out, yeah, of where the teeth are yeah, and I think one of your most invaluable advices to me when I was trying to get rid of doing the guides, because I was annoyed with having to print them for every case and they didn't always see perfectly, because sometimes those designs can be off. No shade of JV is putting the teeth back in the socket. So one thing that I had issues with early on was getting a proper prosthetic exit in the anterior, which made for thick prostheses. One of the most common issues that you'll have early on more than likely is thickness. Not always in the posterior you may have it, but it might not actually bother your patients that much. What will bother them is having a thick anterior hard palate area because your exits came out way too palatal there. It's hard for them to clean, it affects their speech, it feels really thick, it's much harder for them to get used to and it's a harder thing to fix Like you're going to have to change a multi-unit.

Speaker 1:

So one thing that helped me out was try to get those upper anterior teeth out whole, of course, and put them back into the socket. So when I go into that sort of that palatal island between the central and lateral teeth I will actually put my drill right there, I'll stick the tooth there and I'll just go ahead and angle the drill such that it would come out the cingulum. Now this is where it could be that I'm preserving the class relationship. If I'm changing that at all, obviously I have to make some changes there. Like if the upper teeth need to come back, then I need to be coming out a little bit more palatable than I would. But assuming that we're preserving the incisal edge position, I'm able to measure with the natural tooth exactly where that cingulum is and the prosthetic exits have been absolutely money since I started doing that, as well as that slight buckle flare is really good.

Speaker 1:

The timing looking for that buckle flare and using the existing teeth has completely eliminated guides for me and I'm not going back. I think the only indication that I would see for it is maybe like a really atrophic case that was a dentalist that I don't really have a lot of reference for, or one where I'm doing extreme class correction. I did a really fun one a couple of months ago where it was just like a complete class three upper was entirely inside the lower and in that case we did have some guides so I could check out that relationship and ended up being on the money in the patient's class one. Now it's so cool. Those are amazing cases, but that's the culmination of like really nailing down, being able to do all these things in a class one relationship. And once you get really comfortable with that, you're not needing to use guides and you'll feel a lot more comfortable with those types of cases. Perfect.

Speaker 2:

Yeah Well, I think we've hit a lot of efficiency tips. If you guys have any questions about our surgeries, if you have any questions about little things we've talked about, if you want us to expand on them, reach out Again. My Instagram is Dr Soren Poppy Tyler's is Dr Tyler Tolbert. More than happy to reply to any of those. You can also reach out to us at the fix podcast. That's the instagram tag handle. We'd love to answer questions on there as well.

Speaker 2:

I do want to get say one more quick one for those of you who are doing analog conversions take your um.

Speaker 2:

You always need to do figure out, like where those implants are coming out, right prior to putting temp cylinders on, because you need to drill all those holes. So take a bite reg of the intaglio under your denture prior to suturing. That way you can hand that denture off to your tech and he can be drilling out the access holes while you're. Don't wait till after you're suturing and then sit there till your tech is drilling those holes out. Do it before the suture, make sure that you don't get any bite reg under the flap, hand it off to him, let him do that, and then that way, right when your suturing is done, you can start putting those temp cylinders on and it'll be like right about when your tech is passing it off to you. Before you do the pickup on the upper, get them numb on the bottom. That way, after you do the pickup you hand it to the tech. The patient's already numb, you start on the bottom.

Speaker 1:

Those are probably my two big ones for analog, but yeah and in the upper conversion doesn't have to be completely done to do the lower pickup. Don't be waiting on the lab to finish their upper conversion.

Speaker 1:

Before you do that, you can just screw it in wherever they're at in that process. I'm sure they've at least done the backfill. You can just screw it in, do lower pickup and then you hand it off and they'll finish both of them at the same time. You don't want to be waiting on a lab process. Also another caveat I was always a huge advocate for using lab putty instead of instead of a bite ridge, because it doesn't have a liquid phase. So you can either use lab putty or you can use like a silly putty, like material.

Speaker 1:

I've actually used silly putty before. Don't use the kind of glitter in it. Which really nice is that you can mold it into the denture and then you can do the seat. And if it didn't come out right, you don't have to load up another tip and do another bite ridge. You just smooth it over and do it again. It's rigid enough to where they can drill through it without a problem. It's reusable. You could even reuse it on the lower as well. It was just a small speed tip. There's a putty block is available through like major suppliers. But, like I said, you can also just use some like silly putty from amazon. I'm past that world. It's not my world anymore, but it was a pretty good one that I was pretty passionate about.

Speaker 1:

Yeah yeah, anyway oh, oh, and if you have a sinus exposure or something like that, it's not going to run up into the sinus. We have seen blue, like bite red get into someone's sinus before. But yeah, no, I think this was an amazing episode. I really hope that there's some implementable, bite-sized tips here. There's probably like 200 tips that you just gave people and absolutely dropped gold on them.

Speaker 2:

I hope you guys are out there.

Speaker 1:

And if you guys have anything that you explained a little bit better you need some more pictographic information or demonstration we can definitely try to provide that. You can also email us at thefixpodcast at gmailcom. I did recently make a short where I included all the forms that we've made for you guys to send us some feedback and some suggestions and things. We're actually going to put that in the Instagram bio as well. So if you have any questions for us to answer on the show suggestions for topics, guests you can go that route. If you have a case you want to show off or you have a case you want to help with, you can do that. Or if you're looking for sponsorship on the show, we have forms for all of those things. So please engage with that. We'll be looking for it and we can't wait to start mentioning some of you guys on the show. We're just having so much fun with that and we want you to do as well.

Speaker 2:

So thanks so much for listening guys. We'll see you next time on the fixed podcast.

Speaker 1:

You got it.