The Fixed Podcast

Roadmap to Remote Anchorage with Dr. Clark Damon: Part 2

July 25, 2024 • Fixed Podcast

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Ready to transform your approach to implant dentistry? Join us as we unpack the critical pitfalls and invaluable lessons from the first hundred full-arch implant cases, ensuring you sidestep common errors and refine your technique. We'll delve into the delicate art of alveoplasty and the precision required in drilling to safeguard against bone damage. Are you torn between sticking with analog workflows or embracing digital methods? We'll weigh the pros and cons, advising newcomers to master analog basics before transitioning.

Gaining confidence in advanced procedures like pterygoid implants takes time and experience. With insights from our guest Clark, we share practical advice on building surgical skills incrementally. Learn why extending incision lines and practicing safe drilling techniques are crucial steps in preparing for more complex cases. We'll also discuss the importance of patient interactions and managing expectations when complications arise, sharing personal journeys to highlight the need for patience and mastery in advanced implant techniques.

Ethical considerations are at the heart of implant dentistry, and this episode emphasizes long-term patient care and trust-building. Clark shares how the Texas Implant Institute can further hone your skills, with special courses designed for advanced techniques like engaging the nasal cortex. We discuss the significance of ethical practices, such as not charging for replacement of failed implants, to foster patient trust and positive word-of-mouth. Join us for a comprehensive discussion that aims to elevate your practice and enhance patient care, backed by the educational opportunities available through the Texas Implant Institute.

Speaker 1:

So you know we've talked about you know, case selection for zero to 100. What are some common pitfalls that people will run into when they're trying to do these first 100 arches? What's going to slow them down? What's going to frustrate them? What are the problems that they maybe don't see coming after? You know, listening to the Fix podcast and watching surgeries and shadowing?

Speaker 2:

What are some things we can do to kind of hedge against that? Yeah, you know, some of the things that I see is they will under-reduce on the alveoplasty or they will over-reduce. It's kind of like finding that good balance.

Speaker 1:

Goldilocks zone.

Speaker 2:

Yeah, I mean we kind of mentioned like, hey, on your average dentate patient, you're going to take away three, three, four, five millimeters of uh, of bone, right for an fp3, and uh, you know, you'll see the guy who like only hears that in in clinic right and or in in the course, and then he rolls into the cadaver, you know, and he gets an edentulous patient and, just you know, whacked all the bone away and he's like oh, I thought you said take away five millimeters of bone.

Speaker 2:

you know it's like you know, we got to think on this, right, like, like, why are we taking the bone away? Right, yeah, and then you know the patient's got a denture base like 20 millimeters thick, right and so yeah, so so, over reducing bone thinking that everything applies, you know, to every can, every, you, every type of situation that you get involved in. Yeah, so under-reducing, over-reducing.

Speaker 2:

And really the big thing that I see a lot is people are, when they're drilling, it's like man, they've got the foot on the pedal as hard as it goes and it's going like 1,000 miles an hour before they even put it into the socket, right, and it's bouncing all around and then they finally get it in the hole and they're like, oh, thank goodness, I got this in the hole. Okay, now let's just get it all the way down, you know, and they're not even feeling, right, they're only caring at that point about depth. They've forgotten about. You know, you know medial and buckle and you know lingual angles, and you know, now it's just like depth, Right, but then they're not feeling the bone and then they're overcooking the bone and that's the thing, right, Like being able to feather your drill is a huge step, is is is a huge step.

Speaker 2:

You probably won't get that until you're 250 and up um you know, just kind of being able to feather that drill, like, hey, I'm just gonna, you know, turn this drill at 50, 50 rpms, or I'm gonna turn this drill at 2000, you know that's good, that's good, yeah, yeah, I just wanted to mention something about the over reducing, under reducing.

Speaker 3:

Just a quick tip that, um, I'd recommend for people in this hundred to zero to a hundred arch range, um, if you are doing, you know, zero to a hundred, I think that is. This is kind of a controversial topic because, uh, there is so much you know, digital, uh workflow, kind of propaganda out right now, um, and I do, I do a partial digital protocol, so, um, you know, I totally understand, but I think clark, you still do all of our cases analog um so if you're doing yeah and I oh, go ahead yeah, you know, we, we have experimented with the uh, digital workflow.

Speaker 2:

Um, you know, you know to. To me, you know, it's, it's it's kind of like what works in your hands, right, and uh, you know, I, I like being able to have like that little trough. I like to kind of know where the teeth are. You know where the teeth are designed. So I want, I want like a guide to go in and you know, I don't want to have to deal with impressions, I don't want to have to deal with photogrammetry, you know.

Speaker 2:

You know, hey, we can't get the pterygoid, or you know you know we can't get this scan or that or you know, then you get all frustrated right like then.

Speaker 3:

That's the stressful software is not working.

Speaker 2:

Yeah I mean I can't tell you how many times you know, you know, you know I have all the stuff right, like we've got itero trios, I've got, I've got iCam, all those stuff has problems right. Like you know, all of a sudden, randomly, your stupid, you know cord to the little scanner goes out right.

Speaker 2:

Or you know your assistant that always, you know, damages you know your assistants are always out to get you, you know, or they break your laptop screen you know right when you're rolling in and you're like this is the only way I can do this case Right, like the only way I can do this is digital and we got to send it to the lab and then print it, or worse, you do prints Like. I know doctors that'll print two at the same time. Use two printers, because if it falls off the damn printer, you know it takes longer. I mean, printing is coming faster, right, but I don't know.

Speaker 2:

I mean to me, you know, I'm using this really cool system now called NeoConvert. It's like the Smart Denture, it's very similar to that, it's just more affordable on the Neo convert side. And you know, we'll just kind of zip through a case and then by the time I've sutured, right, like so, I've had to deal with no photogrammetry, no impressions, no, you know, intraoral scanning, no placement of fiducials, right. So take all that out of the equation. And it takes five minutes to screw, or maybe three to screw on you know your 12 neoconvert caps. And then we take their denture, you know, load it up with acrylic boom, lock them down, snap it out. So literally 10 minutes, right, and we're done.

Speaker 2:

And there was no stress of we can't get this scan. This wasn't working, you know cause. Then all the time, then you add all this equipment into your surgery room and it's like, oh, we got our, you know, scanner here. We got you know, micron mapper, we got this, we got you know all the stuff. It's, it's a lot. And then your anesthesiologist is sitting in the corner being like man, there's barely room for me, you know, um. So that's, that's just kind of me, you know Um yeah, no, I, I totally understand.

Speaker 3:

I think, uh, if you're in that one zero to a hundred arch range, I think you know analog is just a great way to get a lot of the basics down and it's an easy way to get to start, kind of like entering into the space, right? So you don't need to spend $30,000 on a Micron mapper, you don't need to spend, you know, 20K on your scanning and laptop setup, and then it's another 15K for the full digital suite to print the arches, right.

Speaker 3:

If you just want to get going in it and you want um to give it a try. I think analog is a great approach and when you start right, you're talking about over reduction, under reduction get a, get a denture made. If you don't have a, the, if you don't have a lab tech in your office and you're outsourcing your dentures, um, get two dentures made, get one and a duplicate. That way you can do the guide yourself. It's not hard to make a guide. You just measure from the incisal edge to 15 millimeters. You can cut that off and and blocks or the whole thing in the front and then you just make a trough behind the teeth.

Speaker 3:

I like to go from you know you can do second pre or even all the way to the molar and make it wide enough that you can fit your multi-unit pickups whatever you want to call them, multi-unit, like pickup pieces to go through it. And then you have a reduction guide where, if your patient is a dentulate, you can just stick that on and see exactly where your reduction line should go. That on and see exactly where your reduction line should go. If your patient is dentate, you can do the same thing and just double check it after you take all the teeth out or after you reflect your flap. Clark talked about this earlier pretty quickly, but he likes to do a mark across the whole arch. You know, do you do? 13 millimeters, a great, a little bit short of 15,. Um, for your, for your, your line that you're going to trough through and then set in between all the teeth, no, I, I just do um, you know a 702.

Speaker 2:

So it's three millimeters. So I, I, I don't mark um, uh, but I do. I do a three millimeter trough, you know, mesial, mesial, buccal, distal, and then pop the teeth out. You know they come out in five seconds Um and uh, and then you know, then I'll do my reduction, um typically, you know.

Speaker 2:

I just sorry, I eyeball it and, um, you know when, when you've done, you know 3000 cases under your belt or whatever. You know, you, you can, and you just you know. When you've done, you know 3,000 cases under your belt or whatever. You know you can and you just know, right. So landmarks I'm looking for, can I pull the palate, you know, to the buckle edge, right, that looks like that's. If I can't, that's a red flag for me, like, hey, you know, take some more bone off, or maybe you're kind of sloped right and the palate edge of the alveolus needs to be further reduced. So I want to, I want to know, you know, in the molar region, you know, can I pull that palate all the way over to touch that you know buckle of the maxillary alveolus? You're?

Speaker 3:

talking about the tissue, the palatal tissue.

Speaker 2:

So if I't, that's a red flag, um, and then I take, I take the denture, I I score in the denture itself and then you know, then I put it in the mouth, so the denture scored and I'll, I'll send you. Uh, you guys can upload a picture now.

Speaker 1:

Yeah.

Speaker 2:

So then. So then, um, you know, and you can kind of measure that you know, like you said, you know 15 millimeters from the incisal edge. So, yeah, I would say you would mark, you would start your, your cutting at 13, so then then you've got your 15 right and and then I put that in, and then then you know if I see any bone through those windows, then that lets me me know. Hey, you know I need to reduce more.

Speaker 2:

Um, so I think great way, great way. So I, I, I check it, you know, by only doing half, half the mouth, first Right, and then then when I do the other side, I still leave, you know, right, between eight and nine and that whole palatal area. So I can always go back and measure and then you know we're looking at frankfurt horizontal and make sure that you know it's not canted and stuff like that so I've got three checks.

Speaker 2:

one is did I reduce five millimeters in a dentate patient? And then I can you know, basically fit the burr and it's like even on both sides right, um, I use like a five millimeter round burp. Can I pull the palatal tissue and does it touch that buckle line angle of the maxillary alveolus? And then, I can you know, put in the scored prosthesis Scored denture Because there's nothing worse than having to redo that.

Speaker 1:

Yeah, yeah, I think that you, you know, definitely for the zero to 100 segment, having redundant references and verifications for your alveo is extremely important because you don't want to be redoing any of those first 100 within a short period of time. You know, if you, if it's your first 100, you don't get to count it for your next 100, it's just a redo. So another one that I don't think we've mentioned yet, but I know at least Soren uses it as much or more than I do is when, once you've taken the teeth out, usually you're saving your centrals and you're saving your canines. And, provided you get them out in one piece after you've done yourveo or even during for reference, you can put it back in the socket and then you're able to actually measure from your incisal edge to where your bone level is at. So that's another good one. Also, preoperatively in your CT, once you've decided on your alveo line, you can figure out how deep certain sockets should be when your alveo is done. And it's not all cookie cutter either, right, it's not all just like five millimeters in every patient, just like you were talking about. You know people that go to your cadaver courses. They're just raising bone every time.

Speaker 1:

This all has to correspond to the smile line, right? The minimum of how much we need to reduce for FP3 is going to be 15. But also, if someone has a higher smile line, we want to take, wherever that lip is, millimeters just to make sure we've hidden that transition line. And that can all be coordinate with the denture that you talked about. Scoring that, trying it in the mouth, you know, measuring from the incisal edge, uh to uh some future crystal level prior to taking the teeth out or even after, if you put it back in, you can measure. And those teeth can also serve as a reference to where those teeth are going to be.

Speaker 1:

And so you can kind of figure out your angulation of your drills, especially in the interior, to make sure you're not coming out super, super palatable and having a really thick prosthesis in the interior, um. So you know, say all that to say, have multiple ways to check these things. You can never know when something might not be quite as useful, uh, as a reference, as as you would hope. And so just having all these different things in your toolkit to make sure that you've reduced adequately is going to save you a world of headache. It's one of the worst cases you'll ever do is the one that you already did, and now you have to go back in and undo all of your work, and now you have yourself um your very own homegrown revision case. Um, it is just one of the worst mistakes that you can make in full arch. Industry is uh under uh or over.

Speaker 2:

I think it's super common too. Sorry, it's very common. I would add two cases to avoid for the under 100.

Speaker 1:

High smile line yeah.

Speaker 2:

Also a gullwing lip. Okay, Right, so you know, a gullwing lip is like that Mercedes where you know you got the gullwing, where it really rides high.

Speaker 1:

The corners get high.

Speaker 2:

The corners get really high. So like you can look at eight and nine and you're like, hey, that's not, that's fine. But then when you're like, hey, you know around, you know 13 and 14 area, it's like there's a lot of, there's a lot of gingiva here, right, yeah. And a warning sign is, if you see the mucogingival junction, you, you're gonna have a problem, okay yeah, there's nowhere else to go yeah, so that that that would be mute, very smiling, with exposed muco.

Speaker 2:

Gingival junction in the posterior needs to be relative or absolute contraindication for anybody under like 250 arches that's great.

Speaker 1:

That's great, and we can talk about how to manage that once you're a two 50 plus as well. Yeah, yeah, that's great. Um well, I think that's actually a pretty decent uh transition into getting into, uh, the more advanced arches. So let's talk about you know someone who and are we doing okay on time? By the way, I don't want to keep you Okay.

Speaker 1:

So if we're talking about you know someone who has done, let's say, 100, very competent arches and they've gotten themselves in a few situations where they say you know what I need to expand myself beyond my traditional all in four. I want to take on some more complex cases. Or maybe I've had some issues with my own and I want some other things in my, my toolkit, so I don't have to send this case down the road. Where should people be looking first? You know what kind of cases should they be looking at? I mean, personally, if I may be so bold, what I think is a great thing to start incorporating is pterygoids, right, like that's. You know, once you start remote anchorages, it's great to be able to eliminate that cantilever in the back. It can be a little bit ambitious at 100 arches. Maybe you want to be doing this around 250. What's kind of your take on? Once you start getting into that on-for and beyond area, where should people be starting?

Speaker 2:

I think it's really hard. I mean, I wasn't doing pterygoids until 500 arches, and I know other people kind of share a similar sentiment. Um, but just because that that was my experience doesn't mean that it has to be somebody else's. And you know, it's kind of like how many cases do you want to compromise? Uh, you know, and just be like oh, you know, I don't know. You XYZ says I can't do it until I do 500 arches. So I do think 100 is probably the minimal barrier.

Speaker 2:

And I kind of say that in our Texas Implant Institute course I really want to limit, you know, attendees unless they've done over 100 arches. Now, that being said, you know, if you send me an email and you're super gung-ho and you realize like hey, this may be way over my head and you know you want me to take your money, we will, but you know, I think it's a better investment. You know, doing it later, you know, maybe around the 250, I think. I think most people would be like all right that that seems, you know, relatively reasonable.

Speaker 2:

But, like I said, I mean if you're willing to pay pay for you know to. I said I mean if, if you're willing to pay pay for you know two advanced courses, and I mean you know to be honest, I mean I've taken, you know five or six advanced courses. Right, like you're, you're not going to stop, you know and and there's not just one center that you need to go to, you know.

Speaker 2:

So anyways, I mean yeah, I mean I, I, I think you know 250 is, is is very easy. I think if you're an exceptional, you know human being and and you're like hey, I can, I can manage a big bleed, you know you know I've, you know, been been around, you know you know I, I feel really confident, then then then fine, you know you know been around, you know I feel really confident, then fine, you know a hundred, you know have at it. But you better have some good hand skills, you better have some good thought processes and you, you know, better have some good case selection on it. You know probably what I would say um, you know, maybe just reach back there, and you know, kind of after you've taken a course, you know you know maybe not necessarily start placing pterygoids, but just on your fixed arch. You know, on your all on four standard, maybe just reach back there and drill right like get used to the flap.

Speaker 2:

You know, I, whenever I make my incision back there, I want to see the, the lateral pterygoid muscle, right? So go investigate that, you know, go find that you know, go reduce back to the pterygoid plates and um, and then you know, palpate the notch and say, you know what? I'm going to just stick a drill back there, right?

Speaker 2:

you know, don't go beyond 20 and because you don't know where you are right and you know, see if you can, you know, find all the hard bone. But you know, take a course first, because you know if you're drilling back there and you go lateral, you'll be into the infratemporal fossa and you can create a really big bleed. So I don't want to just say like, yeah, just go drilling around. But if you want to start by saying, look, I've done a hundred arches, I've done some education, I've taken an advanced course, I want to start getting into some pterygoids, that is not a bad way to go.

Speaker 2:

And then the patient wakes up from surgery and guess what? You got two pterygoids in there that they didn't pay for. And so probably your next, you know 10 arches that you're going to do pterygoids on. Don't make the patient pay for them. Tell them you did something absolutely wonderful for them. That was a $5,000 value, and they're going to be ecstatic and just say, hey, pay me back by going and telling you know three or four more patients to come here for their arches, um, so that's, that's, that's a way to kind of dip into it. Um, you know, I mean even yesterday, okay, I, I tried six times, you know, uh, to get a pterygoid in on this, on this lady, couldn't, I, couldn't do it. Okay, you know, know, the guy that has pterygoids, you know, you know, we'd, I do, at least you know, eight to ten pterygoid implants a week. You know, I still couldn't get one to stick, okay, so, it's gonna happen.

Speaker 2:

You know I've got credibility, you know. Or, or then we'll just opt for as I go when that happens. But you know I can. I can handle a patient who's like, oh well, why didn't you do it? Why couldn't you get it right? Like I tried? And if nobody else? And if I couldn't do it, nobody else could. But it's different when you're, you know, so young, right, like then all of a sudden, oh, you didn't get the pterygoid to stick. Well, now what else is going to happen? Are all my implants going to fail, right? So all of a sudden, you start out on a terrible path with that patient.

Speaker 1:

Sure.

Speaker 1:

So, yeah, and one point I like to make as well and you may disagree is even when you are starting, there are some things you can start doing that won't compromise your cases or cause any issues. That will help you. Already be practiced for some of those skills, like extending. You should always extend your incision line all the way back there. Right, like you should be getting back there, your alveolus should be carried all the way back to your medial plate. You should have that habit, no matter what. No one's going to be hurting from that.

Speaker 1:

And don't be doing it for your first time when you're trying to get into a pterygoid, because those are some things that you can easily kind of screw up and make your job way harder. You could have been doing it from the very beginning. Have that same incision design. You don't have to change anything when you start doing pterygoids. If you've been doing it that way the whole time, go ahead and extend it all the way. Get behind the heel of that. You know that's a. That's a very good habit, even though you're not actually going to put anything back there in the very beginning. Um, go ahead and create that real estate.

Speaker 2:

Yep, yep. And you know the other thing I would say here uh going from a hundred to whatever our next uh level is maybe a thousand. Uh I think, I think here. This is when you're going to get better or you're going to spend more time with your soft tissue Right.

Speaker 1:

Slow down.

Speaker 2:

Yeah, you know, I mean, like early in my career I was like, hey, you know, we did an arch in 28 minutes. You know, sure, it was flapless and it was brain guided, doesn't take very long right To drill four holes. But you know, you know, and I got to where I was doing, you know, standard all on four in 45 minutes in arch. Well, you know, so when you kind of start, doing more you now know better and you're like, oh okay, you know.

Speaker 2:

so some of these things that you know, we kind of flew past you know, now we're like, okay, well, that's a problem, we're going to navigate this way because it's going to bite me in the butt later. So then you know, your actual time spent on cases is actually going to go a little bit longer, right. Spent on cases is actually going to go a little bit longer, right? So certain things that I think that that people are going to be getting into at, you know, a hundred to a thousand is going to be, you know, thinning your palate doing tuberosity reductions right, so you don't get those mustache bars or mustache prosthesis.

Speaker 2:

You know, kind of doing like a distal wedge and managing your soft tissue better. You know you're going to be using like a soft tissue punch. You'll pull the tissue from the palate over the maxilla. You know you'll start using some transosseous sutures really to, you know, pool the tissue down. You'll be looking for cases. You know, or you will now be saving, you know, all of your connective tissue that you harvest out of the palate. You'll save that because you'll know there'll be a number of cases that you that you're gonna need it for the lower and you can just there'll be a number of cases that you're that you're going to need it for the lower and you can just, you know, at the time of surgery go ahead and attach that underside of your flap and then now you've already done a um so that the epithelial connective tissue graph to augment, you know, uh, around your posterior implants, Cause that. That that is that is needed on. You know, know, quite a substantial number of cases and it's obviously easier to do it at the time of surgery than it is to go back and down the road. So this is the phase where you're going to be doing more soft tissue innervation and you know spending time, you know doing a better job with your soft tissue. So so, trimming it better, it's going to approximate better. You're going to spend longer time on your suturing.

Speaker 2:

Okay, I saw a case on Instagram the other day where somebody was like this is an Instagram suture, it's perfect. Nobody does it because you can't get your prosthesis on, you know. And then they were like this is, this is mine. And it looked terrible. It was like five interrupteds and just like I don't know, it looked like something out of the stranger things and he was like this is what I do every day. And I was like no, like, like my case is actually every day. It looked like the Instagram thing you're talking about, because you know we're doing, you know a special running horizontal mattress and then we overlay that with a baseball suture.

Speaker 1:

Two-step basically.

Speaker 2:

Yeah, very similar to you know, two-step. I'll incorporate some lockings as we as, as we're actually doing our running horizontal mattress, I'll put in some lockings. But I mean, you know I was, we were doing that before it had a name, um, but uh, you know, just because you know, when you incorporate principles that you learn at my course, you want to ever your tissue right when you ever your tissue and you can only do that through a mattress suture. Now we have even more lamina propria right.

Speaker 2:

I think that's the correct histological term right, that is touching right. So, so so we're gonna have better, better, better wound healing. You know, the other thing that that that we'll do is we'll make sure that we're spending time attacking areas that want to dive right. So then, all of a sudden, you know you can't, you can't expect you know the outer surface to heal to the inner right, like it's got to be, laminate appropriate, laminate appropriate. So whenever I see, you know, an area that's wanting to dive, you know we'll kind of, I'll kind of re-attack that I may then do like a, like a running vertical mattress to even more uh evert that tissue and then maybe I'll do a locking there to really kind of, uh, lock it up, or maybe go back and just trim that tissue more.

Speaker 2:

So there's a little bit more of like hey, I don't want to get into. The assistant calls me and they're like hey, dr Damon, we can't get the temp down after surgery. There's tissue in there, so it's just heading all that off to where you know at at this stage in my game.

Speaker 2:

um you know I've rolled off, we're we're doing the next case when they're delivering the temp, so I'm not going to unglove and come back in. It's, it's all got to work so that you don't create problems, and so it's. It's seeing that. So it's like, hey, you know what? We're going to spend an extra five minutes here. We're going to get this right.

Speaker 1:

Yeah, yeah, definitely slowing down the front end can save you a lot more time on the back end for sure.

Speaker 3:

Yeah, that's great. I think here too there's a lot of. You know, in order to get that kind of watertight closure right, like the closure that you want, you need to be able to kind of eyeball how much tissue you're removing at your initial um phase of of your alveoloplasty. So at least for me, like I'm, I'm quite a bit more careful now with like how much tissue I'm removing and what kind of tissue I'm removing. So when I do my closure everything lays flat and really nice.

Speaker 3:

I think during this phase two like that in the beginning, maybe like the 100 to 500 range you are getting a lot better with efficiencies with your team. Your team is really you know. You should have a solid team in place at this point. They should know exactly what to do and when to do it. They should be handing you instruments at the correct times. You shouldn't be like reaching for instruments throughout the whole surgery, because this is going to just cause a lot of issues with efficiencies during the case. So you should be locked into the surgery the whole time focusing on these things that Clark just mentioned, where proper tissue closure, proper implant placement, maybe parallelism throughout the arch on both sides, and instead of getting the perfect case every one in five arches, it's like you're getting almost perfect parallelism, every single case, and if you look at my cases now it it's like really hard to tell the difference between one case and another.

Speaker 2:

Right, they look the exact same yeah, and I would say it's not parallelism, it's symmetry yes, yes, correct, yeah, and, and, and also uh, as you do more cases and you get better at this, you're going to be using less straight multis because you're going to want to angle all of your implants. So, like, if you look at this you know implant case that we got behind me, most of those implants are angled, at least you know with. You know 10 to 17 degrees in the anterior and you actually get more. Um, you know I can get a much better screw channel with an angled anterior implant than with a straight right.

Speaker 2:

Right, because if you just have a straight, then you have to check every single osteotomy. Is it in the right spot? Right, because you only have basically three options and one of them you barely ever will use. So really you only have two, which is a straight or a 17. So I've got two degrees that I can change if I do a straight axial implant in the anterior. So every one of my cases that you will, you will see they are all angled, you know, angled towards the crest and angled in the mandibular anterior. Now, they're not 30 degree angled, you know they're, they're, they're, they're 10, they're 10, 15, 17 degrees. But then now I can easily just through the changing the timing of the implant, then I can get a much, I can get a more degrees of freedom.

Speaker 1:

Screw channel access. I like that.

Speaker 3:

More real estate right To work with. So if one of your distal angled implants fails and you angle those anterior implants forward, you have a whole chunk of bone then that you can engage and hopefully you've done a pterygoid too. You know, in this kind of range of cases and you don't need to worry quite as much about that access coming out. You know, in that molar area or in that second premolar area, if you got a pterygoid and you're coming out the first pre, you're still doing pretty good and you'll be fine for the case as long as the pterygoid stays secure. I think another thing in this avenue of arches from the 100 to 1,000 is just less stress for your cases.

Speaker 3:

I know when I was kind of in those first 100 arches, you know maybe I'd be a little bit nervous before the case. I just wanted making sure I wanted to go well, no unknowns coming up, and at this point you've kind of went through a lot of these unknowns and you've seen, you've hopefully any of these cases that you know the implants have failed and you have a little more confidence going into the cases and, um, at least for me the it was, it was definitely just more. It's more fun, uh, to be practicing this kind of dentistry when you're in these, this kind of avenue of arches, because, um, you are a lot more skilled at it, um and it, and you have a better team in place. Your outcomes are better, the cases look nicer and patients just leave happier, thinner prosthetics, and I think it's much better for the patient.

Speaker 2:

Yeah, I mean this is kind of the sweet spot, right, because you're not seeing a lot of your long-term complications. Uh, you know you'll, you'll see those when you get, you know, beyond a thousand. Uh, they, they come in um and you're like, oh, you know, that was, that was an early one, you know.

Speaker 1:

Yeah.

Speaker 2:

I have never seen a nasal crest implant fail. So'll just say that. You know I've seen multiple axial implants fail. I had a lady lose both of them. You know, luckily her. You know distal angled ones were fine. We threw in some pterygoids and you know it failed. You know because with my technique is, you know, I engage the floor of the nose, the nasal cortex, and we're either right at it, we are through it, so we're typically level with the floor of the nose and we lift the nasal mucosa and that's the technique that I teach. So you can see right. So you're never, you know, you see these horror cases where somebody's got them, you know, five millimeters into the nose or something like that. So that doesn't happen because we have direct visualization. However, you know, on the case that I had that failed. I mean you know when I took the two implants out. I mean you know we're looking at nasal mucosa by the time it's there and so being able to use the advanced techniques really comes into play beyond 500 to 700.

Speaker 2:

Once you see your longer-term success, um, you know. Once you see, you know just kind of your, your longer term success. You know what I will say is, you know, once you hope if, if you're hoping an implant's going to work, it won't. Now it may last five or six years, right? I mean, I've got, I've got plenty of cases where you know, literally you know at at six months there was maybe a millimeter of crystal bone loss, like that's it. Once you get that, you know, start the clock. Okay, you're going to be replacing that implant at some at some point. Um, so you know, I I think it's better to do that sooner than later. Um, I think you know it's better to do that before you've finaled the case. You want to keep your costs down. It really sucks when you've got to replace an arch because an implant failed, but that's the game when things fail you fix it and you don't charge them.

Speaker 3:

Yeah, that's what I was going to ask you. If you have a failure of a case of a patient in a zirconia, do you have a timeline of when, um, you know, let's say a implant fails under a zirconia arch, five years down the line, would you charge that patient for, maybe like the lab fee of the zirconia or like the the um prosthetic fee or anything like?

Speaker 2:

that, yeah, I wouldn't charge them a dime. The second you do. I mean you know it's just, you know it's an uphill battle. I think you know, hopefully by then you've got 30 arches a month that you're doing and so it doesn't matter, right. But I think I think ultimately just view that as marketing dollars, right. Like you know, if you treat one patient well, they're going to, you know, tell, tell others. You know you treat one patient bad, they're going to take, tell 18 people and so, and so you know a lot of these.

Speaker 2:

You know what everybody has to realize is you know these patients, you know some of them are, they don't care what the financing cost is. You know, I mean, I've seen them, you know basically say like, hey, I literally want this, my teeth are crap. You know, I don't care what it costs. What it costs, I don't care what the interest is. I'm sorry, but I've got to do a 10 year with Proceed. I've got to do $600 a month and what's sad about that is $100 delta. Like if they paid $700 they could probably get it paid off in 7 years. But about that is a hundred dollar Delta, right, like if they paid seven hundred dollars they could probably get it paid off in seven years. But you know, when they get that, when they get the financing paperwork, and I think what we don't realize is how much they're actually paying for it. They're not paying the, the fifty grand to us. They're paying ninety, five thousand dollars to proceed right, and so they're paying that for,000 to proceed Right, and so they're they're they're paying that for for seven, you know, five, seven, 10 years.

Speaker 2:

And so I think what you got to realize is that patient is probably not even through paying for your services and you're wanting them, you know, to at least pay the lab bill. And so I, I, I just, I just don't see how that is a practice builder, you know whatsoever. But I do think if you said like, hey, it's been, you know, five to seven years, you know, sweetheart, I've got you covered. They're going to be like holy crap, like I'm going to tell everybody to go see this guy because he's still taking care of it. He didn't do it. The last other two dentists where, when I got my crown and it broke in a year and they wanted to charge me again, right, like they've all been through the, they've all been through this game, and so I, I just think you know how would you, how would you want your mother to be treated, how would you want your mother to be treated right, like if you're a non-dentist and this is your mother?

Speaker 2:

would you really want your other dentist charging your mom for a lab bill Because my lab bill may be cheaper. I mean, your lab bill may be cheaper than mine, but other people's lab bill may be five or six grand and I don't see that as like a reasonable thing. I think when we get into this and we accept their money, this is a marriage and I think you've got to say hey, I'm going to take care of you, and I think that's what you've got to do.

Speaker 3:

Yeah, for sure, great points.

Speaker 2:

I don't know if that's so.

Speaker 3:

You know, let's yeah hopefully, hopefully a lot of other clinic.

Speaker 1:

Yeah, hopefully, hopefully, oh but I think that's more the exception than the rule.

Speaker 2:

Yeah, you know, I wonder what some of the you know what, like you know clear choice and and stuff like that is. You know? Yeah, you know I.

Speaker 2:

I wonder what some of the you know, what, like you know clear choice and and stuff like that is you know, um, yeah, you know, I don't know. I mean, uh, you know, I, I, I, I know that they, they've got to be doing some, you significant refunds. You know, I wonder what their P&L of refund amount is. Because I have seen through my clinic, I've seen multiple patients be like you know they had a bad thing happened, you know, blah, blah, blah, and they're like I'm getting a refund. And then they come back and see me. I'm like did you get your refund? They're like, yes, you know full refund all across the board.

Speaker 2:

And so you know, obviously, they, they, they went down the legal path and you know, I, you know, I will tell you, you know that that that to me is is worth, um, you know, you know, whatever, whatever that lab bill is, you know, just just make them happy and uh, sure. So you know, you know, whatever, whatever that lab bill is, you know, just just make them happy. And uh, so you know, let's, uh, you know, at, at, at. So at this point, um, you know, thousand plus. You know, you're you, you've going to be, uh, you know, wondering like golly, when, when do I do zygos and stuff like that? And I definitely do agree, I think pterygoids is the first step. It was not the first step for me, you know, dan was the first step. You know, I mean, we all give credit to Dan for compiling the list and for him writing the new pterygoid book.

Speaker 2:

But also, you know, man in 17, um, in 16, you know, only avenue was to drill. You know, there there wasn't the osteotomes, and so that's how I learned, you know, my uh, pterygoid technique and you know it was perfect. You know, and writing the book and so so anyway, so most people now will learn pterygoids than zygos. You know, I learned zygos Mm-hmm.

Speaker 2:

Mm-hmm, mm-hmm, thank you, they can shot up a bunch of water. And then now they got cellulitis, right, because they, oh, that's the one implant I'm not supposed to water pick. I water pick all these, but but not this one, right, and then, so that you know, they shot a stream up in there. You know, or you get, you know, oacs and you know, there's all sorts of stuff you know.

Speaker 2:

So you've really got to be able to manage, you know, post-operative infections and complications and you've got to be able to use long drills. You've got to be able to know your anatomy. When you get into these big zygote cases you are really going to lose your reference points and you're looking at different angles you're not used to for fixed full arch. Um, yeah, you know, you're kind of looking, looking, you know up and you know, instead of back, and uh, you're placing your retractor here instead of just here. Uh, so, um, but, but, but this is a good entry point, you know, for your Zygo education, to get into Zygos. You know, definitely there's not one course. You know there's not two courses. You know you're going to need to do six and you're going to need to do cadaver. You're going to need to do live patient. You're going to, you know, potentially, you know now, I mean, juan will fly into your office and he'll, he'll sit beside you and watch you. You know, be there, you know, if you need him. Uh, you know, do it doing some zygos. And so we're, we are, we are in such a good place now.

Speaker 2:

Um, where it's it's, it's not the wild west. You know our, our tooling is better for zygos. Our zygos are better, the abutments are better. You know the drill sequences are better. You know Norris and JD have a good kit. You know I like the Neodent, I like the barrel burr that they have. You know I kind of incorporate the barrel burr that they have, los Aparicio's technique where he kind of violins a nice approach. But you got to create a little bit of Carlos and it creates a nice little trough and we're not doing these big holes in the in, in, in the maxilla. And so you know, literally, if you look at some of my zygote cases and kind of the way we teach zygote is, do a zygote like you're going to do it on your mom, right. So you know, basically drill a hole and fill it, that's it. So then when you look at the retracted cheek, you see beautiful, you know maxillary alveolus that is still virgin and untouched and you got a zygote coming through it. So, um, it's very conservative, very kind to the sinus.

Speaker 2:

I think you start there. Um, uh, you know we're, we're, we're're gonna be winning also with our zygos. We're really trying to get them into the first molar position. You know, really try to. You know, get them. You know, fairly far back and very low into your zygote. You know and, and, and. You know that way it sets you up for a frame technique when you go into your quad. You know the Brazilians really like a parallel technique. You know that way it sets you up for an A-frame technique when you go into your quad. You know the Brazilians really like a parallel technique. You know, and it's like your AP spreads like five millimeters.

Speaker 3:

So I think that that's a problem. Yeah, I also think in this you're talking about kind of getting into Zygo. It was like some starter cases. Are the the cases that you know you haven't been able to get, like I've? I have cases that I've had to do six revisions on you know five, six revisions because I haven't jumped into the zygote territory yet. Um, but if I was going to jump into the zygote territory, it would be a single zygote. You know one side, just to fix that case. That's been bothering me forever. It's not going to be a quad right off the bat.

Speaker 2:

Yeah, yeah, yeah. No, I mean my first zygote case. I thought I could do a quad. I mean it was absolutely nuts. You know, we broke a screw off into the zygoma you know, and prostitute.

Speaker 2:

It was a nightmare, it was one of the most stressful cases ever. So, yeah, uh, you know, aparicio says love yourself and uh, just just do one. Um, yes, yeah, uh, but um, yeah, so, yeah, I mean you, you brought up a good point. Yeah, I mean you brought up a good point, right, like, hey, I've got a case where I've done sinus lifting. You know we had a posterior implant fail so we lifted the sinus. We did, you know, buying room. You know lifting up the sinus. You know to add one. You know in like the first molar spot. You know let's try to do like a palatal root. You know half the palatal roots don't work. Um, you know they're short and you know that that bone, for whatever reason, that bone is just not very cortical. And uh, you know, so, yeah, so, so zygos in that instance I think are are much more predictable and much more predictable than um think are much more predictable, and much more predictable than sinus lifting.

Speaker 2:

You know, I got referred a case by these guys that you know they had done, you know, like five or six interventions on this guy and they were like, oh, I just don't want to uncover. Uncover this guy and find out that the implants we put in into bovine won't torque and then sinus graft. They sent them to me. What do you think happened to zygos? And so he was out under general, you know, backed those, backed those out at five newton centimeters in and threw in two zygos and the guy had posterior support with one surgery. He was like I am, you know, so thankful that I did not have to undergo multiple other rounds of revisions, you know, or having having his gum split open, you know, and so so that's the why right, why do advanced remote anchorage is to treat your patients better, right, Treat them like you would want to be treated and not have five surgeries, you know, just to get some teeth.

Speaker 3:

That's good. Well, I think we've gone over some great tips from you know, zero to 100. We kind of recapped those 100 to 1,000, like we said, you're kind of in that sweet spot. You're cruising, probably not taking on crazy cases yet maybe not quite at your revisions from the cases that maybe weren't so great in the beginning. And then 1,000 plus when maybe you're tackling some of the zygomatic cases, a little bit more difficult cases, you know, maybe doing some stuff with like contraindications that you weren't doing before, you weren't doing before I think you know.

Speaker 3:

I think this was a great recap, going through all of the all of the cases that you know, the different chunks of where you should see yourself at clinically. I would love to get some questions from our listeners about. You know. I think Clark is one of the most skilled surgeons that we've had on the show and you know he can answer any of these questions that you guys might have about. Okay, well, you know I've done 40 arches and I got this patient that came in that has been on, you know, iv bisphosphonates. What do I do? So please send those our way. And, clark, I think we'd love to have you back on just strictly answering some of our listeners' questions what do you think, Tyler?

Speaker 1:

No, I think that's a great idea. I actually have a burning question that I want to ask before we let off, though.

Speaker 2:

Let's do it.

Speaker 1:

So I saw a thread very recently I actually don't recall which group it was posted in or who originally asked it and I think, clark, you actually commented on this one. And I think, clark, you actually um, you actually commented on this one, and I believe it was referring to mandibular flexure and there had also been a comment about using retroframinal implants and how that might actually have an increased incidence of complications resulting from mandibular flexure. Can you kind of speak to that? Is that something you've experienced? Do you think that that does kind of increase the incense of that and if so, how do you handle?

Speaker 2:

it? Well, I think it does exist. I think it's as simple as close your teeth together and then really give your jaw, really engage those masseters.

Speaker 1:

I can feel my teeth touch more, there was more room. Yeah, something else happened there.

Speaker 2:

So the question there is did we have PDL depression right, or did we have actual mandibular flexure? So you know, I don't really know. You know, I would be in the camp of that's probably PDL depression and we're just feeling more and then the mandible really didn't flex. I do not, you know again. I mean you know the beauty of having you know me. Answer this question is okay, you know again. I mean you know the beauty of having you know me answer this question is okay.

Speaker 1:

You know I've been doing six on the mandible.

Speaker 2:

We've been doing that since 2019. And so you know, at, you know, 300 a year. So I've got 1,500 patients. How many of them have received. You know, at, at, you know 300 a year. So I've got 1500 patients. Um, how many of them have received?

Speaker 2:

You know, complications, right? Um, okay, so what would the complications be? Fracture? Uh, my cases don't break due to that. Um, and you know, if I do get a fracture, it's it's it's it's typically, you know, because I do all zirconia, we have zirconia over zirconia, and if so, if, if I see a fracture, I it's typically a lab caused fracture where I didn't, you know, have it thick enough or potentially, you know, whenever they were contouring in the green state, they took one of those diamonds and they just got it too far. Um, so typically, I see, you know, if, if my stuff fractures, I'll see it around the canine, Um, so you know, if, if mandibular flexure were real, I would see my posterior implants failing and they're not, I've not replaced a single posterior implant I would potentially see screw loosening.

Speaker 2:

We're not seeing any screw loosening whatsoever. In fact, I see the opposite, right? So so the opposite is oh well, let's just do four, well, okay. So you see, screw loosening in four, right Like so. Why do you think I switched Right? I switched because most of my patients did not want just 12 teeth, right, most of my patients wanted more. And so, you know, I still kept them at 12, but I'm able to make them happier with six, and with six implants and 14 teeth.

Speaker 2:

But if you leave your patient at four, you're either going to underwhelm them they're going to want, you know, more teeth or you're going to, you know, be chintzy and then do do a longer cantilever that you know you shouldn't. And so then what are you going to see? You're going to see screw loosening and you're going to see tie bases. So to me it's like does mandibular, does mandibular flexure exist? I don't know. Do we see complications from it? I don't. Do I see complications from four in the front? Yeah, I do. And that's why, a long time ago, I said screw this. We're going to do the fifth and sixth implant. We're going to do the, the, the fifth and sixth implant. We're going to call it the yacht implant instead of the boat implant.

Speaker 2:

Um, that's a joke but, cause cause on the lower they're free, right, um, but uh yeah. So again you know that's the reason that I got into six was to avoid prosthetic complications related to tie base um uh D bond or screw loosening, you know, and then you know, I think this is a very interesting little segue here. You know, I still do tie bases Um you know kind of the, the question is well, why?

Speaker 2:

Well, you know, kind of the. The question is well, why? Well, I want a point of failure, right, like, okay, so if you don't have a tie base, let's just say you have a bar, it's screwed onto the bar, okay, where's your problem going to be? Your bar can fracture, or now your abutment can fracture, right. Or then you get into screw loosening, or you know, then you're going to fail your implant, right. So I would prefer to have a point of failure at the tie base, and that is a really good indication. Hey, all your tie bases came out and you just have four, and you only had this for six months. Well, sure, you can re-cement your Thai bases Maybe it was, you know, a bad cement job or something like that. But if it happens again, now, this is a cantilever issue, this is a function issue, this is your patient's prosthesis telling you I want no cantilevers. And so the second you go there, then now, all of a sudden, your forces come down and everything is happy.

Speaker 2:

But I still use tie bases today because I want a single point of failure and I want it at that bond junction. And guess what, is that a big deal? No, give us a day or so. That bond junction, and guess what, is that a big deal? No, you know, give us. Give us, you know, a day or so, we'll get them resubmitted on back for you and you're back out the door. But it allows us to then say, hmm, what happened? Let's re torque all of our abutments. Let's find out how many implants you got. You know you got four. You're going to get more.

Speaker 2:

Okay, and I wouldn't charge on that I would be going in and adding two more and remaking their prosthesis at no charge.

Speaker 1:

Yeah, so in other words, that Thai base is a sacrificial glass for you and a diagnostic for, okay, we need to change up the setup a little bit. It gives you the opportunity to do that without transferring those forces directly to the multiunit and thereby the the implant, causing an even bigger problem. Correct, yeah.

Speaker 2:

Okay, Got it, Got it. And then you know now, now, because I do six, you know we have, we have no tie bases coming loose. Yeah, Just because of the reduction of of mean forces.

Speaker 1:

You know average forces, yeah, yeah, yeah, that's good. Well, um, I think that uh storm was trying to transition us and I and I refused cause I had some questions that I need to answer tonight.

Speaker 1:

Um, but Clark, uh, we've. We've gone about two hours here and we've covered, uh, quite a bit of ground taking people from hey I want to do fix to, um, hey, what fix can't I do? Uh, I think you've done a really great job in illustrating that path and somehow condensing 12 very fast years of full arch into two hours worth of recording, and I think there's definitely a lot more that we can shake from this tree in a further session. But I agree with Soren that we should sort of give the audience an opportunity to ask some questions and bring out a few points that we may have glossed over just a little bit on our road to get here. So I think that's a great idea.

Speaker 2:

Sounds like a plan, we'll do it.

Speaker 3:

Yeah, definitely reach out to us from our website, thefixpodcastcom. We put a lot of work into that, so you should be able to ask any questions you have on there. Reach out to us on Instagram. Uh, and definitely check out uh Texas implant Institute. Um, wonderful spot to to get your first uh implant education around all on four, and then your your next step, education around zygos and pterygoids. Uh, so thanks so much, clark, for coming on tonight. Um, taking off time after a long clinical day, I'm sure, so we really appreciate that.

Speaker 2:

Okay, Thanks guys. It's always fun and yeah, thanks for plugging the course. You know, like I said, check out TexasImplantInstitutecom and we've got some courses there for you, and soon we'll be getting the 2025 schedule up and going. Expect two full arch courses and two uh zygo courses, for sure.

Speaker 3:

So love to love to love to meet you guys see you next time at the fixed podcast. All right,