The Fixed Podcast

Utilizing the PATZI Protocol with Dr. Samy

August 06, 2024 • Fixed Podcast

Share episode

What if you could revolutionize your approach to dental implantology with a single protocol? Join us on the Fixed Podcast as we welcome Dr. Samy, a full arch implant dentistry virtuoso, who will unravel the intricacies of the PATZI protocol. From his robust training in Chicago to establishing his own practice in Austin, Texas, Dr. Samy shares his journey and the methodical steps behind the development of this groundbreaking protocol. This episode is designed to elevate your understanding of full arch surgery, whether you're a seasoned practitioner or new to the field.

Throughout our enlightening discussion, we dive deep into the non-clinical facets of the PATZI protocol, underscoring the significance of standardization, classification, and intraoperative algorithms. Discover how a unified approach can enhance global communication among dental professionals, leading to consistent treatments and predictable revisions. We also touch on the future implications of the rising demand for dental implants and the essential need for planning long-term revisions, illustrated with a compelling real-life case from Dr. Samy's residency days.

In the final segments, we tackle the complex challenges of placing dental implants in scenarios with insufficient alveolar bone, and the innovative solutions like transnasal implants that can be employed. Dr. Samy outlines an algorithmic approach for these difficult cases, emphasizing the need for specialized training and international standardization. We also explore the potential complications of remote anchorage implants and the critical role of dental labs, such as JB Dental Lab, in ensuring successful outcomes. Tune in for an episode brimming with practical insights and expert advice that will significantly advance your practice in implant dentistry.

Tyler Tolbert:

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

Tyler Tolbert:

Hello and welcome back to the Fixed Podcast.

Tyler Tolbert:

We have our second guest episode here and it is a heavy hitter. I am really hoping that this episode is going to showcase all the things that we're trying to do here with the fixed podcast and adding this visual element, because what we're about to be going over is something that would absolutely not be serviceable on an audio only format, because you got to be able to see this stuff to really understand what's being talked about. We're going to get really nitty gritty and get into some finer details that I'm sure will humble Soren and I as well. So, fortunately, we have a very knowledgeable and very experienced you probably already know who he is Dr Sammy here, and he's going to be telling us all about the Patsy protocol, the ins and outs of it, the applications and highly advanced cases. So we're super, super fortunate to have him here and he's going to have some slides for us as well, and I think this is going to be one of our most educational episodes ever. So super excited to have you on, dr Sammy. Thanks so much for coming.

Dr. Samy:

Hey, thanks guys for having me on, and man, you definitely set the bar pretty high, so we're going to have to deliver. But yeah, no, it's great what you guys are doing. I think incorporating a visual component is really important when we're talking about these kinds of concepts.

Tyler Tolbert:

For sure, for sure.

Soren Paape:

Yeah is really important when we're talking about these kinds of concepts, for sure, for sure. Yeah, I think this is a great episode coming off of Clark Damon's. We just had Clark Damon on Sammy. We went from beginner to remote Anchorage and we just kind of dabbled a little bit in Patsy protocol, like talking about some of the, some of the like where people should be at before they start trying out these types of implants. So I think for the, for the audience, if you guys want like a little more approachable episodes, start with that one and then, once, once we're through, then we can, you can, jump into this one.

Tyler Tolbert:

For sure, Absolutely. So. Just for everybody at home that, for whatever reason, is somehow unfamiliar with Dr Sammy, if you wouldn't mind, just kind of give us a little bit of a background who you are, what's your training like? Where are you at? Dr Sammy is actually six months intoa startup, which is really cool. We can certainly talk about that a little bit, and then we'll kind of bridge into talking about what Patsy is and where it came from.

Dr. Samy:

And then we'll kind of bridge into talking about what Patsy is and where it came from. Yeah, so I'm Sammy. My full name is actually Shovik Panasamy and I just kind of adopted Dr Sammy, kind of then transitioned to Dr Sammy. So I'm from Chicago originally, so all my training was done in Chicago University of Illinois and I stayed there for oral surgery. So I finished up, let's see, in 2020, right in the middle of COVID, and I did a little bit of associateship, almost two years of a private practice associateship there.

Dr. Samy:

I'm super passionate about full arch and doing just really kind of transformative cases as much as I can, had a little hand in academia a little bit, and then I moved to Austin at the very kind of end of 2021. And what I did is I started to do some kind of full arch like part-time full arch and then part-time traditional oral surgery, and during that time I was kind of prepping for getting my startup going, which is Neva Dental Specialists and Tyler, like you mentioned, we're now we've hit the six, six month mark. So, uh, it's actually it's crazy how far that uh, how fast that time has gone by, but uh, it's a lot of fun and um, uh, that's like a separate episode.

Tyler Tolbert:

We can talk about that. Yeah, no, that's awesome. So, um, you know, clearly you have a lot of experience in full arch. People are starting to see your face everywhere.

Tyler Tolbert:

Surgency, the Patsy protocol, um, you know, being talked about in full arch conferences all over the world and, and I think that you know when people, when we started to get into this, what, what, what really the essence of it is is that you know, it's a formula and it's a, it's a, it's a venture into what's going on to the mind of a full art surgeon as they try to work through a case.

Tyler Tolbert:

And and personally and we'll kind of get into this a little bit later I believe that even if you're not the most advanced full art surgeon, even if you're just trying to wade into the waters, understanding concepts like this, understanding how that brain works, is super important and it's something you can start from the very beginning. And as you add on techniques and get that sort of comfortability with more advanced or revision type cases that Patsy protocol you'll start kind of adding letters to what you're able to do. So can we talk a little bit about? You know how Patsy came about. What was it born from? Why is it named this. You know, let's kind of dissect it a little bit, if you don't mind.

Dr. Samy:

Yeah, absolutely. So what we can do is we can kind of just jump in or double click on that kind of journey from Chicago to Austin. Really, the main reason why I kind of made that move was to get the practice started, but also to have the opportunity to work with Dr Holtzclaw, dr Dan Holtzclaw and Dr Juan Gonzalez and they had a small practice out here kind of north of Austin it's a town called Round Rock and basically a full arch center that Dr Holtzclaw had started many years back and at that time you know we're talking five years plus it was very unique because Dr Holtzclaw had already been placing pterygoid implants for many years, kind of from incorporating pterigoid implants into full arch, and he published a paper about the pterigoid fixated arch stabilizing technique, the FAST we you know I make the same mistake of pronouncing it, pfas yeah, I've said pfas all this time it's FAST.

Dr. Samy:

Yeah, he'll, it's.

Soren Paape:

FAST. Doesn't Holtzclaw get frustrated? Yeah, yeah's fast. Yeah, it's fast. Does it hold until I get frustrated?

Dr. Samy:

Yeah, he's like it's so obvious, but I called it PFAS for a long time until I heard him say it, but that was kind of the first time the world had seen. Oh man, if you put pterygoids on a full arch case, there's no cantilever and there's high composite torque value and we can get these beautiful full arch prostheses, you know, without having a shortened dental arch in the case of those really severe pneumatized, anteriorly pneumatized sinuses. So he was already doing that. And then when Dr Gonzalez joined him, he was already well-versed in zygomatic implants. So they had this kind of nice interplay there where the story goes that Dr Holzklot taught Dr Gonzalez zygomatic pterygoid implants and then vice versa, dr Gonzalez taught Dr Holzkloth zygomatic implants and that kind of put them in this really unique position. Remember, this is like a while back this is like five years plus and they were kind of the only center in the area that had the ability to really do both and that kind of enabled just extreme versatility in handling the really tougher cases, really atrophic cases, and that's what attracted me. So the reason why, what I think and you can ask him, but the main reason I think why they were okay with me joining or why they selected me was because I had some experience with zygomatic implants and I had just published my paper on the zygomatic implant. Basically it's like a restorative protocol for zygomatic implants Razor Razor, correct, yeah.

Dr. Samy:

And I joined Juan and Dan and we're seeing these cases and I like to think my brain is very algorithmic. I like to kind of systemize things and I'm also learning at the same time. I'm learning from these guys and I'm just trying to think well, what would I do in that situation? Or what if I don't get the pterygoids here, what would I do? And a big part of that RAZR protocol was building off of Bedrosian's kind of algorithm. From that, you know the zone one, zone two, zone three, and then he kind of goes through. You know, if you have bone only in zone one, you do this. If you have one, two, three, you do this.

Dr. Samy:

So what I wanted to do is I thought you know it'd be really cool to incorporate a algorithm protocol for full arch that can incorporate zygomatic implants and pterygoid implants and any remote anchorage that there is. And I started watching the way this is. When I was mainly with Juan, I started watching the way he'd do cases. You'd always start with the pterygoids. And then he would go to the anterior and he would always say, hey, that way, you know, you're really establishing your posterior and your anterior stops. And then the variability here is going to be where your sinus is pneumatized. You know how anteriorly pneumatized is it, how is it not? And then he would do those, the tilted or the middle ones last, and I was just watching him do these fast cases.

Dr. Samy:

You know I'm like man, this is really cool, but every now and then either he wouldn't get a pterygoid don't let him hear you that I said that or he would he's batting a thousand the tilted implants would end up being so anterior because of how pneumatized the sinuses are, that your arch length would be super short, like first premolar, or even like some of these really severe cases, it's like the distal of the canine, almost so even with one tooth cantilever, it's just it's not a very aesthetic uh arch and it's not as functional as we'd like it to be.

Dr. Samy:

So what he would do is he would say, okay, if I can't, if I can't get you know, anchorage back further than the first premolar, second premolarolar, and I don't get a pterygoid, I'm going to do a zygomatic implant. So, between all of kind of like learnings and kind of my own interests as far as trying to systemize, systematize this thing, what I was doing I was looking at how can we kind of how can we create an algorithm that incorporates all of this knowledge and have it in a systematized fashion. So that's really how it came about, and then the three of us kind of put our heads together and put out the paper. So you know, what we can do is let me actually just share my screen here because I'll show you kind of an example of a great example of like why it is important to have something like Patsy.

Soren Paape:

Dr Samen, can I ask you a quick question before you jump? Into this when you were in your oral surgery residency, did they do any sort of remote Anchorage-style implants? Did they allow you to place any of those while you were? Good question?

Dr. Samy:

So I was very fortunate. I trained with Dr Michael Maloro and he's been placing zygomatic implants for 20 plus years and I also just had a personal interest in it. So in general, at least for our, the way our program was structured, it was very much kind of residency is what you make it. You know like there are different kinds of folks out there, more interested in orthognathic surgery, some are kind of more interested in trauma surgery. I was very interested in full arch and dental implants and he recognized that. So I was able to do a good amount of zygomatic implants and the way that was done was I would do half, he would do half. We did some quad zygomatic implants. So I had some experience coming out of residency. So I was super fortunate for that.

Dr. Samy:

And UIC in Chicago excuse me, they have a PROS program too. It's like a pretty big PROS program. It's like a pretty big and well-known PROS program. So we had a lot of good collaboration with actually being able to see some of the restorative side of, like you know, the remote anchorage and really actually it's a good question because that experience was seeing these cases being restored all the way through and seeing some older cases from like generations before me. I was seeing the prostheses where the zygomatic implants were placed like on the palate, you know the old intra sinus technique, and that was actually kind of the inspiration for like, well, how do we do this in a way that we're not just delivering a fixed denture, we're actually delivering like a hybrid prosthesis that's streamlined and doesn't affect, doesn't negatively impact the patient's speech? So yeah, I was super lucky at at uh uic. I did get some good experience there yeah, that's excellent.

Soren Paape:

We get a lot of um students and people kind of you know more and more people are knowing about full arch these days. So people d2, d3 students asking like what the best way to get um good experience in this style of dentistry? So it's good to know that there are oral surgery residencies out there that um are to allow you to place some of these remote anchorage implants and for a lot of people, four years and getting that experience is a great opportunity for the ability to treat more and more patients that maybe wouldn't be able to get treated at some of these, like you know, full arch clinics popping up that they don't have the experience of placing remote anchored style implants absolutely, absolutely.

Dr. Samy:

Let's jump into the kind of a little example here, um I just like, have this slide here just kind of representing, um, the clinical outcomes or the benefits of Patsy. So for those listening, patsy is unique because it still is a graftless protocol, so similar to like an all-on-four, this immediate load graftless protocol. But it has a unique advantage that we can get full arch length right and I would just define that. As to the first molar, let's say so, a 12-tooth prosthesis which is comparable to your more traditional style, delayed full arch reconstructions right with sinus lifts and GBR, wait six months and then you can do, you know, six axially placed implants and that takes a long time but you have this beautiful arch length.

Dr. Samy:

So Patsy does kind of check that box. And then, as far as the cantilever goes, even if you don't get the pterygoids, if you follow the protocol you will have really minimal to no cantilever, which of course from a prosthetic standpoint is optimal because we're reducing those kind of abherent forces on those distal cantilevers. We're reducing the number of prosthesis fractures, the amount of distal bone loss on the last implants. You know, we all know we want to avoid the cantilever as much as possible. So the three kind of clinical takeaways with Patsy is that it's graftless, we can get full arch length and we can avoid the cantilever.

Dr. Samy:

There are some other kind of non-clinical aspects to Patsy that I do like to discuss, which a few of them are standardization, so this is kind of something that I've been talking with a lot of my colleagues about, where you know, like you mentioned, tyler, there's folks across the world that are doing full arch and that are employing the Patsy protocol, that are employing the Patsy protocol and if we're all going to be treating each other's revisions and we're all going to be helping each other out for the next 30, 40, 50 years, it would certainly help if we all kind of have the same mindset and if we were all placing our zygos low on the zygo right, or if we were all trying to optimize our AP spread so that we have minimal prosthesis fractures. So standardization is kind of one aspect of this, classification is another, so we'll kind of get into it. But there's classifications of what type of configuration that you ended up with and that allows kind of easy communication between two full archdocs. It also helps to predict prognosis. What I mean by prognosis is how much bone is left whenever there's a revision needed, whenever there's a revision needed. So the further along you are on the Patsy protocol, the harder it becomes to do a revision, because there's just less available. So the classification is for communication but you can also kind of get an idea for, like man, if that needs to be revised. Like you know, very few people can do this and I'll show you an example.

Dr. Samy:

And then intraoperative algorithms. And I'm sure you've both been there before, tyler and Soren, where you're doing a case and you just don't get primary stability, you just don't get torque, it's just butter bone, right. You're like man, what am I going to do? And this represents an intraoperative pivot, which hopefully doesn't happen that often. But you do enough cases. You're going to get these kind of intraoperative surprises. And having a backup plan where you know you feel confident that okay, I can do this and the literature supports it, really helps. In fact, this is kind of a little aside. When I was doing the submissions you know to do, like revisions, with the reviewers of the journal, one of the reviewers uh, commented they said intraoperative changes like if you're, if you're planning your, your cases on the cbct, there should be no. You know, if you're planning it properly, there should be no intraoperative changes, and just like a lot of this you do enough cases you know you're going to get this, so yeah, and then the last last thing um, tyler, I'll credit to you.

Dr. Samy:

Um, I think you said, uh, that Patsy brings the fourth dimension to like full arch or something. So, um, but actually this is, this is really key. So it involves, uh, what I call temporal contingencies. So, uh, with the boomers getting older and retiring, there's a huge, huge, just influx of demand of dental implants and therefore full arch, and we're starting to see folks that are getting full arches earlier and earlier, which means we're going to have lots more revisions. So if we can set up our case and our geometry kind of in an ideal fashion, then the revision 20 years later will be a lot more predictable and we can build in kind of backup plans for those future revisions.

Tyler Tolbert:

Absolutely. Yeah, and this is something that you know. I feel strongly that you know. Even people who aren't ready to do these cases, they should understand how these cases are done and understand how to leave room for the next person, you know, should that happen. Um, so I think it's extremely important. Yeah, I appreciate you bringing that up.

Soren Paape:

Absolutely yeah. I also want to mention, guys, that, uh, that we are playing this through a video. So, um, if you want, you should definitely tune into our YouTube video for this portion of it. Obviously, you're still, you'll still get a ton out of the audio portion, but, um, we are showing a protocol via slideshow at this portion. So go ahead, sammy. Thank you.

Dr. Samy:

Yeah, I'll just kind of share one case with you to kind of kick things off, and this is a. This is a case from my residency where I was working up a case and, um, I got this email I believe it was from the patient and, uh, it was saying that, hey, you know, I had a really bad cold or allergies or something. I sneezed really hard and my implant came out of my nose. And she sends this picture of the first one was like an implant and it's like tissues, and the second picture was like she's holding her implant. You know, people will say patients will say, oh, I think my implant came out. It might be the abutment or, you know, it might be something else. No, this is the actual implant. So on the screen I'm just showing the actual photo that was sent to me from this interaction, which is kind of what kicked off this case here. So what we had is this nice lady I think she was in her 50s, actually fairly healthy. She had been in a full arch prosthesis, upper and lower, for many years, treated by a local surgeon in the area, and what had happened is one out of the four of her implants had failed, essentially, and you can kind of see, I'm showing a clinical photo of some really kind of boggy and kind of erythematous soft tissue around one of the anterior implants, and that's the one, you know, that failed. And the peculiarly, these two the two implants on the back are actually zygomatic implants and the two in the front are, are, you know, traditional implants. This is what the the Trupan looked like. So, basically, basically, the setup was almost kind of like a Bedrosian style, you know, two posterior zygomatic implants and then two anterior implants. However, one of them has now failed, so we can't, you know, load the prosthesis on only three implants.

Dr. Samy:

Now, here's the thing you know. We talk about kind of setting yourself up for the future. I like to kind of show an example of typically what's done, and this doesn't mean that everyone has to do it this way, but you know when I teach these techniques and whatnot, this is and I think most of my contemporaries are doing the same thing where, in general, if you're placing a zygomatic implant in the posterior region, you want the apex of the zygomatic implant to be very low on the zygoma body and the purpose of that is to preserve that superior bone. And I'm just showing a picture here of an example of if you ever have to go back in the future and place a second zygomatic implant, or maybe even your first zygomatic implant fails, you have more bone above it and I'm just showing an example of kind of like a standard quad zygomatic implant configuration where the two front implants, the apex or the apices, are engaging the superior portion of the zygoma body and then your posterior zygoma implants are engaging the lower. So this is, I think, uh, fairly well kind of accepted in the kind of full arch community.

Dr. Samy:

Um, however, the the interesting case, uh, the interesting thing about this case was that the two implants were posterior but the apices were placed in the superior aspect of the zygoma body and it's just kind of one of these things where you know if you weren't really thinking about it and that's just kind of where you got, where you got anchorage. It doesn't really matter, right, if you're just I'm just trying to get you know, torque, and that's great, but we're not just trying to get torque, we want to make sure that we're setting ourselves up in the future. So what we had to do is it makes it much more challenging for us to be able to engage any more bone on the zygoma right. So really and for the pictures it's super it's a very atrophic case. The implant was actually kind of.

Dr. Samy:

It was kind of within. It was beyond the piriform, really within the soft tissue of the nose, and that's why, you know, came out through her nose. There's very little bone left, so the only bone that we really had was at the inferior border of the zygoma. So we had to do this kind of unique kind of like, almost like a crisscross pattern, in order to get the anterior zygomatic implants. Now, in retrospect, I would have just, I would have also placed two pterygoid implants, uh, on this, but you know we weren't doing that at that time and that resulted in this what do you call this kind of like crisscross or like exosigoma?

Tyler Tolbert:

for those who are you don't have, like you don't have the antero superior implant, it's now like an antero inferior implant and vice versa. Wow, okay, yeah.

Dr. Samy:

And this was a really hard surgery to do because we only had that little amount to get. But you're, you're kind of angling it so far. So for those that are listening, it's basically these two zygomatic implants on each side are like crossing each other, it's kind of like a crisscross. So in retrospect, you know, if this goes back to that standardization piece where if we were all kind of aligned, if all the full arch docs were kind of thinking the same kind of way, it would have made this case a lot more straightforward and kind of from a prosthetic standpoint, a lot easier to deal with.

Tyler Tolbert:

That makes a lot of sense.

Soren Paape:

Absolutely. This is almost. Yeah, we just saw the post by Holtzclaw where this is a little bit different, but he did it through the temporal fossa, um, and it almost would have been like if you were trying to get more posterior support here. That's probably where you would have gone in order to engage that inferior part of the zygoma without um, without, you know, still getting that posterior spread. Is that correct?

Dr. Samy:

yeah, yeah and and um, that's kind of a. What I love about patsy too is because it's really exciting time to be involved in full arch, because I mean there's kind of new techniques uh coming out it seems like every year, um just with uh the advent of some really good kind of implant technology and um, just really kind of increasing um the the number of doctors that are doing this and kind of implant technology and just really kind of increasing the number of doctors that are doing this and kind of collaborating together and kind of coming up with different ideas. But some kind of evolution to the Patsy protocol is that we're kind of it's really kind of built to be intra-alveolar things and extra-alveolar things. It's more of like a categorical based protocol. I, you know we named specific techniques in it but, for example, you could incorporate the palatal approach, for example, onto the tilted section. You know we didn't specifically label that one, For example the Dr Holtzclaw technique.

Dr. Samy:

Soren, that you're mentioning the Hessian protocol, the way that in the paper Patsy is set up right now is that if you don't get the pterygoid there's nothing else for that kind of molar option. So in cases where you really you can't get anything posterior to like a first molar or sorry, uh, first premolar or second premolar and let's say there was already a zygomatic implant there or maybe a failed zygomatic implant, or sometimes you have to cut the zygomatic implant. So what he did is he he angles it very far, uh, posterior, posteriorly, so that the platform is coming out almost like where a pterygoid is and he dissects the infratemporal fossa and he comes up immediately through the infratemporal fossa and pops out anterior to the zygoma and he's able to get a zygomatic implant. That's kind of pitched fairly posteriorly. So these kinds of techniques are just continuously evolving in a remote anchorage and the Patsy protocol you could certainly add these techniques kind of as an as-needed basis.

Tyler Tolbert:

Yeah, and I think it's so important too because you know, with a technique like that specifically, that you know its emergence is going to be very similar, like you said, to a pterygoid.

Tyler Tolbert:

So if you miss the pterygoid, that might be an option.

Tyler Tolbert:

But now you're also using that zygomatic real estate and you also need to consider, well, what do I have up front? Am I going to need other spots in this zygoma for other points of anchorage further anterior? And so if you're not thinking about this algorithmically, you may end up kind of sacrificing some real estate that you're going to end up needing later on in the case. And so I just love how there's this stepwise function as you're working through the case to establish that anterior-posterior spread. And especially, you know, like you were alluding to earlier, dr Sammy, you know you have to be thinking about, you know, if you yourself have to revise this, what you're gonna have to work with and if someone else is going to have to do it, making sure that you're following along with this so that you're leaving room, even if that's not within your clinical suite. You know you need to make sure that there's still going to be more interventions possible later on, and I think it's just brilliant. It's providing a framework for new innovations to come in, so I love that.

Dr. Samy:

Absolutely, absolutely, um. Well, I think what we can do is perhaps we can kind of, uh, break down each, each category, um, and kind of go through it, cause, especially for the folks that are listening, is is probably kind of confusing. So let's just jump into the actual, uh, kind of algorithm here. So I just included this just to kind of give you know some ode to Bedrosian, who really kind of came up, I think, with the original kind of first algorithm, so to speak, for full arch, which is talking about zones one, two and three or zones of bones, where zone one is, of course, the anterior maxilla, zone two is the premolar area, zone three is the molar area. I've seen some kind of adaptations of this where you could call zone four the zygoma and zone five the pterygomaxillary complex. So how do we incorporate those on top of this? So this is kind of the photo or the kind of figure that we showed, where, for those that are listening, it's basically kind of like a stepwise, like down arrow for each section posterior, anterior tilted and then zygomatic implant, and it's done in that order. So posterior, this would be referring to a pterygoid implant. Some of the kind of editors or commenters on the publication were suggesting like, well, you could get a first molar axial, you could. But the thing is, if they're getting full arch, it's very rare that you do have alveolar bone to do something traditional like that. The three of us actually are not the biggest fans of those short implants, at least personally, kind of in the posterior maxilla with that really kind of buttery bone, I do prefer getting something a little bit longer. That's kind of engaging cortical bone. So what we decided to do here is just say, okay, pterygoid implants, go ahead and attempt to place your pterygoid implants. Let's say we get both pterygoid implants, okay, great, now we're going to move on to the next section in the algorithm. If we don't get pterygoid implants, we're going to consider this no meaning. We didn't get any any pterygoid implants, so we'll move on.

Dr. Samy:

Now we're jumping to the anterior section and this is kind of where you'll start to pick up the pattern that it's categorical. So each section from here it's like you have one section which is like traditional implants and then you're going to have an extra alveolar section. So let's say we go to the front, we got our pterygoids, we're going to place some anterior implants and we show kind of many examples where you can do kind of piriform rim, engage in piriform rim implants. You can kind of do an overlap where one is kind of towards the anterior nasal spine, one's towards the nasal crest. You can do lateral nasal wall implants towards the lateral nasal wall. In you know very challenging cases. You can do a nasal palatine form, but we need some kind of anterior, you know, anchorage.

Dr. Samy:

Now here's kind of the where the algorithm kind of comes into play, where, let's say, we don't get any anterior implants, traditional. In this case we have the option of going to the extra alveolar option in the anterior, which is a transnasal implant, and this is also somewhat of a newer technique. We can kind of we won't jump into specifics, but basically it engages the, what we call the Z point, or basically that bone where the inferior turbinate joins the maxillary process. But it's cortical anchorage and by doing this you can actually avoid that anterior zygomatic implant which would be the next backup plan. So if we couldn't place any anterior implants, we would assign this section as no and we would continue to move on.

Dr. Samy:

So then we'd get to our tilted section, where in the intraalveolar section we're placing two regular tilted implants anterior to the maxillary sinus. If we can't get that intraalveolar option which, by the way, you could add certainly you could add the palatal approach kind of within this section too. If you couldn't get to, if you couldn't get a regular intraalveolar option, you would then move to more of a trans sinus approach, which is essentially elevating the anterior aspect of the maxillary sinus membrane, traversing your drill through that anterior maxillary sinus and then engaging the lateral nasal wall. So you can actually get your platform pretty far back with these. But it just depends on the thickness of your lateral nasal wall. It's got to be thick enough to get anchorage there If we can't get that.

Tyler Tolbert:

Sorry at the. At the risk of going too tangentially, do you always elevate the membrane when you do your trans?

Dr. Samy:

sinus, or have you ever just blown through it? I do yeah. I personally do. Um, I know some folks don't. Um, when I was first trained in zygomas, we were just, we were doing that, we're just kind of going right through, and I saw a lot of complications with that. So whenever, even when zygos, with everything, I'm, I'm very, I very much respect, uh, the maxillary sinus membrane.

Tyler Tolbert:

Very nice.

Dr. Samy:

Got it. Um, let's say, okay, we didn't get anything in this section, we'll call it null. Here is kind of where the kind of algorithmic side of things pops in. So what I'm showing here is a zygomatic implant section. So essentially there's three subsections within the zygoma section. If we're unable to get a tilted implant, it directs you to placing a zygomatic implant.

Dr. Samy:

But there's styles of zygomatic implant. In the tilted section, meaning premolar section, we do what's called a Z1 zygomatic implant. Z1 means that the platform is coming out the premolar area and the apex is in a low on the zygote. Basically, the next section is, let's say, you couldn't get a pterygoid implant and your tilted implants are really far anterior. So you're going to have that short arch length or we're going to want something back there, right, and that's where we're going to do. It's called a Z2 zygomatic implant.

Dr. Samy:

So we get basically a platform of the zygomatic implant at the molar region and the apex is low on the zygote. So the chart basically tells you hey, where's your implant position, implant platform position, where's the apex position? It's very kind of specific. And then, if an anterior section, if you couldn't get any anterior implants, you couldn't get any. You couldn't maybe the patient's not a candidate for transnasal implants. That's when you actually place that anterior zygomatic implant with the platform and the anterior region, perhaps the lateral incisor or the canine, and then engaging the superior aspect of the zygoma. So this is really the only publication that we know of that specifies where is your apex going to go, because it highly depends on the anatomy of the zygoma body. So in this way, any section that we were not able to get you make up for it in the zygomatic implant section. So what we can do is how about we just kind of go through a couple of quick examples?

Dr. Samy:

and it might be able to kind of help visualize. Does that sound okay?

Tyler Tolbert:

sure, please yeah, absolutely.

Soren Paape:

I have a quick question. I'm learning a lot from this, so I really appreciate it. Uh, so in the anterior region, um, in your opinion you, if the patient is a candidate for a trans sinus approach or, I'm sorry, a transnasal approach, you would place that transnasal implant over, doing something like a quad zygoma, to keep that zygomatic bone for a future?

Dr. Samy:

um correct, potentially correct? Yeah, I personally would. But the thing is is that you need at least three millimeters of kind of alveolar bone before getting to the inferior. You know the, the piriform rim there Cause this risk of oral nasal fistula. So if it's too thin there, or a lot of times they won't even have enough bone there, like at the Z point, yeah, so sometimes they just you can't and then you're basically doing a quad. But the idea is like, hey, how can we avoid doing a quad? You know as much as possible, because after that you know that's really it. I mean, there's subperiosteal, you know custom subperiosteal, but essentially we always try to avoid doing a quad.

Dr. Samy:

Pull up a couple of these cases here. Okay, so here's kind of an example of a PFAS or you know FAST, right, a little trivia here is a PFAS is the same as a P1A1T1Z0. So these are pretty common cases that I do where I really don't need any zygomatic implants, but to kind of walk through the Patsy algorithm. This is showing a case where we started in the posterior. We got both pterygoid implants bilaterally. Then we move to the anterior. We got two piriform rim implants anteriorly. Good, good torque. Now we're going to move to the tilted section and we've got a nice good position of tilted implants with good torque. We've got six implants, all good torque, immediate load. No, no issues. No zygomatic implant is needed. And this is where the numbers kind of come into play, where you know, the lower the numbers in general, the more real estate there is to play with in the future. So if this patient comes back in 30 years and let's say that the right tilted implant fails, well, you have an option. You could leave the span from those two implants. Or I could place a zygomatic implant here at the inferior portion and really kind of preserve that nice, even spread. That's kind of ideal from a prosthetic standpoint.

Dr. Samy:

Here's kind of the next iteration here. This is an example of let's say, we don't get pterygoid implants and in the unique scenario where maxillary sinuses are super anterior, I mean they're just so pneumatized. So let's say, okay, we start in the back, couldn't get pterygoid implants right, and we've all been there. Torque, there's no stability, butter, bone, whatever, whatever it is can't do it. Now we go to the anterior place two anterior implants this case is actually a dr juan gonzalez case two anterior implants. Great, now let's go to our tilted. Now we, although we have bone for tilted.

Dr. Samy:

If you look really closely, this he was like he was basically hugging that anterior maxillary sinus. It was very pneumatized. So, going as far back as you possibly can, the picture basically shows that probably you'd end up I mean, the lateral nasal wall is around the canine Probably you'd end up around first premolar to the most posterior extent if you were done here. Right? But we want to get a little bit more anchorage so that we don't have a two-tooth or more cantilever. So in this case zygomatic implant was placed, but it was specifically the Z2 zygomatic implant because the posterior section was null implant because the posterior section was null. And what does that mean? That means you place the zygomatic implant in the molar area and the apex at the inferior aspect of the zygoma. Yes, here's kind of where we start to get a little bit more kind of into the remote anchorage.

Dr. Samy:

We're honestly, these cases just wouldn't be possible, you know, 15 years ago without some of these techniques. So this is a case where, okay, we start, start in the posterior, we get pterygoid implants, get both sides perfect. Let's move to the anterior. This is a. This panoramic is very severe atrophy in the anterior, unable to get any traditional anterior implants. So transnasal implants were opted and were successfully anchored. And now in this case this case is actually even more pneumatized than the previous one so very atrophic alveolar ridge, severe pneumatization of the maxillary sinuses. So the zygomatic implants are placed here in the premolar region, which the algorithm will tell you platform, in the premolar apex, low on the zygote. And this is strategic, just in case one of the transnasals fails or maybe one of the zygos fails. We're still preserving that superior zygoma bone for the future if we need to put another one in.

Tyler Tolbert:

So yeah, future, if we need to put another one in, so yeah. So, in other words, you've got your furthest posterior extent as far back as it could ever be, as far as anteriors were ever going to be, and we're trying to bridge that gap somehow and we're using sort of the most conservative zygomatic implant we could, which is very inferior, and we're just trying to get something between those uprights.

Dr. Samy:

Exactly, exactly, and you can imagine the span, you know, if you didn't have those middle implants, pretty much kind of from lateral incisors all the way to kind of second molars, you know, if you were really truly just doing four, which this is you know, depending on the bite force.

Tyler Tolbert:

Yeah, and this is something I'm curious about too. So there's a very significant population of full arched dogs now who have not bridged into zygos, who are competent with pterygoids, but sometimes in that sort of tilted region it might be kind of hit or miss. You know how far do we have something in the literature sort of guiding us as far as you know how long that span can be without creating that sort of you know moment there, that where things can flex and break that's a good question so um yeah.

Dr. Samy:

So, um, in some of dr holtzclaw's lectures if he's showing some cases and some literature reviews where essentially, like, the middle implant has failed and that now you have a span, you know, from like canine or lateral incisor all the way to the pterygoid and essentially those cases are still in function, personally I'm just not that most comfortable with it. I typically don't like to have a span of really more than like three teeth, even like two and a half teeth, without having an implant. I mean nowadays, especially post-covid, the amount of bruxism and bite force you know, uh, the amount of uh, just heavy, heavy grinding that we see.

Dr. Samy:

I always just try to brace, brace my cases as much as possible, because it also makes, you know, my restorative colleagues happier, because, like less, you know fractured prostheses, especially with zirconia nowadays. So, um, the literature says that you can have a span that long essentially, but I wouldn't, I wouldn't bank on it yeah, I mean, I think it's one of those things where we we may not know exactly what our tolerances are.

Tyler Tolbert:

It's not like the whole ap spread thing where you know we have very like specific instruction on what can be tolerated for you know a cantilever. But it's just, it's intuitive. You know, like if it's that long of a span, there's going to be flexure there. Our materials, especially Zirconia, is not going to tolerate a very long span for very long. You need something to fixate and bridge that gap. I think it's just an intuitive thing.

Dr. Samy:

It makes sense, yeah, oh go ahead.

Soren Paape:

Sorn, I just had a quick question about transnasal. I feel like whenever and I know they have been around for a long time, but I feel like they might be more recently People are starting to talk about them more the transnasal and always the first thing people talk about are the issues that can arise with these implants. Right, when Zygos first came out, there was a lot of people hesitant about them because of all these issues and it's kind of become more popular now and I feel like trans and nails are nasals, are kind of in that beginning category where some people are nervous to place them. My understanding is, one of the biggest uh complications that can arise are is damaging that lacrimal duct and causing, um, you know, like excessive, you know crying or like like tear, tears and then having to send the patient to an ENT to then repair that duct and I know it is repairable. But is that kind of the main complication you've seen? Has it happened to you before? How have you managed that? You know, those are kind of my main questions.

Dr. Samy:

Yeah, and and sorry you cut out for just one second, but I, I think I heard basically, like what are, like, what's like your main concern with, uh, transnasal implants, right, yeah, correct, okay, um, yeah, so so the main one is essentially there's, uh, the nasal lacrimal duct is quite close, so uh, there's basically, um, there's like three possibilities of in general, of like what they could look like with how far that kind of Z point bone is from the nasal lacrimal duct, and it just anatomically, some folks have it where there's really not much bone there. And it's those cases where, if you're angling the apex of your transnasal implant a little bit too far, posteriorly you can actually damage the nasal lacrimal duct. So, uh, the problem with that is what you can get is you can get epiphora, where basically the nasal lacrimal duct you know what it does is it drains the tears from the eyes essentially down through the, the nasal system. So if that's happening, if the nasal lacrimal duct is blocked, what will happen is the patient will just have constant kind of tearing like overwhelmingly. And there's a procedure typically done by these are usually done by oculoplastic surgeons or perhaps ophthalmologists, but at least the ones I've seen were oculoplastic surgeons where they basically have to kind of move the connection to drain to a different spot. And you know it's called the DCR, dacro-rhino-cystostomy, where we had to do stuff like that with reconstruction, like maxillectomies and stuff for different reasons. But we like to avoid that.

Dr. Samy:

So we should probably also say just for everybody like these remote anchorage cases, you know you've got to get training, these aren't really things that you just kind of want to jump into Pterigoids, you know, zygomatic implants, transnasal implants, like the cases that you know we're showing. You know these are all done by, you know, heavily experienced docs, so, and there's lots of opportunities to learn. But I don't want to I guess I don't want this to come off as like we're underplaying the complexity of these, because you know you got to get training and there's a lot of complications. But yeah, that's the main, that the complexity of these cause, you know you, you gotta get training and there's a lot of uh complications, but yeah, that's that's uh, that's the main, that's the main one. And the other one is oral nasal community. Uh, oral nasal fistula, because an oral nasal fistula is a whole lot harder to repair than oral antral fistula.

Tyler Tolbert:

Yeah, and I think you're. I think you mentioned your guideline on that is having at least three millimeters of sub-antral or sub-nasal bone there.

Dr. Samy:

Yeah, and that I believe that's from the Vanderlim paper. Camargo Vanderlim he was really the kind of the OG who described it. To my knowledge, there's really only three or four papers on this. David Zellig, simon, oh, have one, you could name it. On how many docs are you know, on one hand, how many publications are out there, so this is very new.

Dr. Samy:

Um, however, it's a. It's becoming popular because of how much remote anchorage has become. It's just demand is out there now. That's kind of why we're seeing so much more of this now. Right, yeah, let's do.

Dr. Samy:

I think I have one more here. Yeah, okay, yeah, this is kind of, of course, the most, the most uh, severe here. So a severe atrophy. So, um, what? What the screen is showing is essentially a quad, quad zygoma configuration.

Dr. Samy:

But, uh, the point here is that you know the surgeon. The surgeon has given an honest try, or at least has really considered all of the options, to try to avoid getting to this. So in the posterior they were actually able to get both of the pterygoid implants. In the anterior there's really not enough bone for traditional implants, not enough bone for transnasal implants or, for some reason, just contraindicated. So an anterior zygomatic implant was placed and then the posterior, I'm sorry, in the tilted region. Not enough bone for regular tilted implants, very kind of thin lateral nasal walls. You can't really do a trans sinus implant. So a posterior zygomatic implant was placed.

Dr. Samy:

So what you're seeing is basically a quad zygomatic implant with pterygoids and this is kind of the end point really of Patsy, without going to something like a having to. You know, if this fails, there are docs who can, there's a few docs who can handle that. Like revising these cases Usually these quads you've got to cut the implant, you've got to find. Like revising these cases, usually these, these quads, you got to cut the implant, you got to find. But it's very challenging. But if you had to truly do a complete revision, there's very little options. And that's when we'd be talking about something like a custom subperiosteal implant or a removable, you know, like a removable denture.

Tyler Tolbert:

So I'm curious about something too. So there's this. I mean, I mean, for those of you who aren't seeing it, all these examples and what's below it have this really brilliant sort of way of codifying all of these cases. So we have the P-A-T-Z and then you have the subnumeral there with the 1 and the X. That corresponds to this really awesome graphic that we have. But I've noticed that on all these examples they've been symmetrical. I've noticed that on all these examples we uh, they've been symmetrical. I'm curious have you guys figured out a way, a notation for left side? Look like this. Right side, look like that.

Dr. Samy:

Good question, yeah, great question. For the purposes of like simplicity for the paper, you know we kept them all symmetrical, but the reality is you've probably seen some of my cases.

Dr. Samy:

You know it'll be a unizygo or it really kind of just depends on what the case needed. So what I like to do in those cases is I'll just put like R and then the whole thing, okay, and then L and then the whole thing. This is still kind of new so people don't even know what I'm talking about, so I don't really do that. There's a doc who does it a lot, dr dr tyler rushing, a great surgeon here in austin. Yeah, he, he like, will always like number his, his patsy. That's love to see it. And then, um, dr uh thomas, uh, tomas uh, krasinski in poland. He also beautiful, just beautiful cases. He also does it too. But, um, I'm sure a lot of the audience, of their followers, are like what is this like numbers? So you know, I tend not to show too much of it, but yeah, easiest way it would be like right and then left if it is an asymmetrical case yeah, I mean, I think, it's just so.

Tyler Tolbert:

We've been talking a lot about yeah, I was just gonna say something anything like that.

Dr. Samy:

We were kind of like shied away from um because of the repair that would sometimes have to go into that Um, but I did do several of them kind of for a different indication, like for like an amyloblastoma resection, if if that tumor is involving a portion of the nerve that needs to get resected.

Tyler Tolbert:

Yeah Well, like you know, we go on Instagram and we see all these you know post-op CBCTs with crazy implant configurations, zygos, transasos, all these things and it's like we can share the pictures and we're like, oh wow, check out this case, check out what they did here. But we haven't, up to this point, like had a way of actually classifying what was done, to where you could just look at this algorithm and have an idea of what that case actually looks like. That's why I think this is just absolutely brilliant. It's really cool.

Dr. Samy:

Yeah, and it just kind of helps. I mean, the world is becoming healthcare is becoming a very kind of global phenomenon, right? I mean we're seeing people who have been treated in different countries for Full Arch, people from the US that have been treated for full arch are going to other places for revision, so there's just kind of like a mix matching and that causes, of course, a lot of issues with compatibility, difference in philosophy, just difference in techniques. I mean there's so much variability that goes into just healthcare in general, let alone full arch implantology. So this is kind of at least our best effort to try to at least standardize the way of doing these particular cases, which are usually the most challenging, because that way, you know, if I see a case and I need to send it to Dr Zellig in New York, we can kind of speak the same language.

Dr. Samy:

You know, I can say, hey, this is what I did, I think. I think this I left. There should be bone up here, like look at the scan there. And that's kind of how we can communicate with each other, versus that first case I showed, you know, with the bone that was occupied there. You know, I wasn't able to. I should have been able to use that bone right to put a zygoma implant, but it made the case much more challenging and, you know, difficult to restore.

Soren Paape:

I really appreciate these cases you've shown. They look excellent and I think, like you said, getting to the point where we all can utilize a similar system to do these more advanced cases, I think will help everyone in any country or any region. A question I have for you is, as far as you know, a lot of these approaches are maxillary right and we do have limited options for the mandibular cases because we have the IAN running through there, the mental nerve, and I feel like feel like for the.

Soren Paape:

You know we have the traditional all-in-four and then obviously, if you can play six, you can do that how?

Soren Paape:

And then the going beyond that is subperiosteal style implants.

Soren Paape:

Um, a question I have is, you know, when we have these cases where patients have really soft bone and we do see that pretty often in the mandible, with the wide hollow mandibles where you replace your spade drill and you're kind of just pushing it through that region I'm seeing more people like Juan Gonzalez and a couple other surgeons who are starting to place some of these really long implants in the mandibular region to engage the inferior region of the mandibular bone in order to load these cases.

Soren Paape:

Instead of delaying those cases and I always, you know, my thought is where and I'm curious what your opinion is Do you find that for a patient like that, it makes more sense to place maybe like a 20 millimeter implant in the mandible in order to engage an inferior cortical bone, or doing something like a delayed load protocol and then maybe saving some of that bone for future use? My biggest concern with it is, you know, let's say the implant does fail and all of a sudden you're removing a 20 millimeter implant in the mandible that's going to do a lot of damage because of how thin that mandible is versus you know, a lot of times the maxillary bone is a little more forgiving in that aspect.

Dr. Samy:

And that's a. That's a great question, because what you're doing, soren, is you're basically adopting that mentality of like, how do we plan for the future? How do we optimize this patient so they're going to be in the best hands for the surgeon who treats it 30 years later, which is really kind of what Patsy's about. So that's awesome that you're thinking that way, and I think it's a matter of philosophy, because this will come down to doctor preference for sure. So I think a lot of the cases that you're seeing you know, juan Gonzalez, dan Holtzclaw those docs like basically it's a zero, like it's 100% immediate load, like they're they're not going to want to do a delayed protocol just because of not when you have to put the patient to sleep twice or not having like a recovery and just kind of patient satisfaction. So I think it comes down to weighing your risks and benefits. If it's super atrophic and you're running the risk of like fracturing the mandible or something like that, then I mean, so what If you get immediate load, who cares if the mandible is fractured? Right, just do a delayed load. But basically for like remote anchorage for the mandible, you really only have the inferior border.

Dr. Samy:

Um, you know, I I've seen.

Dr. Samy:

I've seen folks put a pterygoid implant, you know, in the tilted section to get all the way down to the inferior border, um, because they just couldn't get any, it just couldn't get torque and and that's the tough thing, the only other thing really when it comes to these revisions, the only other thing really when it comes to these revisions, the only other technique that I can really point to is is basically, uh, nerve transposition or nerve lateralization, which you know it's, I mean, I think, in in the right hands.

Dr. Samy:

Sure, I mean I did some of those more for like a reconstructive purposes, like resections and stuff, but the there's a lot of. There can be some morbidity associated with that, with, you know, delayed kind of paresthesias and stuff like that. So I think, in the right hands, it's a great option to really just kind of, you know, be able to use like a posterior implant where you can actually engage the inferior border without having to worry about that nerve. So that's the the only technique I can think of and it's not really a widely practiced. I know some folks that are doing it very well, but it's less common.

Soren Paape:

Are you doing any of those nerve lateralizations commonly in your practice?

Dr. Samy:

I'm not In my residency we did a lot of nerve grafting. So we were kind of like, like Dr Melora is kind of like one of the leading experts on nerve repair. So we got a lot of referrals, you know, from across the US for nerve injuries from implant placement, from wisdom teeth, orthognathic surgery and we go in there and have to kind of resect a little neuroma and then hook it up and and graph the nerve. So some of these procedures that are would have like a slightly higher air paresthesia rate, or you can kind of chart a path, create like a new kind of mental form and pull the healthy part of the nerve out, graft it, or rather, you know, anastomose it proximally and then you can take the distal end of the graft and you can insert that into the soft tissue stump. This is kind of like reconstruction type of stuff, but it's the same. It's really like the same concept with just with dental implant. You're putting a dental implant there instead of just removing the bone. Hey, everyone.

Soren Paape:

thanks for taking a second to listen to the episode with Dr Sammy. Make sure to tune in for a follow up episode where we discuss some of the really difficult cases he has and how he manages those. Also take a look at JB Dental Lab. We use them for all of our fixed arch treatment and they have some really good analog and digital protocols for any workflows that you have in your office. Thanks again.