The Fixed Podcast

The Evolution of Implant Dentistry with Dr. Chris Barrett: Part 2

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Join us on a captivating journey through the world of implant dentistry with the esteemed Dr. Chris Barrett. From customized implants to zygomatic and pterygoid options, we uncover the critical need for backup plans during surgeries and the importance of comprehensive informed consent. We tackle the tough conversations around patient risks and explore the transformative power of practice and training in building confidence for complex procedures.

We reflect on the strategic planning necessary in all-in-four dental cases, addressing challenges like surgical fatigue and phased approaches. New practitioners, take note: we reveal key strategies to overcome common pitfalls and ensure both practitioner and patient satisfaction through effective planning and execution.

Looking towards the future, we explore the groundbreaking advancements in dental technology poised to revolutionize the field. From tetranite and robotics to AI and 3D printing, these innovations hold the promise of more precise and personalized care. We discuss how these technologies can enhance diagnostic and treatment processes and contemplate the exciting potential of large data sets to shape a future of more predictable and evidence-based dentistry. Tune in for an enlightening conversation about the future of dental care, where technology meets art and science for the ultimate patient experience.

Speaker 1:

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

Speaker 2:

implant dentistry, yeah, I think the other consideration as well, and I agree with all that, and I think it's it is interesting to, because everybody that's coming up in the implant dentistry they all have different backgrounds, right? So, like you said, bernardo, maybe he's just seen a lot of complications with zygos and that's enough for anybody to say, eh, maybe this isn't the best route for me.

Speaker 3:

For sure yeah.

Speaker 1:

And I think like one thing that a customized implant can't do is what you described earlier. So you were doing conservative approaches. You tried the palatable approach, you did the trans sinus. You weren't getting anything. So then you pivoted to a zygote.

Speaker 3:

Intraoperatively I was going to say I can't do that with the customized implant. Yeah.

Speaker 1:

That's out of the bag, so you have to have something for what happens on the day.

Speaker 3:

And I'll have during. I'll have the patients that I treat. Just sign a zygoteary consent form, because you can't might have mid treatments. Hey, do you mind if I do this, mrs Jones? So just having that and does it happen all the time? No, but when it does, it's great. You're going to get the outcome that you're paying me for, not the implant.

Speaker 1:

So this is a bit of a tangent and, soren, I don't mean to leave the question. I was. You just mentioned that.

Speaker 2:

It was exactly what you said yeah, I was going to say pivoting. It's hard to do that when you have to have a ct spliced weeks prior than a custom implant come yeah, you just got to have it ready just in case.

Speaker 1:

It's paid five thousand dollars for the backup. But but no, my question you see you brought up something I've been asked about before is a zygoteary specific consent form. So I'm like I'm curious about what sort of things need to go into that, because I've had some people ask me about this is do I need to talk to my patients about pterygoids? If I'm going to be doing that, what do they need to know? Do they need to know what kind of special considerations are there?

Speaker 3:

Uh, you know, when I took Vichy's course, he basically gave everybody a consent form that he used. So I'm more than happy to send you your way. But I think a lot of it is just hey, what are the malpractice carriers want you to talk to your patients about? Nerve damage, eye stuff, with zygos, recession, sinusitis, I think the pterygoid the biggest risk is some sort of bleed.

Speaker 3:

But yeah, I think if you select the cases correctly and you don't try to be too much of a cowboy, I would say that posterior lower zygos are, I think, easier sometimes than pterygoids. And I think people are like no, I'm going to learn pterygoids first, because there's not an eye next to it and that's like the kind of they don't maybe talk it out, but I think that's what they're thinking or they have that thought process. And then once you get both of them, you're like, oh, I could just do lower postures. I goes all gray and versus guide. You miss on the Terry and it's gotta find a new spot and maybe it's more difficult to get your photogrammetry in the back there there's all sorts of like different, like little nuances to it Jaw form, arch form, patients gagging, stuff like that.

Speaker 1:

But yeah, I think that. So what I liked is one of our first courses learning Zygos was at the Texas Implant Institute with Clark Damon, rick Klein, leighton Great, juan Gonzalez, and they taught both at the same time. So we learned Terry's and Zygos and I think in general, when you're getting to the point of wanting to get into remote angerage, the sort of cases that you'll want to utilize terries for are still standard, all-in-four, adjacent right, like you can do terries on the standard all-in-four case to add more support and give it more utility, give you backups and stuff like that. But when you start getting into zygos, those are inherently going to be more extreme, more atrophic cases. So I think learning that lower posterior zygote, that unilateral zygote, should it come into play, is good to have.

Speaker 1:

But you're approaching cases where it's okay, standard plus terry and I'm going to get comfortable with cases that can be secured with the front four, but I'm going to try some terries and try and get my feet wet with that, and then you're just keeping that zygote in the back of your mind. Okay, I did that a hundred times. You know I did on cadavers and on models. If the time should come then I'll be ready for that and have it as a rescue implant for a while, and then, once you're really comfortable with Terry, then you start taking on even more atrophic cases, and now that zygote is more likely to come into play, I think that's maybe a better middle ground to approach it. But I can totally agree, though, that I can see where the difficulty of getting comfortable with Terry's is almost a little bit greater than that lower posterior, posterior inferior Zyko, because you can see that one that Terry is like a you can almost close your eyes and be just as good.

Speaker 3:

Yeah, I don't disagree with you. I think one of the things that really helped me also was I would print models and practice on them ahead of time and just getting those reps and the mental this is what it looks like and going through that visualization process, as well as having a model chair side where it's intraoperatively, I'm double checking and say, hey, is this the landmark that I said? This is where I was going to start, Is this really where I am? And then that just it's almost like a little bit of a crutch, but it helps for sure.

Speaker 1:

I think that's something I've really underutilized printing for. As a biomodel because a CBCT, you can think you have it all mapped out in your head but for some reason when you get in there intraoperatively, just in 3D space, things are just not where they're supposed to be, like like you. Just it's easy to get lost and you're like all right, there's supposed to be something right here. But the spatial relationship between these two landmarks is not what I thought it'd be. You can get a little loss, but a mile model, that's not going to be an issue. So I think that's a good idea to have that on.

Speaker 3:

I actually I'm not an expert in 3D printing, but I went out and helped Alex Smith do his IGO case in Oregon, I don't know six months ago. He has an awesome lab guy, beautiful new office. I wish him and tell him the absolute best. They're great guys. I, for any case, I go mentor, I'll print models and then take them with me. And this lab guy was like oh yeah, I use blue skies, new auto segmentation and it took me 10 minutes and printed this in $15 resin. I had it professionally done for like 100 bucks because I'm not going to like segment out. So I was like, yeah, I was just you kids have it like $100 because I'm not going to segment out stuff.

Speaker 2:

You kids have it all figured out. I was just going to say a quick tip that I'm sure a lot of people appreciate hearing, and I'll try not to hide it anymore the easiest way to do it and maybe Blue Sky Bio now has an even easier way, I don't know. If you go on, it's relueu r-e-l-ueu. It's a like ai segmentation software. So all you have to do is, whatever your ct program is, you just export your dicom, upload it and onto relu. It splices it out for you super easy and then you can just download the stl and you can print it on your $300 frozen printer, just with the traditional plate. You can use Frozen's water washable resin. It's $30 for a liter, so cheap On Amazon.

Speaker 1:

On Amazon.

Speaker 2:

And you can print it. It's super easy to print and you have a full skull for like literally. I think the most expensive thing is to splice each CTU. Splice is three or four bucks or something like that. But for what you paid for probably four of your professional models you could buy literally the printer, the resin and be able to do them forever.

Speaker 2:

So if you're listening and you're like man I'd love to be able to do biomodels, but I don't want to pay $200 on this case. Do it like that. It's super straightforward and that's like the walkthrough. I figured it out by myself and it's not hard to do. The ReLU it's R-E-L-U dot E, r-e-l-u dot E-U is like super basic software. All you do is upload your com, you export your STL and then you can just print it right on the frozen. You can't really print it well on a Sprint Ray or on any printer that doesn't have a large build plate, because obviously you want a large enough build plate to print the maxilla up to the zygos in the inferior aspect of the orbit. But if you have a frozen, the build plate it comes with is pretty large and it's a really easy way to make biomodels for any kind of case. You can also get your pterygoids in there, your zygos. Even if you're just getting started with traditional all-on-four, it's an awesome way just to be able to visualize the anatomy of the maxilla does that water washable?

Speaker 1:

does that drill? Okay, if you ever wanted to actually practice on them, you can drill into it too hard.

Speaker 2:

You can definitely drill into it, but it's not, don't worry, use the drill. I wasn't gonna say that. I was just gonna say it's not like the same feeling you get with bone. So that sure, yeah, there's a couple 3d printers that have the filament resin, fdms, that is like specific for bone, so it's like very similar to bone but if you want to go off the deep end and get really into biomodels. That's what I would recommend doing.

Speaker 2:

But the, the filament resin that's like similar to bone, is crazy expensive if you just want it for visualization purposes, definitely just print in frozen water, washable on a frozen like what is it?

Speaker 2:

The sonic 8k and the whole setup is going to be less than 400 bucks and you can print models for the rest of your life and that's like a whole another like, if you want to, if you want to get into that stuff, rick ferguson has a really good dental group um that talks about frozen, but I actually, for a year, printed all of my stage two models in rodent titan on my frozen $300 printer um, and I genuinely think that the uh prosthetics I got were more accurate than those that I had printed on any of my other printers. It's pretty crazy what that printer can do if you have the settings correct. That being said, a lot of times it takes two or three prints because the printer is a little bit finicky and it's it does take two hours to print something and if you're printing a model, it's like it takes overnight. You just print it overnight.

Speaker 1:

It's not like a 20 minute print, but it does do really nice work and that's like a whole another avenue that don't get me started, but between rick ferguson and the 3d printing dental group, you'll get better customer support on that printer than you will any legacy dental company. I'm down here right now yeah you get immediate like in your computer. Let me fix this for you. Type support it's amazing it is.

Speaker 2:

We have an incredible community yeah, the next thing I wanted to talk about, chris, was what are some of the more more common mistakes that you've seen docs run into being? And I know we've talked about like treatment planning right, that's a big one, but like just with traditional all-in-four, what things do you think? What do you wish you would have known when you first started getting into it? And then, what do you wish you would have known when you first started getting into remote anchorage cases? Let's see here cases.

Speaker 3:

Let's see here Things for basic all-in-four would be having the ability to have an anesthesia provider in-house. Sorry, one sec, yeah, all right, basic, all in force. Things that I would do different or things I wish I would have known about. I did some IV sedation training but I never really utilized it.

Speaker 3:

I will say, trying to complete these cases as double arch cases with local anesthetic over a long period of time, it causes surgical fatigue. It causes surgical fatigue and you are boxing yourself in to a corner that, as you're starting to do this, you're adding pressures that you don't need to add. So I would be saying phase your cases. If you're doing them with local, just do the upper, get it done, set the bite, come back to the lower. Live to fight another day. You can take more time to do each step in a very excellent way, so that step two builds off of step one and as soon as you're five or six steps in and you're battling something and you just have this surgical decay it's, you're starting to compromise and in a majority of the time what happens is the young docs or the new ones into it. They compromise on their plasty because their flap isn't big enough. The cardinal's in.

Speaker 3:

They're feeling something and as soon as you don't plasty correctly, you're causing a problem for you and the patient and that's probably like the biggest. That was a very big realization Once you do that one time and you see the outcome of okay, this is not exactly how I wanted it, but you just don't do it again. So, phasing the cases, if you don't have the ability to provide a re-anesthesia, what else from some of the basic stuff, just the treatment planning and reading the CBCTs, the ability to just and this just comes with reps but you just see the problems before they happen Teeth that are spaced really closely together and so all the roots are right next to each other and there's just like crib of form plate after crib of form plate and you just there's no intra medullary bone between any of them and you take everything on here Like why is this?

Speaker 3:

case different than like these other cases, and it's like some of the nuances of it. So just those reps will help the remote anchorage stuff. Yeah, what would be some like really good takeaways before you go into that.

Speaker 1:

Yeah, go ahead.

Speaker 2:

Oh, I was just going to. Yeah, before you go into that, I was just going to say that I've seen so many doctors fatigue out because they weren't able to provide adequate sedation and they've had patients that they couldn't get numb and case after case was just like a nightmare and in my that's how I started to oral conscious sedation for my cases and I quick. I remember like one or two cases in particular that just went, not that the outcome went bad and like all the implant positioning, everything was good but the patient just had a miserable time, and so did I during the case, because they were just one of those patients that it took a little bit more to get them numb. And then you're battling with your limits of epinephrine, your limits of anesthetic and and I think it's much. Now it's funny because I stopped doing oral sedation after a couple of those.

Speaker 2:

I was like I'm only doing patients under IV sedation and I really think that if you're able to offer that service, it's 100% the way to go. And now that me and my team are so much more efficient with these cases, I do oral conscious cases pretty frequently actually and they are a breeze, and the reason that they're a breeze is because I'm efficient, my team's efficient, we can get in there and get out of there in a timely manner. And it's way better to be a provider that if you're just getting started in these, if you have a clinic that is you're just starting up or like you are, or like getting into more fixed cases, do IV sedation first and be price your price, your archers a little bit more, and then, when you want to get more competitive and you want to get more reps, you can drop that price a little bit and take out the sedation aspect and offer oral conscious when you know that your team is prepared and you're prepared to be able to do these cases efficiently.

Speaker 3:

Yeah, I think that's a good call. I think I remember, I think, the phasing of the cases too. I think everybody feels like they got to do all the doubles at the same time. I remember mike freymuth. He would do these staged cases of these fp1 cases where extract some of the teeth, place some implants, graft. He'd prep the other's teeth and then they leave in basically this like molar and canine, like provisional, and they'd come back four months later, slick the other teeth, pick up the implants maybe place two more and attach a new provisional, all those other ones. So it's a longer period but the patient always had a very nice temporary bridge that would really look and function like teeth and you had a provider that was very confident, that would deliver the treatment just like they said that they were going to and the patients were okay with it.

Speaker 3:

The big thing is when we over-promise and under-deliver and then patients aren't okay with that. So if, like you're saying, soren, if you tell the patient, hey, this is the best option for you and this is the way that I would treat you If you were in my family, they're going to believe it, regardless of whatever it is. I've got a buddy in Kansas city family. They're going to believe it, regardless of whatever it is. I've got a buddy in Kansas City. He doesn't immediately load anything and he does arches all the time and he says, hey, the best course of treatment for you is for these implants not to have anything on it. Do I agree with that? No, but does that work for him in his practice? Just like you're saying, if you need more reps and you need to do a certain thing and you need to tell your patients, this is like the best thing for you to do right now, just 100%. Do that to get a good outcome for you in your office.

Speaker 2:

Yeah, absolutely, tyler, you were going to say something.

Speaker 1:

Yeah. So I love all the advice, for people are just getting started looking to do full arch the right way, and if you listen to this podcast, that's what it's all about. What would you say to some of the more, let's say, moderately advanced practitioners? So they're past 500 archers. They've done all the traditional on four one can do. They have advanced techniques, they're comfortable with Terry's, they're starting to wade into the revision territory, zygos, things like that. What are some key things that you would give to someone who already knows a lot of that stuff? What are, like, some of the finer points of those really advanced cases that you've picked up along the way?

Speaker 3:

I don't know if there's like a necessary, like a really definitive thing. I'm trying to think through maybe some of my earlier cases or things that I would do differently Maybe having. I think the biggest thing would just be choosing easy cases to start. So going back to that thing just because you did the course, I would not come back and do like a quad just because that was the first case that walked back in your office Because you're setting yourself up to have problems and now it's that whole thing of you get burned by your first two or three cases and you potentially don't want to do another case, three cases and you potentially don't want to do another case. So I loved what you said earlier, tyler. Where it's, I have a great case already regardless if I do any remote anchorage and I'm going to add pterygoids.

Speaker 3:

And if I don't get the pterygoids, or it's not exactly how I want them, no harm, no foul patient's going to get the exact same outcome.

Speaker 3:

I think that's it. I think when you get beyond that and you're like, hey, I can transition at any moment and add these implants as I need to, one of the things is you get a little cavalier and I will say sometimes I will just walk into the operatory with a little bit of the attitude of whatever's here, I'll do, and it's not necessarily like the right attitude to have all the time, because every once in a while you're just like, hey, I wish I would have reviewed this a little bit more. Honestly, the biggest thing is relying on making the assumption that the team has all of the correct diagnostics. Worth not having my own office where it's like, hey, here's the protocol, I'll get sent cbcts to review all the time. I don't always get like a high smile line photo and I know we're getting slightly off topic, but it's one of those things where patients when they're in that first phase of treatment and they're during their consult or the records appointment.

Speaker 3:

A lot of offices will have them say smile, or smile as big as you can and they might have not smiled for years. I remember treating a patient putting in his teeth he comes back for a post-op. I sat in my truck for 45 minutes practicing smiling in my rear view mirror because I have not smiled in years, practicing smiling in my rear view mirror because I have not smiled in years.

Speaker 3:

So you have these patients where there's a guy who took a course Matthew Calkins, awesome guy, he's up in North Dakota, he's hey, I have my patient snarl. So patients might feel like they don't want to smile or it's guarded or they don't know how. But I feel like everybody knows how to make a mean face to try to get that douchey smile or that, that upper leg. So don't get complacent with some of that stuff Having. If everything is, if you're not complacent and you have all of your diagnostics exactly how you should. Maybe some of the more difficult things are practicing, getting really familiar with the anatomy. I'll say the more cases you do, the higher the reflections can go, the closer to the orbit you can be. I'm not saying be in there, but it's like you can see the anatomical difference between where the base of the zygoma is and where the infraorbital is. When I mentor cases, I'll typically talk to patients about what I use is like this triangle or zone of safety where, if I can identify these three landmarks, then I feel like I always have something to go back to where I'm not lost. So it's based on the edge of the piriform rim, the infraorbital and the base of the zygoma. A lot of times when guys or gals are first starting, they get in there and they you've got the attachment of the masseter. And then they don't want to get too close to the eye and so they end up with this like little landing strip and they also haven't reflected up to see where the infrarole is. And it's not uncommon that you have these little accessory vascular canals or something and they can be way down here and thinking like, hey, this is the infrarobital and I'm not going any higher. Now you've got a low, you've lowered your superior part and you haven't basically dissected any of the masseter, and now you have a higher inferior part and now they're drilling, and they're drilling like mid-body as opposed to going and dividing it into two zones. So as you get better at it, you're going to start dialing in where you want your placements to give yourself more flexibility in the future If you do revise anything or if something happens.

Speaker 3:

Those are things that you just pick up along the way that you're like, hey, I've just seen this a lot before and you just make those little mental file folders where it's like, just through the reps, through the reps. So I would say do these things prior to needing them. Just going back to your point, tyler, where it's if you're doing lateral sinus lifts, you don't have to reflect that much more. To do a post like a lower posterior zygote, pretend that this might be a quad case and go find your anatomy and reflect how you should, yeah, and clean everything, and then at the end of that, guess what, you don't have to do a quad. It feels great, hey, yeah, and then do that 10 times and now it's okay. Edge of pure form for orbital base zygoma. Right along the edge of the orbit, guess what? There's a little ridge. Go gently find that ridge. Oh, here's a little fat. Okay, I'm not freaking out because guess what, I don't have to drill up here.

Speaker 3:

You do that a bunch of times and you're just like I'm seeing this over and over so that when you do have that case you're like the reflection is not like the new part that you're like I'm a little like antsy doing it's.

Speaker 3:

No, I've done this a bunch of times now. I just need to focus on my drawing my line correctly. Oh, this is something that I would say. At first, when I started doing this, I stood in the same position to do the left and the right side and I thought I was good enough to be able to get exactly the type of implants that went in the same place and with the symmetry and the parallelism and everything. And what happened was that was not the case. And so I will drill the left side, saying it on the patient's right, and I will move around to the other side and I will drill the patient's right side, saying it on the patient's left. I'll end up actually placing. I'll go back to the same spot and place the implants from the same side, but drawing my line and starting my drilling, I want to look exactly down that line. So, for and for zygomatic implants, you can do that.

Speaker 3:

It's interesting when people post their like post-op CBCTs and you look at their pterygoids, you can tell who's a right-handed operator and who's a left-handed operator because, if you're, if you're standing in like a 10 o'clock position and you're coming around that corner and you're tapping and doing your drilling, it's not uncommon that what looks parallel or the same to you is that one side is just tipped in just a little bit more.

Speaker 3:

You can see it, and the reason why I know that is just because I've done that and on my post-ops I'm like hey, that's not perfectly the same, it's tilted in a little bit more. And what that does is it potentially kicks out the prosthetic part of it when now that little extender that attaches to the terry might be a little bit closer to the cheek on that side. And now the patient's hey, it rubs. Can you thin that out? Those are like small nuances, swallowing your ego or leaving it at the door and saying, hey, if I need to move over to a different side and make sure I can visualize this, uh, don't feel bad about that at all yeah, okay, no, okay, no.

Speaker 2:

I think that's a great tip. It's funny I even when I started taking teeth out in dental school with my mentor, he would like occasionally walk, even just with taking teeth out. He would go on the other side of the patient and be like hey, like I, if you're like, for example, let's say, you get like a root stuck number 31, like a mesial root you just can't get out, it's so much easier to come over to the patient's left if you're right-handed and put a crier in there or something and just pop it out real quick. And he would do things like that, where he would come on the other side and be like hey, it might not be the most practical thing and maybe, like some people wouldn't suggest, it doesn't look as cool to do. But if it makes it that much quicker for you and the patient and it more symmetry, like better outcomes, like definitely just go over there, get a better visual of it, make sure that it's done correctly and then you're good to go.

Speaker 3:

Yeah, 100% for sure, I think all I think the other thing too is choosing the right implant system that has the right drills and the right kits and, um, I do think that matters with some of this stuff. We're talking a little bit about nothing against nobel, but I don't think they've got the best stuff. As far as for doing zygos and terries, I think neodent has some awesome stuff, but I don't love their helix. Long for pterygoids. I think you have to prep that differently. I'll say it's like a new operator if you are trying to figure. It's already hard enough to figure out where this little landing zone is and now you have to prepare the apical portion of this just right to get the tip of the implant to bite just. You don't need like that extra pressure. So you are looking for some certain styles and characteristics of some of the implants and the kits for some of these things.

Speaker 1:

So that's something I'm actually really curious about. So just to get down to the nuts and bolts, so what's your go-to teri implant and technique?

Speaker 3:

Right now I think Norris probably has the best pterygoid on the market. I've helped co-develop the new SIN, Zygomatic and pterygoid. The pterygoid is very similar to the Norris. We have some slightly different widths. The tip is maybe slightly more narrow. I do think the new kit that is FDA approved and out is a little bit better. We've got to work on the osteotomes but as far as the design and the biting aspect of it, I think it's an awesome design. As far as the Pterigoidids go, I have not used any southern stuff. Southern has a very narrow one where you can almost just use a lance drill and twist one of those in. I would like to get familiar with those yeah.

Speaker 3:

I don't know if anybody's looking to head to South Africa in the next year or two for any sort of training, but make a little business right off and head down and check out what they got going on down there. But yeah, for pterygoids you do need some instrumentation, specifically that's long enough to stay outside of the mouth. That is really helpful as far as preventing user error. As far as just trying to figure some of this stuff out, I would say, out of anything, the pterygoid instrumentation and the kits and the drivers and stuff like that is is really pretty helpful. You can fudge stuff around using zygomatic drivers to put pterygoids is. There's an implant company called jd. It's italian.

Speaker 3:

They have a very nice kit and I will use their long zygoma lance drill that has a barrel on it and from the tip of the lance drill to the edge of where the barrel is it's 18 or 20 millimeters, so it acts as like a depth stop.

Speaker 3:

Now they have specific pterygoid drills for their pterygoids, but I know if I sink that in, I'm 18 20 millimeters in, so I'm giving myself. I'm not falling into something with a long lance or something. New users using osteotomes tend to mallet a little too hard and you can break the plate off that way. So having something that's slow and rotary, that gives you a little bit of feedback, I think is nice, so I'll use. I have a versa zygo kit and so I'll use that lance and then I'll use one of the zygo versa densa drills which is longer and you can drill it and keep the handle outside of the mouth so you can uh, densify the tuberosity if you need to, and then as you get closer, you flip it back into forward and then go back into the length that you want and they typically place.

Speaker 3:

And yeah, no, if you're doing oral conscious sedation or if you're, if you are not sedated and you're ostetomying for pterygoids, I'll tell you that the patient is not happy. It's a horrible practice builder. Having the ability to figure out how to do this without any osteotomes has been really nice yeah, I never actually a patient will never forget the net and they're gonna tell everybody about it.

Speaker 1:

They were lightly tapping.

Speaker 3:

They'll say you will not believe what this guy was.

Speaker 1:

He was hammering this thing into my head. Yeah, yeah, he's putting in a rail spike.

Speaker 2:

Yeah I have always, just because we learned from the full arts club with bernardo and his approach is all drill driven. So I've actually never done, I've done cadaver osteotomes, but I've always done drill and I find that, at least for me, it works really well in my hands because I do have that appropriate, that feeling, the proprioception of going in there and I can literally usually I just push it, I push it through the tuberosity, unless it's like really hard, and then I I can just feel I hit that cortical plate and then what I like about it is that I can really like navigate through the where the lateral and medial wings meet, and I can just poke through that, whereas when I was doing cadavers and the and maybe it's just because I didn't have a ton of experience with it, but I just felt like I didn't get quite, I felt like it would slip- more for me.

Speaker 2:

Like it was easier to slip, and I just, I also have seen some reports about what is it? Tinnitus with patients in the ear from that mallet stuff, and I just I've always been okay with the drilling protocol.

Speaker 3:

That's where I fall as well yeah, yeah, using a long lance as a probe to go back there and just push through and then find, yeah, I want to trademark like this probe pop in place because I feel like it's the three piece, and that's basically what you're doing now everybody's gonna know so put on a public podcast.

Speaker 1:

man Bad tactics.

Speaker 2:

But yes, that is great and I'm going to have to look at the two drills that you mentioned, because that sounds really powerful.

Speaker 1:

As far as I like the Osseodensify, that's really interesting I never thought about doing that with a tuberosome.

Speaker 3:

Yeah, you can go slow, you can go back and forth and all you're doing is you're creating like a glide path to get these implants accepted. So, yeah, and the fact that they're longer drills, one of the biggest issues is that if you don't have long drills and you're trying to use like a drill extender or you're trying to fudge it with something else that's why the osteotomes are nice is because they're longer, they're outside, they show you trajectory. So you grab some long drills that are meant for zygos and you know the specific depths. I'm not like a public service here, like announcement. I'm not advocating zygo drills in pterygoid region and I do use them, but there's like depth stops and known measurements on these.

Speaker 1:

So yes, yeah, don't go 50 uh millimeters down there. Yeah, no, definitely, and that's what I do too.

Speaker 2:

I actually use what I typically do, and I haven't used a lot of other kits for pterygoids asides. Besides the sin kit, I actually have my their new one on the way. I should have it next week so I can test it out. Yeah, the new ones all, but I just use their long kit typically to place mine, and the way I do it is I use their lance, and usually I can get by with just a lance, but some patients their arch form it's really tough with their cheek to get the correct angle. So then what I do is I put their extender on it, and that really allows me to come outside of the mouth. I don love doing that every time, though, and I would never recommend it to someone who just started, because those it's not a like locking mechanism in there. You can, it's now. That being said, sometimes I have to grab my ranger just to pull the.

Speaker 2:

It gets it gets locked in there, but there is like a risk of that coming out if it was like too dense or anything like that. But I do like the ability of coming outside of the mouth, which would be a similar situation using Zygobur or Zygoburst, for, but getting outside of that the mouth, it allows you to to correct your angle a lot better. And I see patient people when they're placing pterygoids, instead of instead of getting into the correct position to place that pterygoid, they're worried more about the patient's cheek and then you don't get the correct angle into the pterygoid and then you might maybe you find out that your pterygoid, because a lot of times what ends up happening then is that your pterygoid goes lateral because you can't angle it medial enough and if you put an extender on there or you use a longer lance, you'd be able to get outside of their, their mouth, to place that pterygoid and I bet you'd have better success with hitting those more more often.

Speaker 3:

Yeah, that, and I would just say starting.

Speaker 3:

If a lot of times docs will start their osteotomy in the center of the ridge and they're drilling at an angle and so they're gonna hit bone on a on an angle and when, before they know it, their center of the ridge is way lateral and they've just been pushed that way, or as the implant is engaging, it's like you've got a plate of bone and then the rest is styrofoam and since it's at an angle, if it goes in now, all of a sudden it gets torqued and it's getting torqued out the other way as it's getting engaged.

Speaker 3:

So you'll learn, you'll get burned a couple times and then, before you know original, you know what. I gotta start way medial here, because I know my end point is going to be a little bit. It's no different than like when you first learn that drilling on a narrow ridge or on a quarter or on some curved bone surface, it it's like, hey, start drilling at 90 degrees and then as you go in you're going to tip and then, as opposed to this whole sliding and before you're off on a and maybe that's just a nuanced surgical thing, but starting maybe a little bit more medial on some of those cases so that the prosthetic or the platform ends up more centered and not so lateral.

Speaker 2:

Yeah, that tuberosity bone could really, and that's why it goes back to what I said in the beginning. I like having the ability to really dictate that angle and be able to put pressure on it because I don't want, because it's so easy to hit that hard cortical bone and then just go off course. Yeah, and in the tuberosity region, because sometimes the bone back there is just like basically just fat. There's like nothing back there at all for sure totally.

Speaker 1:

I find too like when I was first starting on pterygoid cases, I felt very dependent on there being a decent amount of sub-antral like tuberosity back there to establish that glide path and can make. If I could just get the angle right the first time on the osteotomy and find the pterygoid, I was going to be okay because I had all this tuberosity to just keep me where I wanted to be. But then as I've gotten more comfortable, I've started dealing with less and less tuberosity. So something I'm curious about is what are some of your kind of like limitations in terms of candidacy for someone to receive a pterygoid if they don't have a whole lot of tuberosity back there? If it's eggshell, if you're, I've done one where I took out an impacted pyrmolar huge void now but I could still get the pterygoid. What are your thoughts around? Do you need tuberosity back there? Is it doable without it? Is it okay to be intra or trans sinus with your pterygoid?

Speaker 3:

Yeah, so I've done a number of trans sinus pterygoids and they seem to be fine.

Speaker 3:

My thought process is do I really need a pterygoid there for some sort of stabilization, and is it something that I'm adding it where it could potentially even be transitional, meaning that, let's say, there's no subantral bone? I'm getting 30 newtons to work. There's only three millimeters of bone engagement at the apex, but it's good enough to load to help these other implants heal. Yeah, and the spread of the other implants of this fails is still okay. Yeah, that's my thought process on it. I've grafted a couple times. Where I go back, I move the membrane out of the way I prep, I'll graft almost like you're doing, like a, a sinus, a lateral wall and placement at the same time. So you pack the more medial side, you place the implant and then pack, and I'll do that. I've done that a couple times. Seems to be fine. The biggest issue is typically access back there. But yeah, yeah, one one of the things too is trans sinus gets thrown around almost like it's a thing that you can do all of the time, like like it's a technique and hey, you can, you can just do it. I could transize whether or not. We're talking about an anterior, traditional trans sinus or let's say, like with the pterygoid, brandon Mark has a really nice way of it's categories categorized by basically this interior part of the sinus and how it relates to the nose and the relationship of those two things and how much the body of the implant. It's almost like a zaga classification, but for the sinus. So there's a different spectrum of when someone says trans sinus, they might say 95 of the implant is in bone, but the body of it in one small section is in the sinus. Then you have other parts of it where it's like, hey, depending on the crustal portion, if you have more than four millimeters or less than four to five millimeters, you either need to graft the area or not graft the area. So let's say you make a hole, move the membrane out of the way, puncture through area. So let's say you make a hole, move the membrane out of the way, puncture through, place the implant. But you've got a good amount of bone on the sub-antral part, say five millimeters. Hey, you probably don't need to graft that mid-body. But the idea is you've got three millimeters at the apex, let's say at least three millimeters of engagement at the crest, that seems to be, and I don't know if there's any studies on this, but I think the studies that are out there.

Speaker 3:

Six millimeters of osseointegrated implant seems to be about the minimum that people are okay with as far as loading. So, whether it's transnasal or whether it's trans sinus or whether it's trans pterygoid or whatever it is there's, the suggestion is three millimeters of osseointegration at the apex and three millimeters regardless of the length of the implant and I'm not talking about zygomatics, I'm just talking about these other transients. You would have the three millimeters at the base of the three millimeters. That gives you your six. So same thing with your transnasals. You might have about two to three millimeters engagement in that couch area and then you've got, or at the z point, and then you've got, let's say, three millimeters crisp. So now you're at that six again.

Speaker 3:

There's the difference being with, let's say, a transnasal, the bone quality underneath the piriform rim is a significantly different than bone quality in a posterior transitis and that almost never gets talked about where you could have four or five millimeters of bone back here.

Speaker 3:

So technically it qualifies for not grafting your trans sinus implant. The problem is that four to five if it's D4 versus D1 or D2, it would change how I would treat that patient, whether I'm going to graft or not graft, because I'm not counting on D3, d4, because the bone to implant contact at the platform area is going to be significantly different. Regardless of that height, it ticks the box. So same thing in the teragord area. If I threw my plasty or just, there's just no sub-anestral bone, there's just minimal there. Am I going to graft it? Am, am I not? It's much more difficult to graft back there than it is with the traditional sinus. But those are the things that I'm thinking about as I'm working through it and how that bone feels for those cases yeah, yeah, I can't even imagine grafting back there, to be honest that doesn't seem fun.

Speaker 3:

Well, what's interesting is when you get into doing sinus lifts, when people start them, the place that they miss the most is this anterior part, because they're working back towards yourself and it's difficult to get to. So actually, when you go back there depending on the cheek and just range of motion stuff going back further you're looking straight at it and it's actually a little bit easier to get it out of the way.

Speaker 3:

It's just whether or not you can pack stuff there and drill through it and have all that stuff. So I can see that. Um, from an access standpoint, I actually think it might be a little bit easier than the interior part gotcha gotcha.

Speaker 1:

That's definitely something to consider. I've got a few pterygoids out there that I feel like they kind of work similar to like a wheelie bar on a drag racing car, where I'm like, okay, like I, I I got some stability here, but I don't know that much about how well this is really going to hold up long term because of what's going on near the crest. It's just there's not a whole lot of bone there, maybe it was really fatty. I placed this through this big space and it's good to load and it's going to help support those four front implants that are just going to act like the four tires of that drag racing car and once they get traction they're fine. But at the start we need something to give that stability in the back.

Speaker 1:

I think that's a decent analogy. I made it on the fly, but but yeah, I'm curious about how those types of pterygoids will really hold up, how they stand the test of time, and mechanically they're great for a loading situation. But what do I really need for that to actually hold up long-term, to integrate and to be useful for throughout the life, the life cycle of that patient? I don't know on someone.

Speaker 3:

Yeah, I don't think anybody does, so we're just overseeing what happens?

Speaker 1:

Yeah, no, I hear you on that, I hear you.

Speaker 2:

Chris, I think we're getting to the end here of our. We got enough content for two parts here and we really appreciate you taking some time out of your Friday afternoon to to be with us here on the podcast and discuss what you do day to day and I know you just got off of a double today. I think you had a pretty long day yesterday too, so again, we really appreciate it. I think I'd love to, as a closing remark, just hear what maybe you're most excited for in our implant profession coming up. What's the what's like the next big thing that you're excited about coming up here in implant dentistry, and then we can wrap it up and call it a night uh, things that I would be excited about in implant dentistry.

Speaker 3:

I'm in the phase of my career where I've ticked a bunch of boxes that I thought were personal things that I wanted to achieve a little bit as far as some of the clinical stuff. So I think just some of the advancements and things like there's something called tetranite. If someone comes up with just some glue or cement, you can just squish in there and put the implants in, and now all of a sudden we don't have to do any of this stuff. I think that's interesting. I think some of the robotic stuff is interesting. I've been to two different Yomi lectures and I know a guy here in town.

Speaker 3:

I caught myself thinking some of the same stuff about oh, I'll never do this remote anchorage stuff, like a few years ago and before it's gone, I'm doing a bunch of it and it's oh, I would never use it. Why do I need to spend $200,000 on a robot and it's oh, I would never use it. Why do I need to spend $200,000 on a robot and it's maybe in two years I'll have a robot? I think it'll just be one of those things where I'm not sure exactly what's coming. I think some of it will be out of the orthopedic field. Maybe some special surface coatings that can osseointegrate in a couple weeks, just stuff like that.

Speaker 3:

Just honestly. One of the reasons why I got into this is because general dentistry is fine, it's great, but to make an impact on someone's life in my very first Olenek case was this young female and it made such a huge difference in her life and I didn't do the surgery but I restored her. I was like that was that kind of pushed me in this direction and being able to treat more patients and get them to a really good outcome, where it makes you feel like you're having like an impact to your profession, if we can get technologists or different things to allow us to treat more patients and do it easier, where we just make a bigger impact, I think that's. I think that's something to look forward to.

Speaker 1:

I like that. That's great.

Speaker 3:

Yeah, I think that. How about you?

Speaker 1:

any. What do you guys? You're at a slightly different phase than I am. What are you guys excited about? No-transcript, and we're just going to be guiding these like new tooth buds, right, like it's just going to be a totally different form of dentistry, like a regenerative. We're not even there yet.

Speaker 1:

But I think more on the AI side of things, with digital design, digital planning, I want to get to where I can just take a CT scan and the AI is just going to take it from there. I just tell them what we need to do and it's got a prefab hybrid design ready for me to go ahead and just do the case and then I'm going to submit the stuff in there to some other splicer or whatever and it's going to. It's going to spit out a hybrid case design right away. I'm very curious with how smart AI gets in terms of diagnosis, treatment planning, case design, how much easier and faster that makes it for us, and it could get to a point where we conduct the surgery, we take a few scans. It's probably going to be one like integrated device we're not going to have separate photogrammetry for too much longer, probably and then you submit everything and then, before you know it your printer's already going off or your mill's going off?

Speaker 1:

Whatever the case may be, how many more things can get automated once we really start thinking with that sort of web 3.0 type of mind and to see just how far it's come, even just since I became a dentist, which is practically yesterday compared to a lot of leaders in our field. I think it's going to be really interesting to see what full arch and beyond looks like in 10, 15, 20 years. I don't think we can even really wrap our heads around that yet.

Speaker 2:

Yeah, I would say for me, I'm excited about 3D printed prosthetics and the material stuff coming up. I'm guessing in the next, pretty soon, we're going to have the ability to do everything 3D printed. We won't need to mill anything. Everything 3D printed, we won't need to mill anything. Patients can basically be in a final same day and if you need to make a change, it'll be very quick and hopefully pretty reasonable for us to do. I would love that kind of capability and I think that's probably going to be coming here relatively soon. That's next on my docket for big things.

Speaker 1:

I want to see 3D printed arches that, like the material, can be a different color depending on the wavelength that it's exposed at, so you can have a single resin that will print out red and like different characteristics at different slices and then you can just make a fully characterized yeah final when it prints. I think that'd be really cool too. We'll probably see it. Yeah, it makes a lot of sense some sort of chameleon effect.

Speaker 3:

yeah, yeah, I talked with some guys about some ai stuff, when I can't remember adso was ADSO or Dicom or what, but talking with them but like the Pearl guys and some of the other guys say, do, I think that'll be really interesting. What I would love to see, that I would actually get really excited about, is if you could input all the patient's health history. You take the scan, you have all the Hounsfeld units and then you have basically this AI program that can basically walk you through the different treatments that are available for this patient and would give you the prognosis before you even start. So you say, hey, we're going to use these implants. It's already been based off of the 3d scan. That's integrated.

Speaker 3:

Megagen actually has, like the CT scan that's facial, I think, a facial scanner. So you do the CBCT, you get the facial scan, you throw it into their design software and here's the design all in one thing. That's, you do that. Now you've got Hounsfeld units and bone density. Now they you might take a blood test and you get quality of bone metabolism and like some other factors. And then you put all this together and say, hey, mrs Jones, and this is all within shorter period. Mrs Jones, here's your prognosis. You've got a 75% chance that this will last you 20 years, based off of these factors or something like that.

Speaker 3:

That's actually too unreasonable.

Speaker 1:

No, it's not. I love that, cause that's kind of what I was alluding to with the treatment planning from the CBCT. It can give you different matrices of here's the chances that you'll need a quad zygote for this case, or you could probably use this and that, and it'll tell you, like, all the different anchorage points that you could use. And I think there's just so many things. I love that you mentioned blood tests too so many things that happen in implant dentistry and so many failures and complications that happen, like we describe it to. This is just biology.

Speaker 1:

Things happen by chance. We just hope that something works. And by chance, we just hope that something works. And if it didn't work, then maybe we don't know why. So we're just going to try it again and hopefully it works the second or third time. There these things are causal, like there are deterministic things around it. Um, we used to think that bone loss was just something that happened right, like you had to play subcrustal because you were going to lose a millimeter and a half to two millimeters of bone, no matter what, and we don't know, we don't totally understand why. But yeah, it happens, so we just compensate for it. There's so many other things that when we know more about it and as AI learns and gets all that together, we can make more predictable dentistry. We'll have a better idea of what will work and what won't. It won't be so much just anecdotal feel right For sure.

Speaker 3:

I think, for whatever you think about DSOs and large groups and them getting into education and different things, I do think a potential positive is just large data sets. I mean you look at a clear choice or something. If you could run through all of those things and say, hey, you can categorize down to the health histories and basically all of the failures come in with these groups of people and we can like weed all that stuff out, I think, yeah, I think that's powerful stuff. Yeah, for sure, for sure.

Speaker 2:

Cool, hey, chris thanks so much for joining us today. I know that we really appreciate it. I'm sure all of the listeners really are going to take a lot of golden nuggets out of this podcast as well. Thanks so much for being here and we will see everyone next time on the Fix Podcast.

Speaker 3:

Thanks guys, it's been a pleasure.