The Fixed Podcast

Unveiling Three on Six: A Revolutionary Approach to Implant Prosthetics with Dr. Logan Locke: Part 1

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Dr. Logan Locke joins us to unravel the innovations behind the three on six FP1 full arch method. Discover how Dr. Locke's journey alongside Dr. Randy Roberts, starting with affordable single implants in Utah, evolved into groundbreaking procedures like all-on-x and the three on six approach. Learn how these segmented arches, supported by six implants, offer both cost and functional advantages over traditional methods, and hear about the early challenges they faced, from milling limitations to achieving cost efficiency.

Explore the strategies Dr. Locke employs to manage implant bridge failures and the solutions necessary for long-term success. We delve into the flexibility of treatment plans, such as transitioning from three on six to two on five designs, and the critical importance of maintaining bone integrity. Special considerations for younger patients are discussed, alongside the potential implications of initial bone removal and the role of FP3 prosthetics. We also touch on advanced solutions like zygomatic implants, which extend the lifespan and effectiveness of dental treatments.

In this episode, we explore the intricacies of prosthetic placement and surgical workflows in dental surgeries. Dr. Locke shares insights on how prosthetics influence bone resorption and tissue development, emphasizing the transition from cement-retained to screw-retained systems. Discover the strategic use of multi-unit abutments to maintain implant integrity, and learn about the challenges and benefits of in-house prosthetic production. With a focus on atraumatic extractions and the importance of avoiding unnecessary bone removal, this episode provides a comprehensive look at the techniques that enhance patient outcomes in implant dentistry.

Tyler:

My name is Dr Tyler Tolbert and I'm Dr Soren Poppy, and you're listening to the Fix Podcast, your source for all things implant dentistry. My name is Dr Tyler Tolbert and I'm Dr Soren Poppy, and you're listening to the Fix Podcast. Hello and welcome back to the Fix Podcast. We are here with a pioneer in implant dentistry, dr Logan Lott. We are super fortunate that he's been willing to spare his time with us and we're going to be covering some really interesting concepts, a little bit different from the typical fare that Soren and I talk about. So I think in this episode, you and I are probably going to be taking a little bit of a backseat, learning about some interesting surgical and prosthetic concepts and different ways of thinking about and approaching full arch. So, dr Logan, we really appreciate you coming on?

Tyler:

Yeah, happy to be here. Thanks for having me on, guys, awesome, awesome. So for those who are not aware of you, those shamed people may they be, could you help us out just a little bit and kind of give us a little?

Logan:

bit of a story of how you got to where you're at and where you're at. Yeah, so, um name's Logan Locke. Um, I'm on here basically because I'm I've, uh, I've been with three on six for, uh, basically since its beginning. Um, my partner, randy Roberts, and myself, um, he, really, he really started it back in like 2016. Really started it back in like 2016. And I jumped on shortly after that. We started doing the first cases in our office. I assume we'll get into three on six.

Logan:

I myself, born and raised in Utah, went to Creighton for dental school and just kind of gained a passion for implant dentistry. There had some really awesome mentors. Can't say enough about how much they allowed me to do in dental school, which I think, after talking to a lot of people, I thought it was normal. But I think my experience in school was far different than most. And then so came to work for Dr Randy Roberts and we just did a billion low-cost implants and that's kind of how we got started with in the full arch as it slowly progressed and and into attempting FP1, basically.

Tyler:

Okay, and so what was kind of just the general landscape back in that time? So you said a billion low cost implants, what. What did that look like? What were most people in your town doing at the time? What was the market?

Logan:

Yeah, so Utah is a heavily, heavily saturated place. Um, it is hard to compete in this area and so we were running basically a quantity program. We were doing implant above and crown all the way through for 1500 bucks. Um, we were using, when I first started, we were using high-tech implants, I think they're I don't even know where they're out of Um, and then we slowly transitioned to neodent CM. Um, we were doing most of our crowns on a CEREC. So you know it was. We did a lot of implants and really experience-wise, I couldn't have asked for more, but it had its own challenges and so, yeah, that's $1,500 all the way through. I wouldn't do that right now, but there was, it had its own challenges and so, yeah, that's 1500 bucks all the way through. I wouldn't do that right now, but Definitely got me some good experience.

Tyler:

For sure, for sure, that's awesome and so you know, being sort of the economy, I guess single implant guy, were you approaching full arch at the time or was there a modality that you guys were utilizing at the time For that, or was it more just like single tooth replacement bridges?

Logan:

mostly single tooth and implant bridge and uh. And then I started to dive into all on x, um, so I took some courses on that, did quite a few cases. Um, that's about around 2017 is when uh partner Randy started doing. He essentially started doing FP1 with Sarek Bluecam and we were just. He had a cousin that needed a full mouth. He didn't want to remove bone, decided to put some implants in and after they healed up, we put just stock abutments on and scanned them and then we designed our own bridges. They did not look the most beautiful at that time but it's. It functioned and that's kind of how the whole thing began.

Tyler:

Okay. So yeah, I'm very naive to the concept of three on six. I mean, I've looked at it. I kind of know it from just a bird's eye view, but the basics that I know is that you were working it's a fp1 full arch method where you have segmented arches, so it's a total of six implants and three separate restorations that are just kind of butted up at once against against one another in a way that looks, you know, fluid and looks like a full arch. Um, but that's about as far as I go. So I'm interested to see what kind of advantages you guys saw versus all annexes and I love that you have that all annex background. So what was so attractive about that modality?

Logan:

The. The gist of it was, you know, we started to see, once we did the first cases, we got people coming in and they're like, we really like this and it was super, super challenging at the time to do us, you know, even a full arch bridge. We'd try one piece but our pucks weren't big enough. Um, the cost to go through a lab was incredible. It was just way too high to try and have these um fabricated at the labs that we were using. Um, they were weaker when they were one piece, so we'd we'd see fracture more, more frequently. We were using Emax at the time because it's just what we could mill out. Um. So, yeah, three on six, basically, is a FP1 modality Um, by no means did we invent FP1, obviously, um. But the main issues that we saw we had a younger patient, a younger patient base coming in, a lot of addiction, completely broken down dentition and they needed full arch. And the problem that we saw, or the ethical dilemma I think that we felt, was the bone room. We know this stuff isn't going to last forever, this stuff isn't going to last forever, um, and so when we were looking at, you know, 7 to 15, sometimes millimeters of bone reduction in order to hide a lip line or create a prosthetic space. In a 28 year old, it just, um, yeah, we decided we wanted to look at other options. So so three on six is a modality, an FP1 modality. It's a way, from start to finish, to do FP1 slash FP2 consistently and affordably.

Logan:

So we essentially found that we couldn't use outside labs because they weren't proficient enough to get the pontic site development that we required. They were way too expensive, so we were having to charge patients way too high of fees and so they just didn't want to do it. So our barriers were bring the cost of the procedure down, bring the skill needed down, because it is a tougher procedure to do, and and make it so that more people could do it consistently. And that's kind of where and I guess the latter part of it is create something that's marketable, because no one knows what fp1 is.

Logan:

Patients don't understand. And often I think patients don't understand when they're getting an all-in-x. They don't understand that they're going to have fake gum tissue, that they're going to have fake gum tissue, that they're going to have bone removal, cause often we just don't. That's part of the process. We don't describe that when we're selling patient um, which I don't think is terrible. It's just part of the process. But most of the the people that come to see us didn't know that until they Googled it after a consult.

Tyler:

Okay, okay. So one thing you said there I can kind of imagine some people having a little bit of a knee jerk reaction to if they're kind of very set in the you know all on X uh cross arch stability world. As you said, that it was weaker when you were doing one piece all the way across the arch. So how did segmenting help us out with that?

Logan:

Yeah, so the I mean the reason we need a prosthetic space right is for the strength of the prosthetic, and so that's part of the reason that we have to remove bone. Cross arch stability is is crucial for the initial stability and the healing of the implants. And we still our initial prosthetic is one piece. We we want cross arch stability, we want those implants to be supported during the healing time and then, um, after that is, once the implants have integrated, that's when we start to segment, uh, in order to give them, one, a more durable prosthetic. And two, we want, we want to start increasing the load on the implants.

Logan:

We looked at a lot of research, for you know, when we look at, say, an all-on-six, say we're doing six implants, the research that we found suggests that the anterior two implants get the bulk of the load, the posterior two implants get the bulk of the load and really the ones in the middle are taking much, they're not providing a ton of extra support. And, uh, we know that implants don't do well when there's not a load against them. Uh, we've all seen an implant come in with a healing abutment after 10 years that never got restored. You're always bone loss, yeah, and so the idea of it's progressive loading. I guess Progressive loading these implants as they heal is kind of what drove us Well. Honestly, the initial part was that was as big of a puck as we had or as big of a block as we could mill with our CEREC.

Logan:

That's as big as we could get of a block as we could mill within with our seric that's as big as we're on again. But then we started, you know, looking into it further and it was working and and implants were retaining bone and we were getting really good scans of bone density and um bone deposition and and so we basically it was a accident, well, not an accident, but kind of lucked into something that we believe works better long-term and distributes load more evenly across more implants. That makes sense.

Soren:

So a question that I have for you as far as the three on six goes is I mean, that makes sense to me. I think the first thing I thought of when I was looking at 3N6, I think the first argument a lot of people have regarding it that I've seen is the well, there's no cross-arch stability for, you know, to get past that primary stability portion of the implant, and if you are getting that cross-arch stability, that's great.

Soren:

A question I have, though, is, let's say, when we're doing a fixed prosthetic on four or six implants and you know what our philosophy is, we typically do pterygoids in every case, so we're doing all on six, with four on the anterior, and where we see a big benefit to that is if an implant fails down the line. Right to that is, if an implant fails down the line right. Um, we, there's a lot of real estate where we can remove an implant, place another one and load another temp, or or even, if they are at the phase of zirconia, um, mill another zirconia pretty easily. Um, how do you guys combat the issue of you know, if you have three different bridges and one implant fails? I feel like that might be a bigger headache for you as the clinician to then go in there, and you might be kind of limited with the amount of space and bone that you have to replace that single implant on those bridges.

Logan:

For sure. Yeah, so I mean, if, if, if we're talking, you know, 10 years they're already in segmented bridges. They come back and an implants fail. It's pretty easy for us to be able to take our design and basically remove one of those, one of those um splits. So, you know, maybe we turn it into a two on five um, basically creating those segments in different areas.

Logan:

Worst case scenario we can turn it into a full arch prosthetic and you know, at that point your biggest weakness is just the full arch. You know one big piece of zirconia. It tends to fracture more frequently. So at that point we'd maybe warn the patient that that's something that could happen down the road, being that we're not having a 12 millimeter restorative space. Oftentimes we're in the, you know, six to eight millimeters. So, um, so that's kind of the worst case scenario.

Logan:

But we, we find that, um, it leaves us so much, so many more opportunities because, yeah, we've got these implants in but we didn't remove any bone. We, uh, we kept every ounce of bone that they had at the beginning. We're placing these implants at a prosthetic spot where we're getting good pontic site development and then, let's say, 30 years from now, this sucker fails, we're getting bone loss and it just doesn't look good anymore, we'll take the implants out. We'll put them in an All-On uh. Do some pterygoids, we do um.

Logan:

A lot of our um providers are placing pterygoids. They're using those within a uh three on six slash four on eight framework where we're we're still segmenting against those pterygoids Um. So all of the things can still be applied. My belief is that we're giving them an extended life on what bone they have, because it's you know all of this stuff how long it lasts. We're going to see the ramifications of what we're doing. I think 30 years from now. We'll see what happens with all these full arch cases. But if we've got a lot of bone and we can still We'll see what happens with all these full arch cases.

Tyler:

But if we've got a lot, of bone and we can still go to an all on X, from a three on six, then great, okay. So in other words, if you're losing one of your guys down the road, this is a long term failure, like late failure. Yeah, five, 10 years down the road you could lose that implant and you don't necessarily need to be replacing that implant and just making a new segment. You're actually now going to, you're going to refabricate a whole new one that connects two segments, so that that way you know it's kind of like you didn't really lose much at all because the other implants were already integrated.

Tyler:

So now you're just sort of swapping it out, going from three on six to two on five, or maybe you started four on eight. I had to think about that one.

Logan:

Yeah, you got to think about how many bridges are on now. Now, yeah, and if you think about, I mean so, our general placement of implants, if we can get them straight up and down in the first molar area, great, but we still angle with the sinus quite a bit in the posterior. So let's say three to four to uh, we almost always place an implant in at number six, uh, at our canine sites. So six and 11 are getting implants, and then um seven and 10 generally. Now, if we had number seven fail, I'll just put an implant. We grafted everything. We graft every single socket that we take out of. So usually I have a, let's say, seven fails, I'm going to put an implant in at eight. I'll kind of leave her seven off of it, and I've still got a three on six. So there's still, um, still a lot of opportunity to move things around, um, with what we're doing, because we just we generally keep just a ton of bone.

Tyler:

And it's really too like.

Soren:

I really like that. Yeah, I was just gonna say I really like the idea of it because, you know, something that we talk a lot about on the podcast is the fact that, um, you know and, and that primarily what we are doing is FP3. Uh, and what ends up happening is right, you have patients that go into FP3. Um, that being said, a lot of our patients are patients that come in that you know that indenture or they've been missing their posterior teeth for a really long time. So it's not like a huge jump to go to FP3. But it sounds like a lot of your patients you guys are marketing towards. So maybe you're seeing some younger patients with, you know, addiction issues or whatever it may be that's causing that decay earlier on in their life. But something we definitely talk about is the fact that when we remove that initial bone and we go to the FP3 style down the line, if something fails, then you're getting into. You know some of the more advanced implant techniques, like Zygomatic implants.

Soren:

Yeah, definitely. You know, even we're kind of seeing, you know, subs now and all this other stuff to to repair those defects that they initially had. So you know, it's kind of like your initial set of teeth is phase one, fp3 would be phase two and then a remote anchorage is phase three, but you guys are just adding another phase on it, which is wonderful for the potential of the lifespan of these implants. Yeah, out of these implants? Yeah, how do you see like the tissue over time? Are you losing any of those papillas over time? Are you having any issues with aesthetic concerns?

Soren:

That's something that has, even, like FP1, has kind of made me nervous about going into doing a lot of FP1 cases is because if that you know what FP3 allows us to do is it kind of avoids any of the aesthetic recession problems.

Logan:

Yeah, so I'm curious what you have been seeing over time and how you combat those problems if you do see them so the way that we, the way that we do the case and the way that we train guys to create really as much keratinized tissue as possible, we're finding more and more that that's what, that's what drives the success of the implant. So, um, when we're doing an fp1, we're using the pot, the initial prosthetic, the temps to separate the keratinized tissue, let's say, on the upper. We're going to pull a lot of tissue from the palate the day of surgery and we're going to leave it. We're going to leave the bone basically exposed under the prosthetic and we're going to allow secondary intention to fill in that area. And so we tend to get really, really good KG over time.

Logan:

Do we still see a little bit of gold from an abutment showing um from an mua? Yeah, we can still. We can get some of that stuff over time. We're not seeing most of my patients. Papillas remains awesome, assuming that they're cleaning it. Um, papillas remains good. Everything's hidden underneath the tissue, but occasionally we have a little MUA exposed. That's about the extent of the issues that we're seeing and that's. You know, for me that's a sacrifice I'm willing to explain to the patient. You know why they have a little gold exposed when they pull their lip up real high.

Soren:

Yeah, is there anything you do about that, like if it's an aesthetic zone?

Logan:

We can, we'll try. If they're showing it when they're smiling, then we'll uh, we'll get some alloderm in there. We'll try and cover it up. We'll uh. Generally we try and plan our cases with um with space to drop down muas. So we plan our implants fairly deep, use a longer mua to start, try and gain the tissue at that and then, if we need to drop it down later on, we can can and hide that MUA.

Soren:

Got it. Yeah, Are you able to? I know that I mean, if anything you feel uncomfortable sharing, like, just let us know, we're happy to keep it. I was just curious what your the prosthetic work, the surgical workflow, looks for you guys. You said that you leave some, some bone under the prosthetic, which makes sense. But like, are you guys, is there like is it two millimeters that you kind of like give between the prosthetic and the crest of the bone in order for that tissue to heal in, or what? What does that kind of look like? And then are basically you suturing under cause. That's like kind of typical FP1 style, right, yeah, so I'm just curious, kind of what that surgical workflow looks for you guys and um, yeah yeah, so, uh, just a bit.

Logan:

Once we have our, our implants in, um, for the most part we're we're uh photogrammetry and printing same day. Our lab for all of our providers is basically on. They get scheduled for the day of surgery so they can immediately convert the wax up and we can print it and just go direct to connection. We place the prosthetic and oftentimes we are going to allow the prosthetic to drive any resorption that may happen. So a lot of times we see uneven bone. It's pretty rare for us to remove bone, usually only really gummy smile, but we'll see the prosthetic up touching the bone. We usually try and keep it a millimeter and a half to two millimeters off of the bone. But we'll let those pontics you know in the posterior oftentimes, where it's uneven or we're switching from let's say we're switching from two premolars and two molars to, uh, one premolar and two molars, that uh, that prosthetic is going to drive the resorption and then, as the KG fills, in underneath it, it's going to create that pontic shape and size that we want and that thick, characterized tissue.

Soren:

Got it? Are you? Are you guys flapping during your procedures or typically, like I'm just curious about the surgical workflow? So, is it? Is it extraction, no, flap implants kind of go where you can find that initial bone and then you just go to the because that's. If it's that way, it seems like it'd be a pretty efficient surgery yeah, yeah, a lot of the time we can do it flapless.

Logan:

Uh, depending on what sort of dentition they're currently in, um, this is a fully guided surgery for the most part. So, um, we almost always require licensees so that we can manage the implant placement. Um, we help them plan the cases, get the guide sent over. So everything for the most part is guided into place, because it's such a difficult procedure to get those MUAs and those scaraxes channels coming out, not out of an embrasure. So everything's pre-planned. But, yes, oftentimes we'll flap, like I said on the upper A lot of times.

Logan:

If I'm missing posterior teeth, I'm going to pull a lot of that KG from the palate, I'm going to move it over to the buckle of my prosthetic and leave the bone exposed underneath and let that fill in. If they've got a full set of dentition, then we can do the cases without flapping and basically our lab is just going to get those every pontic right into the sites where the teeth were originally. So you know, we like to say, if it's, we're treating these cases exactly as if you had a patient lose seven through 10. And you know, at that point we're not removing bone, we're not trying to hide a prosthetic really high. We're going to try and create as natural of a of a papilla and natural of an appearance as we possibly can with a bridge from seven to 10, we're doing, we're doing the same thing, just all the way across.

Soren:

Got it. That definitely makes sense.

Tyler:

And it sounds like everything is going to have a an MUA. You're not going direct to fixture, it's going to the MUA. You're not going direct to fixture, it's going to the MUA. Or do you do some direct to fixture? I'm just kind of curious about some of the prosthetic nuances of it.

Logan:

Yeah, we've tried a few different systems. So we started off doing all of these cement retained. The first cases that we did, uh, in the first three or four years probably, we were doing fully cement retained cases um it. They turned out really beautiful. Um I still some of my best cases as far as pontic site and tissue development came from those cement retained cases. But it was really complicated and really um it it threw off a lot of providers that just didn't want to deal with how complicated it got.

Logan:

Yeah, um, now everything we do is basically a direct connection on muas, um, all screw retained. We have tried a couple implant systems out that would go direct to implant with with immediately printing and putting that connection really close to the bone. It worries me a little bit so I prefer to have a little bit of space with an MUA. But we can. That's the other, that's the other part of you know, if you have an MUA exposed, we can always put on either custom or stock abutments for that specific bridge and you could pivot that way as well to drop that closer to the implant level.

Tyler:

It does seem to me that kind of the keystone and being able to do this and be flexible with any type of prosthetic complications that either happen now or later is that you're able to make these with your own lab. I can imagine if you're very dependent on sending out to external labs and you're paying a large lab bill for this and you start having some complications and having to change the schema of this whole three on six thing. It can very quickly land you being underwater, Would that be?

Logan:

it. Yeah, I mean, that was the initial issue that we had is they're charging us, however many dollars per unit and we're making this huge bridge so you have to replace even an immediately printed case where they didn't want to send you the file or you have to pay extra to get the file so you could keep printing it in case you had any issues. It just became it was too much. I mean, I remember taking my first all in X courses and they, they would brush over FP one. You know they, they told us about the different classifications and they would brush over FP1,. You know they told us about the different classifications and they would say, yeah, if you want, this is, this is the unicorn. It's for only very specific patients. It's really complicated and you have to charge your patients 80 grand per arch and it's like man, probably never do that, never do that.

Logan:

Um, we created our lab in order to essentially remove that for ourselves and then it turned into removing that for our licensees. So you know, for us uh to, let's say, we had to remill, uh, a full arch. I think our lab right now now is charging maybe 300 bucks for the full arch of zirconia in a remill. It might be less than that, I'm not sure. But as far as our pricing goes, just to kind of give a framework of things, we deliver basically the full arch to our licensees for $5,000 an arch. That includes the implants, the abutments, the immediate prosthetic, the secondary prosthetic, the final zirconia. So basically your surgery in a box is $5,000. And that's surgical guide as well. So we feel like it's a pretty fair price for everything you get, especially when it's including the implants and abutments and uh. And then, like I said, we we take those costs and any redos, remakes, anything like that. We just lower it as much as we can so that people aren't restricted by the cost of things wow, wow.

Tyler:

So are all the people that you guys are licensing out to you, know I? I assume this means they can market three on six and say there are three on six providers. They're all going through the lab that you guys developed and then that's hub and spoke type of thing.

Logan:

Yeah, so that's, that's the only thing we require. Um, uh, we kind of have over the years it's kind of created these fan clubs, which is kind of funny on you.

Logan:

you know, we get these groups on facebook that yeah just love that three on six and so that all we get all these patients coming into these groups. And one of the issues that we we found early on is patients being afraid that they're going to get a worse or a different product than if they came to utah to see us. And that's one that's one of the hurdles that we wanted to get past, because even still, most of our patients fly in from out of state searching for this. So as we started to put these providers out, we wanted them to be delivering the exact same stuff that we were putting out, so that we could go on there and say, no, don't come to Utah. That's your name. Yeah, stay there. You're getting the same exact product. So we do require, if you're marketing three-on-six, use our lab, use the implants, so that we can say, essentially, stay in Chicago, we've got a great doctor there.

Tyler:

He's doing the exact same stuff. Okay, okay, so what is kind of that sort of curriculum? So let's say, somebody wants to incorporate doing three on six and they reach out to you guys and now they want to get into that world. A what do they have to do to get involved in it? And B, once you see that person that wants to do it, what do you need to see from them in order for you to say okay, you, you're good to do this?

Logan:

Yeah, so they we hold a training out here in Salt Lake Um. It's essentially a four-day training. Wednesday through saturday um heavily wednesdays, didactic thursday, basically full model work um friday, some prep for a surgery and then saturday where we we get each um trainee, uh, an arch of three on six to do on just some of our own patients that couldn't afford it full price. So everyone gets to do a full arch when they come through our training. The cost of the training is $25,000. Five of that is our one-time licensing fee, so we don't charge any licensing fees beyond that.

Logan:

That gets you kind of up on our website as a provider on that. That gets you kind of up on our website as a provider From there. If we feel like a student needs a little bit more one-on-one time before we can confidently put them up on our website, then we suggest kind of some further training which we can do. We've traveled out. I've traveled out to a lot of our licensees offices that kind of want to run it in their own office and I'll help them get their staff set up and help them run through the workflow, get their printers all going, you know, just make sure everything's dialed in in their own space, so they feel confident doing it.

Tyler:

And what would you say is kind of like a baseline. You know I have X amount of skill. I'm ready to go do this four day course and by the end of it I'm going to be probably ready to go and do some zero ounce X.

Logan:

Yeah, we, we, we require them to a place. I think at least 150 implants is where we just kind of guessed where we wanted them to be, guessed where we wanted them to be. Um, we love getting FP3 providers because they're just so much more used to, uh, surgical complications and so we have guys that have come through that are just amazing FP3 providers that just added this to their workflow. Um, they charge more for it because it's more complicated and the longer surgery, sure, and they're still doing, you know, they can place pterygoids super easy. They can, they can do everything and it makes our lives a lot easier when these guys come through and they have all that experience.

Logan:

But we've also trained doctors, general dentists that looked at fp3 said now they didn't feel great about, um, some of the issues with fp3 and, and so this is their entry into FullArch and it just requires a little bit more input on our end and we feel like we've kind of created a family within this three on six group where these providers they'll text me directly, we walk them through cases, all jump on and help with their implant planning For their first four arches after they've gone through the training I on and help with their implant planning For their first four arches after they've gone through the training. I basically manage all of their cases, start to finish, to make sure that the wax ups are done properly, that we go through their implant planning together to make sure that they're thinking of different things that can arise during surgery. We try and really baby them into this because it is complicated and most of them have just taken it and ran with it.

Tyler:

So it's been great to see so is that to say that you know, after they've had those first sort of you know cases where you've been holding hands through the planning and everything you know, they're feeling confident to go ahead and do their own implant planning and their own surgical guide fabrication. Like, at what? At what point are they having to, uh, coordinate with your lab? Is that just when the final process come along for the second? No, so they're they're.

Logan:

They're doing it from the beginning. So our lab will do. Does the wax up? Um, our, we have one um employee that does all the implant planning because she knows how we like them planned and so she's going to guide all of the surgeons, all of our, our licensees, through the implant planning process. I'm on a team's chat for every single one of those, so if any of them have a question they kind of just tag me in those things and I can hop in and help them with the implant planning. If it seems like a more complicated case, um, we try and make it. So we're as available as possible to help them through those. But yeah, after four arches I guess their their initial arch. During training we baby them through their first four and then we kind of set them loose and they just ask us if they need anything from there wow, wow.

Tyler:

So it might assume and correct me if I'm wrong, because you have mentioned using teragoids and things like that. So in my head when I'm thinking about doing you know six implants and, um, you know when I've seen most FP1 cases like this is usually going to be a younger patient, not necessarily, but they've got, you know, bone and all the Bedrosian cells like the. You've got bone that you can use all the way back to the posterior and we're probably placing axial implants. But in some situations we're tilting a little bit like how how do these usually end up looking? Do we have angling implants?

Logan:

yeah, we, we usually, I would say most cases we have to angle with the sinus.

Logan:

Still, um you know these type of patients. At this point they've lost at least some bone in the posterior, sure, um? So we do angle. I would say what we find is most a lot of patients that you maybe wouldn't think are candidates for fp1 are in fact candidates, or maybe virgin, to an fp2 type of territory. But, um, the.

Logan:

The comments that we get more frequently than not are I don't want fake gum tissue, um, and I don't want any of my bone removed. Those are the two main things people come to see us for and um. So the, the. If, if the teeth end up a little bit longer than a natural tooth, then it's, it's generally not a concern for most patients. Now some, some are going to be pretty picky about it, um, and then if they're going to be, if it feels like they're going to be very picky, then we go through the fp3 process as well, discuss how we can make their, their tissue maybe look a little bit better if they, if they go through that. But here are the drawbacks we have to remove a little bit better if they go through that. But here are the drawbacks. We have to remove a little bit of bone. We have to hide that joint up a little higher. So as long as we're providing that context to patients, then I think we're in good shape.

Logan:

But yeah, as far as the implants, the planning goes, I think you'd be surprised how many patients are candidates for this. And basic framework yeah, we're're in the. If we can get implants straight up and down in the posterior, we're going to do it. If we can't, we'll move to pterygoids. We'll angle with the sinus um, but we almost always have to get implants in at six and eleven and then we will do seven and ten is kind of our primary place for so laterals um. But we will oftentimes, if lateral um bone isn't great, we'll place at eight and nine cantilever off laterals um.

Logan:

But almost never cantilever a canine on the upper okay, um so I guess that leads to.

Logan:

One of the trickiest parts of this whole thing is, um, just learning how to do a traumatic extractions, because I think that's where we see the most issues with our licensees. They come in and that canine buckle plates gone and then pre it presents a ton of issues moving forward. So we we really harp on a traumatic extractions getting the teeth out without, um, without destroying the buckle plate. Um, we have some doctors that socket shield, that do some of these other techniques to help keep that bone in place. So, um, there's, there's a lot of stuff we can do to help keep that bone in place. Do you have any? Uh?

Soren:

do you have any tips for people on atriomatic extractions and kind of you know things that you like to do to try to prevent and restore that buccal plate?

Logan:

yeah. So the main thing that we I use an ash forcep for almost every anterior extraction yeah, if you can, if you can figure out rotational movement and shoving it up into their brain as you're rotating, you can generally get the canines out without removing any bone. You can get most teeth out without removing any bone. We do eye section canines all the time. I will break it into a thousand pieces before I'll let the buckle plate go. So that's one of the things we we focus on. A lot is okay. This is how you're going to section it In order to preserve the buckle plate. We will oftentimes we'll use our guide and we'll just. If there's a root tip left, we'll drill straight straight through it. Use that space to pull the rest of the tooth out. There's a root tip left, we'll drill straight through it. Use that space to pull the rest of the tooth out. There's a lot of techniques that we go through throughout our course. That kind of help guide them on how to prevent bone loss.

Tyler:

Yeah, yeah, I mean, I think that's one thing that initially, as you're kind of walking us through the surgical approach here, that's what pings off in my head is you know, when you have, uh, this, you know, full dentition, you need a traumatic extraction. You probably got a bunch of teeth that are broken off below the gum line. Trying to be conservative with your flap, trying to work with the surgical guy, trying to make things come out in one place, like that's, that's not an easy thing to do, um, and if you're primarily an FB3 provider, you don't worry quite as much about those things and, frankly, even if you break off a buckle plate, you probably still be okay.

Logan:

You move around a lot of times.

Tyler:

Yeah, you don't really need that type of architecture. So this is definitely a much more intricate, delicate procedure, at least as it appears to me.

Logan:

Yeah, and it will take you longer.

Logan:

We have a lot of guys that come out and I think I I talked to a few that say, well, I've done a ton of fp3, I don't need the training, can I just get going? And it's like now we gotta have to come out, we gotta go through this stuff, because it's it is more complicated than you would think and, um, the surgeries tend to take seven, eight hours, whereas you can do a. You know you can do a full mouth fp3 a lot quicker than that most fp3 providers can, um, so the cases they're longer, they it takes more time to do this and so that's why we generally tell our providers, you know, charge more for it when a patient, when a patient comes in, if you want to sell them on an fp1, you got to sell them on what it is and the difficulty of it, and this is why it costs a little bit more than the FB3, make it worth your time, um, because it's a, it's a longer procedure and you're going to be in there for a bit more time.

Tyler:

Yeah, yeah what do you typically?

Soren:

charge for, if you don't mind, for like your uh all on six or three on six procedure in Utah we're about 25 an arch 22 to 25.

Logan:

Um, we charge 18 to 20 for our FP3 cases. So we try and stick about 5,000 more per arch. If we're doing four on eight, so we're just doing more bridges um more implants than I think we're into the 30 per arch territory. Um, we have providers in in chicago, san diego, um florida that I think charge a decent amount more than that yeah, no, I mean for your time.

Tyler:

I think that makes a lot of sense. So, yeah, I'm kind of, I didn't mean to cut you off no, you're, you're good.

Logan:

Yeah, it's just. But at the same I don't know. At this point I have a hard time with how much we do. If they're a candidate for FP1, I have a really hard time telling them that for five grand less the I'll remove the bone. I do an fp3, so I think they'll just take that they don't value it the same way.

Logan:

Yeah, and so it's a for me. I try and do what I can to get. If they're if they're a really good candidate got loads of bone, they're young, then I'll do what I can to push them into that fp1 and all. Yeah, you know, for me it doesn't cost much more as far as lab fees and everything. It doesn't cost me a ton more to do an FP1 versus an FP3. It's only my time and it's just that initial surgery, everything thereafter, is fairly similar to an FP3 case. So you know, for me, if I've got a young patient, I can discount it a little bit to get them in and and help them preserve a little bit of bone. Then I'll do that.

Tyler:

So I'm curious about you know, at the flagship office that you're working at, what does? What's the whole infrastructure that you have? So you have a ton of ops. How many providers is there an in-house anesthetist, things like that? What kind of volume are you guys looking at per month? And let me share what you're comfortable with no, yeah and share what you're comfortable with.

Logan:

We built this office, I believe, about three years ago. We're pretty close to, kind of right in the heart of Salt Lake County, so a pretty good location. We've got 18 operatories in this office. We've got two surgical suites. We actually regret only making two of those. That's quite a ratio.

Logan:

Yeah, well, at the beginning, you know, we didn't know how much this was going to take off. Yeah, and so Randy, my partner, he was doing, he kind of switched a while ago to only doing full arch. I still and I mostly do full arch right right now. I still love prepping veneers and I love doing, yeah, root canals and I'll do all sorts of stuff. I like it all. Um, so we, we have an associate that does most of the general dentistry here. Um, we trained a doctor about two years ago that ended up staying on with us, uh, dr weisenisenberg, and he helps me with the training. He's super knowledgeable and he's been great to have around. So we've got basically the three of us Dr Roberts, myself and Dr Weisenberg that are mostly full arch. As far as you know, we try and get about two cases a week for each of us. It doesn't always happen, but um, yeah, we're, we're doing quite a bit here and, like I said, most of it about half of it is patients that travel in from across the country.

Tyler:

Yeah, yeah, I'm curious about, um, how you guys kind of got the word out and then you know cause I, from what little I do know about three on six. I do see people asking about three on six and all the other dental implant groups, um, that I'm a part of, you know, and a lot of those. Most people are talking about FP3 and I'm talking about prices between oh, I went to clear choice, I went to new via, I went to so-and-so, um, but uh, every now and then someone will say, oh, what about three on six? Yada, yada, yada Right. So I'm curious, where where'd that national appeal come from? And how does that usually work when people are traveling in and then traveling back and kind of work that out logistically?

Logan:

Yeah, it's kind of funny. It's grown so much in the last few years. I was renewing my uh, my um, malpractice insurance here in Utah and, uh, I was going through the questionnaire and at the very end it said do you do all on four, or three on six? And it was funny to see that specific on a malpractice.

Logan:

You know, it's just in the last two years kind of done this. We put out a lot of content on YouTube initially. We still do a decent amount, and so most of our patients, basically they'll I would say 90% of them them come to us after they've been told by someone they need an all on X. They go on Google and they type in all on X versus, and three on six is the only other thing to come up, and that's going back to what we said about having a marketable FP1, basically, and so a lot of it is just the content that we put out. And then these Facebook groups started and so patients talk within those groups about what we're doing, and so you know, if someone is searching for an alternative to All in X, they usually find us because of the stuff that we've been putting out there, usually find us because of the stuff that we've been putting out there.

Logan:

The idea of starting this licensing program was well, don't travel to us, stay where you're at. This is a lot less complicated if you're close to your house, and so that was the main goal, and I think we've done a pretty good job at that, and these doctors that are doing a lot of this are getting a lot of notoriety in those Facebook groups people saying I went to doctor, whatever, and he's doing awesome cases and they're showing their results, and so we get less and less of these patients traveling in from out of state, which is good, but yeah, I would say online YouTube videos that kind of thing. And, yeah, online YouTube videos that kind of thing. And yeah, it's, it's funny. We're starting to see YouTube content against us. Um, guys that think that, uh, what we're doing is crazy, which is is perfectly fine, but it's, I mean, it's been around forever. This isn't something really new. It's just a way to do it affordably and predictably in my mind.

Tyler:

Well, I think that everything the three of us do was crazy at one point. So yeah.

Tyler:

All right guys. So thank you so much for listening to part one of our episode, with Dr Logan Locke discussing three on six. So we talked a lot about the context of three on six, where it's coming from and the general concepts, but for part two, next week, we're going to be going into all the odds and ends, the nuts and bolts, learning how to really accomplish this procedure, how you too can also be a provider of three on six. So stay tuned and thanks for listening.