The Fixed Podcast

Remote Anchorage and Full Arch Excellence with Dr. Simon Oh: Part 1

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Dr. Simon, an esteemed expert in implant dentistry, particularly Full Arch procedures, joins us to unravel his captivating journey from a conventional dentist to a revolutionary implant surgeon. He shares his experiences in trauma surgery and how a passion for transformative dentistry led to a focus on full arch implants, reviving his career and offering life-changing solutions for orally compromised patients.

Venture with us into the dynamic world of Full Arch dentistry as we explore both the advancements and challenges facing dental professionals today. Dr. Simon highlights the growing importance of mastering complex cases, underscoring the necessity of continuous learning in a field where the potential of AI is becoming increasingly significant. We discuss innovative implant techniques, including zygomatic and pterygoid implants, emphasizing the balance between surgical precision and personal experience in optimizing patient outcomes.

Our conversation takes an insightful turn into the technical aspects of sinus reconstruction and the innovative strategies that are shaping the future of implant dentistry. From creating sinus windows to managing sinus complications, Dr. Simon details his hands-on training experiences that have honed his expertise. We also explore the promising future of materials like Tetranite, which could revolutionize current practices and improve surgical predictability. Join us for an episode that promises to enlighten and inspire dental professionals and enthusiasts alike.

Tyler Tolbert:

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. One thing that we pride ourselves on here is having the clout to bring on the best implant surgeons in the world, and I think that we have not fallen short of that today. Today, we have on Dr Simon oh, who, if you don't know him then you're probably pretty new to Full Arch. So this is somebody that Soren and I have been following for a long time. I've actually interviewed him before, and he's graciously agreed to come back on and talk about all of his expertise. We're huge fans of him, of his Instagram channel, of his work and also his work with Orca Global, which I'm sure you've heard of, as well as their upcoming symposium. So we're going to be getting into all that, but before we do, welcome back to the show, simon.

Simon Oh:

Hey, thanks a lot, guys, good to see you again, For sure, for sure.

Tyler Tolbert:

So it's been a little bit since we've talked and certainly things have grown and we want to talk about all the updates that are going on in your life and career, of course. But for those who don't know who you are, would you mind just kind of giving us a brief introduction as to how you got into implants, how you got to where you are, from dental school to here?

Simon Oh:

Yeah, sure, I reside outside of Philadelphia in the suburbs. I ended up here. Because I ended up here, because you know, I grew up in Maryland. I actually have only lived in two states, maryland and Pennsylvania Went to all the state schools, so University of Maryland, college Park, for undergrad, university of Maryland for dental school, and then I ended up at Hahnemann Hospital for oral surgery and basically I did that until med school ended up, leaving the program but and I was planning to move back to Maryland, but I met my wife. She was a med student at Jefferson at the time. She was doing a residency there and then like, okay, we're gonna go back now, and then that didn't happen. We had kids and then then, you know, they had friends and so like, of course.

Simon Oh:

But yeah, I mean, you know, in terms of implants, um, we didn't do too much in when I was in residency. It was mostly trauma uh center of philadelphia, um level one trauma center, just gunshot wounds non-stop. You know, like that's basically like what we did um. So you know, after um I left, I I picked up a uh position as like a traveling exodontist, slash implant person, um. So you know, exodontia is really cool I, I like it because, um, just from a lifestyle perspective, like it's very simple. You know you meet the patient, they're in pain or they need their wisdom teeth, whatever, and you get them out, you say hello, goodbye, and then maybe you see them for follow up and that's it, and you know that's, that's pretty convenient.

Simon Oh:

But, you know, in terms of like impact, I'd say like the implants is really where things sort of like my focus went into, because that's that really made people happy. You know, people aren't exactly happy to get a tooth pulled, they're happy to get tooth restored. So, um, you know, little by little I started with singles, did multiples edentulous ridges and then, um, you know, at one point I was actually considering leaving dentistry because I was getting pretty tired of it. A lot of people were not exactly thrilled to see you, but then I stumbled onto a full arch. You know, like I started learning about it, reading about it, you know, following a lot of guys on social and reading articles, reading the history.

Simon Oh:

I really enjoy reading that and I just realized, like, realized, like, wow, like you can, actually, instead of just like a single tooth or a bridge or something, implants like you could do their whole mouth, change their life in a single day. Give them function again, give them aesthetics again, um, and like, that just changed the whole game for me. So, like ever since, that's pretty much all I've been doing, I haven't. I mean, I maybe placed like I don't know 50 single implants a year or something, like not really that much, but like full arches are just that's that's all I do.

Simon Oh:

So, yeah, I mean, in terms of impact, I really like it because, you know, like in anything in healthcare, you sort of treat a certain segment of health, so, like you know, veneer people take somebody that's already healthy and makes them a little bit better, right, like they're at the upper echelon of like health. And then you have like your middle segment, which is, like you know, crown and bridge and just routine dentistry, and then you have, like the very bottom segment, really, the orally crippled people, and what that procedure does is we take those people and bring them all the way back up to here again, um, so I I think it's just great. Um, I, I love the, I love the work, I love the technicality of it. Um, I love the sort of um geometric aspect to it, um, like geometry, and I don't know if you guys remember the PAT from the DAP.

Tyler Tolbert:

Oh yeah, we remember.

Simon Oh:

Yeah, for me it's just so interesting. So that's really all I really love right now, cool.

Soren Paape:

I really like that analogy. I might have to steal that one of the three tiers. That's really good. You know it's funny, simon, I always say the same thing and I've probably mentioned it in the podcast before. But something that I love about full arch dentistry is the fact that, instead of your patients coming in for like a routine checkup and you telling them that they have a cavity and it being like the worst thing of their day, you know you're the people that are coming in to see you. They already know that a majority of them already know they need their teeth out and you're there to provide them a solution. Um, and instead of being someone's you know worst part of their day, you can, you can really make someone's day, uh. So I really love that about full arch dentistry as well.

Simon Oh:

Oh, dude, yeah, yeah, I mean, and you know the, the people that you meet along the way, you know, like, for all the consultations that we do, like you hear their stories and it's sad you know, a lot of them really live in the dumps, like mentally.

Tyler Tolbert:

You know, yeah, and yeah that's uh, I like sort of helping those people you know, yeah, totally, and I think there's I mean, there's just so few things in dentistry that you can do that so quickly improve all aspects of someone's health, you know, physically, emotionally, nutritionally, uh, everything that goes along with that and and kind of going along with what you're saying, is like the kind of dentistry we do, like these are.

Tyler Tolbert:

These are treatments that patients get to have done.

Tyler Tolbert:

They don't have to have done always I mean, have to is kind of a different term but they feel this opportunity, like when you come in and say, yes, I can do this, they've probably already been told several times that it couldn't be done, they didn't have enough bone, and I know for sure that you're seeing cases a lot of times that have maybe already been done and things are going wrong and it's looking really bad. Or maybe a patient that just has so little bone left that they couldn't find anybody that said that something could be done, um, at least in a reasonable manner. Because you know we, if anyone's familiar with your page and your cases there's a whole lot of, you know, quad, zygote cases, terry cases, things that are, you know, combination of remote anchorage and stuff, and we definitely want to get into that. But, um, you know, just being able to make what patients thought was impossible possible is the coolest part. And seeing that surprise in their face it really never. It never gets old. It's very rewarding dude.

Simon Oh:

Yeah, and you know, I've noticed a uh, an uptick in uh, people with failing implants too. Of course, one thing to have, you know, a failing dentition or just completely a dentureless, but then you have the people who have already been through that you know, and then you know. So, um, yeah, it's, it's sort of getting a little more complicated. Just cool for on the technical side and the sort of interesting aspect, a little bit sad for, you know, humanity, yeah, I can't say for sure for sure I would say, uh also, I've seen a lot of an uptick in my office of I would.

Soren Paape:

I would consider them prosthetic failures, where they come in and maybe they went to a dentist who, um was was just getting started with with full arch or who who know, who knows why. But you know, they come in and their prosthetic is like basically a denture. You know it's so thick and they're just like. You know, dr Pabby, I've been dealing with this for the last two, three years and I keep going to the same dentist and I just don't feel comfortable in it.

Soren Paape:

It's been like a nightmare and I thought it was something that would be like an easy solution. So I find that kind of fun, too, being able to take those cases. Um, so I I find that kind of fun to being able to take those cases and whether it means, you know, sometimes replacing implants, other times just putting on different multi units and trying to trying to get them to a point where we can make them a prosthetic that's a little bit thinner, that they can talk with better, that they feel more comfortable with it in their mouth. Um, I find that really fun and challenging as well.

Simon Oh:

Oh, absolutely, man. And you know that's sort of like the best case scenario for call it a revision is small tweaks to get them comfortable. Yeah, I mean, dude, if we don't have to put a scalp on someone's mouth, that's a good day.

Tyler Tolbert:

Yeah, definitely I'm curious. So you see a decent volume of revisions. So the ones that you're seeing, you know, are these kind of, from what you can tell, are these being done 10, 15 years ago, Like what's kind of comprises like the bulk of those revisions? Are some of them more recently but poorly done? Or are they just aging at this point, Like what are you seeing most of the time?

Simon Oh:

Yeah, I mean you know, for I guess I guess for my practice it's probably different because you know we get a lot of referrals for rescues and stuff and if someone's having a hard time with the case. But yeah, I mean I would say you know, I've certainly seen a lot of old school dentistry, like some of the first pterygoids that went in, like I saw a bunch of blades from Link Out. Like some of the first terroids that went in, like I saw a bunch of blades from link out, you know, like years ago, and like cases from like so Tom ball, she used to practice near me. He was like the first terroids, the first like full arch, sort of concepts that we're doing all the time now. And yeah, I'm seeing a couple of cases like that come in. But I've also seen a lot of cases that are doing stellar of theirs.

Simon Oh:

So it's kind of hard to say. But yeah, I mean I would say a lot of the problems that I do see like on a day-to-day is more recent. So that sucks, you know. That sucks, you know, for having to sort of go through this all the time. But you know it is what it is, you know, as long as we're all doing our best and sort of keeping the patient's best interest in mind, you know.

Soren Paape:

Yeah.

Simon Oh:

There's no way that we don't have crystal balls to predict the future and see how certain patients are going to turn out the future, but um, and see how certain patients kind of turn out, but um, but yeah, it's. It's sort of a mixed bag, I'd say, but a lot of them, a lot more than I would think um, are recent cases.

Tyler Tolbert:

Yeah, it's interesting because, you know, especially when you're seeing historical cases from people who you know, of who you know did some of those early cases and things, it's like you're a dental anthropologist or something and you're just, like you know, finding fossil evidence of, like our history, of what we do. It's really cool. But yeah, I think it's probably. You know, you talk about seeing a lot of recent stuff and I imagine that's sort of a multifactorial thing, right, because so many more people are doing full arch now. You know, even if the rate at which those would be complicated was similar to the how it was 20 years ago, you're still going to see a lot more cases just because it's become so much more commonplace, um, but at the same time, you may also have a lot of people who, because sort of the barrier to entry into this kind of thing has been lowered, you have people maybe getting into it a little bit sooner than they need to be doing it improperly, not quite having the right training or taking on cases they aren't aware of how complex they actually are prior to getting into it, maybe. Um, so, yeah, that's definitely interesting. I think that, you know, for a lot of the people that are, you know, have been doing full arch for a couple years now, getting really comfortable with it, starting to identify as full arch doctors.

Tyler Tolbert:

What we also have to realize is that we're not just going to be like the primary full arch people. For someone who's getting full arch for the first time, you really have to learn, uh, you know historically, like what all these restorations um, or look like how to take them apart. You know, if I ran into a blade, I'm not entirely sure exactly. You know how I rehab that and the best way to take that out and what to do with it, um, so, learning that history and how all those things work prosthetically, the types of drivers you might need, you know how to pick these old cases apart and how best to revise them. You know, conservatively is going to be a big part of it because we're going to be fixing the new Fuller surgeons work as well. So I think that's just kind of a mantle that you have to take up as someone who, you know, wants to do this exclusively.

Simon Oh:

Yeah, no, absolutely. I mean, you know the what sort of comes to mind is like an edentional search, like we all get it. We tilt the posterior implants 30 degrees, interiors somewhat straight, if you can Otherwise tilt 30 degrees, basically to avoid stuff. What's going to get interesting is when we start to develop protocols or techniques for the revision. I don't think anybody has really thought that through in terms of like okay, this one fails, what do you do next? Is it okay?

Simon Oh:

to have a conserved arch up front with pteroids or something to avoid a zygomatic. That's where I sort of I have some relief thinking about that, because we're having AI come in and so, like you can, I think that that complexity would be something that machine learning could be pretty useful for. You know, to sort of analyze, we can upload a DICOM file into the machine and it spits out an algorithm of like hey, this is your best chance of long-term success for this patient. Yeah, yeah.

Tyler Tolbert:

Yeah.

Soren Paape:

I really like that.

Tyler Tolbert:

Yeah, I mean we, we kind of see, you know that future coming on, uh, from different directions.

Tyler Tolbert:

Like we're getting new ways to get data right, like obviously our data acquisition is getting better. On the CBCT side of things, we're getting good at um arch tracing, where we're able to map people's bite forces and things like that. And then, you know, ai can go in there, kind of consider those types of factors, maybe parafunctional habits, occlusal dynamics and things, and then it can look and find, you know, you know where, where are zygos going to be best suited on on this bone? You know where are we going to be able to fit that? Is that really going to make sense? You know it can kind of analyze, based on the arch form, you know how much tuning fork motion you're going to have on your anterior superior zygote if it has to go way up front or something like that. It's really amazing to see or to just think about where this might be in, you know, five to 10 years and how we can really be assisted through AI machine learning. But yeah, that's a great point. I'm very interested to see where that goes.

Simon Oh:

Yeah, you know, I was listening to Elon Musk on an interview just what his sort of predictions were for machine learning, and apparently it gets better by 10 times every year, so about I don't know four or five years, 10,000 times better. So it compounds.

Tyler Tolbert:

So yeah, life and practice is going to look much different very soon, you know yeah, for sure, yeah, we, we may soon be dinosaurs and we'll just have yonis doing everything, something of that sort um, simon, um, I'm uh, I'm curious.

Soren Paape:

You know we talked a little bit about your background, getting into full arch. Um, I'd love to hear a little bit about, you know, your progression through full arch from just maybe traditional all-on-four to what, what courses you enjoyed the most, getting into remote anchorage and um. For someone who maybe is is doing like some pterygoids or like doing all-on you'd recommend for um to to bring get them into like the remote Anchorage world. And I know you you have Orca and some of these courses. But I'd love to hear your history and how you kind of started getting into that style of dentistry.

Simon Oh:

Yeah, you know, um, I guess, uh, I first heard about the possibility and I think I did what a lot of people who had been placing conventional single implants for a long time would say, which is like that's crazy. You know you're going to load it right away, you know you got to wait, and so that really piqued my interest and caught my attention. So I just started reading, I read, I read a lot of articles, I read a lot of textbooks on the on the subject matter and and it was very compelling evidence that this is a very viable and very good treatment option and protocol. But you know it didn't really. You know like you can take concepts and think about it and learn statistics and everything, but it doesn't really click clinically. Like you have a jaw flabbed open. You know what do I do right now. You know like what's what, like where I put these things, you know and, and so I went online, I started placing them the best way I thought, and I made mistakes along the way. In hindsight, I wish I did some sort of overseas conventional only live surgery course, because that would have made it click very quickly with the right instructions of course. But yeah, I made some mistakes along the way, I started getting better at it. But I started realizing, hey, some of these upper back implants aren't talking like what do I do right now, you know, um? And then I would see other patients who just don't have that bone segment and I'm like I really want to help these people. So I started looking into zygomatic implants. Um, that came first for me, before the pterygoid. I didn't even think about the pterygoid. I was just like zygos are cool, like look at those x-rays. But I sort of got obsessed with it at home and started reading about it, exploring different brands, following other guys in social, and then I was like I'm not going to do this, I'm not just going to try to shoot from the hip with this thing.

Simon Oh:

I went down to Brazil, a town called Campinas, right next to Sao Paulo. There's two really good guys, Abelio Copete and Thiago de Maio, not very well known, but they're good guys. Actually, the Neodent rep hooked me up with those guys. So me and my buddy, um, alex Banner, we went down there. Um, that's where I met Chavane Gupta. I don't know if you guys know him, he's in Georgia. He's a good guy, um.

Simon Oh:

But yeah, we, we sort of jammed out a bunch of Zygos down there in this really, uh, sort of um, um, kind of a sketchy, or there's like there's three rooms, there's like a tummy tuck here, us, and then like some other body part procedure, and there is one anesthesiologist and like at one point, like the suction went down or like what the fuck is going on. It was pretty crazy, man, but like it was fine, you know, it was safe, nobody got hurt, um, it was fine, um. But yeah, we just we were jamming out zygas. They had. They had lined up like, uh, like a ton of cases um, for for the week for us. So it was muscle memory, you know, like, and and that's what I wanted, which was like a very immersive course that you can just go boom, boom, boom, boom, boom and get like really tired at the end of the day, because that's when it really registers. You know, um, keep doing it over and over and over and over and over, uh, understanding what the zygomatic bone looks like from the mouth, like I had seen it uh, uh, during like trauma cases from here and here, but like never from, like intraorally, and so like, like it's very new and just, you know, extending a long drill in there, you know, so that that really made it click. And so, like, when I got, when I, when I left there, that's when things really sort of took off, cause I could, I was able to treat every patient that came in the door and and yeah, that, that, that sort of that was like the inflection point for my full arch career.

Simon Oh:

Was that course in Brazil. After that, you know, I started getting into pterygoids. I'm like, oh, it'd be nice to get some back there, started seeing some guys out there, you know, like Dan Holtzclaw, ramsey Amin, like you know the OGs of this space, juan Gonzalez too, and I was seeing pterygoids. I was like that's really cool, like I could maybe avoid this or, you know, this helps sort of stabilize the whole thing because I guess flex, um, so sort of reading about that, reading about that, reading about that, and just and and started sort of doing it.

Simon Oh:

I I created my own sort of algorithm along the way to make sure that I get into the right spots. It's you sort of pinpoint the hamular notch and the greater palatine canal. Just go right between the two. You start at the level of the GP canal, because that kind of goes straight up and you just start at the same inter posterior line and then you just go right in between the hamular notch and the GP canal. You pinpoint it but but yeah, that that sort of that was like the next step. You know like it was starting to go like that and then you know you've seen like stocks and stuff do that, so that's that's sort of where it is. And then you know, along the way start seeing more problems. I want a solution for that problem. Some are going to fail. What do I do after that? You know, or like, is there a better way? So I noticed a guy, uh, a Vanderlim on Instagram transnasals was like what the hell is that Like?

Simon Oh:

how are they going to prove?

Simon Oh:

Um but it turns out, you know, like I I lecture on this where, um, it's, it's very clever, it's, it's sort of like a hack of the nasal cavity because it does not obstruct airflow by x-rays you're like that's going to obstruct airflow. It does not obstruct airflow. So if you think evolutionarily, whatever your faith is, but from a functional standpoint, our olfactory senses are at the cribriform plate, which is the base of the skull, which is right above the nasal cavity. That's where we smell stuff. So you know, functionally, all the air goes up there, you know. So, if you see, there's a technique called acoustic rhinometry my brother-in-law's an auntie, um but there's a technique where you can measure airflow and actually goes way up high to the superior turbine area and the airflow is the lowest where that implant is.

Tyler Tolbert:

So it's, it's pretty awesome, yeah okay, it's great so you're saying that it's kind of like it's like a, a wind tunnel that goes not in the direction of the inferior conscious, so there really shouldn't be anything along that path.

Simon Oh:

Anything along that path is not really going to obstruct the airflow, despite what intuition would suggest yeah, no, exactly, and you know, think, think of, like what's out there in all of mammals, like smell is a big way to detect a predator. You know, yeah, and so you know it would make sense for that sense or for the airflow to go where the uh directly to where the olfactory receptors are going to be.

Simon Oh:

Yeah, yeah, exactly so it's like it's. It's such a smooth, um sort of sneaky almost way of getting by getting anchorage up front in the intermaxilla without creating any functional harm. It's pretty cool yeah, that's interesting.

Tyler Tolbert:

So I'm curious about you know, uh, you know you mentioned juan and uh, we've uh talked to dr sammy before and uh, holtzclaw as well, and uh, you know the patsy algorithm gets thrown a lot and I think you know they've done some incredible work and really trying to, you know, codify that into something that's easily digestible and helps us understand how a, you know, fully remote Anchorage certified surgeon thinks through an arch. Would you say that that is, you know, really part and parcel how you think about a full arch, or are there kind of some nuances about the types of techniques that you will go to first, what you start with things like that?

Simon Oh:

Yeah, no, that's. That's a great question, you know, I think I think Patsy's a really, really smart way to approach it. You know, I would say that there are, there are definitely times where I go where I place the pterigoids first, that way you know what's going on for the rest of the arch. But you know, I, I'm a creature of habit, I guess, and I I always start with the anterior and if I'm questionable about the middle, yeah, I'll do the pterygoids second. But, like for me, I want to get warmed up, you know, I want to get my rhythmized, get the turbine spinning. So I always know I want to get my right nose, get the the turbine spinning, um, so I always do the first, just out of habit, I guess.

Simon Oh:

But I, I don't think algorithmically it really changes anything if you place the front first and then the turquoise, because, like you know, the front doesn't work. You know what's your next option. It's basically the same algorithm. So I, I don't, yeah to me, you know I maybe I'm wrong, but like I don't think it necessarily, at least on a conventional arch, I don't think it, uh, really changes much, um but yeah, I mean the the reason why I go up front first is because you know the, the anterior bone for the, the upper and the lower, is always going to be better than the posterior right, always that, always.

Simon Oh:

So I I use the anterior as a litmus test. So I will. I will do my normal protocol. I'll drill. You know, if it's a 4-2 implant, I'll drill to about 3.2 a lot of the time and I'll see what the torque is if I'm just at 35 newton centimeters I now know that I'm not going to do any better with the same protocol in the posterior, so I I under prep it, after that use Densibers, so that's that to me.

Simon Oh:

It sort of gives me the best sense and then, you know, once I've built my confidence, that's when I feel good to hit the territory. So yeah, maybe there's like an emotional, like an anxiety protective kind of feature for me to not do the teragrace first Cause, like if I had missed my teragrace.

Tyler Tolbert:

I'm like girl like what am I going to do now Different? Yeah, I can, actually I can totally relate to that, cause there's definitely a point during a surgery where you know you got the critical implants that you need and then everything else is kind of just like ah, we're good, I got the case, like it's secure it's like nothing's really going to go wrong at this point exactly yeah yeah, because yeah, I mean you, you guys get it it's.

Simon Oh:

It's a high stakes game, you know, like if we don't hit our numbers, we're not going to be able to deliver the promise to the patient. They're going to be really upset you know, know, yeah, so yeah. I, I think just from like a mental point of view, terror goats first kind of freaks me out a little bit. I mean, if I have to do it I will, but I definitely like to go up front first. That makes sense.

Soren Paape:

Yeah, I do the same thing. I like to get my security with my front four.

Soren Paape:

And once I have my front four, I know, okay, I can load this case regardless, and then for me it's like I can add a little more support for those tilted implants and a little more teeth for the patient if I get those pterygoids in. But if I miss them, the patient's still going home with a loaded prosthetic and I don't have. I don't have to have a conversation with them about why, you know, maybe the case wasn't able to get loaded. So I agree with that. I mean, I think it is a sense of security where you get your front four, you get the prosthetic to a point where you can load it for the patient and that way, no matter what, the patient's going to go home happy and then just adding that extra security of placing those pterygoids goes a long way.

Tyler Tolbert:

Yeah, I think the only, the only nuance I can think of when it comes to being anterior first, and obviously your whole mental calculus is different when you know that you're in a severely atrophied situation. But Juan was talking about in a case that he knows that is going to be a zygote case, he will, in the interior, go for a nasal palatine and try to get that to reduce how far interior the anterior superior implant needs to go so he can use a shorter implant and reduce that tuning for capability. So I guess like it doesn't necessarily mean that, uh, you can't go to the interior first, but you kind of already have to have in mind what's going to happen after that to determine whether, um, maybe you're going to do trans nasals or you're going to try to do two in the front, or whatever the case may be.

Simon Oh:

Yeah, you know, that's interesting, I never thought of it that way and I talked to Juan like all the time. So like I'm surprised that, uh, we haven't talked about that. But that makes a lot of sense because the um, the lever arm on, uh, say, a lateral incisor um position on your superior is pretty far, uh, even though it's, you know, just one tooth segment of right. I would have to think that the um it's sort of logarithmic with the amount of flexure the longer you go. So um, so yeah, that makes a lot of sense to go for the nasopalatine um position and then sort of load it from there.

Simon Oh:

I, I uh for quads, I have always um done the nasopal or the midline nasopalatine implant last for some reason, you know, because there was a study that I read that the all-on-four or the four-implant configuration with one Zygo on each side, two conventionals up front, had a higher rate of failure of the anterior conventional implants. And to me my hypothesis is that the posterior implants are flexing, putting a lot of stress on smaller implants. So I would have to think that the fail rate on a nasopalatine implant with the quad segment would be higher, and so I'm just one. I don't know what the answer is, but that's interesting though.

Tyler Tolbert:

Yeah, yeah.

Simon Oh:

Yeah, so like say it does fail or you have a patient that is high risk or the torque is only 30 or something, would I have rather have less anterior cantilever with anterior superior zyggas going more anteriorly? I don't know what the answer is to that. But, that's definitely a discussion I think we need to have.

Tyler Tolbert:

Yeah for sure. And I think too is like, with kind of pioneering these algorithms, we don't have really the luxury of tons of data with all these different configurations in mind to really know like a lot of this is more intuitive and just kind of thinking about biomechanics. It's not necessarily in the numbers. We can't really look at the force vectors over 10, 15, 20 years, and so you know, for the most part we're just kind of shooting, shooting from the hip and doing the best we possibly can. You know so, but of course it's important to you know plan for failure. And and I thought about that too when I heard that, I was like well, if you lose the nasopalatine and you kind of scooted back your anterior superior implant, now you've got this huge anterior cantilever. You know is, have you kind of compromised the case a little bit in that way?

Simon Oh:

It's hard to say, you know, when you we it comes down to is is the, the decrease in flex, the decrease in flex enough to have increased survivability of the naso pallet implant? Yeah, to the point where it really makes sense to do that, and that's sort of. I think we need engineers, probably people better with numbers than us yeah, materials involved.

Simon Oh:

Like it's going to be different for grade four, titanium versus 23 or five, you know. So like yeah, uh, yeah, I mean that that's all um again. I I hope that freaking chat gpt can help us, maybe that, maybe it can yeah, chat.

Tyler Tolbert:

GPT. Well, based on what Elon said, by next year. We don't even need to record this anymore, we just say it's a conversation between these three guys and it'll use our digital avatars and make the whole episode. It'll be great. Yeah, that's awesome. So you actually you recently posted a case, and it was.

Tyler Tolbert:

It was really auspicious because Soren, myself and our third partner, caleb Stott, were having a conversation because a case had come through Soren's clinic where he had a patient with a. It was a younger patient with a high smile line and very severely pneumatized sinuses not just pneumatized, but those would look like the Kelly syndrome, where it kind of is actually coming in sort of almost into the plane of occlusion and there was no way with reduction to hide the prosthetic line. And so we were talking about options with, you know, a factory in the sinus floor doing lifts on both sides, coming back alveoli later. And then it was, I think, either on that day or the day after you posted your case, of doing literally the exact same thing. So I was wondering if you could just kind of expound a little bit on that and just kind of talk about how you thought through that case and how you approached it.

Simon Oh:

Yeah, you know, I sort of recognize that sort of complex case conundrum several years ago when, yeah, I mean, because we all look at the Duchesne smile and the big smile um, when we evaluate like where a reduction plane is going to go, and uh, yeah, I mean in in terms of solutions, I didn't really have much. I mean, there there was. There's always times where we sort of kiss the sinus floor on our reduction. You know, like we always see that, um, but like, what do you do when it's like way higher than that? Is that going to seriously injure our patients? Is there a one step option to to sort of fix this problem?

Simon Oh:

So I started doing like an up fracturing technique, so similar to what you said. I used to take a piezo and sort of cut like one in the middle and then crosses like sort of like a pack of ice cubes you know ice tray. I would do that and then sort of try to tap it up. Because my thought process was OK, well, we'll still have periosteal attachment to those bone segments, so that'll be fine, that the segments might actually create a little bit of stability of the sinus floor. And what I did after that was I would take something that would a biomaterial that would harden to an extent. And so I used Augma for that, which is hydroxy by basic calcium sulfate. It becomes hard. So I did that but I found that, like you know, it had good success, but the the times where it didn't work were bad, you know, like terrible.

Simon Oh:

We will have sinusitis or an ancho fistula, like oh God, what a nightmare, you know. So that that to me, you know, made me really sort of careful with how I approach those cases. And so you know, just, maybe it's I'm getting older and I'm like tired, but I don't want to deal with that like complications, like, um, if I can avoid it, um, I will. If somebody's very sort of, if somebody twists my arm, yeah, I mean, I'm not like a robot, you know I'll think about how they're they're feeling about it, but, um, ultimately, you know, my, the way I've sort of been handling it these days is serial sinus lift and then go in, do your reduction plane. Even if the sinus bone doesn't convert and it's just powder, at least you have some sort of biological barrier between the sinus and the cavity. Who cares if it's living bone or not, as long as it doesn't get infected? That's me, if you do a zygomatic it'll be nested in a nice little thing, you know.

Simon Oh:

So that's that's sort of how I approach them, I, I, I like predictability and sort of you know, getting these people through smoothly. Yeah, I mean, if, if you can, um, I guess the the hard one is the edentulous patient with that, because, like, if somebody has a few teeth, you can give them a partial for a while while they heal, you know, and let the sinus lifts heal. But the full denture patient, I guess they sort of just have to. I guess they've been in a denture for a long time, but yeah, it's not really an easy thing. Um, but yeah, it's not, it's not really an easy thing. I, you know, I'm that's uh, that's one of the reasons I'm really looking forward to, um, this product called tetranite, which is, uh, rev bio.

Simon Oh:

So those guys are smart too. So, like they took, um, they took a protein from one of the only creatures that can create adhesion in in water in the ocean. They took that protein. Um, I don't know if I'm allowed to say what it is, I forget if I signed an nda but um, they took that protein and, uh, uh put it in bone grafting material. I'm sure you guys have heard of it, so like, I tested that stuff is crazy. So like, yeah, it comes like in a old amalgam, or like uh the cement, uh container, where you like put in the the shaker, take it out, you put in that uh the triturator yeah, yeah, whatever it's better than it, yeah, yeah so it comes in that thing, you squirt it in, um, it becomes hard within like five or three, five minutes or something.

Simon Oh:

And I tested it where it was an empty hole, I injected the material, just sat an implant into it, let it set. It torqued to 45 Newton centimeters when it set. So that stuff is rock hard, like you can bang on it. It sounds like. It sounds like I don't know plate or something. So I'm just wondering if, um, that is going to change things. I don't know what the sort of blood flow requirements of that is.

Simon Oh:

And there's a lot of sort of uh research and development of like what the proper protocols to convert that into bone are going to be, but like if that can repair a sinus floor, um, that'd be amazing. Um, or if that could sort of like uh, wipe it over the, uh, the the up fracture, if that could be a viable option, that would be sort of revolutionary. You know, I think a lot of people at least the people that are careful enough that can think through these kinds of patient problems um, that's going to be revolutionary for for everybody, you know.

Tyler Tolbert:

Yeah, and if nothing else, if it couldn't um sustain an implant longterm for I don't know blood flow reasons or whatever, I'm not even sure if it's that relevant with that type of material. But you know, it's still that inert barrier kind of like what you were talking about instead of just counting on the sinus grafting bone to heal after six to nine months or whatever you know, if it just instantly hardens right there, you've already got something that's going to support it and might actually be an instantaneous solution, because you could just go ahead, lift the sinus floor with that material, do your alveo and just finish the case. I mean, that would actually be a instant thing. So that's really cool.

Soren Paape:

Yeah For my. I actually called Simon about this case.

Simon Oh:

Uh.

Soren Paape:

I think I'd talk with you and I'd talk with Chris Barrett if you're familiar with Chris and because I was like you know, just I really wanted to help. It's a young, young patient he's, I think he's like 30. And he at least in my benefit he's been. He's kind of had his teeth at the gum line for three, four years now. So he's never really he hasn't had teeth in so long and I wanted a solution for him in a day, right. I mean, like that's always kind of the goal, but in his case in particular I had the conversation with him. Just let him know like, hey, your best bet by far is if we could do bilateral sinus lifts, let that heal for about five, six months and then at least we'll have when we go in and do our alveoloplasty, we'll have something supporting the sinus floor. Otherwise, you know, you could end up in a situation, like you said, where if we end up with an oral-antral communication that we can't repair, you're going to be in much, much worse shape than you are now. So you've been three years without teeth. It might be another six months, but the chances of survival of that case are going to be much higher than trying to get it done in one day and as a young guy right 30 years old, he's got a long life to live with these teeth. Like three, six months is a small portion to pay for for something that I think is going to be much better suited for him.

Soren Paape:

One, one complication that I'm having with this case and I'm curious how you treat it, is that his right sinus is like completely full. Um, I think it's because of the, because of the his dentition, like he just has a bunch of roots in there that are just causing infection. Um, and I think I saw him out like december 1st and I asked him to go to an ent to see if he could do like a fast right to clear it out. But is you know, in your let's say, that he came into your clinic and he didn't want to go to an ENT, would you, would you still do that sinus lift? Would you? Would you maybe make a small hole and clear the sinus out yourself? How would you manage that?

Simon Oh:

no, so if all right. So the scenario is a 30 year old or 30 some year old guy with a portentation, so like root carries or like carries into the pulp sort of situation.

Simon Oh:

Yeah, so if the sinus is completely pacified, yeah, I would not do a sinus graft. I mean, the sinus has to be healthy in order for that to work out. Be healthy in order for that to work out, what if? If, like, say, health insurance is an issue you know, which sometimes is what I would propose to him to sort of work with him, would be to remove the teeth that have protrusion or proximity to the sinus and see what happens. You know who knows, so, like, but yeah, in terms of grafting, or even zygomatics or um trans sinus implants with the opaque sinus, now, I would get that cleared up before you do anything else, you know yeah, I've got, I have to.

Soren Paape:

I have a call with him tomorrow and and hopefully he's seen an ent in the in the meantime and maybe, um, he's gonna have a solution for that. But if not, my plan was remove the teeth first, see if we can get some clearance on the sinuses and then go do the large sinus lifts and then, you know, in some time come back, do my traditional all on four with with pterygoids probably, or however, we'll see how the sinus lifts heal. In the case you recently did what did, do you know how much graft you used to lift those sinuses?

Simon Oh:

um yeah, we, we lost. I I lost count after um 10 cc's yeah I don't remember, because I was just like, oh, my god, god, it's not stopping, like I'm like shoveling the stuff in there and like run out of bone, I'm like I need another, I need another. So, like there, I would, if I had to guess, it would probably be 12 CCs and, yeah, it was combined with a sticky bone or, like you know, prf, lpr. So so, yeah, that that was interesting, yeah.

Tyler Tolbert:

How do you know when to stop?

Simon Oh:

It's, it's a very, um, uh, subtle thing. So the way that I tested, I sort of got a sense of like, okay, if I poke the window with my finger, it feels like this much tension. Window with my finger, it feels like this much tension, um, and that's okay, no one to stop. I, I can't really explain it to you. I, I um, because like, if you push too hard it's gonna burst, you know, everywhere. That's like horrible. So, um, I, I just I fill it up until it gets into the window. I gently push to see if there are any pockets where you know it's not stuck and then keep filling it. But yeah, I mean, there's sort of like a tension type feeling that I sort of got used to. Very light, not very light.

Tyler Tolbert:

Yeah, and with regards to the window, what for a case like that? You know what's the most strategic but conservative place, and what kind of size of window do you really need?

Simon Oh:

Yeah, you know, for for that case I couldn't afford any perfs, you know so as of how much I wanted to get done. So I I made a window, basically expanded from anterior to posterior, except I didn't go as far back as the tuberosity. I sort of had enough access because, you know, we see things from the interior, so I could sort of peek in there without sort of getting rid of that bone, yeah. But yeah, I mean, I would probably guesstimate about a centimeter in height from anterior to probably like the first or second molar area. Okay, that's significant, yeah, it's very significant. But I always make sure to leave a shelf of bone it's not at the floor of the sinus, that way it can sort of hold it. And I always try to keep the windows away from the incision line, because if you keep both at the same area you sort of risk the problems by doing that. So I always try to offset them somehow. Keep it, yeah, but about a centimeter height, enough to get the entire uh side action sinus, uh curette in there.

Soren Paape:

You know, okay, okay yeah, that was my plan a long like a long thin window all the way across Cause. Again, I can't perfect either. Like it's perfect that we're in a really bad spot.

Tyler Tolbert:

So that was, that was my plan as well.

Soren Paape:

Um with that case in particular.