The Fixed Podcast

Shaping the Debate: Opinions in Full Arch Implant Dentistry with Dr. Damon vs Dr. Stanley: Part 1

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The debate of pterygoid and zygomatic implants takes center stage as two masters of implant dentistry present dramatically different philosophies on full arch restoration. Dr. Robert Stanley, a dual-trained PhD engineer and dentist, maintains that 99% of patients can be successfully treated without remote anchorage techniques when proper prosthetic principles are applied. Meanwhile, Dr. Damon reveals he incorporates pterygoid implants in virtually all his cases, citing biomechanical advantages and superior outcomes.

This riveting discussion dives deep into the engineering principles that govern implant success. Dr. Stanley introduces the concept of "truss systems" that explains why tilted implants work in full arch configurations despite contradicting single-tooth biomechanics. He emphasizes how proper prosthetic design—utilizing adequate vertical height, strong zirconia materials, and limited cantilevers—can achieve excellent long-term outcomes without resorting to specialized techniques.

Dr. Damon counters with compelling arguments for pterygoid implants, noting their ability to eliminate cantilevers completely while anchoring into dense cortical bone of the pyramidal process with longer implants. His philosophy that "the best zygoma is the one you never have to do" highlights how pterygoids can often help clinicians avoid more complex procedures.

Both experts share concerns about inexperienced practitioners attempting advanced techniques without proper training, noting an alarming trend of recent graduates jumping directly into complex full arch cases. Their contrasting approaches demonstrate that in implant dentistry, understanding fundamental principles allows for multiple pathways to success based on individual patient needs rather than dogmatic adherence to a single technique.

Whether you're just beginning your implant journey or looking to refine your approach to complex cases, this episode provides invaluable insights from two different yet equally successful perspectives in modern implant dentistry. What will you take from this debate to enhance your own practice?

Dr. Tyler Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry. Variety of opinions here, and I think we have so much to learn from the areas where we agree, but I think we have a lot more to learn in areas where we disagree, and we can kind of help people that are listening to the show kind of find their own way in things by learning from experienced guys like yourself speaking on these topics and wherever you may differ, people can kind of find themselves in different places and sort of figure out the way that they want to approach. You know these full arch cases and that's what we're all about. So again, thank you guys so much for coming on and welcome to the show. Well, thank you. So, yeah, for sure, for sure. And Dr Damon, welcome as well, of course. Welcome back, yeah, thanks for having me again.

Dr. Clark Damon:

Good to see you all.

Dr. Tyler Tolbert:

And Soren.

Dr. Robert Stanley:

I suppose you're welcome too.

Dr. Tyler Tolbert:

Though you may be the co-host of the show, I want to make sure you know you're welcome too. So yeah, I'll kind of talk a little bit about just sort of the format of the debate and then I'll kind of lead in with introductions for you guys as well, just to give people context that they don't already know who you are. So for this format, for this debate, we have a few different topics here and I'll start by just giving some context from the topic where we're coming from, what the subject is and kind of a little bit of the perspectives that I've heard, watching you guys' videos and going to lectures and things like that. And then we'll be taking turns, giving Dr Stanley and Dr Damon the opportunity to speak on the topic, go ahead and give their perspective with whatever supporting evidence that they have today, and then after that the other will have a chance to respond. And then from there we'll kind of moderate sort of a more open-ended discussion as well as present some questions that we put together ahead of time for those topics, and then we'll just kind of let those live out as they may. We'll try and find a middle road if we can, and if not we move on to the next thing and then from there we'll see what our audience has to say about it and maybe in subsequent episodes we can do some follow-ups and talk a lot more about it. So I'll go ahead and get into our introduction.

Dr. Tyler Tolbert:

So, dr Damon, I'll start with you. So Dr Damon is a dentist and educator with extensive experience in full arch, from advanced surgeries to prosthetic fabrication. He is the owner and operator of Texas Implant and Dental Centers in Dallas, fort Worth and Amarillo, texas. He's completed thousands of fixed arches and educates doctors on everything from basic all four to the most atrophic cases we encounter, utilizing zygomatic implants, pterygoids and other accessory techniques to treat the most difficult cases. Dr Robert Stanley is with us. He is an oral surgeon and diplomat of the ABOI and the ICOI. He is a continued education instructor and founder of the Stanley Institute. His channel has posted over 400 videos on the topics of dental implants, guided surgery and full arch dentistry. He is also an adjunct instructor at the UNC Chapel Hill and somehow has found some time in his day to come on our humble podcast. So I really appreciate that. Thank you so.

Dr. Robert Stanley:

Dr Tola, real quick I do oral surgery, but I am not an oral surgeon.

Dr. Tyler Tolbert:

You're not an oral surgeon. I could have sworn you were an oral surgeon. Yeah, no, I do.

Dr. Robert Stanley:

I do a lot of surgery, so that's it's a common, it's a common mistake.

Dr. Tyler Tolbert:

but I, I'm a dual trained PhD in engineering and dentist. Okay, very good, very good. Well, you fooled me. I could have sworn you were an oral surgeon, but I appreciate you clarifying, yeah. Okay, so we'll get into our first topic, and that's going to be the role of zygomatic pterygoid implants and other remote anchorage techniques.

Dr. Tyler Tolbert:

One of the most popular topics in full arch dentistry currently is the utilization of extra maxillary techniques such as pterygoids and zygomatic implants. Dr Stanley, in your video I don't need pterygoids or zygomatics in my practice you stated that 99% of patients can get by without the use of pterygoid or zygomatic implants. With the focus on advanced techniques that we're seeing in the full arch landscape, there is a notable asymmetry between what you say and also what the general consensus around full arch seems to be that these techniques are indicated a lot more often in full arch patients than they can be usable even on a daily basis. Could you elaborate a little bit on this point, and how are you able to circumvent some of those situations where most providers are opting for some of these more advanced techniques?

Dr. Robert Stanley:

Sure, I'd be happy to. So the first thing that we need to make sure we understand is that doing these remote anchorage solutions, they're not contraindicated. Okay, they're just another tool in our toolbox. But, as it happens in so many things not even just dentistry, but just in life when something new comes along, there's energy and excitement and people people have tendency to jump in and and go oh, you know, I've learned this new technique. And then on Monday they see a case. They go.

Dr. Robert Stanley:

Well, I could actually do that on that case, and so what I feel like what we're having right now is just we've got a deviation from the mean, where we have a lot of people that are learning about these remote anchorage solutions and yet the traditional root form implants are more often than not, sufficient to suffice for just about like I said in my video 99 of the cases. So what does that mean? Well, it means if you actually do a prosthetic protocol where you start with the teeth and then you back into the way the implants and you use some CBCT scans and optical scans to do that, you can almost find enough bone, almost always find enough bone, and so you go. Well, if I'm finding the bone, then you have to ask yourself if I've got enough bone to do an all on X, but you know between the sinuses or between the foramen or something like that, then why would I want to bring into my practice this other solution? Well, the first answer is is if you don't have that bone, then that would be a good place to start looking right, so you would start to look at other places. So that's the first thing. The second thing is is that you would say well, I'm looking for increase in stability, and as a mechanical engineer, you can imagine that I have a very strong belief about reducing mechanical complications through basic mechanical principles.

Dr. Robert Stanley:

And having a distal cantilever that's excessive can really cause a lot of problems. And so you know, you look to the literature and you have a lot of people that are saying, if we don't have a terminal abutment on our prostheses, there's a lot of complications associated with it, and that's true. But there's a couple other things that go into play here, and that is the type of materials that are being used to implement these solutions. So, for instance, let's say you're doing an FP1 where you just have regular crown and bridge height. You don't have a very tall bridge right, your beam is rather narrow, and so if you have a long span cantilever with a small interocclusal space and you don't have a strong impact if you put all those things together, it's like gasoline and matches right You've just put yourself in a position where you're going to have a lot of complications. However, if you take on the philosophy that I'm only going to cantilever small amounts enough to get me to first molar occlusion and I'm going to use zirconia for my final prosthesis and I'm going to do FP3, so I'm going to have a minimum height of, say, 13 to 14, 15 millimeters of arch height from the incisal edge to the intaglio surface and you use a reputable implant which is made out of like a titanium alloy, then all those problems go away. So at that moment you say, well, can I get by with first molar occlusion?

Dr. Robert Stanley:

For the vast preponderance of people and it's been my experience is that most people that need full arch are about 55 years old and they haven't enjoyed their smile their entire life. And what I mean by that is they've either been plagued by rampant caries or they've been plagued by periodontal disease their entire life. So at 55, when you tell them, listen, mr Smith, I can wrap you in a warm blanket, put you to sleep and wake you up in an hour with a brand new smile, and that's pretty, pretty powerful, right? And that's the kind of space we're living in. Now. Let's say you don't have all of those, all of those things don't align and you don't have enough bone. Well, that's when you would want to look to one of these railroad anchorage solutions.

Dr. Robert Stanley:

And my contention is this unless you've set up your practice in a way where you're doing these all the time, you don't need to be doing them. And what I mean by that is if you're not doing something all the time like I mountain bike on the side, right If I'm not in the field, if I'm not out in the woods mountain biking I get rusty. So if I'm not doing these advanced techniques, often I'm going to get rusty, right, and then that's when you can really hurt someone. So my contention is this if you don't have those conditions in place, then I would send it to someone who does. I would send it to someone who's qualified, who does this, basically the one guy in the county or the town or the city or the state that focuses on this one solution, because they're so rare. I mean, the indications are so rare to need them that when you need it, send it to somebody who's qualified. When you need it, send it to somebody who's qualified.

Dr. Tyler Tolbert:

Okay, yeah, no, I think that's an excellent position. So before we get into you know, rebuttals and those points I know we're all kind of taking mental notes about a lot of the different things you said and I appreciate your well thought out response. Dr Damon, would you like to take a turn to this as well?

Dr. Clark Damon:

Yeah, I mean I think that there's definitely some things that I agree with. You know, talking about doing a maximum of a one-tooth cantilever, talking about doing FP3. I'm a big proponent of FP3. And same with zirconia and you know, making sure that your zirconia thickness is adequate, right. So minimum of you know 13. So I think there's a lot of you know, a lot of stuff that I definitely agree with. Where I tend to, you know, have a different philosophy is just well, let me. Let me ask Stanley this Are you doing so? Typically, all of your all on X cases in the maxilla are anterior to the sinus.

Dr. Robert Stanley:

I would say if I had to guess, I'd say about 50%%. And the reason is is that we have the new short implants right and so that allows us to get a short root form implant typically in that second premolar, sometimes even in the molar position, and it helps to eliminate needing to do a lot of sinus grafts as well, because you can get that posterior anchorage you're looking for with the new short implants.

Dr. Clark Damon:

And so you're just doing this sub-anchorly A lot of times.

Dr. Robert Stanley:

Yeah, what size. The short implant that I have available to me the shortest one is 6 millimeters in length and it's 5.2 in diameter.

Dr. Clark Damon:

So, yeah, I mean I'm not. There's no biomechanical advantage having six implants anterior to the sinus. The four is all that you need. And in fact, if you're going to do six anterior to the sinus and if this patient ever needs a revision, they're going to be an automatic quad. You're going to have so much iatrogenic bone destruction when those implants get removed.

Dr. Clark Damon:

I don't advocate for six anterior to the sinus. I don't advocate for six anterior to the sinus. I mean, I definitely appreciate Dr Stanley's desire to want to be safe and desire to want to have the best outcome for the patient. Right, and you know there's absolutely nothing wrong with referring. I think.

Dr. Clark Damon:

I think, you know I, I do agree with Dr Stanley and the fact that you know we are seeing a deviation from the mean. I think it's because a lot of young docs I mean I can't tell you how many docs out of school come in to take my full arch course. It's their first, it's their first course and they've already, they've already done 10 to 20 arches and I'm like, okay, wait a minute, where, where did you guys get your education? And they're, they're, they're just blowing and going. So you know, I, I don't know how to describe it. You know, maybe, maybe a lot of younger docs are just, you know, very hungry and, you know, willing to take on a lot of risk. I think that they don't even know the risk that they're taking on. So I kind of think this deviation from the mean is not only just with respect to, you know, treating atrophic maxillas, but I think it's also guys getting in and jumping into full arch way too early. So I don't know, dr Stanley, do you think there's something there?

Dr. Robert Stanley:

I would have to concur with you.

Dr. Robert Stanley:

I did a course recently. I was invited to teach a course for two days and it was like a DSO, so they procured their patients, their doctors, and about halfway through the first day you know you get a sense for the level of understanding in the room. And there were only four people in that room of 70 that should have been in there. The other group of people should have been in the onesie, twosie implant course. They shouldn't have been in the full mouth course. It was kind of shocking.

Dr. Clark Damon:

Yeah.

Dr. Soren Paape:

I would say uh go ahead, Soren.

Dr. Soren Paape:

Yeah, I was just going to say.

Dr. Soren Paape:

You know, I feel like there's so many um whether it's podcasts or uh just just hype around full arch dentistry right now, where these large DSO groups are um, right now, where these large dso groups are um, they are needing to to fill that void of patients and and they want to, they also want um to sell these treatments right, but they don't want to pay for uh providers who maybe have uh been doing this for 10 years.

Dr. Soren Paape:

So their solution is to um to make full arch dentistry like the new cool thing to do. Uh, and I feel like a lot of these these groups are sending doctors right out of school because those are the people that jump into their office. You know they're, they're. They come to the office to get surgical experience, to take teeth out, and then next thing, you know um, they're kind of like pushed into, let's do full arch dentistry, and then they end up in courses like like yours, clark, and probably the one that that yours, you were teaching as well, dr Stanley, and I agree, I think it's, I think it's really scary and you know, I see a lot of cases coming from those clinics and Tyler and I being the clinical director for a large group, dso. We saw the quality of some of these treatments being done and they were very much under par, for sure, yeah.

Dr. Tyler Tolbert:

Yeah, I mean, I think something that we're kind of touching on here is that, for one, you have people who are inexperienced, sure, getting into full arch, and you know there's questions about you know who should be doing full arch and who's really qualified to do that, and I think that's an entirely different subject altogether as valuable of a conversation as it may be. But one thing that I think becomes a little bit contentious is especially, you know, as it is relevant to the topic too is you know, when we start talking about the advantages of, you know, let's say, pterygoids first of all, right, I mean we can talk about zygomatics, because those kind of come into play with really atrophic cases where you have very I mean little, I mean no subantral bone really and nothing really in zone two whatsoever. But with pterygoids, one of the purported benefits of it is, you know, you go from talking about what is a tolerable cantilever to having no cantilever at all, and a lot of people can purport the benefits of that and saying, okay, we have absolutely no cantilever. That's clearly better than having some right. And then you start to hear things about that being, you know, potentially even a standard of care.

Dr. Tyler Tolbert:

So now someone says, okay. Well, I'm experienced enough to get into full arch. I'm starting to do some all in four. I'm doing that, I'm running into some problems. Here and there I'm having a posterior tilted implant fail, then I'm having to graft it and I'm having to deal with all this. I need something else to kind of supplement, where I'm running into trouble and then they hear people talking about the biomechanical advantages of completely eliminating the cantilever, and so they're saying, well, if I, you know upper arm and forearms, now I need to be doing pterygoids, and so there's just this sort of immediate succession into a different level of care if you're going to be doing some full arch. So you know, we've kind of already lowered the barrier of getting into full arch in the first place. There's a lot of advancements in the past few years that have made this a lot easier. There's a sort of this very stepwise trip into doing really the most advanced level of care that we do.

Dr. Tyler Tolbert:

I guess the question is what really is the indication for it? Of course we can talk about those benefits. There's also risks that come into play, and so I think really it comes to question is you know, how necessary is it to do, say, a pterygoid. I mean, yes, we can completely eliminate the risks that are associated with I wouldn't say completely, but we can really mitigate the risks that are introduced with a cantilever but is it worth it to go that extra step and start doing that extra, more advanced and potentially dangerous technique for the sake of doing that? And it's a risk-benefit analysis.

Dr. Tyler Tolbert:

And so you know, dr Damon, you know I'll kind of point to you because you were the person that definitely pushed us, myself and Soren, to do a lot more pterigoids. We already had kind of been introduced to the technique, but for us it was more of okay, this is to help us rescue ourselves when we have a tilted fail. You kind of changed our mentality a little bit as young doctors into thinking, okay, you know, if I started doing pterygoids more often, even on cases where I could get away with it, I'm going to have more success long-term because I have less biomechanical stress. Can you speak to that just a little bit and maybe kind of provide some guidance on that?

Dr. Clark Damon:

Yeah, so you know, I think you know, one of the reasons why I wanted us to interview Dr Stanley is because you know I do pterygoids on 99% of my cases and he says 99% of his cases don't need them.

Dr. Tyler Tolbert:

And I was like man, this is, this will be a perfect discussion you know, but yeah, so you know to.

Dr. Clark Damon:

you know, darge Stanley, to one of your points, right about, like you know, if you mountain bike, just on occasion, you know, you kind of better be careful and not go on a super tough trail, but you know if you're mountain biking every day you know you're ready for the Olympics, so you know there's a small degree to that right.

Dr. Clark Damon:

So like you can't be ready to treat the atrophic maxilla if you don't practice the atrophic maxilla on a regular basis.

Dr. Clark Damon:

Now that doesn't mean that we put zygos in on people that don't need them, but I can't think of a reason not to give my patients a pterygoid and so everybody gets them right. So we go with the no cantilevers. Wilkerson has a really good biomechanical article talking about pterygoids and how it reduces the stress when you compare it to the standard four. So we're eliminating stress and strain, increasing our stability. And where I challenge Dr Stanley with doing the sub-antral shorter implant, while I would prefer to do that over a sinus graft and then come back in place, I would first prefer to do a pterygoid because one we can utilize a longer implant my average pterygoid implant length is 18. And we're able to really lock it in into the pyramidal process, which has a lot of very dense cortical bone, and so our cumulative torque values go up, the stresses come down and I see less failures, I see less prosthetic complications.

Dr. Clark Damon:

In fact I don't. I don't see any prosthetic complications with the pterygoid, other than if you have a you know, an 85 year old patient, on occasion they can't. They can't handle the pterygoids. I think their tongue gets pretty big and and and they just don't like it. That's the only patient that I can think of that doesn't need a pterygoid is an elderly female patient. They just don't get along well with stuff in their maxilla. But that's kind of my rationale for doing pterygoids on everybody.

Dr. Soren Paape:

Yeah, I would say yeah, and I'm curious as well about Dr Stanley, your prosthetic. When I say prosthetic failure, I don't mean, like you know, in zirconia, but like fractures of temporary loaded. Are you typically doing like two to three month temporaries in your office and then transitioning to zirconia after those two to three months?

Dr. Robert Stanley:

Yeah, so we do a. We do immediate provisionalization and that would be a prefabricated provisional. So we just pick it up that day but it's prefabricated, and then we let them wear that. It's a nanoceramic and we let them wear that for six months. And the reason we go a little longer than most people in the industry is they really want the predominant amount of shrinkage of the soft tissue before we go to the final zirconia. And that way when we go to the final zirconia you don't have them. They say, three years down the road going, I got a whistle, I'm getting food underneath my zirconia, which you can fix, but it's a pain, right? So that's our typical protocol Since we've gone to the nanoceramics monolithic nanoceramics.

Dr. Robert Stanley:

So the back of the day used to be a titanium bar wrapped with PMMA. That was our long-term provisional and those fractured a lot. We got a lot of fractures during the healing phase with that and it makes sense when you have more components in a system you have more possibility for failure. But once we've gone to the new nanoceramic we just don't have fractures in those long-term provisionals. And the really cool thing is that even if we did, we can print a new one in 23 minutes. So if we had to, we'd just print a new one and bring them in and just unscrew it and put a new one in, so we can manage that really well.

Dr. Robert Stanley:

But I think that it's interesting that we should probably and this is something in the industry that we don't really discuss too much there's two kinds of problems that people talk about. When we talk about complications, we talk about forces and stresses and these kinds of things a lot, but there's the risk to the mechanicals, the mechanical operation. There's a risk to the biological right, and the literature is pretty clear now. Whereas we used to think that there was a significant risk to the biologics of force, that was predominantly taught by Carl right, carl Misch, and he was worried about overstressing the bone and that would cause bone loss. But we know that there's no evidence that that happens. Okay, so you can put a lot of stress on the bone and, if you think about it, the purpose of the bone is to carry load, right, that's what nature made the bone for. It's designed to carry load. So that kind of concept goes away. So when you really talk about what are the risks when we have a cantilever to our system, the real risk you're talking about is mechanical. Okay, so we can call it biomechanical because it's part of the body. But what you're looking at is fractures of the prosthesis or, like you said, it's screw loosening, it's abutment breakage, it's abutment delamination from your prosthesis, these kinds of things. Those are the predominant problems and the literature is pretty clear on that too. We're seeing three to four times more of those than we are the biological one.

Dr. Robert Stanley:

So what oftentimes happens is when you have a case and you have a failure like an implant that doesn't integrate properly, it's so many reasons why it could not integrate. Right, I've got 52 that I've listed it just at the high level. You could go even deeper if you wanted to. So when you have a failure, sometimes it's very difficult to differentiate between I think this failure was because of mechanical loading or this failure was because of biologics, right, and what I would argue is that the vast proponents of failure to integrate are biological in nature. Okay, in other words, we didn't get the implant in the right location, we didn't get enough bone around it, there was a failure to get good wound healing and then the implant it partially integrates, it has stability, but it doesn't integrate long term, and so you get a failure downstream. So getting that implant in the right location in the very beginning is really paramount to preventing these kinds of problems happening later. Then the second part is is if the implants are in the right location and your prosthesis is properly designed, you're going to minimize your off-axis loads, ie you're gonna minimize your cantilevers or eliminate them in the cases of doing the remote anchorage, and that's a really good thing for the system, right? So if you do that, that's great. But if you do everything that I'm talking about in terms of the method that I that I described earlier, where the implants are in the right location, they're actually loaded.

Dr. Robert Stanley:

You've got a tall prosthesis and it's made out of strong zirconia. We've never had a. We've never had a zirconia fracture. We've never had a zirconia prosthesis fracture ever in our in our entire career.

Dr. Robert Stanley:

And Tischler you know Tischler took the payday. He's gone now, right but when he was working he published a really neat paper. I think it was 2,500 FP3s that he did. He had like a less than 1% complication and of those I think he had really good explanations for why they broke. So I think that it's pretty clear that if you have enough height to your zirconia, you're not going to have a lot of problems, right, you're not going to have a lot of fractures and such. So that's really the key.

Dr. Robert Stanley:

And when we see a lot of people that are pushing for FP1s right, traditional crowded height space, where your connector space between an FP1, your connector space gets very, very tiny, and if you have a very tiny connector space and your implants are spread out like an all-on-four and your beam length is long, they're going to break. They're going to break all day long. And then you start looking for, well, why are they breaking? And if you say, well, maybe remote anchorage, so I don't have this cantilever, well, that makes a lot of sense. But you see, it's more than just one variable, isn't it? It's a combination of variables that, if we put together, it's all about reducing that risk and improving the outcomes for the patient. But you've got to take a look at it more than just one parameter that you're doing in order to have that kind of success.

Dr. Tyler Tolbert:

So you bring up an interesting point with respect to the loading of the implants. Now it does sound like you're making a few different points here. For one, we can compensate a bit for the presence of a cantilever by having implants in the correct location. And I assume, since you mentioned axially loaded implants, that you also mean that the implants are being axially placed, which is kind of implied that that is what you consider to be the correct location. So in a lot of patients one of the main reasons that we have tilted implants is all in for in the Paul Malo technique is because of the anterior border of the sinus. You're tilting an implant in order to obviously decrease that cantilever and you're tilting that. And so I guess really the contrast here is you have, in one case you might have six implants anterior to sinus placed axially. Perhaps you have a subantral short implant right and some mitigated cantilever.

Dr. Tyler Tolbert:

We've managed to get the patient back to first molar, versus having the you know tilted configuration that's more typical in the palomelo and then having the pterygoids as well. So you know, I know we're talking about biomechanics, I know we're talking about how the implants are loaded. I guess it really is kind of a question of you know, is six implants with no pterygoids place axially going to be better biologically or mechanically versus those tilted implants? How do you kind of you know what are the different things that you're considering between those two? You know modalities, because they are very different. Right, you have long implants that are tilted versus shorter implants placed straight. What is kind of the rationale?

Dr. Robert Stanley:

That's a great question and this is something that a lot of doctors get really confused on, especially those young ones, doc, when they come out and they're like, wait a minute, I thought you said you want to actually load your implants, but how do the all-in-fours work? Because you've got a tilted implant there and they get really confused. So let me clear this up for everyone. Really, really simply, if you're doing a single implant, the way an implant is designed, it's designed to be loaded axially, which means all the forces should be directed down through the long axis of the implant.

Dr. Robert Stanley:

Okay, anything that you do that creates a bending moment on, that is going to create problems. So if you get the implant in the wrong location, let's say you're doing a first molar and you put the implant in and you get a little pucker factor, so you scoot it a little bit towards the distal and now you've got a cantilever to the mesial. So you've got a cantilever. If you look at the two-dimensional radiograph, the crown that you put on there looks like a Snoopy, and so I call it a Snoopy. When you see it, it's got a long nose on one side. Right, it's short on one side.

Dr. Robert Stanley:

That's a cantilever on a first molar, they bite and they hit the medial marginal ridge of that prosthesis. It's going to bend that. It's going to bend that. And what you're doing is, every time you're bending that prosthesis, you're torquing the entire system. So you're putting the stress onto the abutment screw. You're putting the stress onto the cement that cements the zirconia crown, to the hybrid tie base and the hybrid tie base to the implant. So none of the system, none of it, likes that, likes that. Okay. So you want to prevent that off-axis load. You want to load axially. So that makes a lot of sense. Would any of you think it would be a good idea to place a single implant at 30 degrees and load it with a crown? And I think all of you would say, well, no, I don't think that's a good idea at all. Right, so? And I don't, I don't know that I've seen anyone actually do that, where they've placed a single implant at a 30-degree angle and then used a 30-degree correction to design a single crown. However, in Turkey, in Turkey, yeah, yeah.

Dr. Tyler Tolbert:

We see a lot of cool stuff in Turkey.

Dr. Clark Damon:

Yeah Well, y'all have all seen the lateral incisor implant where it's coming like this, and then I think they put maybe like a 55 degree or like a 60.

Dr. Robert Stanley:

You're going to have to share some of those pictures with me.

Dr. Clark Damon:

And it looks, it looks terrible. You know the, the, the, the bone regeneration doctors in New York, they get these things all the time. Sure, yeah, I would like to see some pictures of that.

Dr. Robert Stanley:

That's good. So now here's because you're waiting, so you want to know well, how do angled implants work. When you do an all-in-X, you change the complete dynamics. It's called in engineering, it's called a truss. Okay, if you're going down the interstate and you see one of those signs across, that's bridged across, it's got the, you know. It tells you what interstate you're on. It's made out of a series of bars and those bars kind of go zigzag like this, right, and that's called a truss.

Dr. Robert Stanley:

And what happens when we put something into a truss? All of the elements that are loaded in the truss are loaded axially. Oh right, are you guys getting this? So when you tie, when you tie a uh, an axillary implant with an off-axis implant and you tie them together with a prosthesis, and at the base they're tied together with bone, you've just created a truss, which means that implant is not being loaded off-axis, it's being loaded axillary, which is something that that I always wanted to talk to Carl about. That, because Carl would always say you know, remember that debate he had with Paul DiMallo? Right, it was brutal, right, they got on stage and they were going at each other and he was like would you build a tree house for your kids with posts like this.

Dr. Robert Stanley:

And he was like no, you wouldn't right, but what he wasn't talking about and what he was failing to kind of bring to light was that it's not a single implant it's a system or a system together is a trust, and if you put the trust together it's incredibly strong, which is why which is why, when you put your prostheses on top, it should be rigid.

Dr. Robert Stanley:

So there was a time where people were thinking maybe I should put some like a small, like an elastomer type of plastic on the top that would give right, so that it would absorb the occlusal loads and such. That's a terrible idea, because now your implants are going to be not rigidly coupled, which means they're going to be allowed to bend and that you lose that trust, you would lose that trust function and it would fail.

Dr. Robert Stanley:

So that's why using something really rigid like a nanoceramic or even more rigid, like like a ceramic, like an oxide, like zirconia, that's why it works. So that that is a distinction that really. I hope that people are listening. They really understand. There is a huge distinction between loading individual implants and tying them together in a prosthesis. It's a completely different animal.

Dr. Clark Damon:

Right, I mean that's that's why we see our implant success in all on X be so much higher than you know, our our single units Um but, you know I still, I still would prefer a longer implant in the pterygoid than a shorter implant sub-antrally.

Dr. Clark Damon:

And it's not just length or location, it's really kind of more type of bone. You know, the bone in the posterior maxilla is oftentimes just garbage. The posterior maxilla is oftentimes just garbage and it's not something that I want to. You know, really sink my teeth into right and you know, going back to the truss, when you look at those pterygoids, you know, then you know, if you look at many of my cases, you know it's leaning back into the pterygoid.

Dr. Clark Damon:

You know posterior, superiorly, and then you've got the posterior ones leaning, you know, anteriorly, in front of the sinus, and then when I do the, the nasal crest, you know everything is at an angle and so it's. It's a huge trust. So I'd like to encourage you, or Stanley, to, uh, you know, consider doing some terror droids.

Dr. Robert Stanley:

I, I, you know what I, I, um, I would love to. I, I love to do everything in this planet and I'm running out of time. My, my days are becoming limited. I just told a colleague this morning. I said I've got to start telling people no, and he said what do you mean? I'm burning the candle at both ends here, I'm trying to get my book written and, on top of all the other things I'm doing, I'm like I got to start telling people no. He started laughing because he knows I'm never going to do that. So, yeah, I'd love to do it, because why not? I mean learning. The only way to improve yourself on this planet is to learn right, and so learning is paramount, right? You've got to keep expanding, you've got to keep learning.

Dr. Robert Stanley:

Yeah, and you know one of the reasons to actually do a pterygoid is because the best zygoma is the one you never have done. Expand on that.

Dr. Clark Damon:

We can all agree to that. So we can, we can, we can use. You know, I started doing zygomatics first in 2014, 2015. And then I started branching out in 2016, 17 into doing pterygoids, 2016-17 into doing pterygoids. And you know, interestingly enough, you know we didn't have osteotomes, so so, so I I drill my pterygoids and um, because we didn't have the instrumentation, and so that's that's how I learned and developed my technique, uh, developed my technique. But you know, I would have saved myself the hassle of doing lots of other zygos had I been able just to pop in a pterygoid.

Dr. Clark Damon:

You know literally I've got a video start to finish with the abutment on. I think it is like two minutes and 19 seconds from initial osteotomy, and so you know they go really well, they go really fast. You know you've got to get your angles right or you can be in the three neighborhoods that you don't want to be in right, lateral to anterior and, you know, to superior. You hit the big red IMAX, but I do tend to think, or I know, uh, two, superior you hit the big red IMAX, but uh, I, I do tend to think, uh, or I know that the, the risks of pterygoids are, I think, overstated and, um, I think, I think it's, it's it's wise to have an appreciation for, uh, the risks and the danger, but I don't really feel that a properly, you know, trained individual is, you know, can really risk the life of a patient.

Dr. Clark Damon:

Now that being said, I have seen a properly trained individual with a 25 millimeter implant. You know, way in the back, you know very close to where I think the IMAX would be and you know I don't know what that individual was thinking when they did that. But even in a trained individual you know there are. You know you can get disoriented. Maybe I don't know, I wasn't, I wasn't there, but the x-ray looks pretty bad. But you know, I think that pterygoids help us avoid zygos.