Speaker 1: 0:40

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. And welcome back to the Fix Podcast. I am super excited about today's episode. I know I say that every time, but this time I mean it a little bit more than I usually do. So today we have an absolute powerhouse of speakers in here. If you combine the number of orches that have been done between these four people, myself included, I'm sure you'd be somewhere in the thousand, maybe five digits, I don't even know. But today we have Dr Clark Damon who is returning to the show. Welcome back, clark.

Speaker 1: 1:19

And he has graciously brought on his good friend and colleague and mentor to all of us, dr David Zellig, who instructed me not to call him doctor, but you know, I'm from the South. It's going to be hard for me to avoid the formalities. But just as a brief intro for David, as he likes to be called, he is a board certified oral and maxillofacial surgeon and a nationally recognized leader in implant industry. Surgeon and a nationally recognized leader in implant dentistry. Dr Zellig, excuse me. David earned a bachelor's degree from the University of Memphis, followed by his DDS from the University of Tennessee College of Dentistry and completed his residency in oral maxillofacial surgery at the Long Island Jewish Medical Center. His years practicing in Memphis, david served as an associate professor in his department of oral and maxillofacial surgery at the University of Tennessee. He was an active member of his craniofacial surgery team, specializing in orthodontic and TMJ reconstruction, alongside his implantology practice. Since relocating to New York, he has held key roles with Clear Choice Dental Implant Centers, among several other centers, where he leads advanced implant surgical programs, including full arch, zygomatic and pterygoid implant procedures and a host of other procedures we're going to be talking about today.

Speaker 1: 2:28

David has zygomatic and pterygoid implant procedures and a host of other procedures we're going to be talking about today. David is also a contributing author in the textbook Remote Anchorage Implant Leave no Trophic Maxilla Behind quite a title there which focuses on zygomatic, pterygoid, transnasal nasopalatine and trans sinus implant techniques, featuring case contributions and protocols from leading surgeons in the field, including himself, of course. So, david, welcome to the show. That ended up being a whole lot more jumbo than I ever planned on and I think it was still abbreviated from your actual career. But again, welcome to the show. Thank you so much for sparing your time. I'm so excited to learn from you today.

Speaker 2: 2:55

It's actually pretty cool to hear a eulogy about oneself and to be able to speak afterwards. But thank you for those words.

Speaker 1: 3:05

Of course, of course, of course. Now did that more or less summarize your career. I'd be interested in how you would add to it what sort of uh things you hang your hat on?

Speaker 2: 3:11

how would you define your career as well, just to give uh the listeners some background well, I, you know, I came out of out of residency and started my own practice in memphis. Um, I'm, you know, the southern the Southern part of me is still polite but I? Um it turned into a full scope practice and I was very proud of that. Um coming back to New York years, years later, after 20 plus years of private practice, back to New York, um, I got really very active in trauma surgery and we'll talk about it later. I think that helped. I got really very active in trauma surgery and we'll talk about it later. I think that helped. That just the more you can do makes you a better surgeon. So I just everything you do, even if it, even if you distill your life down to arches, anything you can do to make yourself a better surgeon helps, and my life is distilled my professional life is distilled down to arches, of course.

Speaker 1: 4:04

That's what happens. Yeah, absolutely. And can you tell us a little bit about your current clinical practice? We were talking a little bit before we turned on recording. It sounds like you're going around to tons of centers helping folks out with remote encourage cases, still getting yourself bloody and helping people out of trouble and, you know, putting out fires all over the place. What does that look like for you?

Speaker 2: 4:24

Well, you know, putting out fires all over the place. What does that look like for you? Well, I was an early. I drank Palo Malo's Kool-Aid kind of early in my career and, you know, brought that deal on four idea to Memphis years ago. And then when I came here, kept that up and after a lot of trauma, surgery and orthodontics and others still doing art is at the same time I was approached by. It was a clear choice to open a couple of their centers and it was pretty much focused on arches. And when that got so busy I started mentoring some juniors and when they got proficient I was left with only the extreme arches, and that's where I am. So you can't have enough extreme arches in one place. So I'm running around to a lot of different places doing their extreme arches. That's what's happened.

Speaker 1: 5:15

So you're the fixer.

Speaker 3: 5:16

Well, that's really cool. So I just have a question so when did you go to the Mollo Clinic, like what kind of talked to me about that path.

Speaker 2: 5:27

Yeah, first I drank his Kool-Aid in this country first. Actually, one of his early students started teaching it in Kentucky and I went to I think it was Lexington way back when, back when, and then, and then learned from Milo after that and just I don't know what to say. When, when I think it was Bo Rangert that kind of convinced me to say that wow, I'm using engineering principles here and we're bringing engineering into dentistry. And when I say it's a bridge, it's a bridge like going over a river and how many abutments you need is based on how thick the roadway is. That kind of thing. It was engineering principles. It just hit me. I guess I was a physics major in college. Not that I remember anything about physics anymore, but it resonated with me.

Speaker 3: 6:23

It made sense, right anymore, but that they're kind of it. It resonated with me. It made sense, right, so so did you. Did you wait until the uh 20, uh 2011 article came out, where he kind of published like his first 245 cases, or were you doing it um sooner than that?

Speaker 2: 6:37

No, I was, I was um, I was early, early 2000.

Speaker 4: 6:42

It was before it was cool. Yeah yeah, david, can you talk to us a little bit about um? You know how you've seen from the early 2000s Cause you're probably one of the first guys in the U S you know to to really take it on Maybe not the first, but like in the in that first realm Um and maybe you know what things you've seen change over the last two decades. Uh, you know pros, cons, kind of thing would be great.

Speaker 2: 7:09

Uh well, uh, two things really. First of all, we all came from dental school and we all respect bone and the idea of bone reduction was anathema to all of us and that's what that was. The big thing that we had to was anathema to all of us and that was the big thing that we had to the big river to cross to get to effective all-on-X treatment was that amount of bone reduction. So we I think all of us were a little hesitant at the beginning doing the bone reduction that we really needed. And I don't mean just to hide a transition line.

Speaker 2: 7:42

I'm talking about to get a good all-on-four-shelf table, to be able to get implants in solid bone, to apply the other principles that other giants gave us, like Dennis Tarnow, a couple of millimeters of bone buckle around the implant. So that was one thing that's changed. The other thing that changed, I think that, well, prosthetic materials certainly. You know the initial acrylic bridges that we were using worked nicely and maybe did have the idea of some shock-absorbing effect on the implant, but they ended up looking horrible after a year or so. So moving into ceramics, zirconium, certainly was a big deal. I think those are the real advances as we went along.

Speaker 3: 8:34

It's amazing because I was doing arches probably 2013 is whenever I started and, you know, hit them pretty heavy and, looking back from really 2013, which I felt like I was, you know, fairly new I mean, I wasn't, you know, one of the first, but you know, still in 2013, I was having to deal with, you know, the dogma of bone reduction with you know the dogma of bone reduction, right, the dogma of, you know, taking out a few healthy teeth, and you know the dogma that was also like, hey, these are all going to fail really, really soon. And you know it's amazing to see where we are today. And you know, I really kind of think, like right around COVID and and maybe a touch before, it really seemed like the implants got so much better, like 2019, 2020, the implants that we have in the abutments just seemed like everything got so much better. Do you kind of feel similarly?

Speaker 2: 9:44

it's interesting because I'm looking back at. Unfortunately, when I first started learning all on four, I said, wow, I need to go to a course to learn how to put in implants that aren't parallel. All of my implants were parallel. You know, it was the learning curve. All my implants looked horrible and I look back at them.

Speaker 2: 10:01

What the idea of doing fewer implants as opposed to arches of eight and ten implants was was another river to cross and you look at the failures of those arches with the titanium overdoses and and that kind of thing, and when they fail, they fail miserably. Yeah, even if this, even if an implant fails in an all-on-x, it's, it's you at least have more bone because you haven't occupied the entire arch with titanium. So I think that was a benefit too early. You know, listen, I was doing implants when they were machine surfaces, brown marks and then later hydroxyapatite coated implants and that didn't work out. You know, I did press fits. We went through the whole. Yeah, I went through the whole. Wow, I'm sounding like um, god, I'm sounding like I'm tating to something right now you're bullshit or something.

Speaker 2: 10:56

Wow, I don't know how that happened so fast, but I went through that and yeah, so the implants did get better, but I think, uh, we also just the understanding of the principles. It finally clicked.

Speaker 1: 11:10

Yeah, I think the general trend has been that you know, through clinical practice we've kind of discovered you know what works and what doesn't, and we've had a lot of people doing that hard work to go through all the things that didn't work and now it's getting down to the actual product level where you know a multi-unit is shaped in such a way that we don't have to bone profile as often you know. Just all the little nuances is now we're not going to programmed in to make full arch a whole lot more predictable. And there was a lot of grunt work that happened in the past 20 years or so to get us to the point where you know we have things that just work and I'm not sure that you know people like myself and Soren that have you know, come out in the last, you know, half decade or so, and then doing this, I don't know that we can fully appreciate all the things that came and went um to get where we're at.

Speaker 1: 11:51

And it's, you know, we love talking about not not just the things that guys hear but where we're going. But we certainly appreciate that we're coming into the game after people have already spent so much time figuring out all the things that didn't work. So we do appreciate, you know, you guys contributing to that body of work.

Speaker 2: 12:05

Of course, Well, that's actually a very you know. They say that there are three kinds of people Some people can learn from a book, and some people can learn from other people's mistakes, and some people got to pee on the electric fence themselves and it would be preferable to learn from someone else's mistakes. That's right, that's right.

Speaker 3: 12:21

That's right, that's right that's right, yeah, I mean, I remember uh using the, the nobel, the nobel system, and you know you had to what one.

Speaker 3: 12:31

The abutments didn't always, you know, fit very well onto the internal connection and then you had to profile every single one of those and what's?

Speaker 3: 12:40

What's kind of a funny story is, in 2017, I bought a ton of Nobel implants and then I think 18 or 19 switched over to Neodem, so I didn't have to bone profile anymore and I just left, literally, I think in my Amarillo office I left 500 Nobel implants and so, rolling into 2021, I was like these things are all going to expire. So I had to do probably, I don't know 60 or 70 arches all with Nobel and it's and I mean, it's so frustrating because you have a bone profile surgical kit. You have, like you know, several. You have to have so many surgical kits out to you know to do a case and then you know, lo and behold, if you want to do a 4.0, well, then you got to reach for a speedy, groovy kit and then that has its own bone profilers and different abutments. I mean it is my assistants hated 2021 because we were using all these antiquated systems and it's really hard doing pterygoids and having the bone profile back there.

Speaker 3: 13:52

And you know if you're concerned, is your abutment seated all the way, you know, because that Nobel multi-unit abutment doesn't have a full 360 degrees connection. So it's really interesting, you, you know all these things that we take for granted now, that really speed up our surgeries yeah, absolutely the.

Speaker 4: 14:10

I'm sure your assistants weren't too happy if they forgot to sterilize one, one thing during your kit. And then you're well, or?

Speaker 3: 14:16

if they, if they lost the bone profiler, the, the little, the little guide that sits on top of the implant once it's placed, and you know if it's a speedy groovy compared to a Nobel active. You know, they're like. These things look like healing abutments too. Oh, they look like enough.

Speaker 1: 14:33

Yeah, there's way too many yeah.

Speaker 2: 14:36

You missed the Nobel's egg almonds, though, didn't you?

Speaker 3: 14:40

Yeah, I got, I got, I got, I got a bunch of them right up, right up here, okay yeah.

Speaker 2: 14:43

I got a bunch of them right up here. Okay, that was another one with a mount. That was impossible.

Speaker 3: 14:47

Yeah, we'll try my first quad that I ever did after in like 2016 or something or 15. I broke the mount inside of the 45 degree abutment and so there's a whole screw in there and you know you're trying to back a screw out after you know your first quad psychoma case. Luckily I had a colleague that was there who was like, hey, you did the case, let me back out the screw for you, and so luckily he navigated that.

Speaker 4: 15:19

But yeah, lots, lots of uh great time, lots of frustrating things, it's for sure I'm kidding, so go ahead all right, I was just going to say we uh have gone through, like you know, with clark previously a lot of the um zero to 100 when it comes to full arch, uh basics, what you need to do to get started, good protocols to learn prior to, you know, tackling your first arches. So today I think what we wanted to go over was a lot more of the remote anchorage transnasal quad zygoma stuff that you excel in. So I'd love to kind of start our discussion on that with um talking about transnasal, you know, like the Z point and that kind of thing, and uh, go over your expertise on what, if doctors are looking to get into transnasal, maybe what continuing education you'd recommend um key anatomical points, that kind of thing would be very very helpful for our listeners.

Speaker 1: 16:22

And I think, starting first, we should just go with definitions Like what? What is a trans nasal?

Speaker 3: 16:27

what is the point, so we know what we're doing.

Speaker 2: 16:29

A good start all right well, you know, the first thing that came out and and malo wrote about it, only jensen wrote about it, others wrote about was the trans sinus implant, was the idea of using, if a to get whether it's because the sinus anatomy is such that the anterior sinus wall is anterior to ideal position or just to extend the AP spread.

Speaker 2: 16:53

A trans-sinus implant is one that has crestal anchorage underneath the sinus and apical anchorage at the lateral nasal wall, with nothing in between going through the sinus, with the membrane lifted ideally, but plus minus lifted membrane but crestal anchorage under the sinus and apical anchorage at the lateral nasal wall.

Speaker 2: 17:16

And the idea here is in a transnasal is going to go bypassing the lateral nasal wall, having crestal anchorage underneath the nose and subnasal bone and apical anchorage at the lateral nasal wall. Well, in this case the implant is at the lateral incisor position, just as anterior zygoma would be, or an anterior implant. But if you don't have enough subnasal bone to put in whether it's endpoint or towards the nasal crest of the maxilla bone to put in whether it's endpoint or towards the nasal crest of the maxilla, the alternative is to use the subnasal bone if you have at least three millimeters plus of subnasal bone and then get into the lateral nasal wall at this junction of and I call it the confluence of the lateral nasal wall, lateral maxillary wall anterior to the nasal acromal duct, at the level of the inferior turbinate. You got that. It's kind of three-dimensional.

Speaker 1: 18:09

We triangulated it, yeah.

Speaker 2: 18:11

And that is the target that some people have called the Z-point. I can't call it that.

Speaker 3: 18:20

So where do you think that name comes from? The Z-point.

Speaker 2: 18:24

Yeah, I think Dan Hulsklaw did that for me.

Speaker 2: 18:32

He calls me the pioneer. I don't want to be a pioneer, I just want to follow giants that I stand on their shoulders. But that's the idea. So the apex of the implant is in the lateral nasal wall, at this confluence of lateral nasal and lateral maxillary wall, and the posterior margin is a nasal lacrimal duct and fortunately the ENT literature has done our work for us to help define where that is and where we can find that preoperatively on CT scans. And there's in two-thirds of the population there's adequate bone for this implant. The apical anchorage I'm talking about two-thirds of the population has it where there's enough bone anterior and enough thickness anterior to the nasal acromal duct.

Speaker 2: 19:23

As far as training to see it technically, the way I teach remote anchorage, except for the pterygoid, is visualize everything. So there's no minimal invasive surgery for a zygoma in my opinion, not because you can't get the zygoma in the right place, but it helps you avoid some of the complications. So wide exposure, seeing the entrance and the exit points. Do exactly the same thing with the transnasal visualize. What made it reasonable for me as an oral surgeon is because you know I've been there before for orthodontic surgery, so you're in the nose a lot. You know what you're looking at, you know what to avoid, but it's eminently teachable. You know, this is pretty clean, direct dissection.

Speaker 2: 20:14

As far as education, yes, where you can get this, where you can learn this, well, you can learn it in books, but you got to see it and do it. So, fortunately, well, unfortunately, early days, when I had dark hair, there weren't a lot of courses and there certainly weren't books for any of this, and then you just had to base what you did on principles that existed before. So that's generally what I've done is use previous principles and kind of expand on them. In this case, now there are cadaver courses, there are live surgery courses, there's mentorship to a bunch of us guys that are willing to go around and look over your shoulder and hold your hand. It just didn't exist in our field. It didn't exist 10, 20 years ago, but it existed in medical education. Medical education is really interesting If you think about the way internships and residencies there's someone holding your hand at the beginning, like riding a bike with training wheels, and slowly, as you get proficient, they're watching you holding your hands almost literally.

Speaker 2: 21:21

And then they let go of your hand and they're still watching. They're still holding the bicycle seat as they're running down the driveway and eventually they let go of your hand and they're still watching. They're still holding the bicycle seat as they're running down the driveway and eventually they let go and you're flying on your own and we finally have that in dentistry. We just didn't have this before and it's nice to be able to say we got cadaver courses and live surgery courses and mentorships and it's all out there. Cadaver courses and live surgery courses and mentorships, and it's all out there. Back in back in the day, back in the day, I flew all over the world to watch people do these things Um, literally all over the world. It was crazy because there was no place to go officially, just nice guys that let me watch.

Speaker 1: 22:03

And, um, eventually you just got to a point where you say I gotta do it and that's what it was that's, that's really incredible um, david, just just the lengths that you had to go to following it's fortunately we're living in better times and for some things, for some things not, but for this we have, we have podcasts now you can speak, speak yourself.

Speaker 2: 22:23

Now the transnasal. Back to the transnasal. So it really is an alternative in many patients for a quad, for the anterior zygoma of a quad zygoma, and this is something I'm curious too about, david and I.

Speaker 1: 22:35

Actually I took the liberty of messaging a few friends that we were going to be interviewing you and got some questions back, and so my good friend, dr Sean Lan, out of Atlanta, georgia. He had been reading through your 2025 paper on the placate guidelines and he's asking with regards to the Z-point implant we've been talking about, he said would engaging the lateral nasal wall be a viable alternative or would you go straight to an anterior superior zygote? So I guess what he's saying is, if you had difficulty engaging the Z Z point or if it were insufficient, is there a world where you would go through that subnasal bone and just engage the lateral nasal wall, as opposed to finding that conflict.

Speaker 2: 23:16

Yes, there is one type Well, in a way that is still the it is lateral nasal wall that this is engaging even in that world. But so here's the thing the lateral nasal wall, that this is engaging even in the world. But, um, so here's the thing. The lateral nasal wall in about a third of the population is what simon daniel simon classified as a type three, where there's a lot of space between the late nasal lacrimal duct and the anterior edge of the lateral nasal wall. But it's very thin and in those cases I term it exteriorized.

Speaker 2: 23:43

As you're going up the the lateral nasal wall, you're hugging the lateral nasal wall, but because it's so thin, it's dehiscence on the nasal side, not through the nasomycosis.

Speaker 2: 23:55

It's still deep to the nasomycosis and on the facial side as well, halfway up, but the apex is still in solid bone. So the answer is yeah, you can do that. That lateral nasal wall is is as long as it's surrounded by bone, and the higher you go it gets thicker as you go. As long as you know, you can know, you can locate where that nasal acromal duct is radiographically. So the answer is yes. The only place where you really should not do it is in what simmon called the type one where there is no space between the nasal acromal duct right and that and that edge of the lateral nasal wall, and also in very hypoplastic maxillas, not just severely atrophic but hypoplastic, where there's a real class 3 ap relationship because that this implant is palatal to the crest as opposed to a interzygoma, that's on the facial aspect of the, of the of the of the crest right. You would actually make your ap discrepancy worse yeah, that's.

Speaker 1: 24:51

That's actually something that uh simon made a post about I think it was maybe three weeks ago, and he was talking about disadvantage of the transnasal versus doing anterior superior. Zygote is that you have a lot more prosthetic flexibility, uh, when it comes to doing interior superior, whereas with that transnasal you might just fixate into that palatal position.

Speaker 2: 25:10

But in a non-hypoplastic maxilla, in a normal position maxilla. I would say that 90% of my transnasals have a 17 degree multi-unit abutment coming forward and it puts it right over the the lower incisors.

Speaker 1: 25:26

So that's generally where I go, great, generally where it goes.

Speaker 3: 25:30

Yeah, so and and this was, uh, one of the questions that I had. Uh for you, david, in regards to some prosthetic challenges, um is is with the class 3 patient. Um, so you know, obviously we want to avoid a significant anterior cantilever, and you know my question there is, you know, if you have a very hypoplastic mandible, oftentimes let's also say maybe their zygoma is, you know, not very tall, maybe. Let's just say it's, you know, 15 millimeters, right, I don't know if I've seen a zygoma that short, but let's say there's one where it precludes you from that. So you're almost forced into doing this on a class three. Would you then prosthetically recommend that we maybe bring the mandibular teeth back and kind of retrocline and just kind of pull everything back in, so it's not as anterior.

Speaker 2: 26:30

Yeah, I think there are a couple of things. First of all, there's still a place in the world for orthomatic surgery and if we all me, you, the patient, everybody understands that in an ideal world we would fix your skeletal deformity before we did anything else, if we're accepting that, we're not going to do that and we're going to camouflage or we're going to compromise, then sometimes you have to compromise your occlusion as well. That end-to-end, edge-to-edge occlusion may be the best you can get and ling, lingually decline the lower anteriors to get back as an orthodontist would do camouflage, non-surgical orthodontics. So that is a possibility. There's really no other alternative. I mean, the alternative, of course, is grafting, major grafting, but I've been that gamut and long term that just is not a good answer. Right? Well, in my hands, even the patient-specific implants, these subs, you can't correct that much that way either. Well, you're still on the same base of bone.

Speaker 1: 27:42

So I'm curious about this too, because I think it was Dr Zach Brown that presented on this recently at the last ORCA symposium. He talked about prosthic mathics right, so this thing that we're able to camouflage and compensate for these things with prosthetics. You know, when you're evaluating these hyperplastic cases severe class discrepancies where do you kind of draw the line? And how do you draw the line between this really is an orthognathic case or no? This is something we could accomplish with just some prosthetic black magic.

Speaker 2: 28:13

So I mean age of the patient realistically is one thing we really have to think about. What's realistic for the patient? We can explain it to the patient, give these options out there, but that's a that's a whole lot to expect anybody to go through nowadays, especially in this age of instant gratification.

Speaker 2: 28:31

you know, like finals, final arches, final teeth in 24 hours. We can discuss that in a minute too, but I think that that's. That's a big thing. You know a patient can be, can, can explain all. You can explain everything to the patient ahead of time, and smile design is critical ahead of time. Really, get a smile design. Show a patient what you can do, even if it means in plastic. Just show them what you can do, what's realistic and what's not. I think that these huge anterior cantilevers are just as bad as a huge posterior cantilever. Anterior cantilevers are just as bad as a huge posterior cantilever. There's only so much you can do with a nasal palatine implant to try and avoid an anterior cantilever. It just doesn't go as far as you want it to. So these are things you have to consider for long-term solutions.

Speaker 1: 29:19

Definitely, definitely. So, as far as when you're doing these transnasals, is there ever an indication to do any grafting? So if you were to elevate the membrane, is there any reason that you would want to pack some bone in there? Is there any possibility you'd get some bone back?

Speaker 2: 29:35

There's a Professor Almeida who did the first English article on this. He showed grafting on his cases and I did one after a while. Here's my thinking. The area of the mucosa that covers this implant on the nasal side is pretty robust. It's pretty thick mucosa. It's not like a sinus membrane at all. It's not mobile mucosa. It's not like a sinus membrane at all. Right, it's not mobile mucosa. In fact, you know the way I describe it in courses if you pick your nose you don't even get to the bony nose. You're in the soft tissue nose. You don't even get back there. So you're not in area mobile mucosa. Nothing's hitting it. It's not being compressed. However, the idea was to graph that to cover the threads of the implant there, not necessarily for osteointegration, but to protect the navel mucosa.

Speaker 2: 30:33

The problem with that is this implant is not and this is my argument against it, by the way, that part of the implant is not in the narrowest part of the nose. The narrowest part of the nose first of all is in the soft tissue nose, not in the bony nose. And the narrowest part of the nose first of all is in the soft tissue nose, not in the bony nose. And the narrowest part of the bony nose is on the medial most aspect of the inferior turbinate right and we're lateral to the medial most aspect of the inferior turbinate. So we're not in the narrowest part of the nose. So I don't see us narrowing airway space unless you graft. If you graft you could potentially bulk that out too much and narrow the airway space and then you are compressing that mucosa.

Speaker 2: 31:14

Now there's a new implant that I helped design that has a bald, non-threaded portion on the mid shaft of that implant so that you can and it's timed such that the hex works that the medial aspect underneath the mucosa there does not have threads. So it does away with that whole argument. And as far as grafting for increased stability, I'm getting typically 60 newton centimeter torques on these. It's cortical bone, it's hard bone. Um, that's generally what I'm looking at. So I see graft.

Speaker 4: 31:41

I see, can you talk a little bit about, um, your indications as far as and maybe even mentioned to like, trans sinus? I know we've gone through this on the podcast before, but when you're doing a trans sinus, when you're doing a trans nasal, um, how much crustal bone do you like to have? How much apical bone do you like to have? When you're doing a trans sinus, um, are you typically, um, you know, lifting the membrane? Are you going through the membrane? Um, what are your indications for doing both of those?

Speaker 2: 32:14

I think that's great, you guys are great, you guys are great, these are great. So, first of all, yeah, I do lift the membrane. It's not that big a deal, you know it's. It's uh, almost like an aside to get a good round diamond burr and get through the bone and lift the membrane. Um, can you do it without it? Sure, but what can happen? I don't know.

Speaker 2: 32:34

We saw a lot of sinusitis from the, the og method of, of zygomas. So why not stay outside the sinus, just like we do with zygomas now? So, um, as far as the amount of bone, so the literature supports and that's that's um. Ollie jensen wrote about it, like I said, and milo also that you need greater than three millimeters of sub antral bone to not need to graft, to not need to do a sinus lift. So I I use the same thing. I want more than three millimeters of subnasal bone as my crestal anchorage.

Speaker 2: 33:10

The literature on the trans sinus suggests that you need two millimeter thickness of lateral nasal wall and generally, yeah, that's what you have. I just double it kind of empirically. I just said empirically if we can do two millimeters of lateral nasal wall thickness for a trans sinus implant which goes through the lateral nasal wall more perpendicular. This is going more parallel along the lateral nasal wall. So I'm just going to say I can do double that easily. So I aim for four millimeters. I'll hit that inferior terminate point and then enter four millimeters superiorly for apical anchorage of at least four millimeters. So I got an eight millimeter implant, essentially four millimeters at the apex and four millimeters at the crest, and I got good stability.

Speaker 1: 34:01

And in order to, because I want to make sure everyone's appreciating what you just said. So you're saying you're doing the trans sinus and you're actually targeting the Z point itself for your ankle anchorage? Is that what you're saying?

Speaker 2: 34:13

No, no, no, no, that's really hard to that's hard to aim for that. That's why I'm Anytime you go from the trans sinus, you're going through the sinus. What bone are you going to hit? You're going to hit the lateral nasal wall. Of course. I suppose you could, if you're that much of a sniper, expose the lateral nasal wall and triangulate. Yomi could do it.

Speaker 1: 34:38

Yeah, let's get Clark starting on Yomi.

Speaker 2: 34:39

Yomi, good, but I don't. You know that you have two millimeters of thickness. You already looked at your CT scans. You know what you have and, like I said, you're hitting that more perpendicular. You're not really tangentially hitting that lateral nasal wall. That's not really the apex. It's nice if you could hit it, but that's not part of that. But that's not part of that.

Speaker 3: 35:13

Yeah, I was going to ask your opinion on a trans sinus that goes up to the Z point there. I've always avoided that, yeah, for fear of it's much easier to hit the NLD from a posterior approach than it is directly visualizing that. So I wondered if you felt the same.

Speaker 2: 35:30

Absolutely. I think that the idea here is, especially if you've opened the sinus window, is to hit that curvature of the anterior wall of the sinus where it meets the lateral nasal wall, and you can almost see it if you need to. If it's really thin, you could actually watch it come through, the facial aspect of that bone, the apex, coming through if you need it correct um, I have another question for you.

Speaker 3: 35:58

Uh, you know, I've I've probably completed 20, uh transnasal implants and maybe a touch more, but probably about 20. You know, if I liked calling it, you call it crystal or you could call it the coronal entrance point point. So kind of walk me through. There's a little bit of a learning curve because you almost have to not over widen your osteotomy at the crestal aspect but you need to have a little bit of degrees of freedom to really kind of get your pilot drill, an initial prep.

Speaker 2: 36:37

Yeah, sure, um, so first of all, I generally will mark lateral incisor and junction of second premolar, first molar. I'll mark that on the alveolus. That's going to be my ideal positions for the four of all on-on-x, all-on-four, part of an all-on-x, and I'm going to keep that. I know that Vandalum talks about. If you need, depending on the lateral wall thickness, he moves that laterally or medially, but I'm going to idealize that position lateral and sizer. Let my axis hold me in the cingulum of that lateral. They all look alike that way and I'm going to start my osteotomy with a, with a Lance pilot drill. Uh, the near dent, two millimeter, um, sharp pilot.

Speaker 2: 37:37

Um, the beauty of that burr is that it only cuts in the in the, the part of the tip that has sharp sides, flat sides. So the in the, the part of the tip that has sharp sides, flat sides. So the shaft, the long shaft, doesn't cut, so you just get through. Again, you got to be palatal to the crest at this point. You get through into the nose. It almost doesn't matter where you end up in the nose, you just want to see it underneath the mucosa and once, once you're up there, then you start directing laterally, visualizing that point that you're aiming for, aiming, aiming, coming in and out of that osteotomy because it only takes.

Speaker 2: 38:13

It's the only part you can direct it or change. The direction is down on the tip of that burr as you go in and out until you get right where you want. Now the same thing goes for anteroclosteroly Same thing You're just using that two millimeter drill out until you get right where you want. Now the same thing goes for anthero posteriorly same thing you're just using that two millimeter drill. Once you get to that and you really have to direct the burr because it's going to want to skim along the medial aspect of the nose.

Speaker 2: 38:35

Once you get into that point again, you hit it. You can see where the lines are on that burr and just go another four millimeters for your apex and then switch to what I use that burr and just go another four millimeters for your apex and then switch to what I use. I. I've used the, the heel, the neodent helix long burr until, actually for a long time, until the norris pterygoid kit came out. Norris pterygoid kit has a, has a second as an implant specific kit, has a second, has an implant-specific burr and that one is a conical burr the whole way. That cuts the whole way Again, not just the tip. I'll use that Once I use that pilot drill, I'll use that next drill as my final drill and I'll go right again watching it hit that apical target, that osteotomy that I made at the at the target spot, go in another four millimeters and that's my osteotomy, so it's a highly tapered uh yes

Speaker 4: 39:32

drill right, so that that way you're able to.

Speaker 2: 39:36

You know kind of, you have some freedom there on your right again, I think I really I really form that direction with that pilot drill, first the two millimeter, and then I go to a it's a two, two, three, two, three, two, I think, is what it is, um, and then just follow it with that, but again it's, it's got to be under direct visualization. Oh, totally, I think that. I think that direct visualization thing is so key in not just this zygos as well yeah, I'm always interested with how, how lazy people can be.

Speaker 3: 40:13

Um, you know every, every, every case and you know I, I teach and encourage everybody. You know, on, on, even on your, your standard easy case, still still lift the nasal mucosa. I feel that I have so much more control of my case when I know exactly where all of my drill tips are.

Speaker 2: 40:34

I think that I'm going to use this kind of symbolically when I say that the thing that's important for an archer, for an arch surgeon, is to lose the loops. I mean you could use the loops Don't get me wrong, I don't use them but lose the loops because you've got to see the whole picture and it's not just even seeing the whole arch. It's when you strip the nasal mucosa and you're seeing this just like your model. I mean it looks exactly like that, you know what you're looking at. You just model. I mean it looks exactly like that, you know what you're looking at. You just see so much more. So it's almost like symbolically losing loops, seeing the whole picture.

Speaker 1: 41:11

I think that's important, yeah, so something I I've struggled a little bit with intraoperatively, and I couldn't agree more about visualization, illumination, you know all of that is what really makes full arch doable and fun, frankly?

Speaker 1: 41:25

And but something I've struggled with is I routinely lift nasal mucosa to ensure engagement whenever I'm trying to do that with traditional all in four Um. But I've many times gone hunting to figure out you know where, where's my Z point out, and I've tried to you know kind of go up that lateral nasal wall and figure out where I'm at, and I have a harder time with it. Do you have any tips about how to expose that intraoperatively, identify that anatomy? Are there some things that just kind of help us find our way through the dark there?

Speaker 2: 41:53

Yeah, I think so. I think that first of all you should study your your CAT scan first.

Speaker 4: 41:59

You can almost measure where that is.

Speaker 2: 42:06

Now the tendency is not to go deep enough and you don't need to go very deep. You don't want to go very deep because you don't want to encounter nasal acromal duct. You want to be anterior to that, no matter what as you start to strip.

Speaker 2: 42:15

I'm also, by the way, when when you strip, I tend to want to strip widely and then go deep as I'm wide. So, in other words, I don't want to tunnel. So I'm going to strip the nasal crest of the maxilla straight along the floor up the side of the nose as high as I feel like I need to go, and then go a little deeper each time. So I have the floor of the nose exposed and then as I come up the side, I can go a little bit deeper and my periosteal is going to stop. Or in my case, I use a nasal freer. My freer is going to stop when I get to that widening at that turbinate. So the anterior most point, if you're too far anterior, you didn't hit the turbinate yet you're going to go as high as you want because there's nothing to stop you superficially or not deep in the nose Go a little deeper, you'll get to that widening I see.

Speaker 3: 43:07

I've also kind of found that if you find your infraorbital framing, it's typically right. About that same line, would you agree?

Speaker 2: 43:18

Yeah, it is, but that's a variable point to me.

Speaker 2: 43:32

So the other thing, by the way, is Cesar Guerrero, by the way, has an atlas from years ago and he did a series on infraorbital using the ligoma implant with infraorbital rim anchorage. Not something that I would do, but the idea is that you can go higher along that lateral nasal wall and still avoid the nasal acromal duct. To get to that point. You can go higher if you need to, if that's where the thickness is.

Speaker 2: 43:54

In fact, I was at a live surgery course in Brazil and I was tasked to do a revision on a patient that came back with failures and there really was no way to get anchorage at the typical transnasal point and I just had to go up as close as I could to the infraorbital rim to get anchorage. So there's nothing there to stop me, as long as you see it on the scan ahead of time. What you're avoiding to stop me, as long as you see it on the on the scan ahead of time, what you're avoiding but yeah, generally that's at the level of the inferior turbinate is is parallel with that you know.

Speaker 3: 44:29

Also in that book you referenced there's uh zygoma implants in the mandible yes, yeah, yeah, yeah oh boy you know it's counting on apical anchorage, isn't it?

Speaker 1: 44:43

Yeah, no kidding. So actually I fortunately had a skull on hand just to kind of be steady. I don't know if I can get the camera to focus on it, but I did look because what you just said was very interesting, clark. You said the infrarobal being right at the same level as that terminal, at least in this model.

Speaker 3: 45:02

That's fairly accurate. I mean, I think it'd be in the neighborhood.

Speaker 1: 45:06

It's a reference point, right. It's something just to kind of give us a little bit of geolocation. Oh, he, dave is getting his skull.

Speaker 4: 45:12

I'm sure, david, I did that one.

Speaker 1: 45:14

Oh, look at this you got the t1000 and he really has it too. Oh, that's fantastic. Um, but I also I mean, just just looking at this, I mean it all comes back.

Speaker 2: 45:27

Just knowing your anatomy, I can tell too, is you know, a lot of times when I've been looking for this, I'm not going posterior enough, right it all feels really smooth and I'm like oh, I guess anatomy is not there, but it's, it's back there but look at it, look, if you look at it on on axial slices, you can see just how far back you really have to go to even involve the nasal lacrimal duct.

Speaker 2: 45:48

So when simon said that the average of the anterior part of the, of the inferior turbinate to the to the nasal lacrimal duct, on average is 15 millimeters. You know, you got some leeway. Not every patient, no patient, is average. Um, all of our kids are above average, but uh, in this case you just you should look ahead of time and you'll know where it is. But that is, it's deeper, it is deeper.

Speaker 4: 46:13

I see, I see Can you, can you talk about some of the complications um, around your uh, transnasal and like what you've seen, seen what you've had to fix, and maybe just some like key points?

Speaker 4: 46:28

of absolute no goes, and I know you just talked about how class, the class one, is typically one that you shouldn't do, but for you know, as we're seeing more and more people venture into remote Anchorage, and maybe people that shouldn't be venturing into remote anchorage, I'm sure you're seeing more and more things that are big no-nos that I would love to go over.

Speaker 2: 46:53

Well, I'll say I really think I only had one transnasal implant that failed and it turns out it was a patient that I couldn't get anything to stick on. I finally ended up with a quad that so far, so good is working. But you know, it was like sometimes it really is the patient you know you throw the same thing at everybody and sometimes usually it sticks right.

Speaker 2: 47:23

So I mean it, it sticks right. Yes, so I mean it was a smoker. I'm not blaming that, it's just nothing seemed to stick on this guy. As far as complications, I have not seen any epiphyllum. I've not seen any damage to nasal acrymal duct, nor have I had to treat that. But I know that that's out there, certainly from trauma it exists. But as far as nasal from transnasal implants really it's failures I've not seen. I have seen. I have seen tears and nasal mucosa dehiscence that I was able to treat with local flaps and not GBR but just membranes and that worked out fine. Really, you can hug as long as you stick with the principles. Like everything else in life, if you stick with the principles, you hug the lateral nasal wall so that you're not far off of that, you're not expanding against the nasal mucosa and your anterior to nasal acromal duct.

Speaker 2: 48:24

This is an implant. This is a good, solid implant and use the right implant. By the way, it's important to use the right implant. So the aggressively threaded implants are not made for this. They're just not good. The bone is extremely cortical bone. It'll crack. It'll crack the maxilla. You'll be sorry you did it. So there are implants out there. You know there's just from a, from a company standpoint. You know, neodent, helix Long was. This was the gold standard. Norris now has one that's specific for this. I think that as long as you have a finally threaded implant with a narrow apex, you're good.