The Fixed Podcast

Navigating Transnasal Implant Techniques with Expert Dr. Zelig ft Dr. Damon: Part 2

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Remote anchorage techniques have revolutionized what's possible in full arch restoration, and few clinicians have as much experience implementing these advanced approaches as Dr. David Zelig. With nearly 1,000 pterygoid implant placements and decades of surgical experience, Dr. Zellig shares the hard-earned wisdom that can only come from extensive clinical practice.

The conversation begins with a detailed exploration of pterygoid implant technique, where Dr. Zelig reveals his systematic approach to navigating this complex anatomical region. From precisely identifying the hamular notch to utilizing the pyramidal process of the palatine bone for primary anchorage, listeners gain valuable insights that go well beyond textbook knowledge. "The real stability is along that path in the palatine bone," Dr. Zelig explains, demystifying a placement that many clinicians find intimidating.

When discussing potential complications, particularly bleeding management in the pterygoid region, Dr. Zelig provides practical solutions while emphasizing preventative measures through proper technique. His thoughtful approach to zygomatic implants similarly balances clinical efficacy with tissue management, revealing his preference for extra-maxillary approaches in most cases and innovative soft tissue handling techniques that minimize dehiscence.

Perhaps most valuable for practicing clinicians is Dr. Zelig's candid discussion of surgical ergonomics and professional longevity. Rather than slowing down after decades of practice, he remains passionate about advancing the field and mentoring the next generation of implant surgeons. "I feel like it is spring again," he shares, describing how these advanced techniques maintain his enthusiasm for patient care.

As full arch restoration continues evolving, Dr. Zelig anticipates further advances in patient-specific implants and prosthetic design while cautioning against unrealistic expectations regarding maintenance-free restorations. His balanced perspective, combining cutting-edge innovation with pragmatic clinical wisdom, offers listeners a roadmap for incorporating these advanced techniques into their own practices.

Ready to elevate your implant practice? Subscribe to the Fixed Podcast for more conversations with leaders who are pushing the boundaries of what's possible in implant dentistry.

Dr. 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.

Dr. Clark Damon:

So what is the talk about the Norris? Is this like a 375 or a 35?

Dr. David Zelig:

What's its size? On the Norris it's a 375. It's a 375 with a narrow apex. To me it's a nicely tapered apex and the rest of it is threaded to the crest. Same exact thread the whole way. It's not aggressively threaded and it has that added benefit of the bold surface.

Dr. Tyler Tolbert:

the non-threaded portion, uh, mid-shaft yeah, do you think that that would have any indication for use?

Dr. David Zelig:

uh, with trans sinus as well, yes, yeah, yeah, definitely, it's um, um, yeah, I mean it's. It's really. You don't need that non-threaded surface in the trans sinus, but it doesn't. You don't need threads in the trans sinus portion either. So, yeah, it certainly can be.

Dr. Tyler Tolbert:

Okay.

Dr. David Zelig:

Yeah.

Dr. Tyler Tolbert:

Fair, fair. So one thing I don't think we've put a lot of attention to is pterygoid implants as well, right? So of course we've talked about the full gamut of you know of remote anchorage and things. So you know, I'm curious what kind of you know tips might you have for applying pterygoids in someone's practice? What kind of implant designs are you looking for there? And are you a drill guy, osteotome guy? A little bit of both, great question.

Dr. David Zelig:

It's really funny because I did the same thing. By the way, I flew around the country watching people do this too. It was really no, no defined techniques around and no real defined anatomical landmarks to use, and so it's funny that that I'm. I'm not going to call myself one of the mentors here, but there are a few of us that started teaching this a while back. Each one of us is kind of adopted points of the others and and we've each one is distilled, their own, their own technique. So I generally use I'll start with an osteotomy I use, I really use every landmark that I can. I use the hamulus. Hamulus is the medial most point of the, the inferior most point of the medial pterygoid plate. That's going to be my end point. Typically, I'll just imagine a point 20 millimeters above. That is going to be my, my aiming point for this and the. Depending on how much bone there is under the sinus, I'll start as far forward as I can underneath the sinus or in the posterior maxilla. So typically, let's say, a centimeter in front of the hemular notch, which, by the way, you really do need to reduce the tuberosity to make sure you're not losing all that wasted bone. There's a wasted height, length of an implant. But once you do that you can even even feel it. The other trick that I've been doing most recently is I'll take the the two millimeter sharp osteotome and dissect, well with a with a periosteal dissect, the posterior to the hamular notch and a little bit further posteriorly to see the fibers of the musculature. Then I'll take the point, the osteotome, and put it between those two plates in the muscle just a few millimeters and use medial lateral movement to actually I'm hitting the medial plate, I'm hitting the lateral plate and it really directs me to that medial plate so that that gives me a little bit more. Every possible clue that I can get out of this patient I'm going to use to get me in the right direction. You know we have a very healthy respect for the pterygoid region, all the bleeding things that are back there. So medial is the way to go and I'll use that sharp osteotome first just to get through the maxilla, hit the pyramidal process of the palatine bone, stop right there and then go to the same burrs that I'll use for the transnasal, the sharp two millimeter long pilot, and then followed by that implant specific drill and that's really it. But I use that. I use that, by the way, in the zygoma handpiece, the, the straight handpiece that I don't use for zygomas it's hard to use that for posterior zygoma, by the way, but it should be called the pterygoid handpiece because you're standing behind the patient. Whatever you're doing, the same direction as the osteotome goes, the handpiece goes. And I use that handpiece with both of those drills, the pilot drill and the implant-specific drill, almost as an osteotome. I'm sounding as I go boom, boom, boom, boom, boom, boom, and then I'll go to the.

Dr. David Zelig:

I definitely use the Rosen-Smiler driver. I think that's a clutch. I like saying I make fun of myself, but I was almost self-defecating, not just self-deprecating. When you lose an implant there, you'll lose more than an implant. You know what I mean. It's the worst. So it's a very scary moment.

Dr. David Zelig:

So that Rosen-Smiler driver has just locked the implant in place. There's one for for the internal hex connection is one for the neodymium connection, which is sin. I mean you, you don't need to go without it and it's just a way to stay safe and that's it. I mean it's from an implant choice. I like something more aggressively threaded and generally I will leave the flat hex or the dot, depending on what implant company I'm using, facing forward so that, um, ever so slightly a 17 degree typically 17 degree or 30 degree multi-unit will will come ever so slightly in an anterior vector and ever so slightly in a facial vector so that I can get a driver in there. If it's right over the lower cusps or lower central groove of a second molar, it's impossible to get a driver in there.

Dr. Soren Paape:

Yeah, I would say too, by doing that a lot of times we're angling our anterior implants forward to get that proper prosthetic right behind the iso edge, so it prevents a divergence.

Dr. Soren Paape:

Yeah, um which luckily now I mean I don't know what, if you guys are doing photogrammetry at all or anything but something that's been very helpful in my office is our photogrammetry unit specifically will tell you the divergence.

Dr. Soren Paape:

So you know that day like, okay, I need to make a quick adjustment on my multi-unit. But by having that anterior multi-unit it matches the anteriors a little bit better as well. And a little tip too for listeners that I've been doing is when I have a case of a patient who you know their teeth are flared forward quite a bit and I'm doing my angled, my anterior implants angled forward quite a bit, I will not angle my posterior ones as much maybe a little bit less than 30, because that will pull those forward as well, specifically when I'm doing pterygoids, so that everything's in line and I get much less divergence on those implants. A question that I have for you about your medial angle for your pterygoid implants is are you commonly trying to get full bone in contact, going through directly at the medial plate, or what are your opinions on, you know, popping through the that process into the, the fossa there?

Dr. David Zelig:

Yeah, sure, okay, let me just say that the greatest thing, the greatest thing about you know, one of the things I would suggest to anybody is just don't stay alone in your office and stay in your little world. Just, social media is great and this is a great. Just to share this passion that we all have, it's wonderful. I believe that the I believe that the real anchorage of a pterygoid implant is the pyramidal process of the palatine bone.

Dr. David Zelig:

If you hit a plate, a medial plate, in most cases you're going to hit it in an area where it's a thin plate. It's really not going to give you much. Maybe it'll give you another cortex, another little bit of stability. But I think most of the stability is really that pyramidal process, so that getting through into the, if you get into the pterygoid fossa between the plates, once you're past that you're gaining nothing except maybe causing some trismus for a while, but you're not gaining anything. So extra length once you do that is not gaining anything. So I don't see a benefit there. If you can aim, sure, ideally aim towards the medial plate and if you hit it, then you'll get some more. But most of the real stability is along that path in the palatine bone.

Dr. David Zelig:

And if you look at if you look at, look at an anatomy book and and the kind that separates everything out, and look what that palatine bone is, it's, it's a nice thick, solid bone. Um, you got to be pretty lucky and this is a blind placement. I mean, unless you're, unless you're doing it guided which you owe me another discussion, you owe me all fans of that. It's another discussion. But unless you're doing a guy, you know it is a blind procedure. So you're using the landmarks that you have and you're gaining the stability as you go. So I'm not necessarily trying to pop through. If I do pop through, I sure hope it's after 18 millimeters. You know at least I have 18 millimeters of implant before I pop through. That's my goal.

Dr. Clark Damon:

That's my goal. Yeah, I would say that I would never know if I was right into the pterygoid fossa, right? So just solid anchorage in the palatine bone, versus if we nailed the complete medial wing there, right, I wouldn't know. There's really no way to actually tell. And, and to be honest, if you pop through the medial wing of this, the pterygoid, you're, you're into the nasal fossa, right You're, you're in the nasal pharynx. And so I've seen other people's axial um slices and I'm like that tip of that implant is in air. You know, like if they ever get intubated or whatever.

Dr. Clark Damon:

You know nasally, that implant may puncture the tube.

Dr. Tyler Tolbert:

And this is something too. And I've done this, clark, I've gone, I mean I'll just, you know, I'll put myself out there. I mean I'm always going for that medial wing and just like David was describing earlier with putting his osteotome between the plates, I did the same thing with my Lance drill. Right, I like to get in between there and actually move the head physically and I'm always shooting for that medial plate and I've had a few times little bit more medial and like, yeah, I mean I've got a few that start, you know, edging into that nasal cavity and I've been curious. I mean they've torqued out wonderfully every time, of course, but I've been curious if there's anything, any negative sequela that could come from that. I'm not, I'm not entirely sure.

Dr. Tyler Tolbert:

I've never taken anything out just because of that, yeah.

Dr. David Zelig:

It's, it's way back there. I mean, it really isn't nasal pharynx, so there's good thick mucosa over it, so it shouldn't dehist through. But, like what Clark was saying, I wonder what happens in a nasal intubation or some other trauma or something like that. Right, but generally, how far are you going to poke through? I mean, I would probably say poking through a millimeter or two into the nasal floor is also no consequence.

Dr. Tyler Tolbert:

Yeah, yeah, I mean generally, if I'm deeper than I don't know if I'm going to play something longer than 2022 millimeters I need to really know where I'm at and have a good idea why? Um, most of mine are just 18.

Dr. David Zelig:

So I mean they're not going to go that far.

Dr. Tyler Tolbert:

Um, but, uh. But something I was curious about too is, uh, you know, you mentioned how, um, your, I guess your anterior, posterior entry point with relation to the hamlet or notch, is dependent on how much bone you have back there, right? So I'm curious. I mean, I have some cases where there's really not any runway at all. I mean, I got a shell of bone all the way back, does that? I mean I've done some of these cases where you know, essentially what I'm doing is a trans sinus, right? You know? I mean I'm curious of your thoughts on that, if there's a way to circumvent that, if it's a non-issue, you know, how do you view?

Dr. David Zelig:

it. So the way to circumvent it I'm not recommending it, but the way to circumvent it is the less bone you have under the sinus, the more vertical that implant becomes, more posterior, but then it becomes prosthetically useless. Yes, so you have to play the game. On the other hand, how many cases do we see that your reduction plane is already in the sinus, whether you have to lift or crush the sinus floor, whatever you got to do, even at the posterior maxilla, at the tuberosity. So if you're already at sinus, okay, ideally you've lifted the membrane there and you can actually see the posterior wallilla at the tuberosity. So if you're already at sinus, okay, ideally you've lifted the membrane there and you can actually see the posterior wall at that point, which is not a bad thing, you can see the posterior wall, you can see where your medial plate is and you're you're already in pyramidal process.

Dr. David Zelig:

Yeah, that's great if you can do it, but it does, you know. It leaves a good bit of implant hanging in midair, not not in the sinus, but in midair. What that does long-term do we know. You know, it's not like a zygoma. You have a lot less stability, it's less of a bony anchorage Less of a bending motion Right.

Dr. David Zelig:

There's less of a long arm there, that's true, um, and it is the posterior it eliminates. You can't deliver. So there is a benefit. Um, I didn't. I started this business as a all-on-four purist. You know, clark, you probably did too, you know you. You come out of there and saying any more than four is an emotional implant. That fifth implant is an amaze. You feel better, but it doesn't do anything. Well, we know that it does do something. I mean, at least the territory is eliminated, and you can't believe it does have a benefit. But I came. I came to it a little later. You know, I used it as an emergency for years and eventually it's. It's not necessarily every case, but it's most of my cases.

Dr. Tyler Tolbert:

Yeah, I think of the less emergency. More insurance, yeah.

Dr. Clark Damon:

Yeah, and I think, go into surgery that you're only going to do it once and do it the best you can. I don't understand other clinicians who say, well, we want to save bone, we want to save this for when we have to redo it, like if, if that's your thinking, then why? Why even do it? Because when you have to redo it, it's on you and it's even harder, you know, um, so you know, in in my practice, everybody gets a pterygoid. Uh, I'm, we're doing no cantilevers and I actually compiled my data for vichy and I've got, over the past five years, I've got nine hundred and sixty four pterygoid implants completed, with only four fails so.

Dr. Clark Damon:

So it's interesting, you know, I really, it really is Getting all that data. But yeah, you know, when you go to Nobel, they told you that the fifth implant, like you said, emotional implant or it's the boat payment right.

Dr. Clark Damon:

And you know I've got a lot of cases where, yeah, they're doing great at you know eight, ten years on four, where, yeah, they're doing great at you know eight, ten years on four, but man, if we could have eliminated some cantilevers or given patients extra teeth. You know, one thing that I learned a long time ago is when you're treating Indian patients, or you know patients from you know the East, what do they often have that many of caucasian americans don't? They often have third molars, and so when you give them a all-on-four on 12 teeth, you know they, they are upset, they're like where's my molars? Oh, you've, we gave you a molar and they're like where's the other four?

Dr. Clark Damon:

um, so you know, just, you always have to think of that. That was, that was a big aha, you know, moment of my, you know american americanism, uh, so just think that through and that's that's you know you want to make sure that you're doing teriquids on them. I have have one.

Dr. Soren Paape:

I have one patient right now that, uh, I did. You know I try to do retroframenol on every one of my cases as well to get those back molars and um, it was an Indian patient and I the didn't get torque on that, so I just put a cover screw. I usually come back at three months, especially in that in the posterior mandibleible. Um, sometimes I'll get those where you know, I come back at three months, expose it and then add it to my. My case at that point, and her biggest complaint over and over and over again was that right side, was that she was missing two molars back there and now for the three months that was the worst thing that I ever did to her.

Dr. Soren Paape:

Uh, luckily went back in and you know it would torque fine. Everything looked good, but exact same thing that you were talking about yeah, it's just, you know the learning curve of forage, david.

Dr. Clark Damon:

I wanted to ask you, um you know, often times you know when we're talking about pterygoids and when you talk about patsy protocol. All right, posterior, anterior, um you?

Dr. David Zelig:

know middle.

Dr. Clark Damon:

I, I kind of like Pam, right? Um, that's that's what Juan's been saying lately. If he could rename it, he would rename it as Pam posterior, anterior and middle. Um, I don't like doing my pterygoids first. Um, now, if, if I know off the bat, hey, this is going to be a bilateral zygoma case, then sure I will. I will roll in and do the pterygoid first, but just on my run-of-the-mill standard arch. Let's say it's relatively easy in complexity. I actually like doing the anterior four implants first before I do the pterygoid, so that I can make sure that I get the platform all on the same level right. Whenever we're talking about implant depth, I prefer to have my anterior four abutments on before I place the pterygoid. I find that that really helps me get the correct depth versus having to go back in and forth and take an abutment off because you didn't get your pterygoid deep enough. That's kind of one of the things I typically find in the learning curve is not placing your pterygoid deep enough.

Dr. Clark Damon:

And then when you have your abutment on, it's too shallow and so you kind of get like a you know your bar, your prosthesis kind of dips down where that pterygoid is because you didn't get it prosthetically in the right spot.

Dr. David Zelig:

So yeah, it makes sense. That does make sense. So AMP instead of PAM, Okay.

Dr. Clark Damon:

That's how I approach some of my cases right now, the hard ones, you know. We're doing the posterior, we're doing the posterior, we're doing the pterygoid first, or I actually may do the anterior first on a really hard case. I'll do the two anterior ones just to kind of get a good rep and then I'll do the pterygoid and then finish up with my zygoma.

Dr. David Zelig:

The logic of the pterygoid first is to help you position your tilted or zygoma to have that posterior implant. For example, if you don't get the pterygoid, then your zygomatic implant needs to be a little further posterior just to limit the cantilever. I mean, I understand that logic but assuming that you're going to get them all, your logic is good. Your logic is good.

Dr. Tyler Tolbert:

I'm curious too, david. So when it comes to so, let's say you're in that situation where you haven't been able to get the pterygoid If you don't get it, the patient probably just doesn't have pterygoids, they're just an anomaly haven't been able to get the pterygoid patient. If you don't get it, the patient probably doesn't have pterygoids, they're just an anomaly. But um, let's say you don't have that. Now you're trying to establish that posterior stop and you're going to do that with a zygomatic implant. Are you incorporating the hessian zygo, that sort of infant temporal zygo that goes all the way back to the first molar? Are you trying to do that, or is it more just like a traditional a-frame coming out in the first, second premolar? How are you going about it?

Dr. David Zelig:

I generally. I generally go to an a-frame and go back as far back as I can, hessian. I've done them. I've done them. Um, it's interesting, I've done it in a case. It was a I remember one. The first time I did was a revision case failed zygomas from elsewhere and the only thing the only zygoma I can get was back there. But I started with the pterygoid first, so that the zygoma and the pterygoid was so close they ended up burying the pterygoid, not even using it at the end of the day. So really it really was a way posterior zygoma. So there's a lot of leeway up there there really is is a lot of freedom once you can get back behind the infratemporal fossil like that.

Dr. David Zelig:

I think it's very useful, um, but generally I'm able to with an a-frame limit, the cantilever. The same way are you, tyler I would.

Dr. Clark Damon:

I would say on your characterization there uh, hessian would be more in the pterygoid spot and a a-frame would be more in the pterygoid spot and a frame would be more in the first or even second molar spot. The traditional Brazilian technique is where they're a little more parallel. They're parallel, okay. And that's more in the premolar position. I appreciate that.

Dr. David Zelig:

And, by the way, that's a great use for a zygomatic handpiece when you, if you're doing parallel or an anterior zygoma I love that handpiece yeah, I love that handpiece, but I love it more for pterygoids now yeah that makes sense are you in a situation where you you aren't getting a pterygoid but you are, you can't you do get the standard four in the front?

Dr. Soren Paape:

At what point would you consider putting a zygomatic implant in, because your tilted implants are too far forward? If you're coming out canine, are you putting a zygomatic implant back there? If you come out first pre, what is your logic?

Dr. David Zelig:

The biggest cantilever I want is going to be a 10 millimeter cantilever. So if I can get to second premolar, first molar junction, I'm happy. Ideally I want to be at the first molar exit point. Um, that's, that's my ideal, um, especially if I don't have a pterygoid. If not, if I'm at first premolar or something like that, I'll put as I go in to get back there, got it.

Dr. Soren Paape:

And then the second question I had was more for people who are venturing into the pterygoid space. If, let's say, you get a really bad bleed back there, I would love to hear how you, how you manage that, what you know. Just some tips for doctors if they run into that situation. What are the steps that you'd take?

Dr. David Zelig:

So the really bad bleed. You should never get it back into meaning the pterygoid plexus or the internal maxillary. If you're there, you really shouldn't have been there to begin with. So you're going the wrong way. So you really have to follow your, your anatomy, follow your landmarks. And assuming that you're following your landmarks, I mean it's like saying you know what if you poke in the eyeball, I mean you just shouldn't have been there. I mean there are ways to deal with it, of course, but you got to pack the hell out of it. You should have some tools available to help you.

Dr. David Zelig:

Avertine is something that should be in your office microfibrillar collagen to help the first stage of clots. And, by the way, the best way to use that Avitine is if you take a TB syringe, a 1cc syringe. I do the same thing with bone. You just take a 1cc syringe and cut off the tip, the lower lock tip or the catheter tip. Cut that off and you could use it as a bone syringe too. You take your bone in your Dappen dish and just fill it up from the bottom, like we used to do with impression material. Just fill it up that way and then you can use it. You can do the same thing with Avertine Make little Avertine balls, put it in the syringe and that way you can direct it as you take your pack away direct, and that way you can direct it as you take your pack away, direct that syringe into where it's bleeding and start packing that. So packing obviously is the way to do it.

Dr. David Zelig:

In the case of the realistic bleed, which is one that you're going too far, medial, and you get descending palatine artery, there are two things you can do. First, you can try it depends on where you hit it. You can try and get the palate, compress the palate on the palatal side of the, of the incision, try and get it. If you, if you got that low, if it's high, then you have to get into that, into that foramen. Today, just let me. I told you I did a, just helped a guy out with a zygote case and patient was complaining of some pain, flap was open and he was trying to get a v2 block and sometimes you can hit it and sometimes you can't. I said, well, hey, let's cheat, just dissect that palate a little bit, you can see where the periosteum starts to get into the, the greater palatine foramen, and just once you know where that is. Now you can cheat, put the flap back and you go through there. So I'm saying, do the same thing, get into the foramen and use some epi there. And then the next thing is to get into the osteotomy that you've created that caused the bleeding and pack it. Pack it there, pack it with avatine, pack it with gauze and then get an implant in there. I mean, that's really those are the only ways.

Dr. David Zelig:

Um, bovi is not particularly beneficial at that depth. You're not going to get there. It's great, by the way, bovi is a great tool to have. I think some electrocautery is important. It's most important when you start punching the mucosa around your palatal multiunits and you get these little arteriolar bleeds kind that you can stop for a moment with epi, but then it starts bleeding again when the patient goes home.

Dr. David Zelig:

So use a bovie when you see those, or the posterior superior alveolar artery intraosseous branch that you see it across the lateral maxillary wall before you get into it with a zygoma burr or a sinus lift, just zap it, touch the bone and it'll burn that too. But the DPA bleeds are not amenable to bovies. And then the last thing is don't just let a patient bleed out and die. There is interventional radiology for these things. So pack it if you're really in trouble. Before you get to that level there is, you know, pack it, stabilize the patient, get into a hospital that has IR and that can be fixed. But again, the real trouble one is internal max and you just shouldn't be there. There's no reason to be there.

Dr. Clark Damon:

I mean on the internal max, you're not going to have time to go to the hospital.

Dr. David Zelig:

Interesting it depends, I mean, if you really max, you're not going to have time to go to the hospital. Interesting, it depends, I mean, if you really get it, that's true, if you really get it, that's true. But I've seen some bad bleeds. I have seen a human being bleed out from a face by the way, coincidentally, I was finishing surgery in the operating room this was in Memphis and the chief of surgery comes running up Zellig, we need you in the ER. And I'm like you'll never need me like that. But he's no. This guy got brought in in a helicopter, ejected from a car. They intubated him in the field. He essentially had a split face and I packed everything that you could possibly pack. It turns out there were internal carotid bleeds, ethmoidals. He literally just unfortunately, watched the guy bleed out. It was just terrible. The argument you can't bleed out from your face is just not true. Wow.

Dr. Clark Damon:

Let's get off this topic. I have a Zygo question for you. What do you think about for you? What do you think about Zygo? And or do you do everything extra maxillary?

Dr. David Zelig:

That's a great question. So let's just take a Zy zero or one. We have a straight wall because everything else, everything else, is pretty much going to be extra max light, sure? So the only one that could be intra max, intra alveolus anyway, is going to be a zaga zero or one.

Dr. David Zelig:

And on those cases the big question to me is what am I gaining from saving that little millimeter or two? You know, I mean I'm not going to debate Carlos Aparicio on this, but you know in my own mind what am I really gaining? The only thing I gain from that is preventing some dehiscence of soft tissue over the shaft of the implant, at the crest To me. To me, because I'm not using a threaded implant, so I'm not going to get osteointegration in that crest, so that's the only thing I'm saving. It makes it technically more likely to me to perforate the sinus membrane low, I'm talking at the crest.

Dr. David Zelig:

So, although I've done it in these cases, you've got this really beautiful, thick alveolus and it would be a crime to grind through it. I've done that, but at the same time I've made a window, a long enough window in the side of the membrane to be able to lift everything. Not that I'm an impatient surgeon because I think I got patients to do it right if it takes it, but I just I question the benefit. I question the benefit. So, yes, I've done in some cases. I don't see a lot of those full alveolus cases, so almost all of them are ground down. Use that lateral extra sinus burr.

Dr. Clark Damon:

So let's just say it's a zaga three. You know, you have two options, right. You can either tunnel or channel, right, so um I channel. Okay, there you go all right well what do you do? I'm more flexible, I'm a little more open-minded, I tend to be more Zaga versus extra maxillary, but you're a big Norris guy, right.

Dr. David Zelig:

So Norris likes to. That's true too. Today was a near that case, but um, I don't, I don't, um, I don't know. I just I wonder. I think that the soft tissue management, I just don't see a lot of the dehiscence. If I'm gonna see it, you know, I can generally predict it a smoker or something like that, and I use thick tissue and, by the way, I started on edentulous cases I really went back to a vestibular incision, like a Laforte incision, and bring all that you know, really punch the tissue so that my incision is far from the crest.

Dr. Clark Damon:

So you're going. What 10 millimeters?

Dr. David Zelig:

beyond, or 10 millimeters apical to the… Into mucosa, into mucosa, into mucosa, and bring the whole thing over. It makes, I mean, in a conventional case, in conventional not necessarily zygoma cases, but in conventional cases it just ends up looking like, wow, this is healed already. You know, as soon as you finish your case, it's just, it's so. It just makes it so clean and then you don't worry about your incision line. The only thing I worry about in doing it that way with zygomas is is there going to be dehiscence along the shaft? And I'm using fat, I'm thick and covered, so I really have not seen that.

Dr. Clark Damon:

So now do you pull fat on every zygoma case or will you do like a scarf graft? I do both.

Dr. David Zelig:

I do both. Not on every case, but I will do both. Non-smokers with good thick tissue I don't always do, and if it's a Zaga 1 or so then I don't necessarily.

Dr. Clark Damon:

Yeah, I tend to hold the fat, to reserve the fat and harvest as much pedicalized CT when possible Makes sense.

Dr. David Zelig:

Makes sense.

Dr. Tyler Tolbert:

So I'm curious about this vestibular approach, because that's not something I'm super familiar with. So does that? Is that to say that you're incising into the actual vestibulum and then Not that, not quite.

Dr. David Zelig:

It's called the vestibular incision, but it's not. It's essentially it's what's used for a Laforte osteotomy. You're, you're leaving all the attached gingiva, attached in this case to the palate, um, and you know again, normally you do some little forward osteotomy. There are teeth that stay there, so the attached gingiva stays there. It's not stripped. In this case it's an edentulous arch. So um into the free gingiva, okay, at the attached gingiva, free gingiva junction, almost or further apical than that, and then strip the entire flap over pallet, okay, so you go past the end of the j and then you come back over and now, when you close, it's then I punch through.

Dr. David Zelig:

I essentially am punching through the crest yeah, wow, wow.

Dr. Clark Damon:

One of the drawbacks, though, is that you can't thin the palate. But, um, on the edentulous case, it's really just edentulous cases. Yeah, it'd have to be a case where you don't have to do any tuberosity reduction or thinning or anything like that.

Dr. David Zelig:

Good, um, nice question. So I do. I do when I, because how are you going to get your pterygoid in Same problem? So I do change that incision. I'll have to show you one day. It's towards the crest and then goes vestibular At the tuberosity. It's crestal over the tuberosity and then comes over.

Dr. Clark Damon:

Yeah.

Dr. Tyler Tolbert:

I think I can see that yeah.

Dr. Clark Damon:

Just looks like a denture almost. It kind of goes up and has a flame. Yeah, that, yeah, just looks like a denture almost. It kind of goes up and has a flame. Yeah, yeah, yeah, nice, nice, wow, that's great.

Dr. Clark Damon:

Now one other question, um, you know, you, you brought up in one of the chat, chat groups that we're in about, uh, basically bracing your zygoma shaft along the palatal wall.

Dr. Clark Damon:

And you know, one thing that I will often do is because, on a scenario like what you're talking about, where you've got a channel right along that alveolar wall and like, let's say, it's a, that case would be like a, like a zaga, maybe one or two, something like that. Right, I, uh, chu, I think, is his name, he's out of hong kong, he's got a great article. It's an older article, um, but he, he lifts the entire membrane and actually does particulate grafting there. I don't like particulate grafting with zygos, but oftentimes what I'll do is, whenever I lift, I'll put in maybe some collar tape or something like that, so that I actually will wind up getting some type of bone formation several years after this is all said and done. So I'll still kind of prefer to rest it along that palatal channel, but I'll lift my membrane and then I'll put in a collar tape so that it stays in place and hopefully we get some bone formation later.

Dr. David Zelig:

Alternative. Again, these are cases that you have to do so much bone reduction that you're past the sinus floor, right? That's what we're talking about, those kind of cases. So what I'd like to do is start your reductions until you start to see that membrane and there's still bone over it and just infracture that floor so that there is bone on that inner aspect of your implant still, but it's still it's it's too palatable. I mean, it's still palatable to the ideal, um, but that was the alternative. Speaking of using some kind of membrane is um, I toyed with using volumax thick ossex membrane. When ossex first came out, their big claim to fame was that the membrane itself ossifies, so that the thickness of that membrane. You go back in there sometimes and you see the texture of the membrane still now bone. So Volumax, the argument is you got this thick membrane that will ossify in theory. So I started using that, actually on the facial of some zygomas as well.

Dr. Clark Damon:

Let's see what happens. Well, it's easier than a ramus graft. Yes, it sure is.

Dr. David Zelig:

So that's an alternative is to use something like that, a good thick membrane. Certainly it'll help with any oral-antral communication, but it might help with some ossification too.

Dr. Clark Damon:

I think that's a really good thought there.

Dr. Soren Paape:

the ossic exfoliants Just changing topics a little bit. I'm curious, david, what your thoughts are on the best practices for general dentists doing remote anchorage just for, like, protection from board complaints and being compliant and making sure and I don't know if you've seen it happen or anything but like a general dentist who perhaps had a board complaint or something for a remote Anchorage based implant. Is there anything that you've seen dentists do to protect themselves from that, to ensure that and not not I'm not talking about cases where they were doing something that they shouldn't have been doing or like in a location they shouldn't have been, but just to ensure that they're staying up to par with someone, like like an oral surgeon, oral maxillofacial surgeon. If they came across the board and just said, oh, he's a general dentist, he shouldn't be doing this, so you know, we, we had, we have the same issue, if you think about it.

Dr. David Zelig:

You know, when I, when I wanted a well, so I trained in a training program where we did our own hips, we, we took our own hip bone and most of us do today I went to Memphis, a very conservative town, and they didn't want to let me do it, and so I spoke to the chief of surgery.

Dr. David Zelig:

The chief of surgery was an orthopedist who trained the Jackson Memorial, where Bob Marks was, and they wrote the book on grafting from the hip, and he knew that and he actually supported me. So bottom line is I had the training and I had the support of an orthopedist to suggest that I'm right and it worked. So in this case it's the same thing A general dentist should get the training, and we just discussed what that is. It's the same thing that medical education letting go of the hands and slowly taking the training wheels off it's a learning curve. It clearly is, and probably more of a learning curve for a general dentist that didn't have a surgical residency. So take your time, have the backing of the people that trained you and go out and do it. I don't think that you stay in your lane, so to speak, do what you're trained and well-trained to do, and I think you should have some backup, somebody to call.

Dr. David Zelig:

Well, you know David some of the things that I see is just in record keeping.

Dr. Clark Damon:

That's a good point. It's very technical, yeah, absolutely well, sure, but, um, very simple. You know, everybody who's going to undergo anesthesia just get a medical consult. Right, it's not a medical clearance, it's just a medical consult. So we get that on everybody and what you get back from the physicians is their entire medical history, right, like I've seen people get dinged because they didn't put an ASA classification, you know, on one of their notes. You know, or something, or something crazy. But if you in your part of your record is the patient's record from the medical doctor, you are more than covered. You know, and I you know. I think it's also important that you know the our medical colleagues. They don't give us clearance, right. We are the ones who are deciding to work on. So, and it's just having having a very, a very nice medical consultation letter that you are just asking is this patient medically optimized and do you have any objections?

Dr. Soren Paape:

is. You know you've been doing full, I mean practicing oral surgery and then getting into the full arch dentistry. I would love to hear kind of your tips as far as what you do to for your own personal health, to ensure that you can, you know, keep doing these things, because right now, you know me, I'm like leaned over upside down in the patient and I don't think that that's the best for longevity right, our dogs are okay and I would love to hear your tips.

Dr. Soren Paape:

I know some guys do it sitting down like I'm just oh, here's what?

Dr. David Zelig:

here's what I started with. First of all, I think that all of us are all front anterior chain in physical therapy terms. We're all anterior deltoids and pecs and everything's in the front All right. So our backs are critical. So I came. Before I started this, I was a powerlifter First, it was martial, I was a nut, I was wrestling team in college and power lifting and all this nonsense. So because of that, by now I have a total shoulder replacement, two hips and a knee replaced. That's aside, but I'm still doing all this. I'm still lifting.

Dr. David Zelig:

I'm still doing the rest of it too good so I think that staying, staying fit and stretched and all that stuff is really critical. I really think that's very important, which opens up the other thing balance in life. Because we can I think I was, I had a better balance in life before I became a full arch guy, but that's another discussion you start to get down in the rabbit hole. Um, I do sit. Uh, in the last 10 years probably I started sitting and I use years probably I started sitting and I use a sit stand stool. I use a sally stool, which is like you're, you're almost standing, so you can feel like a surgeon. And, um, no, I'm seriously, because that was the big thing oral surgeons, here you don't sit. What are you a dentist? You know that kind of thing is ridiculous, but but that was it, was the thing. So, and everybody in the operating room stands. So this thing is you, you're almost standing, your feet are almost straight, but you're in a stool. Sally's stool, great for men, has a pudendal groove to let your prostate be healthy and keep the boys from being asleep, so anyhow, so that's, I do recommend that. I do recommend sitting and sitting in a stool. If you're in a horse's saddle you can't slouch, so you really are maintaining a good, a good posture. So I think that's important, um, but sitting high so that you're still looking down and able to see what you need to see.

Dr. David Zelig:

Headlight, like I said, I don't use the loops, um, um, I used to use it for a lot in surgery, but not in arches. You really, I feel like you got to see the whole headlight. What's that? What headlight do you like to use? I have the kls martin, the, the uh med led chrome, okay, um, but I've tried them all. I have another one that sits on my glasses. Oh, I just recently I'm not wearing them now, but I just got somebody bought me a gift certificate, gave me a gift certificate for the Ray-Ban Meta glasses. You know the AI glasses. Yeah, I put the camera in there. I actually started using it for filming in surgery. It's great.

Dr. Tyler Tolbert:

Someone suggested this to me on Instagram and I was curious. Yeah, it's great.

Dr. David Zelig:

You just. There's something. You just. You can't use your headlight when you're doing that, though, it's too bright, but once you you take the headlight off, it's great. It really is very useful it's a high quality video is high resolution. They it's a high quality resolution. They're limited. You can do live stream by the. You can do live stream, by the way. You can do live stream with it, but the video length is limited to like three minutes.

Dr. Clark Damon:

But you know you want to show somebody, something.

Dr. David Zelig:

You can take pictures and you can do little snippets. Oh, that's cool.

Dr. Soren Paape:

When you're doing the. Actually, you know, I was just going to ask about the three minute thing, cause when Tyler and I, previous to our current, what we're currently doing, we were doing a lot of a clinical director like helping people with their first surgery, so we were taking a lot of video and it's always a pain in the butt to have this video camera like above and it's like focusing in and out every time you lean forward, you know.

Dr. David Zelig:

Um, uh, what's that? There is a camera that is on the on the overhead light fujiden, I forget what it's called, but there's one that does well. But the other one I got that um headlight camera. I have that too five thousand dollar, yeah it was. You know, what else am I going to do with the money, you know, but anyway, I it's very uncomfortable and, um, heavy. You're like a lot.

Dr. Soren Paape:

Right, there's a lot of this going on, so, um, I haven't found the secret so when you're doing your um, when you're on your, your sally stool, and you're, you're, you're doing it, you're at the 12 o'clock position. Are you doing your mandibles from the 12 o'clock position?

Dr. David Zelig:

Yeah, mandible, more of the mandible. So 12 o'clock to 3 o'clock. I mean I'm to the side of the patient as well, but I try. More I can do from behind, the better. Patient is flat, that's. The other thing is, you know, when I did, when I'm doing my own sedation, my own deep sedation, the worst position for a patient when they're in open airway is flat. So you know, but it's the right way for us to do surgery. It's the easiest way for us to see the maxilla and the mandible. So I do fight it. When I'm doing my own sedation, I often use a nasopharyngeal airway to help with that. When I'm elsewhere not my own center, I have an anesthesiologist, the patient's intubated, that's beautiful. So I have no airway issues. Um, and when I'm doing the mandible, I'll just sit the patient up a little bit. So I'm looking down, but I try to be from the standpoint of when I'm doing the osteotomies.

Dr. Soren Paape:

I'm behind the patient, which just makes everything symmetrical I have tried doing that so many times and I keep. I always come around to the front of the patient to do mine, but it's just one of those things that you gotta, you gotta, but as long as I mean, if your back is straight, that's the main thing.

Dr. David Zelig:

Yeah, you just keep your back straight and look down, keep the patient low and just look them down and good well, hey, I appreciate those tips, that's great yeah, we need something, something that a lot of people don't think about, but I'm hoping a long career ahead and get out there and play pickleball or something.

Dr. Tyler Tolbert:

Oh man. But yeah, maybe I'll just start wearing one of the powerlifting suits, you know, with the those are beautiful.

Dr. Soren Paape:

Just the belt during the surgery.

Dr. Tyler Tolbert:

Yeah, I have done that actually, but uh, but no, that that's great, and so you know I mean that that question kind of alludes to you know, you know how long you've been doing this and your ability to continue to do it. I'm curious about you, know, looking forward for yourself professionally. Obviously you've been doing arches a long time. You're practicing at the top of what we can really do. Um, you know, what are you looking forward to for the rest of your career? I mean, do you see more advancement, more growth in your clinical uh pursuits? I mean, what do you?

Dr. David Zelig:

see for yourself. It's so funny. You know everybody I have friends that some have retired, some are retiring, some are slowing down, some of everybody else, and I'm like I'm still on fire on this. I love it. Um, yeah, it's great. You know, there was a. There's an old singer that was the other thing I did was I was, I was in a choir, but anyhow, this guy, we did this opera together and the old man sang in the winter of my life. I feel like it is spring again, is what he's saying. I'm not in the winter of my life or anything, but I feel like this is keeping me going, excited in this every day. I love what we're able to do for patients. It's a privilege, it's a real privilege and I love it. So do I want? Yeah, yeah, I definitely want to do more. I want to keep teaching, I want to help the next generation and, um, just keep doing the right things for patients, you know yeah, yeah, and looking forward.

Dr. Tyler Tolbert:

For you know, obviously you you've had the wisdom and the experience to see how far full Arch has come, all the way going back to when Paula Malone was first talking about this kind of stuff. So you have probably as much authority as anybody to say what does it look like for the next 10 years? Where do you think Full Arch is going? What do you think people will be talking about on podcasts in 2035? With regards to Full Arch, that's great.

Dr. David Zelig:

I definitely think that we're getting to a point where we got a system that works. The patient-specific implant is going to find a way to get perfected for the, for the multiply revised cases. Having having had joint replacements, I can I think I could also tell you that orthopedists look at these things differently. They don't call failures failures. You need a revision. And you need a revision because a car is not going to last forever unless it's maintained perfectly. And even an antique car is not going to drive the same as a new car, even if it's well-maintained. So things do change. It doesn't mean failure as long as new guys with the great new ideas.

Dr. David Zelig:

We talked a little bit about the immediate finals. I don't know that that's going to last. I think that you also talked about the lifetime warranties. I don't think that people can stay in business when they're advertising pie in the sky kind of things that are not necessarily going to work. Um, but it might be the, the flash in the pan. It might work right now, yeah, I think. I think the the guys that are doing it right, responsibly, will end up if I could use the term winning, will end up just, uh, being into the long game. You'll end up just uh, being in for the long game. You'll still be doing it by then.

Dr. David Zelig:

Yeah, I don't know about me doing it, but I'm saying you know it's as long as you're doing the right thing for the right reasons um, you'll still be doing it that's great.

Dr. Soren Paape:

well, we definitely appreciate having guys like you that are helping us in the next generation with with uh, you know these advanced techniques and making sure that you know guys like Tyler and I coming up have the ability to to fix these cases when we need to, because without, without people like you, we wouldn't be able to or we wouldn't know where we could go, you know.

Dr. David Zelig:

You honor me by saying that, but I just, you have no idea the you've given us life. I don't know what to say. Great, great to have that. It's great to have that, cause I cause I had that. You know, I had those mentors.

Dr. Tyler Tolbert:

Yeah, yeah, I mean oh Clark, we lost you. I'm mute again.

Dr. Clark Damon:

Yeah, I'm sure Check your. I think now it's easier to have a tribe Right. I think now it's easier to have a tribe right and so it's easier to, you know, collaborate, it's easier to talk about cases, and so I think that you know advancement will be quicker and it will be, you know, better. I don't know what is around the corner, I don't know how it can get any better, you know, I mean I think what Molo, you know, I don't know, I don't know what is around the corner, I don't know how it can get any better. You know, I mean I think what, what Molo, you know came out with, you know really started off a lot, and then what you know, you know things you know like Dan you know coming out and you know.

Dr. Clark Damon:

You know I was doing pterygoids before Dan's book came out, but you know Dan has really kind of helped. You know, talk about pterygoids and then bring in the no cant. You know Dan has really kind of helped. You know, talk about pterygoids and then bring in the no cantilevers and and and really kind of broaden that out to where I really feel that you know our implants are better and our patients are being treated better. So it'll. It'll be a fun. It'll be a fun, you know next chapter, but I think that the the clinicians who are coming up, I think they have a better education experience, better access to education and access to a community yeah yeah and you can find that at clark's course, if you need good education.

Dr. Soren Paape:

It's a good spot to go, for sure yeah, that's right, my uh, tyler and I and caleb, who's our other partner we talk with this a lot about, you know, because we always are trying to stay ahead of the curve when it comes to, like, the business side of full arch. Um, and where we're really excited about is the potential for a lot of like the ai and the prosthetics. As far as um know, I'm sure we'll get to a point where a lot of the design is going to be done via AI and maybe you can take a, take a picture of a patient right and then get a smile design, and that smile design will turn into, you know, a surgical guide right, or or just like the provisional prosthetic already designed for you on those multi unit positions, and that's what we're really excited for, I think that that is going to be coming here pretty shortly.

Dr. Tyler Tolbert:

Yeah, I think a lot of the advancements we'll see are going to be on the prosthetic side and on the actual planning side of things, right, I mean, we had Dr Sven Bone on here not too long ago talking about his programs that are doing a fine element analysis to look at prostheses and figure out where their weak points are, and that's yeah, and that's some well a break.

Dr. Tyler Tolbert:

Exactly precisely and you know that's an AI driven thing. Ai can be driven to, you know, either generate or analyze an implant plan. You know, on an extremely atrophic case, it can figure out where the stress points are, or maybe even a patient specific implant, like David was mentioning, finding where those stress points are going to be and how that's going to work out prosthetically. I think it's going to make us a lot smarter in terms of you know what we're putting on top of our implants. But my hope is that the Yomi never catches up to us and we'll still be the ones executing these surgeries. That will always be a human being. Yeah, that's what I'm hoping for. I hope I get David's age and I'm still talking about slinging arches on the daily.

Dr. David Zelig:

And that's what I'm still going to participate in, and this will only get better as we go. But I guess time will tell I have a perfect. Not that I need a closing line, but we opened maybe before we started recording. I thanked you for sending me this, what I call the Rush Limbaugh EIB microphone, sending me this, what I call the Rush Limbaugh EIB microphone. So Rush Limbaugh, it turns out, if I can quote him again, before he got sick and before he died he was also a tech expert, an Apple expert. He said I'm not afraid of dying, I'm afraid of all the tech I'm going to miss, and I think that applies here, man, we're all growing up and getting older, but look how this is growing yeah it is.

Dr. Soren Paape:

I mean going from just and I think, David, you might have mentioned that you still, a lot of your cases are analog, but from analog to, and I know yours are too, Clark, but go ahead.

Dr. David Zelig:

No, no, no, I said I was analog and trying to figure out all this tech that you sent me to start.

Dr. Tyler Tolbert:

Okay, no, no, no. I said I was analog and trying to figure out all this tech that you sent me to start.

Dr. David Zelig:

No, no, no, I'm mostly digital In that world. I'm mostly digital.

Dr. Tyler Tolbert:

Yeah, clark is not as over here.

Dr. David Zelig:

Yeah, just like you.

Dr. Clark Damon:

Well, I don't have a prosthodontist that I can just bring in and just say okay, you know, give him the teeth. You know, Of course, of course, yeah give them the teeth.

Dr. Soren Paape:

You know, of course, of course, yeah, but the advancements on the digital side? In the last five years have been exponential, which is so cool to to be a part of and, um, you know I'm incredibly excited to see what's to come in the next five years in that front. For sure, for sure uh well, david.

Dr. Tyler Tolbert:

thank you so much, um, for taking this time with us to share your knowledge, your wisdom, and you know the energy you brought forth with this is just, it's just amazing. And you know you're obviously genuinely interested in this and appreciative of what we do, and that's just extremely humbling. You know, just as a host of the show, to have that and and Clark, of course, thank you so much for sparing your time to come on and you know I appreciate, you know the, the how you've escalated these conversations, because you're certainly able to pull more out of david than we are, um, given your experience. So I think this has just been an incredible interview and and I really appreciate you both for for coming on thank you for the opportunity.

Dr. David Zelig:

I want to learn more from you guys well, you're too kind.

Dr. Tyler Tolbert:

Well, maybe we'll have you back on the show in the future and, uh, share some more war stories. So, uh, thank you guys so much and thank you all for listening. We'll see you next time on the fixed podcast. Thank you, thank you, bye, all right.