The Fixed Podcast

Advancements in Implant Techniques: Sinus Crushing and Pterygoid Implants with Dr. Clark Damon: Part 1

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Mastering complex anatomy in full-arch implant cases requires both technical skill and the wisdom to know your limitations. Dr. Clark Damon joins The Fixed Podcast to share rare but invaluable techniques for challenging anatomical situations that every implant dentist will eventually encounter.

The conversation centers around two advanced procedures: sinus crushing and pterygoid implant placement. Dr. Damon reveals that despite completing 3,000 arch cases, he's only performed sinus crushes on three patients—a testament to both the rarity of proper indications and the importance of understanding when this approach is truly necessary. He walks through his precise technique, from the diamond burr scoring to the use of collagen tape rather than particulate graft, explaining how this one-surgery approach can transform cases with pneumatized sinuses that would otherwise require multiple procedures.

Perhaps most valuable is Dr. Damon's candid discussion about knowing when to collaborate with specialists. "Too many clinicians are taking on cases they really shouldn't be doing," he observes, emphasizing that revenue pressure often leads to complications that "come home to roost fairly quickly." Instead, he advocates bringing specialists into your office for complex cases—creating learning opportunities while maintaining the patient relationship.

The episode showcases Dr. Damon's pterygoid expertise, having placed over 1,000 implants with a stunning 99.5% success rate. He details precise placement techniques, including his preferred 18mm length and entry point between the second and third molar positions. Using the analogy of aiming between the "field goal posts" of the lateral and medial pterygoid plates, he demystifies this advanced technique that dramatically reduces stress on anterior implants.

Whether you're looking to expand your implant capabilities or simply understand when to call for reinforcements, this episode delivers practical wisdom from one of implant dentistry's most experienced practitioners. The techniques discussed may be advanced, but the philosophy is universal: always prioritize predictable outcomes over pushing clinical boundaries beyond your comfort zone.

Speaker 1:

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.

Speaker 1:

Hello and welcome back to the Fix Podcast.

Speaker 1:

We have a special guest on today, though he's becoming somewhat of a regular. Today we have on Dr Clark Damon, who has graced us with his time, and today we're going to be doing something that looks like it could be a recurring segment for us. So, um, for those of you who have taken his course, uh, down in Texas at the Texas implant Institute, um, you get, uh, to be a part of the tribe. It's a WhatsApp group with all of the alums from Clark's courses and in there, um, you get to have these really candid conversations with all the other alums doing Fixed for Large, the good, the bad, the ugly. We share cases in there and Clark is very on top of all the messages in there, giving feedback, giving recommendations, sharing his own cases whether they go to plan or not. It's been a really valuable community. So we got to thinking I think it was actually Clark's suggestion that we come on here regularly and talk about some of these topics, and so we really appreciate him taking out the time and welcome back to the show Clark.

Speaker 3:

Yeah Well, thanks Well, and you know, I also wanted you know to, you know, interview you guys and actually let y'all be a part of you know, the tribe that you're creating with your sure. Sure, yeah With with your podcast and and maybe have something that's a little more laid back and you know, just kind of talking about. Like you know what's going on, you know where, where are people headed for CE, Just kind of just a little more.

Speaker 3:

You know more fluff kind of what? A little more. You know more fluff kind of what's working. You know how your practices are moving and just you know there's always these seasons in a full arch practice and you know the seasons can be, you know whenever you started, or it could literally be within you know the quarters of the year.

Speaker 3:

You know, I think typically, you think typically the first half of the year, full arch practices are busier than the latter half, and marketing is always something that changes, and I think that's everybody's vein or bane of existence, and so it's kind of interesting to see what's working, just kind of that kind of stuff.

Speaker 2:

So yeah, absolutely. We'd love to get some questions for you too, or usually on the uh giving end, so it will be nice.

Speaker 1:

Absolutely, absolutely so, um, but yeah, I did want to. Uh, yeah, and you're more than welcome to flip the script on us and, um, you know, it'd be the first time that I think either of us have ever been interviewed on our show, so I'm I'm more than welcome, um, for that. But, uh, but, yeah, so I did. I did put together just a few topics, um, kind of going back through the tribe conversations all the way back to, I think, when, when we first joined, was back in January of this year, and, uh, there was a really um, interesting topic that came up, and I think it actually came up around the time that Soren um had a case like this come through his clinic where, um, you have a patient that, let's say, they have a high smile line.

Speaker 1:

They may not even have a particularly high smile line, but what you deal with is you have pneumatization of the sinuses. That goes so far to the point where where you're trying to do your, your alveo and and raise where that transition line is going to end up being, but you're out of runway, you don't have enough sinus bone to take away, so you've got these gums are visible and there's not any foreseeable way to do that simply with reduction, like we normally do. And so in the group you shared a case where you had done some sinus crushing, so basically upping the sinus floor, doing some grafting and sort of raising that platform. So I was hoping you can kind of walk us through you know indications for that some issues that can come about, possibly some alternatives for cases that look like that, because you know every so often these do come through our door and that's not a simple thing to treat.

Speaker 3:

Right, yeah, so I think you know. The first thing is you know, understand your limitations right and and know when to refer it, or really you know, now there's there's a lot of clinicians. Even myself I'll go into people's offices in Texas and I even recently got an Oklahoma license and go in, go into people's offices and help them out on more complex cases, you know.

Speaker 3:

So one one issue that clinicians have is maybe they can do the lower arch and it's simple, but the upper may be, you know, more difficult, and so actually bringing somebody in is so much easier. You can learn so much from that clinician coming into your office to treat your patient versus just referring them out, like if you refer the patient out, which is obviously can be the best thing for the patient, you miss out on that educational opportunity. And so consider these options. I think Juan Gonzalez can come in and he kind of flies around. I think the difference is a little bit limited to can the clinician actually touch the patient, if they have a license or not. So that's something to take into consideration. But hit me up. If you're in Texas or Oklahoma and you want me to come, do a case and you really want to learn, I'll come and let's get an.

Speaker 3:

I think too many clinicians are taking on cases that they really shouldn't be doing. I think there's a big driver and a big push for revenue, revenue, revenue, top line. But when you push a standard, when you push a case to be a standard, that is not a standard. That needs to be done. Patsy, you're going to have problems and these problems will come home to roost fairly quickly, with temps breaking, not being able to manage a smile line. So on a case where the sinus hangs inferiorly to the reduction plane, clinicians are going to have, you know, they need to one, identify it, and it can be a difficult thing to identify. Two, the clinicians. You know there's no way around it. You can't say, oh, we'll put a flange on it. You can't say, oh well, we'll just have a shortened bridge. In that case, you know, because then it's going to be, you know, a first premolar, you know $20,000, $25,000 implant bridge. So again, the patient's going to be unhappy.

Speaker 3:

So clinicians typically have two options when dealing with this. One you know you have to do something. So not doing anything is not an option. So option one is doing pre-surgical grafting or pre-arch surgery grafting, and that is a very viable alternative. And on certain cases we can do a sinus crush intraoperatively and then that way the patient can have one surgery. Now I would. So what are the indications of a sinus crush? I think number one the patient needs to be a dentulist Trying to do a sinus crush when patients have teeth is going to be difficult Oftentimes. And why right? It is likely that you're going to have some type of communication You're going to have. The sinuses are going to be pneumatized, the roots are going to be into the sinus, so oftentimes we're going to have several tears there. So I would say to do a sinus crush indication would be edentulous.

Speaker 1:

Now, does that mean fully edentulous or just edentulous in the areas where you would be looking to do the crush, so you don't have all that anatomy? I guess that's a good point, right? They could be partially edentulous or just edentulous in the areas where you would be looking to do the crush, so you don't have all that anatomy.

Speaker 3:

I guess that's a good point. They could be partially edentulous, as long as they're edentulous in the area that we're crushing. But again, we're talking pneumatized sinuses. So oftentimes if there's a canine, if they're edentulist maybe they only have the front six teeth. Having a canine may really be pushing it. Always do what's predictable in your hands. If doing a sinus lift is more predictable for you as long as you can nail it and then that way you can come back and whenever you do your alveolar reduction. Now you have sinus grafted material there and you don't have to worry about a low-hanging membrane and you don't have to worry about crushing it.

Speaker 2:

I want to quickly go back real quick to what you were talking about earlier about taking these cases on, and one thing I want to mention for everybody listening to this is if you take on, like Clark was saying, a case that should be Patsy and you do it for a certain price, you're not only putting the patient in the situation where they might need another surgery in the future with, like a zygote or something like that, but a lot of times you should just keep in mind as well that most of these patients that are coming to your office at least most doctors that I know they're charging a set fee for the whole surgery. So if you do that surgery and later it needs to end up being Patsy, just remember that you're probably going to be the one fronting the cost for the second anesthesia, for another provider coming in to do zygos and potentially, like you know, someone coming in to do pterygoids. So, yes, like these cases in particular, combination syndrome, kelly syndrome, zygocases, you know maybe pushing the envelope too far on palatal approach, if you start that case thinking okay, yeah, great, like I'm going to test out these different implants that I know, and that you might end up in a situation where you're paying out $10,000 for another anesthesia bill and another provider to come into the office by not referring that or bringing someone into your office right off the bat. Sorry, clark, from getting aside from the crushing sinus thing. I just wanted to quickly mention that because I think that's a really important point. That because I think that's a really important point.

Speaker 2:

And when I first was like getting into some of the more advanced implants, it happened to me one or two times where we ended up having to pay for another provider to do zygos. Because I took on like a case the cases that happened to me. They worked out, they were just the implants An implant failed and I needed a zygomatic implant. But just something to think about before taking on these challenging cases.

Speaker 3:

Yeah, it's always better to do things right the first time and the cost of bringing a provider in when done the first time, you can still make a fair amount of money on that. It's just when you've already lost your afternoon the first time. You can still make a fair amount of money on that. It's just when you've already lost your afternoon the first go and then now you have a second anesthesia bill, you have a second prosthesis bill, second lab bill, second implant bill.

Speaker 3:

Now you have a provider bill, you know, and then you know. So not only are you not making money, but then now the patient's like oh gosh, you had to have somebody else come fix it Versus. Hey, I know where to go. This guy's really nice and he's hooked me up with some other guy that can come in and take care of me. That's like a win-win-win.

Speaker 1:

You're a quarterback in that situation Looks good. Yeah, for sure.

Speaker 2:

Yeah, and never, you know, don't feel bad telling your patient like, hey, I can do traditional all-on-four, maybe pterygoids very well, but your case happens to be one that needs a little bit more advanced implants for that. Luckily, you know, I am good friends with some of the, you know, whatever circle you're in, but I'm good friends with some of the best implant surgeons in the United States and I can have them come and piggyback me on this case so you get the best possible treatment and patients aren't going to look at you poorly for doing that. You're providing them support and ensuring that they get really good care in your office.

Speaker 1:

And I do have a question about that too, clark. So you know you are offering to others that are in Texas or Oklahoma your services. If someone looks you to come out for placing a Zygo, what have you? Obviously they're not comfortable doing it themselves. Well, they're probably not going to be feeling very comfortable dealing with a Zygo complication, should that happen down the road right. So is that something that you know? Whenever you have an agreement with somebody like, hey, I'm going to come out and help you out with this, you know Zygo case, would you also be available to come out as well if there's any issues with that? Do you want to be there for follow-up? What does that kind of look like? Just to kind of paint a picture of you know, if I'm going to bring someone into my office, what can I expect if there's ever some issues?

Speaker 3:

Yeah, you know. I mean, as you guys know, right, like when you start doing more all-on-X cases, you get more all-on-X cases and it's not going to be, you're not going to have the one time that you need to bring an advanced provider in, right? Like these advanced cases show up on a relative frequent basis, right?

Speaker 3:

so um, what I, what I try to do with. You know the current offices. You know one of my offices that I go to in houston, uh, I'm there once a month. Um, another office you my offices that I go to in Houston, I'm there once a month. Another office you know that I'll go to in Oklahoma, I'm there once a quarter, right? So you know there's a regular cadence on that and so you know often, oftentimes, if there's some issue, you know.

Speaker 3:

But going back, like I mean, I really try to educate these patients like, hey, we did zygos. Do not use a water pick on your zygote. You know sinus precautions for the first. You know, three weeks, don't get on an airplane. You know most, most, you know postoperative complications with it, with a zygomatic, are going to occur. You know, a month, maybe maybe two to three months down the road, right, so then you know your cadence is kind of already there. And then also also when, when you think with an open mind about that cadence, right then now you're going to feel comfortable selling more cases, right, like you know, think back when you guys had sold, you know, maybe under 75 arches. You know, I'm sure there were some cases where you're like, yeah, I can, I can do this. In the back of your mind You're like Nope, don't do it, don't do it.

Speaker 1:

Right.

Speaker 3:

But if, if you have somebody coming in on a regular basis, boom, mrs Jones, we can do this for you. We're going to put that on Dr X's schedule. He's going to be here in two and a half months, no big deal, you know. Whatever we're going to by the time, we, you know, send off your medical consults, your EKG, your labs. We get your teeth designed, smile designed. You're only going to wait a couple of weeks. I mean, you can just kind of create a song and dance, so certain things to just kind of think through. That is the one challenge is, if a patient has a larger postoperative problem, we don't want to abandon the patient, and so the clinician does need to take that into consideration. So, whether or not you meet the patient halfway, the patient comes to your office, you go to theirs, vice versa, that sort of thing.

Speaker 1:

Yeah, so I do want to go back to the sinus crushing just a little bit. So, when it comes to the intraoperative sinus crush, what does that look like? What's the instrumentation? How are you thinking through that process?

Speaker 2:

And what complications have you seen?

Speaker 1:

Yeah, that's great too, yeah.

Speaker 3:

So all right, so we're just going to go back. Indications on that. You know, again, for a signage, crush, I want it to be edentulous, or at least edentulous in the site that we're going to be crushing. The technique you want to use like a number eight diamond burr, use like a number eight diamond burr and you want to score. You want to score that 360 degrees around where you're going to tap in. And you know, obviously these are, these are, it's a sinus, it's a large sinus. So just picture, you're going to want to crush an area that's probably the size of your thumb. Okay, so you want to make a really big elliptical scoring of the bone and especially the palatal bone. So if we're going to be dealing with the palate, we're going to want to reflect all the way down to the horizontal portion of our palate. We're going to want a large palatal reflection, a large buccal reflection, and we're going to want a large palatal reflection, a large buckle reflection, and we're going to do a 360 degrees, scoring roughly the size of your thumb, concentrically around the sinus that you wish to crush.

Speaker 3:

After you've scored it, then you can take your osteotome. You take the back end of the osteotome right, like just picture the Norris 3-0 osteotome. Okay, you don't want to choose the pointy one, but you want to choose the one that has the blunt tip. Well, you're going to use it in reverse, right? So you're going to take the fat end of the handle and you're going to hammer onto the blunt tip of that osteotome and so that's going to crack and fracture in that sinus and then you just continue to push it up and push it up. Then you have to make sure that you've gotten it up beyond your occlusal reduction plane. So how do we know that? Well, you probably need an MUA guide and with your MUA guide you have the teeth there and you need to measure up 12, 13, 14 millimeters. I would measure up 14. I like 14. Make sure that the bone is reduced beyond that and so that way we can establish our restorative space emergence profile and hide our transition line.

Speaker 3:

So to date I've done 3,000 arches and the number of arches that we've done sinus crushes on is 0.1%. So I've only treated three cases with the sinus crush, treated three cases with the sinus crush. Now there's a lot of cases out there. I mean, I think probably both of you guys have seen cases where, yeah, we need to do something here, so it is prevalent. What's been interesting, though, is the patients haven't had the money. The ones that have needed the sinus crushes, so they actually, you know, they haven't had the money. The ones that have needed the sinus crushes so they actually, you know, they haven't moved forward with treatment, which has been interesting, so that's why I only have literally three three out of 3,000 arches.

Speaker 1:

Yeah.

Speaker 3:

So you know complications, you know none of my cases had complications, because again it just kind of goes back to case selection and they didn't have teeth right. So again I'm going to take out variables that I can't manage right. So if, if I get a large fracture of the alveolus, if I get a large sinus perforation, you know, then then then now complications go up, right, you know you can get the sinus to be infected and all that sort of stuff. Another part of my technique is I'm not utilizing particulate graft so we fracture the sinus in. The sinus stays attached to the bone and all of that periosteum and all that blood supply and it goes in. And maybe I'll put one or two pieces of collar tape, no more, and that helps hold up the material. It establishes a really good blood clot and then you can utilize a nice just college and membrane over that to help seal it off. And you know I'll push the sinus up. You know all the way, kind of front to back, I'll get it raised, you know 10 millimeters and you know, put that college membrane in and everything heals really nicely.

Speaker 3:

It takes about a year and a half to really start to see all of that kind of begin to ossify fully in. You can start seeing. At about six months you can really kind of start to see okay, my sinus is clear. You know, what are things we want to see on a post-operative basis? No oac. On a post-operative basis, we want to see that the sinus uh is healing and that the uh sinus is clear and that there's not any um rhinosinusitis or chronic sinusitis. What other questions you guys got?

Speaker 1:

Well, I think the only thing that I have left on that one and I'll leave it because I know we spent some time on it, but I guess I'm just curious about. So you're kind of making this oculus of bone, right, it's like a window of bone that's getting crushed up into the sinus. I guess I'm just curious about how that heals. Like, what is? What kind of architecture do you see in followup? So you mentioned, like a year before, everything ossifies. Like what, what kind of healing are you expecting to see and what does that look like?

Speaker 3:

The only thing that I want to see is that we'll kind of re ossify a floor. Right, we left the bone and so then it will ossify by lifting it up and not utilizing particulate graft the cases where what I'm trying to do is I'm trying to use as much metogenous stuff as possible. I want the patient's blood. I don't want to put a bunch of dead cow bone in there, a bunch of dead human bone in there. I don't really want to do that. But the sinus has such a healing potential. Anything we put to lift it up will turn into bone eventually. And so you know, even on, even on, uh, zygomatics, um, you know, when we do a nice channel along the, the buccal alveolus, there, I'll kind of lift up the membrane. I do not do particulate graft, I'll just put a little um, a piece of collar tape in there and then a year later it ossifies and you get a nice plug of bone all where that sinus was lifted.

Speaker 1:

Very nice, very nice.

Speaker 2:

I think it's a great technique to have in your back pocket for a case that maybe, like you said, you need a minimal amount of sinus lift, case that maybe, like you said, you, you need a minimal amount of of sinus lift, um, but uh, you know, cause, if, if you're lifting the sinus like so, I had a case and I I know you saw this one, um Clark, where the guy smiled and his sinuses were so far down, um, and my plan on that case was option one, big sinus lifts lifts and then coming back and attempting the case in that manner. But there's a lot of patients out there that smile, you know, and they have that Kelly syndrome, they have that combination syndrome, but maybe it's only like four or five millimeters that are showing for someone like that that once they get it done in one surgery maybe doesn't, they can't do the whole, waiting six to eight months for the sinus lift to heal and then allowing it to get it done right away rather than waiting that long period of time.

Speaker 3:

Yeah, the one particular case you know. Obviously, this gentleman smiled really high and you could, you know, see the mucogingival junction bilaterally. He had gullwing lips. You could actually see probably 5 millimeters beyond the mucogingival junction. In addition, he had all of his teeth and they were all just rotted down to the gum line. And so my recommendation on a case like that is edentulate, get everything healed first. I wouldn't even do the sinus lifts Like this would be an ultra-staged case. Hey, we're going to take your teeth out, you're going to heal, we're going to make sure your sinuses heal. I believe that patient had sinus disease too, right, yeah?

Speaker 2:

he did. He had really really bad sinuses heal. I believe that patient had sinus disease too. Right, yeah, he did.

Speaker 3:

He had really really bad sinuses um that's why so he made teeth out yeah, teeth out, then maybe go get a fess and then come back and then get a sinus lift and then come back and then get your art surgery right.

Speaker 2:

So um and that's, that's what I did. A uh took the teeth out, let those heal. Um, he sent him to an ENT. Uh, they, he like, kept pushing off the fest. Um came back into my office. The sentences were a little bit clear, you know a little bit, but not definitely not where they needed to be. Um, and then on what we ended up deciding was he was like you know, I just don't want to do this anymore.

Speaker 2:

Uh, so we put them on the top and, uh, fixed on the bottom. Um, and honestly that was kind of a relief for me because that was like I would have had to. You do a sinus lift that big and you fill it with I don't know, 10, 15 cc's of bone and how long is it going to take for that bone to ossify Like it's going to take a long, long time and you go in there and cut everything down and it's going to be mush and I just I didn't. I honestly like wasn't confident that it would have healed the way that I wanted it to. And you know, the patient didn't want to spend more than our traditional all on X fee and it was a lot of surgery to do with unsure prognosis.

Speaker 3:

Right, well, but let's just assume that he wanted to do it, that he wanted to do it. Obviously your concern is right. Just because we put in bone into the sinus. We've all seen cases where the bone just is mush, right. So then what do you do? Well, now you have a great zygote case because you got the sinuses way out of the way right. Great zygote case because you got the sinuses way out of the way right and so now you can go in like that is, that is a great zygote case because you're not having to worry about okay, well, you know, you know is. Is there going to be a long-term oac here? The sinuses are super high. All you got to worry about is just getting really dense, remote anchorage into the zygoma. So it doesn't even matter if that bone becomes mush, which it may, because it is so large, because you're going to get remote anchorage.

Speaker 3:

I was actually referred a case very similar to that several years ago. They squeezed in an all on a standard arch on a Patsy patient. Lo and behold, three implants fail. They go in. They add in a couple more implants, so the guy had his second surgery. They then said well, you know, things are getting really constricted, you're only on like 10 teeth, so let's go in and do bilateral sinus lifts. So he had his third surgery. It was bilateral sinus lifts, and then they put in.

Speaker 3:

They waited for that to heal and then they came back in and they popped in you know, like four implants into the sinus and they all torqued to like five newton centimeters and these clinicians were like, oh my gosh, and the patient was just worn out. So they referred him to me. They wanted me to just do it and actually just uncover him in hopes that the implants actually torqued or, you know, osseointegrated. But have me have the patient out, sedated and ready to go to throw in zygos. If they just backed out and I mean they backed out in a second, all four, and so you know, which is no big deal, we'll just, you know, roll in and do the zygos, like what we planned, and you know the patient was very, very grateful.

Speaker 3:

I'm thankful for the patient because he got out of that cycle right. But again, um, just because we can sinus lift, you know, doesn't mean that that's the answer to all of our, to all of our problems, for sure. So, uh, you know, if, if you're not wanting to commit to a case like that because you're afraid of mush bone after you do the sinus lift, that needs to be in your head. You need to think you can't just think the sinus lift is going to solve your problems, but roll in and do a zygote or have somebody come and do the zygote then, and then the patient can be a Patsy and it will work great.

Speaker 1:

Agreed about, every maxillary case can benefit from the use of pterygoids, and I think that you, you know you've shared some data I think we actually talked about in an interview with Zellig about data you've collected on pterygoids that you've placed and the success has come about that and they were extremely impressive and really better than standard implants really, and so I was hoping you could share that as well. And then I do have a few, you know, minor, subtle questions about how we place our pterygoids and the ideal depth and multi-unit selection and things like that. So could you talk a little bit about your follow-up on your pterygoids?

Speaker 3:

Yeah, so, um, excuse me, Uh, you know, Wilkerson put out an article in 2000, uh, 2021, and it was a finite elemental analysis article and it showed that by utilizing pterygoids it took significant stress and strain off of the middle implant, which is your posterior tilted, comparing that to a standard all-on-X arch without pterygoids.

Speaker 3:

And so we have data that shows, hey, we can reduce our stresses and strain on our middle implants and even on the pterygoid implants, when you look at the finite elemental analysis, there's very little stress and strain on those back pterygoids. So, granted, no cantilevers. And reducing stress and strain is only one part. Right. The other part of this is occlusion and, you know, having bilateral, simultaneous contacts and not having posterior excursive interferences. If you can do that, you're going to save yourself a lot of trouble. So you know I jumped in and head into the the pterygoids. I started back my my first six pterygoid implants that I did were back in 2017 and utilize those for emergency cases where, you know, I had a posterior implant that failed and I wanted some extra anchorage. So Vishy Broman asked me to compile my pterygoid data, and so the data that I have is actually already, you know, behind.

Speaker 3:

It's probably two months behind, but as of probably the middle of May, I had placed 974 pterygoid implants. So I think Vishy said that, out of the he's collecting all this data, vishy has 8,000, has data on 8,000 pterygoid implants. And the interesting thing that he said was that Dr Clark Damon and Dan Holtzclaw are the number one and two guys in the USA for pterygoids.

Speaker 1:

So I thought that was really kind of cool Congrats. I assume you've hit 1,000 by now.

Speaker 3:

Yeah, so we're at 1,000 by now. Fantastic, and I didn't even. I got lazy, I didn't even look at my 2018 or 2019 data, so maybe there's some pterigoids in that data as well. But printing out a Pano and re-going over all of your cases is actually a daunting feat I can't imagine. So let's see. So the interesting thing here is just kind of the ramp up. Is just kind of the ramp up. I started placing them in. You know, like I said, it's 2017 with six pterygoids in function and I have eight-year follow-up on all of those and zero failures. In 2020, I had, from 2020 to now, zero failures. What's in front of me? I don't have the number of pterygoids I placed in 2020. But in 2021, I placed 70 pterygoids. But in 2021, I placed 72. In 2022, I placed 256, right? So you can kind of start seeing where we're really ramping up here 256, right, so you can kind of start seeing where we're really.

Speaker 3:

There's a ramp up there, kind of ramping up here.

Speaker 3:

Yeah, 23, 238, 24, 260, and currently in 25, I have 144, but that's through May, so it's probably more like 175 by now. So total failures 4. 1, 2, 3, 4 out of the 974. I want to spend more time in the data that I have and look at the number of. You know, I was not shy about if I had a pterygoid that was only at 20 newton centimeters. I would just carefully, carefully, put a cover screw on it and we'd bury it If I felt that it just had stability, just not torque, right. So I want to go through and find, okay, well, out of the 974, how many were loaded? I mean, just off the cuff, I would say that most were loaded. You know, maybe I could probably count maybe to 20 that I didn't load 20. And we would roll back in and uncover and always be able to place an abutment.

Speaker 2:

So if you're putting a targo in and you got like under 20, maybe like a 10, did you ever leave those or did you remove those at the time?

Speaker 3:

My dad is not that specific.

Speaker 2:

Yeah, sure, because I've been, you know, back and forth on some of those where, um, I'm, I'm, if I'm fairly confident that I'm in the right spot, you know, and that's, I think that's the biggest hurdle with pterygoids, right, you, you can't see them, you don't know, know for sure. But before I place any pterygoid I always get my probe in there I'm feeling, making sure that I have bone on all four walls. Yeah, making sure that I'm not through the lateral plate. Or I think one of the biggest, not complications, but biggest issues with placement that I see are when people don't widen the apex enough and they're kind of doing a trans sinus pterygoid and it hits that posterior sinus wall and just slides it.

Speaker 2:

I see that quite a bit. So if I know that I'm through that pterygoid, uh, the, the through the pterygoid maxillary junction. Yes, Through the junction Into the into the pillar. Into the pillar. Then even, even at 10 centimeters, I've put a cover screw on those and I've had success doing that. Um but uh, yeah, I was just curious if, uh, you typically would remove those, or if you had a similar kind of thought process where, if you were pretty confident it's in the right place, you'll give it a shot at least.

Speaker 3:

Yeah, I think, if I'm confident, now the huge concern is just getting your cover screw on and making sure that you don't push it into the infant temporal fossil, right? Yeah, so typically kind of my goal is is, you know, I would like for my you know, because I I place them on the contra angle and I have it set to 30 and 30, 30 rpms and 30 torque I would like to hit 30 newton centimeters of torque on my hand piece within and and still have five or six millimeters of that tear of the implant sticking out. You know, super crustal, right? Um, I basically will stop if, if I get like equal crustal, I'm just like nope, we're gonna, we're gonna back this out and I'm just going to kind of reevaluate. Um, and then, and then two to me it depends on how important it is that we get the pterygoid back there. Whether I'll leave it or not, um, you know like let's, let's just say it's a, it's a quad zygote case, because I've had one of these quad zygote case. I didn't have a pterygoid, uh, get super stable, but I was like I've got to have this. So I left it and you know it's in function today. It's been in function for, you know, three years, um. So I do think that there is some some minor ossifying or minor uh um osseointegration potential back there. I don't think it's a lot. I think most of the stability that we get is from the pyramidal process and most of the stability is going to be primary.

Speaker 3:

But, that being said, probably 30% said. I mean you know I probably 30, 30. You know when, when it happens that I'm getting less than 45 newton centimeters of torque, you know the first step is back it out and and reorient right and and reevaluate. Um, you know, often, oftentimes, you know, when you have not gone through that posterior sinus wall into the pterygomaxillary junction, because all of a sudden you're going to be saying I don't think I drilled it at that angle, because now all of a sudden you're like this is a really superior angle and I was a little more shallow. Well, that's when you know you're totally in the tuberosity. Well, that's when you know you're totally in the tuberosity.

Speaker 3:

And the early data from Linkow and Tulsany and those people was that the pterygoids they had about 62% success and it was because actually a lot of them were more tuberosity implants. And you know, rodriguez et al said that the pyramidal process is about 13.5 millimeters, and that that is, you know, within the palatine bone, 13.5 millimeters high, and so we have to get to that. So we have to go through the maxillary tuberosity to get there, and so what Rodriguez et al said back in 2017 was that the minimal pterygoid implant length should be 15 millimeters so that you can get there. And then that's obviously when we started seeing the pterygoid implant success really, really explode into the 90s 90% off that 15 millimeters.

Speaker 2:

Do you think that that is talking about? If you don't reduce the tuberosity down? Because now a lot of people are doing reductions on the tuberosity and I would imagine that that would decrease that number a little bit.

Speaker 3:

Well, I mean my standard. You know from the guy that's done 1,000 of them. My standard, or my average length of pterygoid is 18. My preference is, you know again, you run into trouble if you're too anterior, right. You run into trouble if you're too anterior and medial, right. You run into trouble if you're too posterior and deep. And you run into trouble if you're too lateral, you know. So I like to place my coronal entrance point in between the second and third molar, and just from geometry, because you're already back that far, typically 18 is what you need and I'm also not looking to take out the medial pterygoid plate and I don't necessarily want it resting on the medial pterygoid plate either. It doesn't have to be all the way there, it doesn't have to brace against that. All too often I see clinicians post their axial cross-sections of these x-rays and I'm like the tip of your implant is in black. Post their axial cross-sections of these x-rays and I'm like the tip of your implant is in black. It's in black air. You're in the nasal pharynx Right.

Speaker 3:

You've gone too medial and too deep. Clinicians always ask okay, I know where the pterygoid fossa is and you know, on one side you have the lateral, on the left side you have the medial plate. Where do I need to be? And my answer to that is you get your stability in the pyramidal process. We're not getting our stability from the sphenoid bones and so we don't need to be in the medial pterygoid plate. Now I teach everybody aim towards the medial pterygoid plate, because you need to be medial and the hamulus is a great landmark. That's where we want to be.

Speaker 3:

But because we're not getting stability back there, I don't necessarily want a 22-length implant bracing against that medial plate. I can't feel that. I don't know if we're there or not because we're blind. The other big thing that. So where do you need to be? Obviously, just view the lateral and the medial pterygoid plate as a field goal. As long as you're in between there, you're pretty good. Obviously, I want you know it's kind of good, better, best, right, like if you're on the lateral, if you're touching that lateral pterygoid plate but you're still within the pillar.

Speaker 3:

Yeah that's good. Better would be straight in between the uprights, right, straight in between your, your medial and lateral plate, and best would be hey, I aimed it and took and went straight, went into the pyramidal process and I stopped right right at that. That. You know kind of that bend where it turns around and it meets, uh, the, the fossa meets the pterygoid plate or the medial pterygoid plate.

Speaker 2:

That would be, you know, great because you have almost 100 bone in contact at that point you have lots, lots, lots of bone implant contact now.

Speaker 3:

Now we're not going to get any stability from the maxillary tuberosity bone, so that bone-to-implant contact there really doesn't count.

Speaker 1:

Well, that's something that really interests me about when we sleep a pterygoid, about when we sleep a pterygoid, right. So you know we don't expect there to be, you know much, if any, stability to come from the osteointegration of the tuber osteobone, because it's mostly fat back there, right, but we're really just I mean, let's say, you go in between the uprights and you go right through the parenteral process near that fossa you know how much bone have you actually passed through that has the opportunity to osteointegrate. It's amazing sometimes that we can actually sleep a pterygoid and just that you know just that amount of bone osteointegrating is going to, is going to grant us. You know that that stability when we, when we go and uncover and put a multi-unit on there and I and I wonder, you know how, in terms of how successful you can be in sleeping a pterygoid and letting it cook for a while.

Speaker 1:

you know how much of a difference it makes if you just went kind of transversely, straight through um into the fossa, versus if you, you know, engage the medial plate, um, you know cause, obviously or at least I would think that with more bone implant contact down the medial wing you're going to have a better chance of getting that um, secondary stability um down the road, whereas if you just kind of just cross right into the foster, there's not a whole lot of bone that's really going to heal around that implant, I'm sure. But but you know all that. All that being said, I mean very similar to your situations where you've slept to ergoids. I mean in times where I've done that, it's been, you know, as long as I'm in a relatively good position, it's been fairly successful. Yeah.

Speaker 3:

And you know, I kind of feel like, on the rare occasion that you don't achieve torque, I kind of do three different things and I think it just kind of depends on how I'm feeling on the day. Right, yeah, I may back it out and we may be like, all right, sweetheart, you got five implants, that's all you're getting. See ya, right, yeah, I may sleep it, or, you know, you know I may say, hey, we'll see you back in three to four months and we'll reattempt it, cause I want you to have a pterygoid. So I really think it all depends, you know, on depends on that.

Speaker 3:

I've been happy on the cases where we didn't nail the pterygoid and we nailed one on the contralateral side, I've been happy not doing an extra surgery and then just finalizing them and just being like that's what you get and then just finalizing them and just being like that's that's what you get. Yeah. And you know, I've been frustrated on the ones where I've kind of gone the extra mile, where it's like, okay, we'll see you back in three to four months, we'll add the pterygoid, you know, cause then it just kind of now they're, they're they're tooth process just extended, you know, yeah. So it's always kind of you know half of one, half of another, and you know some. Some days you get it right, some days, some days you don't but you just got to love yourself.

Speaker 1:

That's right, that's good.