The Fixed Podcast

Advancements in Implant Techniques: Sinus Crushing and Pterygoid Implants with Dr. Clark Damon: Part 2

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Dive deep into the advanced world of pterygoid implant placement with Dr. Clark as he shares game-changing insights that can transform your full-arch implant practice. This episode tackles one of the most challenging aspects of full-arch rehabilitation – achieving perfect prosthetic outcomes through precise surgical execution.

Dr. Clark challenges conventional wisdom about pterygoid implant placement depth, advocating for a more nuanced approach where anterior implants are placed first, followed by adjusting pterygoid depth to ensure all abutment platforms align perfectly. This seemingly subtle shift eliminates uneven prosthetic thickness and tissue complications. The discussion on tissue management reveals how proper thinning of tuberosity and palatal tissues creates silky smooth foundations for prosthetics, saving chairtime and preventing fractures despite initial hesitation about bleeding management.

Perhaps most revolutionary is Dr. Clark's definitive stance on implant configurations, declaring the inverted V superior to traditional axial placement. With persuasive reasoning about prosthetic flexibility and surgical contingencies, he demonstrates why angled implants provide infinitely better options for screw channel positioning. His detailed explanation of multi-unit abutment height selection challenges widespread misconceptions, showing how matching abutment height to implant depth (using 1.5mm abutments for 1mm subcrestal implants) accounts for post-surgical bone resorption and creates beautiful emergence profiles without prosthetic flanges.

For clinicians struggling with postoperative complications, Dr. Clark offers practical solutions like doxycycline protocols and bleeding management techniques using 2-0 chromic gut suture. These pearls of wisdom demonstrate why even experienced surgeons continue to learn from each visit to his courses.

Ready to transform your approach to full-arch implant cases? Listen now to gain insights that will elevate your practice and create more predictable, aesthetic outcomes for your patients. Share your experiences with these techniques and join the conversation about the evolution of implant dentistry.

Speaker 1:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry, let's talk about your placement of pterygoids, how deep you go and how that affects your prosthesis.

Speaker 2:

When you have a good shelf, you know all the way back. And then, after that, let's talk a little bit about M versus V configuration and then, when we're finished with that, let's go into the questions that you have for us and we'll save some of our other questions for the next podcast. And just so you guys know the audience, we do plan on having Clark on, hopefully, you know, once every month, once every two months, and we're going to continue to answer some of these more advanced cases and hopefully make this a continual thing, cause, as everyone knows, clark's a wealth of information and if you haven't had a chance to go to his course, I definitely would recommend checking that out, because every time we know, Tyler and I have probably gone what like four, four four times yeah.

Speaker 2:

And every time we go it's like you pick up new pearls here and there and you have a great stay.

Speaker 1:

For the record, I almost went for my birthday. My birthday was this past weekend and I almost went to the course for that, but my wife had some plans for me, so I had to make the smart decision there, but I was close.

Speaker 3:

Gotcha. Yeah, we just had the course this weekend and it was going to be with Vishy and he was going to come and he had to Zoom lecture. Unfortunately his mother passed away and so he had to catch a plane and get out of there, but we had Dr Fayette Williams come in. So if you're familiar with what Fayette does, it very much humbles what we do. Fayette. We may think that we're doing good with teeth in a day and Fayette is doing jaws in a day. Jaw yeah.

Speaker 3:

And fibula teeth and so he's an amazing surgeon. He does several days a week in the OR doing microvasculature reconstructions, head and neck cancer. He's a guy that I work with in Fort Worth and I've sent him several of our cancer patients and the pictures that he sends me of these cases are just absolutely incredible. He's doing these free flaps where they're doing these lateral pec flaps and tunneling them up through the neck and just all the kind of crazy stuff. It's interesting we were, I was showing he knows about transnasal but he had never done one and I was showing him and he was like oof. And here's a guy that does lateral neck dissections and dissects down the carotid artery.

Speaker 3:

He was kind of like, I think maybe the transnasal thing is not something that I want to jump onto.

Speaker 3:

And I just told him. I just said that's so funny because I would shit my pants if I had to dissect, do a lateral neck dissection. So I just said kind of to each his own right. So it was just kind of interesting what you're comfortable with, but the cadaver course was really great. It was really amazing. I can't tell you how many transnasals we nailed. We got lots of docs doing transnasals and it was really cool to have Fayette come in because he really explained and showed how to advance a buccal fat pad. Here's a guy that is in the face every day, so the attendees really had a good experience with Dr Williams.

Speaker 3:

But, you know, rolling back to the pterygoids, one of the main problems that I see with clinicians is they're oftentimes not placing them deep enough. And you know, I again, you know, whenever we talk about Patsy, you know my approach to Patsy is still the same, exactly the same. So, but I I do say that a clinician can do the anterior, anterior implants first and then go back and do the pterygoid. It doesn't necessarily change up your sequence there, but I do feel sometimes, if a clinician starts in the pterygoid region, keep an open mind, because you may need to go back after you've placed all of your others and deepen your pterygoid so we can still.

Speaker 3:

we can still do patsy, we can still do the pterygoid first place. It just don't put an abutment on. I think that's probably my recommendation is don't put your abutment on your pterygoid. Do the abutment on your pterygoid last. Have your anterior and your middle tilted placed and the abutment placed, because what we all know is for biomechanical success in our arches is that we need the abutment platforms to be all on the same level, and if you're not getting your abutment platforms all on the same level, you're having uneven tissue thickness. You know uneven prosthetic thickness as well. So just really pay attention to that. I want to get my abutment platform on the pterygoid equal to my middle implant and so keep an open mind you may have to deepen your pterygoid, uh to to nail that.

Speaker 3:

So, oftentimes, on the pterygoid, I'm placing um a 17 or a 30. On the pterygoid, I'm placing a 17 or a 30. When I was brand new to this, I placed a straight, and it can still. You know when, if you place a straight in the back, you have to seat your prosthesis anterior to posterior, because it's not going to make that curvature. The challenge that I ran into the ones that we did in 2017 was the milling angles with a straight abutment were way too steep, yeah, and so we still want to place a 17 or a 30. That really has a very similar path of draw to all of your anterior ones. So that's kind of the other reason of why I think you need your anterior abutments on before your pterygoid is because then you have to also look at our path to draw.

Speaker 1:

Yeah, that's a really good point. And I think that's an important nuance, especially like, if you're a clinician, that kind of lives in this middle world between traditional ON4 and Patsy, like, let's say, you're sort of in that PFAS world where a lot of us are living in Patsy. Like, let's say, you're sort of in that PFAS world where a lot of us are living, um, you know, if you're not placing, uh, zygos, you know whether or not you get pterygoids doesn't really inform that much of what those front four implants are going to look like. And so I mean, yes, you can say you know what Patsy says. I got to place the pterygoids first and that's going to eventually inform whether I'm going to do an A-frame or whatever with my Zygos. If you're not doing Zygos and even if you are, you can still and I like your compromise there place your pterygoid, but don't get married to your final depth of placement. Just get it somewhere where it needs to be. Then go place your front four, get some multis on, and now you can look at that plane along there and then figure out what that final depth is going to be. So you don't necessarily have to have your pterygoid settled before you ever tackle the front four. That's something that I've done for a long time. In a lot of my cases my pterygoid multi units are sitting inferior to where or superior, depending on how you're looking at it inferior to the front four abovements, and you've given me that feedback on a lot of different cases. So I've been trying to work on that a little bit and I like what you said there about settling the final depth after those front four have already been chosen. Now you can really cater things. So something I'm curious about too, because we're addressing prosthetic heights of the multi-units in comparison to each other.

Speaker 1:

But what do you think about crestal versus super crestal versus subcrestal placement for the pterygoids themselves? What are your thought processes on that? Because when I first learned about them, I was being advised to leave them one to two millimeter super crestal for access. You know if I ever had to go back and take one out or something like that. Leave it a little bit super crestal, and I think a lot of people are being taught that. And now what we're seeing a lot of in terroid specific implants are tissue collars, so like a two millimeter polished collar or even longer, I think. I think Norris has up to like five or something like that. I could be totally wrong about that, but you're seeing a lot of polished collar implants that you know presumably are supposed to be placed super crestally. So I'm curious about how you weigh in about that and how you kind of you know, cater the design of the implant.

Speaker 1:

What is the ideal implant? I'm throwing a lot at you, but can you kind of speak to the Crestle aspect of things?

Speaker 3:

for cleansability. We would want to polish collar in a case that where maybe there's tissue and not bone. And we may want to polish collar in a scenario where maybe we expect the tuberosity bone to recede.

Speaker 3:

I think too long and kind of atrophy. Yeah, and my thing with that is okay, that's all, those are good, right, so so then. So then at that point, what would we be concerned about right on a traditional, all on X implant we'd be concerned about? Okay, well, that stuff would lead to recession, thread exposure, right. That's kind of that longer term triad complication. Well, okay, I've done 1,000 pterygoid implants. I haven't seen recession on one.

Speaker 2:

Yeah, pretty good.

Speaker 2:

I think that the reason that these implant companies are doing a polished collar is because they're trying to make an implant for the masses Maybe people who aren't, who haven't placed a thousand of them and these doctors are having issues with the tissue around that implant. And what I do and I learned this at your course is every time I place a pterygoid implant I am back there thinning that thick tuberosity tissue out because I want my prosthetic to sit all in one plane, kind of like you've talked about. And if you stick that implant and it's two millimeters super crustal with a polished collar on it, the reason that I think people are doing that is because they they have that really thick tissue back there and they have a difficult time putting the prosthetic on, pushing through, you know, like six to eight millimeters of keratinized tissue and this into all of those problems, and one that's better for the prosthetic is to just grab that tissue with a tissue forceps. Take a a new scalpel blade, just thin that tissue out, that connective tissue there, and all of your tissue is going to lay much better around that pterygoid implant and I think the smartest way to do it is to place it, um, you know, at the level of the crest, or maybe a little bit sub-crestal, depending on where your implant placements are on the anterior fork.

Speaker 3:

Yeah, I would 100% agree with that. Yeah, I just think there's some laziness there. And then it's just kind of having a different mindset, right, because when I teach people at the Texas Implant Institute courses, a lot of times their eyes just get huge and you can just tell they're not going to do that in the clinic, they don't want to do that. But I'm like the second that their eyes are huge and they're like there's going to be bleeders and all this sort of stuff. But then when you show them and then you just lay that thin tissue over it and you just feel how silky and smooth and all the restorative space that you have, then they're like okay, I get this. So it's worth the extra 10 minutes because it does add to some surgical time, but it's not like it's 20 minutes, it's a 10-minute add, but I think it results in a beefier, temporary, less fractures, so that's just going to save you more chair time.

Speaker 3:

But I also to that point. I just want to complete the thought, or I'm going to forget it. But I would say for the pterygoid it does not have to be subcrestal, because we're not going to gain anything, we're not going to get bone to grow over that abutment in the tuberosity region. So sub-crestal is fine, equicrestal is fine, just make sure that it aligns with the abutment. But my other point is, if you were to give me the Norris and say you know, like I w, I would have no way of knowing what implant to select because of that polished collar. You know what I mean. Like, how do you, when, when you drill what, what, what are your drills drilling to Right, like, like, is it just? Is it just the implant depth? Does it have the polished collar on that? How then do you choose your implant depth? So to me it adds more complexity to just the execution.

Speaker 2:

No, I agree. A quick point too the thinning the tissue. Something else that I think that is really powerful and I don't know if I I think I maybe got part of it at your course because you it was back when, you know, rick Klein was there talking about thinning the tissue. And something that I do a lot now and I think it helps me quite a bit, is when people are doing restorative space. I feel like there's not a lot of providers that factor in the thickness of the tissue in the restorative space.

Speaker 2:

So what I mean by that is you know you get patients that do a high smile line and you're measuring from that tooth to the top of the lip, maybe adding two millimeters down there, using that to do your reduction. Or you know I know Clark, you'd like to do your multi-unit guide or you had four. Okay, but you know you can gain quite a bit of restorative space too just by thinning. You know some patients have super thick tissue in that anterior region as well, and if you thin that tissue up, you know you can sometimes save a couple millimeters of bone having to reduce that bone because you can reduce down that tissue. Because you can reduce down that tissue. I don't know if that's something you do too, clark, but I find that when you pull that palatal tissue forward, it can be three, four millimeters thick, and if you thin that out a little bit it gives you a little more restorative space there as well.

Speaker 3:

Well, it's not only an advantage in gaining restorative space, but it is an advantage in being able to buccalize our palo mucosa. Because once you thin that, you know and I'm not, I'm not thinning this just in the kind of more of like the superior portion of the palate, I'm I'm thinning it, you know, 10 millimeters deep right, so that that way it's not just on the top portion but it's also in that beefy kind of vertical portion of the palate as well, so that as we pull, everything is being buccalized and so we're getting buccalized keratinized gingiva from the palate, you know, and just really avoiding any type of periodontal insults with having just the thickest and hardest tissue around our multis. And one little trick is change out your 15 blade. I'll see providers still struggling. I'm like that blade's dull. Just change it out. And you know, some days my assistants they'll bet on how many 15 blades we use in an arch and you know, it's very variable, depends on the thickness of the tissue.

Speaker 2:

Yeah, yeah, yeah, so much trimming.

Speaker 3:

Yeah.

Speaker 1:

Yeah, yeah, so much trimming yeah.

Speaker 3:

But don't be afraid, oftentimes I'll use one brand new 15 for one side of the palette and a brand new 15 for the other. Yeah, yeah, they're cheap, they're cheap. And one of the challenges with thinning the palate is if you perf it right. But that's kind of why you use those tissue forceps and you just go straight down the middle, you allow that metal to guide you to where you're not going to perf and you need to be ready to tie off some bleeders, right, I think, tyler, you wanted to talk about, um, you know, some some bleeding things. Yeah, uh, you know you can use a bovie or electrocardiory. Um, I think, I think a bovie works better than electrocardiory.

Speaker 3:

But, uh, if if you don't have either of those I tell you what just tying off a bleeder is way better than either of those because you can just loop it and I do not control bleeding with Epi because they're going to bleed at home and so control your bleeding without epinephrine. You can utilize epinephrine, say, if you're doing an analog conversion process, just to kind of make sure that you can reduce your heme, your ooze and your bleed. That's just kind of oozing, that's just natural oozing. You can use epinephrine to control natural oozing. But I would not really use epinephrine to control the bleed because it'll just rebound. So oftentimes it's as simple as just you have to find your bleeder and you go posterior to it and then anterior to it and then you're just going to tie a knot.

Speaker 3:

And I've had times where I'll tie a knot and I'll cut off the tail and I'll tell the assistant don't cut it. We're going to wrap several more times around there and then suture that down. I've had some bleeds where we've wrapped them two to three times. Typically I find that the electrosurge works really well for kind of the more you know, as we're getting distal to those arterioles Right, so kind of more in the upper coronal aspect of the palatal flap. The electrosurge works well there. But if you're getting a bleed that's a little closer down to the greater palatine, that's going to need to require a suture. And one of the big things that I've done in the past two years has been switch over to utilize 2-O chromic gut suture and it is so much stronger and your needle is a lot longer and so you can really get to some of these deeper areas and you can pull tighter and you can cinch these things down because you have a stronger rope. I also use 2-0.

Speaker 1:

Yeah, that's something. You definitely converted me and Soren as well, on it's 2L chromic for every Fuller's case. It's fantastic.

Speaker 3:

You can really get aggressive with it and it just makes your suture so much easier and better. And make sure you're soaking your sutures right. All my assistants know we have a bowl of water sterile water and you know the start of the case, that that chromic suture is soaking and by the time we're ready to suture it is just silk and it just it just rolls really good, yeah, yeah, definitely.

Speaker 1:

And I know you know, before we start wrapping things up here. So I know we wanted to talk about configuration. So we wanted to talk about, you know, before we start wrapping things up here. So I know we wanted to talk about configurations. So we wanted to talk about, you know, inverted V's, m configurations, placing your anteriors parallel pros and cons. I mean you see a lot of different things. Now there's some surgical advantages to different configurations. There are prosthetic advantages to different ones. You know, at this point in your career, clark, you know what has become sort of your standard configuration that you will approach your upper flourish cases with.

Speaker 3:

Yeah. So I mean I can say definitively, without a doubt, you know, I am no longer, you know, going to be doing an axial anterior implant, so those are gone. I want to be angling all of my implants and I do it for a prosthetic reason, right, I do it because I now have infinite timing options, because I'm going to place an angled abutment. So if all we do is axillary implants, we only have two options to correct our screw channel axis we have a zero, which is our straight, or we have a 17. So oftentimes, as we all know, sometimes we don't like the straight and then sometimes the 17 is too palatal or too buckle, right. But if we angle our abutments, then I can change the timing two to three degrees and then place an angled abutment on there. So all angled right. So that knocks out axial and my preference. Every time that we can and actually had a case, uh, monday, yesterday, that I could not do, it was just there was a very large infection uh, on number nine, right. So, uh, but just in general, every case I can, I am going nasal. So I want to do the V configuration on every implant case out there. Okay, uh, I, I prefer the V configuration over the M right. So M is is when the anterior implant is going into the lateral nasal. That, to me, the trouble that you get into is. Now you're kind of having to stack your apical tips of your implants. It's a bunk bed, and if you don't have a lot of bone volume there then you're going to wind up blocking your posterior implant out. And that's what Patsy teaches us, because then we can just roll in and do a posterior zygote no big deal. But if if you're not ready to just on the fly switch over to do a zygote, then you're going to have some trouble. So if you do the M configuration, you're, you are likely going to block yourself out on the posterior tilted. So I prefer V on everybody. And guess what? Let's say you have a failure of your posterior implant. Well, now you still have tons more room to replace that posterior implant right, or your middle implant, we'll call it because you haven't blocked yourself out.

Speaker 3:

The only times that you cannot typically do a nasal crest is when you have a very large apical infection of your central incisors. And so I had a case yesterday that was very, very much the case. I nailed one nasal crest and then the other one actually did an axial. It was literally my only option. It was a resorbed case. My posterior Patsy implant was going to block me out and so at that point, what's the harm in an axial implant right Like I would? I would not choose.

Speaker 3:

Oh, for this area on the patient's left side where I could not do a nasal crest, I did lateral nasal and then I'm going to block myself out and then have to do as I go, right, like you know, the best as I go is the one you haven't done, and damn sure an axial implant is going to be way better than having to do a zygote. So you know just a little bit of that shucking and jiving. It's just a. That's a one percent one-off case, so don't think anything into it. But but for sure, nasal crest to me, how I approach every case, we're doing nasal crest every time that we can. So V configuration.

Speaker 1:

So we're all pro V. Establish that. So when you're aiming for the same spot with both these implants, are you crossing swords? How are you making sure that you're not interfering with each other? What's?

Speaker 2:

your approach for that?

Speaker 1:

inverted V, just surgically speaking.

Speaker 3:

So I place these exactly the same every time, right? So so my number seven implant is going to be anterior to my number 10. So my number 10 is going to be deep, is going to be posterior to that. So I'm actually going to angle that you know much, you know much further posterior than my number seven implant and that that way you, you, you always account for it, right. If you do the same thing every time, it's just it just gets into muscle memory, whereas if you kind of futz around and and you're not organized, you know you may do where you angled them both to the same apical in yeah and that's when you wind up, okay, well, one's going to be a 13 and one's going to be a 10.

Speaker 3:

You know so my ideal, uh, so I like to stack them, I like to have them cross at the nasal crest and I prefer to do 13s versus maybe try to have the apical osteotomy converge and then you're doing 11 1⁄2s on either Right right, so I stack mine in the nose.

Speaker 1:

So if we're trying to get some symmetry there, you're saying I think you said your seven is going to be interior to your 10. Is the timing going to be different on that? How is that? How are you trying to get, how do you get them symmetrical if you're aiming for different things?

Speaker 3:

There's still well A like you know where the abutments are. You won't know. Typically on my number 10, right, it's kind of like your pterygoid, right. So, it not only has a medial angle, right, because we're aiming medially to the crest. So that's what I would say. I would say the number 7 has one angle and it's a medial angle, Whereas number 10, not only does it have a medial angle, but it has a deep, you know, and a posterior tilted angle. You're tilting it anterior forward so often.

Speaker 2:

Yeah, I mean the crest of the implant. So well.

Speaker 3:

I just go by the tip, right. So I want the apical tip to be deep or posterior to my apical tip of number 7. So oftentimes the number seven implant may utilize a 17 degree abutment and the number 10 implant may need to utilize a 30, because I'm aiming at 30 degrees posterior.

Speaker 1:

Okay, so that answers what I was getting at. Okay, so sometimes it's going to be a different abutment to account for that different. Okay, yeah, got it, got it, yep.

Speaker 2:

Okay, typically what's your medial angle, but but again, you know, is it a little bit less than your tilted, Is it? Is it pretty similar to your tilted?

Speaker 3:

Yeah, it's, it's. It's typically nasal crests are always less, but there's a little bit of variability in you know where we wind up going based on. I always look for just a concept of what I call bone shields and I want to. I want to use my pilot drill in the anterior and I I want to find the area the most dense bone, the most amount of bone, and typically I am going to place it, place my pilot drill, in the medial portion of the number seven socket, right. Like I don't necessarily want to place it in the distal portion of that socket, I want my coronal portion of my implant to have lots of interproximal bone between eight and nine, and that is going to help fight off lots of stuff down the road.

Speaker 3:

So our options are we can choose buckle bone, the immediate buckle bone of number eight. We could choose the immediate buckle bone of number seven. I don't choose either of those. I want to go within the interproximal bone of number seven and so that can be a little bit variability based on arch form. You know if they had ortho or if they didn't have ortho. So sometimes we may be more at like a 17 degree angle to midline, sometimes it may be more of a 30 degree, so it's definitely more variable.

Speaker 3:

And it also depends on the height of your subnasal bone and also the anatomy of the nasal floor. Sometimes some people have a very nice wide subnasal floor. Sometimes it's a little more constricted and so all of that kind of changes things. But again we're aiming to the nasal crest, which is right underneath that vomer bone. But that vomer bone is further back it's way back there, yeah. Not way back there, but it starts posterior to the incisive canal.

Speaker 1:

Okay so you heard it here, folks, the inverted V. That's the modality. Now we're moving on from axial placement. Shame on you if you do it.

Speaker 2:

I did it today twice. We're with the mandible.

Speaker 1:

Yeah, moving forward.

Speaker 2:

Are you doing a V in the mandible every time?

Speaker 3:

Same thing. We prefer a V. That angle on the anteriors is, uh, less so. I would say it ranges from, from you know, 20 to 10, but oftentimes I mean if you're tilted fails, you got another, another so chunk of bone that you can move that forward one slot and again you can.

Speaker 2:

You can change your timing a little bit better with multiple areas to change that timing correct exactly, exactly.

Speaker 3:

What about you guys? Are you guys doing these or actually on my cases still?

Speaker 2:

uh, but you know, I I 100 agree with everything you're saying. Um, patients that I'll do inverted v on are patients with really pneumatized sinuses. That, um, you know, I want to make sure that I have enough room to uh to place another implant if I need to, if I have a failed tilted implant, um. But typically I'm doing axial uh, but I probably will start doing more of these. I think it's smart. I don't think there's a reason not to, and I agree with all your points for sure.

Speaker 1:

Yeah, for sure, for sure, yeah, and I, I mean, I love the prosthetic flexibility of it. I, you know, I always get this. Uh, you mentioned at the very beginning this conversation is when you're placing axial, you usually only have like two options and you're going to try this straight and then you realize maybe you're a little bit more buckled than you had initially intended to be. Now you're going to be like, okay, I guess I'll put a 17 on there, and then you end up more palatable than you really wanted to be, and so it's like there's there's not really a great world in between.

Speaker 1:

Um, so by doing the inverted V, it gives you all the flexibility in the world to figure out exactly how, how that needs to be timed. I am curious when you're uh, when you're timing those implant, are you usually uh? So I'm always looking at the dot for my timing, right? Is that usually going to be pointing towards the midline with your inverted V configuration? Is that very similar to how you're timing your middle tilted implants? What are you referencing as your timing your implant usually?

Speaker 3:

Well, I think in the inverted V, the most important consideration is implant depth. And oh, we got to talk about this. Yeah, you know, because you're actually going to place especially your number 10 implant, or whichever implant goes deep to the other one. I measure my subcrestal desired depth, depth which is one millimeter subcrestal. You know, measure that on the shallowest part. Well, on on on the nasal crest, that's going to be not on the buckle but on the palatal side, right, and so your, your palatal wall, you know you're, you're going to get your implant one millimeter subcrestal, as measured on the palate, but as measured on the buckle, maybe two, three on the buckle. So these implants are going to feel deeper. So you're going to have to get in the habit of measuring your uh abutment depth on the palate. It's's the same concept as we do on our posterior tilted. It just feels very, very odd to place one so deep, and so clinicians need to take that into account when you're measuring your depth.

Speaker 3:

And again, measure your depth on your drills. And we know exactly the depth to do because we've done a subnasal lift and so we are able to feel our drills Sometimes if we have a wider nasal crest, sometimes we can't, but we'll take an x-ray to account for that. And whenever you're doing your measurements, with whatever method you're doing your measurement, make sure that you are placing your implant to the desired sub-crestal depth. Sorry, you're taking your drill. You want your drill to be as deep as your desired sub-crestal final implant depth, and so that way there's not any variability. But as far as timing goes, I always say that the dot right. Yes, for all of our implants I start checking the timing in our screw access channel by having the dot be pointing to midline. But I always say that the teeth win and so oftentimes the dot will help get us in the ballpark.

Speaker 1:

Yeah, right, but.

Speaker 3:

I'll always be double checking with your MUA guide and and be in your posterior implants. You can check with the contralateral arch. The only implants that we cannot check to the contralateral arch are the maxillary anterior implants. We have to use the MUA guide and know where the final desired position of the teeth is going to be, and that's what gets us the right spot.

Speaker 1:

Yeah, and I'm curious too.

Speaker 3:

Another reason why I do not like palatal fiducial markers.

Speaker 1:

Oh yeah, because you're not going to have a reference for it. I mean, you could, but you'd have to have like a really big recess.

Speaker 3:

You have to have a window. Yeah, and you know I do big flaps, right. You know I'm a big proponent of this and so by the time I put an MUA guide on that, has, you know, a fiducial relief, right? Yeah, well, now I've already disturbed all that tissue and it's kind of swollen and there's some blood in there. So then I really question the accuracy of that. So you know, I know that you guys do a digital method without fiducials.

Speaker 1:

Yeah, correct.

Speaker 3:

Yeah, and so it just makes it so much simpler, oh my.

Speaker 1:

God, yeah, I still use fiducials sometimes for a single upper or something like that, and I suppose that you probably could design a multi-unit, an MUA guide that would sort of allow you to actually guide the fiducial placement. So you could, you know, place it even with teeth on and maybe it's like toothborn or something and it has some recesses in it so you very specifically place fiduciary markers or not fiduciary fiducial markers in specific spots, so that when you do get the teeth out, you could then put it on the MUA guide and it would fit just over where those fiducial markers are. So you don't have this like massive window anymore, it's like pre-planned. But you know, this is getting like wait. I mean, I don't, I don't like fiducials at all, so I'm not going to go through that. But yeah, we, we do a denture wash vest. That it's it's, it's fantastic for that Um. So we can really, you know, we, we have, we can use multi-unit guides and figure out where things need to be.

Speaker 1:

One thing I wanted to make sure we address too, though, and this is brought up by um, I think. I think Adil uh Khan uh mentioned this one. Uh, yeah, he did so. Uh, details on the multi-unit abovement height. So you had talked about, um, you know where we're placing our implants in relation to the crest, what is the height of the multi-unit that we're placing and the biologic width that gets established there? Um, and there's some nuances that you've talked about in the group that I've never really like. I obviously I've heard of these things, but I've never heard of them really talked about specifically in the context of multi-unit abutment placement, and I feel like this is like a really important nuance that we're just kind of glossing over. And if you look at, you know, uh, posts that people make on Instagram of their, of their arches, and that you show them all the new and stuff, there is so much variability in terms of the heights that people are choosing and you know, is it with respect to tissue? Is it with respect to the implant placement?

Speaker 3:

Um, I really liked how you talked about um the establishment of biological width with regards to your multi-unit above height selection. So could you speak to that a little bit? Yeah, I think that many people, many clinicians, try to establish biologic width at the time of surgery and I think that that is false. I think they are missing out on the fact that by simply raising a flap, we are going to have some bone resorption. They are not taking in to the fact the bone resorption process. So oftentimes what I see is clinicians will be placing subcrestal depth to one millimeter and they will then choose a 2.5 millimeter multi-unit abutment, tall and, yes, tall, um, and that that is that is incorrect.

Speaker 3:

If, if, if you have a multi-unit or, sorry, if you have your implant that is two millimeters subcrestal, then you should use a two millimeter height multi-unit abutment. If your implant is one millimeter subcrestal, you should choose a 1.5 millimeter multi-unit abutment. And so, uh, that's that's where I start harping on on clinicians is because they did one millimeter subcrestal and they used a two and a half millimeter multi-unit and it is too tall, and so obviously we're losing one millimeter of restorative space just off the bat. And now I mean, on occasion I I get patients they complain about the abutment showing and it's obviously it's not the implant.

Speaker 3:

You know, and you know on on occasion I mean it's, it's, it's, it's practically unavoidable um in in in many cases, um, and you, you're you're going to overly pronounce that if you're using taller multis. So we want for full arch biologic width is 1.75 to 2 millimeters. That is the appropriate biologic width. That is the appropriate biologic width and we want. So I then account for one millimeter of post-surgical. That is the appropriate biologic width and we want. So I then account 0.75 millimeters supra-crestal, so that after crestal we then have establishment of biologic width and loss of roughly one millimeters of that, that that bone. Three months goes by. We then have a establishment of biologic Right.

Speaker 3:

If you're a buttments, in fact, if your abutments are too proud, too tall, oftentimes what we see when the final prosthetic is made is flanges right, and so that leads clinicians to have to hide multis with flanges. And so you know, if, if, if we all think about it from an emergence profile standpoint, the more emergence profile we have, the better right, so as if we lower our prosthetic margin, then we're able to get a much better emergence profile. And so that's what I am doing with a 1.5. Now, that's not to say that I don't use 2.5s. In fact, I'll use maybe three 2.5s a week, but that's just because, for whatever reason, maybe I wanted a couple extra turns, Maybe I needed a, you know, an extra millimeter of stability.

Speaker 2:

Yeah.

Speaker 3:

And, and I didn't feel like mowing a millimeter of bone down, you know to to kind of to to make it all flow, and so then I'll just grab a two five 17 or a two five 30, and it works out great. But again, you know, all of my abutment margins are all in the same platform, just to make sure, yeah.

Speaker 1:

That's solid. That's one millimeter.

Speaker 2:

Now, when you're placing your tilted, is your one millimeter subcrestal at the mesial aspect? Okay, yeah.

Speaker 3:

Yes, yes, yep, and you know again, on the nasal, on the nasal crest, it's on the palatal.

Speaker 1:

Yeah, yeah.

Speaker 3:

So, and then what you're going to find is, when you finalize your cases, you're going to see just beautiful, uh, flat tissue.

Speaker 1:

Yeah.

Speaker 3:

Yeah.

Speaker 1:

I mean, it's, it's these kind of you know nuances that I think can you know, uh, really make full arch a whole lot more predictable, even when you're doing it at volume. And there's so many little things that are more predictable even when you're doing it in the post-ops with patients, and it's like my new details, you kind of just write it off. It's like oh, these, these things just happen.

Speaker 1:

Like sometimes patients just have issues with this or that, like very recently, I had a patient who you know, all of his implants felt great, except for, like one particular spot that's been giving him all this, all these issues. Um, just it just feels throbbing. It's been hurting. We've taken follow-up x-rays on it and there was no effect and just it just feels throbbing. It's been dropped and I look and it's all around that multi-unit. It's just like it's. It's inflamed, um, it's got like it's feeling is he's, he's reestablishing biological width. I forced that to happen because I didn't pay enough attention. I was, I was rushing, I crushed the bone with the multi-unit and now he's, or anything, that I take his bread. Now I have the answer as to why that was happening and, if anything, that I take his bricks happen and maybe it'll resolve on its own. So these little things, like these very small nuances during surgery, really shouldn't. Just it just feels throbbing. Thank you.

Speaker 3:

Well, well, I wouldn't replace the multi um, you could take it off. You know now, now you know everybody, you know all my staff knows, like we don't touch implants until they're fully integrated. Right, because the second you go back up back a buttmanment off, you never know what's going to happen. Right, and especially these neodent abutments. They can be so difficult to remove because they cold well on there, so good, and it's super frustrating, right, like trying to get a cold welded grand Morse abutment off your implant.

Speaker 2:

Yeah.

Speaker 3:

But I will take that challenge all day long because I know that that is taking the force off of the abutment screw. Right, I know that we are locking that in and and and now we're mitigating abutment screw loosening. You know, um, some of these other companies, you know, when you just kind of get them halfway loose, I mean like the, the nopel stuff, you know, the second you get that abutment loose, it's, it's, it's a while ready to go um, but you know what?

Speaker 3:

what I may just recommend is why don't you just give him 100 milligrams of doxycycline? Okay, and I've begun to use that for anybody that just kind of has some atypical gingival stuff, right, like if there's some foots going on in the gingiva, you know, a hundred milligrams of doxycycline. Or if you have a patient who is maybe they're slow to heal, you know, if they come back they're still hurting at two weeks, that sort of thing. Um, you know, sometimes you can get some postoperative palatal necrosis and, uh, get some post-operative palatal necrosis. And you know, obviously, if and when you have palatal necrosis, you need to remove that dead tissue. You know it's not going to get any better. You've got to get that dead tissue out of there.

Speaker 3:

But then they all get 100 milligrams of doxycycline and that typically speeds up a lot of the a lot of the healing is that I don't?

Speaker 3:

I don't know or what is it? You give it BID. Okay, 100 milligrams doxycycline BID seven to ten days, it it doesn't. It doesn't do anything on the on the healing part, other than it's broad-spectrum antibiotic that helps just if the body is trying to fight off different little bugs that may be impeding your healing. And then now you wipe it away with the doxy, then now the body can just focus on healing. I like that. No, no, that's great, it's, it's, it's, it's. It's definitely been a nice little thing to give. That you know, and, and oftentimes you know, patients just want something right there's just they're just there's a psychological deal where they're just looking for you to do something right.

Speaker 3:

Saying we can't do anything is not reassuring to the patient. It's hopeless.

Speaker 1:

Yeah.

Speaker 3:

Now, now there are cases totally, where you can tell your patient I got you, you're fine, this is not going to turn into an infection, it's. It's too close to surgery. Um, you literally need, and there's nothing I can give you other than time. That also is assuring when they know that it's just a time thing when you're prescribing time.

Speaker 1:

Yeah, that's solid.

Speaker 3:

But not being able to say that and just be like, yep, nothing I can do, but not being able to say that and to feel you and listen.

Speaker 1:

That's fair.

Speaker 1:

Yeah that's fair. Well, clark, this has really been fantastic. I think we may have gotten through 40% of the outline that I made for us. So we've at least got two parts here, and I think that may have gotten through 40% of the outline that I made for us. So we've at least got, you know, two parts here, and I think that's fantastic. And I think we ought to save a little bit for for next time, because I think this is this is going to be a recurring series and if not only for the audience, I think it's for Soren and I, because we learned something every time we sit down and talk to you and you know, there's generally a pearl that we'll carry forward for the rest of our careers just about every time we talk to you. So we certainly appreciate that.

Speaker 3:

Awesome, Well, just kind of like, I think. What did Elon come out? Or it was Eric Schmidt came out and said that we've given AI the fullest extent of all human knowledge. There is an extent to mine, so you know we will reach maximal. You know knowledge that Damon has, so that could come about.

Speaker 1:

So don't be sad when that comes, I don't think we're at the bottom of your large language model. Once we hit that, your chat will be reviewed. It's back to where it was.

Speaker 2:

It's back to where it was.

Speaker 1:

It's funny yeah.

Speaker 2:

Refresher Just like the canaver refresher.

Speaker 1:

That's all it'll be, yeah.

Speaker 3:

Awesome.

Speaker 2:

Well.

Speaker 3:

I really liked her interview with David Zellig.

Speaker 2:

He is a super nice guy and super enthusiastic I I mean, he was more excited than he was I actually left that interview, like you know talk about this stuff and I need to be more enthusiastic about these cases, because that guy has been doing this way longer than I have and he still is 100% I know just stoked, yeah, yeah yeah, just overall super nice guy.

Speaker 3:

And you know, I mean I took, I took, I took two pages of notes just talking with Zellig and I already know all this stuff you know yeah but uh, you know, just kind of the way he talked and the way he presented, I think that'll be such a great person to have on and really we should try to get Vichy or even Juan on to really talk about medical legal stuff. You know, and like what, what, what do guys need to? You know really kind of pay attention to. You know what, what are, what are things that that that they all can benefit from, and and you know, I think there's a lot to learn there.

Speaker 1:

Yeah, no, I agree, I think that's a. That's a good wrinkle that you know I, I think there's a lot to learn there. Yeah, no, I agree, I, I think that's a that's a good wrinkle that you know we've never even touched on and we've both talked to juan before and, uh, you know, I've been trying to get vishy on here for quite some time and, and, yeah, I definitely think they can bring some part of that conversation that would be really interesting. So, um, yeah, I think you've given us some great ideas and you know, we look forward to the next time we get you sat down, and either it'll be conversations with the tribe or conversations with, uh, you know, another, um, you know fantastic leader in full arch. So, again, you know, we just really appreciate your time, clark, and we look forward to next time.

Speaker 3:

Awesome guys, appreciate y'all. Thank you Always, always, always fun to talk and y'all keep me thinking and so it's good.

Speaker 1:

For sure.