The Fixed Podcast

Learning from the Giants: Dr. Jerik's Insights on Subperiosteal Implants: Part 2

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If “more titanium and more screws” sounds like a plan, this conversation may change your mind. We take you behind the curtain of subperiosteal implant design—what the classic meso bar frameworks did brilliantly, why many custom PSI trends miss critical load paths, and how occlusion often determines whether a case survives decades or fails in months. Drawing on tough lessons from early HA-coated, multi-post maxillary cases and the happiest patients who lived well with two-thirds of a frame, we unpack where repairability, segmenting, and tissue-friendly geometry still outperform shiny shortcuts.

We walk through the real differences between mandible and maxilla: cortical density, palatal and nasal spine engagement, lateral sinus walls, and the unforgiving mucosa over pneumatized spaces. You’ll hear how palatal coverage and canine eminences lifted success rates historically, and why skipping them today invites the same old complications with a digital gloss. We challenge the “ladder” mindset—singles to All-on-4 to pterygoids to zygos to PSI—and propose a more honest sequence: remote anchorage first, maxillary subs as rescue, and mandibular subs as a predictable workhorse when designed and maintained correctly.

This is a prosthetic-first blueprint. Nail the occlusal scheme, align DICOM and STL perfectly, and design frames that are thin, recessed, and biologically sensible. Use materials and guidance that absorb shock, control lateral excursions, and make revisions feasible. We share a sobering maxillary failure with sinus fistulas to underline the stakes and offer a practical checklist for vetting labs and designers who can speak both biomechanics and biology, not just software. If you want growth without trophy hunting, and long-term function your hygiene team can support, this one will sharpen your judgment.

Enjoyed the conversation? Follow, share with a colleague who’s PSI-curious, and leave a quick review telling us where you draw the line on maxillary subs.

SPEAKER_02:

My name is Dr. Tyler Tilbert, and I'm Dr. Storin Poppy, and you're listening to the Fix Podcast, your source for all things in plant dentistry.

SPEAKER_01:

Yeah, so I I'm curious too, just to kind of simply lay out a basis of you know what the old versus new is, what um what is ideal and what isn't. Can we just kind of like briefly illustrate, you know, uh what are what are the mechanical ideal mechanical properties of the classics of the classic uh I think you're do you mind if I show a model? Yeah, not at all. Yeah.

SPEAKER_00:

So so this is bear with me here, guys. This is one of my stereolithic models that was done on ICAT, sent to the lab in Colorado. And you can see we're loading the lateral ramus here. We're loading synthesis. We've got a mesobar that comes out of the ascending ramus here, canine. There's only four posts.

SPEAKER_02:

Yeah.

SPEAKER_00:

Very first sub I did was at NISH, and Carl says, Well, we've got to spread the load out. We need nine posts, and we'll talk about coatings. We're gonna coat it with HA. And my mentor and win, Dr. Lil said, Don't do that. And I said, I got to. I got to deliver it at NICH. And so we did. And the guy was uh a classmate of mine, he was a pietodontist, it was his father, and he smoked like a train, you know, like three packs a day. And I said, you know, you can't smoke for two weeks, and we're in Dearborn, Michigan, and I get finished with the surgery, and uh, I don't even think I got to close it because it was over two hours, you know. It's one of these shit show type surgeries that happens to all of us, you know. And so um, I'm in the didactic part and they finally dismiss him, and he's out in the parking lot, and I go out to say goodbye to him, and he's leaning up against the car and he's already smoked a cigarette.

SPEAKER_01:

So yeah.

SPEAKER_00:

Incision line comes open, you know, a lot of the stuff to hisses. I become an expert at removing struts, I become an expert at soft tissue grafting. Life uh core was just coming out with Alloderm at the time. Dr. Lil John loved Perio, and he was doing a lot of work, and I was learning a lot of work and doing a lot of work with him. And we grafted this poor man for years, and I think it lasted 15 years. He actually passed away with the implant, but it went from nine posts, I think, down to five by the time you know he passed away. So, you know, even Carl Mish is brilliant as he was, and I think he's one of the smartest implantologists in our era. You know, he even he had things that he did that were mistakes. And you know, I guess my big message to all the young docs that are wanting to jump right in the middle of this PSI, just like we all wanted to get into zygos and pterygoids and nasal implants, and it's like a trophy up on your wall back here, you know. I did this case, I'm gonna show it here and I'm gonna show it there. It's on TikTok, whatever, Instagram. You know, and that's all great, but you do your reps, be careful, you know, because we're in a very litigious society. And back when I was learning, it wasn't like it is now, you know, and patients were more forgiving, more understanding. Uh, you know, and you know, be careful. But you know, this this implant here, if you look at it, has a meso bar. And everybody wants to do screw retained teeth now. They want uh mobile compliant MUAs coming out, they don't see the value of the meso bar. Well, you know, this implant actually would bond to bone, it would actually be covered with bone in certain cases, or it'd be encapsulated with soft tissue, you know, that ligament that Bob James talked about. So it allowed for a little bit of movement, but the meso bar kept all the struts together. If you had one side go bad, and sometimes they did, you'd literally cut it behind the canine strut, take that segment out, reline the overdenture on that area. Patient lived with two-thirds of their implant, and they never missed a lick. And these were the happiest patients in the world, you know. Um, we come forward to you know, the new PSI designs. Yeah. Here we go. And you can see how much water everything is, and it's all you know, it's depending on screws and that piriform reb. You know, I love it that it's engaging the zygoma. You know, but like this one's in two pieces. Everybody wants to do it in two pieces, or you're missing the nasal spine, which is going to be the thickest bone in your palate. This one has palatal coverage. I looked at a design uh on one of our uh chat's rooms the other just yesterday, and there was no palatal coverage, you know, and what you going against in the maxilla is the fact that there's mimeritous bone, alveolar bone, very porous bone, very poor quality bone, and you have to have enough resistance to your occlusal loading to prevent that thing from setting over the decades. And just because it's titanium, just because it's all this technology, just because you throw a bunch of screws in it, uh doesn't mean it's better, it doesn't mean it's going to resist that occlusal force that you put on it. Uh people want to put zirconia teeth on it, you know. Uh Lenny Lincoln, uh he actually put a study out, I think it was 1998, where he had done 600 maxillary subs prior to describing the problems with maxillary subs. He did an additional 300 maxillary subs and he followed his success rate and it went from 60% to like 70-80%, okay, with these changes. And he did palatal coverage, canine eminence. Uh, he would even uh go over the Hamler knot into the uh that area, and you know, there's a lot of things that have been tried, and a lot of errors that we saw from from the past that we're replicating all those errors today. And uh, you know, somebody said, Well, it's titanium, it's bonded the bone, it's better. Where's the proof? Where's the studies? And and you know, let's say we make this mandibular implant now and make it out of titanium, and we seed it. And instead of doing a meso bar, we do MUAs. All right, so now we've got an MUA prosthetic zert with four you know death screws, vortex, badger, you know, you take your choice, but four buttons screws holding this in. What happens if this segment or this segment or this segment come loose from the bottom? So yeah, it's lost. Okay, yeah. But if you've got a meso bar, yeah, you can segment. No, we've got 80 years of this stuff working, so even if it's titanium or chrome, cobalt and aluminum, we know that it can survive in that suspensory ligament. So the meso bar has has its place. Now, are we working with designs now where we're putting MUAs on top of a meso bar in the lower? Absolutely. You know, so that we can do have a digital workflow because overdentures are pain in the butt to make. You know, the labs, there's very few labs that still make them, uh, and and getting the records for it and having to transport uh analog models and stuff. I hate analog now. I mean, I've I've literally been 100% digital since 2020. We bought pre-medit scanners, tabletop scanners, you know, uh eye cams, everything. And so, you know, I'm I'm all in on digital, but you know, when you have to go backwards analog, uh, there's a place for it. Like even casting the implants. Uh, we did a digital STL and we printed it out, but we cast it. Uh, there's some advantages and disadvantages to casting as well, you know. But um, you know, the the the big thing here is is technology is wonderful. And I'm I'm I'm envious of you young men, uh, to where the next 20 years are going to lead for your careers, you know. As I phase out of the game and y'all go forward, you're gonna remember this minute saying, wow, look at all what we're able to do now. You know, AI designs it and push a button, they print it out, and push another button, and they mill the MUAs and they polish it, and boom, I've got teeth, you know. Uh but uh you know, I think it's very I'll just be nice. I just I just knowing these doctors, studying from these doctors, Luke, again, all their hard, good, honest work. I think we're really missing the boat if we don't know our history. You know, there's uh one who was it said, you know, if you don't know history, you're doomed to repeat it. Okay, and it could be more true in what we're doing right now. And you know, I love some of these young doctors that are promoting the PSI, and I've I've worked with them and I've done demonstration surgeries with them, but uh I do not agree with them pushing this out and promoting it, even over quad zygos, you know. I mean, I really feel like a maxillary subparaosteral should be a rescue implant. And uh mandibular subperoster is a whole different ballgame. I mean, I got a hundred of them over 35 years now, and you know, it's been damn near 100% success. Uh, we've got studies from Dorsey Moore at UMKC. There were over 20 done over or over 18 years. They were placed by other surgery residents, restored by the prostodontists, prosthetic residents, 100% success rate. Um, we had um John Mendochete was doing a study on HA coding of implants. And I just in my research study, how he placed 20 and had a hundred percent success rate at 10 years, max later. And you know, these are all the classic designs, they're all cast. Uh some were uh digital records, you know, some were two-stage surgery. Uh, you know, even Bernardo, as many as he's done, he was like, segmentation is a problem, you know, or the sinus, you know, you can't segment that out accurately. And you know, you've got these big defects. And you know, if you go back to Linkow's 1998 article on the deficiencies, max age subperosteals, he discusses that very problem. And he came up with the solution. He put his support over the sinus on a little finger off the main part of the sub so that if it gets exposed, you only had to cut it one place and pull it out.

SPEAKER_01:

You know.

SPEAKER_00:

So, you know, I I just designed, I don't have that, I I don't have the actual sub with me, but this is a maxillary sub that we designed that we were going to deliver two months ago at Full Archmaster sub course that we did, one of Ron Dunlop's patients. And uh, you know, I was able to take the DICOM data and uh I put one of my screws in the Z point, you know.

SPEAKER_02:

Nice, uh super Z point selling.

SPEAKER_00:

Yeah, yeah.

SPEAKER_02:

We just we just did that one.

SPEAKER_00:

I know you just did. I want I listened to it. So, you know, that's one of my spots. And you know, when I was doing the uh, and I'll go ahead and name it, it's bone easy. Yeah, I mean, and I I did a demonstration surgery with Bernardo and I did a podcast with him for Larch Masters several years back, and we were putting the implant screws around the the nose, you know, super thin bone, and we had rescue screws, and as I'm tightening them down, it's like I'm not getting anything here, you know, they're not fixating. And I'm like, how much good are these doing? And then I'm thinking in my mind, okay, when this patient starts functioning on this and loading this, how much resistance are we going to get? So, you know, there's a right way and a wrong way to make a maxillary sub, but I don't have the answers. You know, I've been doing this 39 years, and I'm not about to sit here and say, oh, I've got the answer for these. I have a really good idea where it should be loaded and how it should be loaded, how it should be designed. But, you know, for a young doctor that's been out less than five years and doesn't have a lot of reps under his belt, doesn't have good support from an ENT or an oral surgeon like I do, uh, you know, you start having complications on these, you got some splaining to do, and you don't have a lot of literature to back you up, you know. And uh I just think that we should really back up and be very careful with what we're seeing promoted, especially by the companies and even some of the KOLs, you know? And uh just this should be something that should be a last resort, but it's a beautiful last resort, and it can work great, okay? Especially on the manible, but the maxilla, it's a complete different animal.

SPEAKER_01:

Yeah. So can we just uh to kind of like briefly summarize, what are the main things that make it make such a big difference between the predictability of a lower and an upper sub? I mean, what I've heard are you know, you have a totally different quality of bone in the upper, the upper has much more complex anatomy. It can be very difficult to create a passive prosthesis there. Um anything else there that they can kind of summarize why there's such a disparity between the predictability of both?

SPEAKER_00:

Uh we'll take uh right off the slide from the lecture from Linkow, inadequate bone support, inadequate cortical bone, you've got alveolar bone, you have lateral sinus walls, you have poor tissue quality, especially over the sinus, you have mucosa, comb beam segmentation issues, and you've got revision difficulties. So, you know, Lincoln's features that are critical to sub. And I'm not a big Linny Lincoln fan at all. He's from New York, I'm from Arkansas, he talks funny, I talk funny, he's very bombastic, I'm a little less, you know. But after reading this article, I'm like, damn it, I wish I'd spent more time with this man because he really was brilliant, you know. And I hear people, oh, well, this is Link all this and that. They don't do the deep dive in this, they don't read this stuff, right? They don't study, they don't understand it. But first thing, low, dense cortical bone. Okay, there's not much up there. You know, what do you have? You know, you can go, yeah, head shells, you know, uh adequate model, direct impression or cone beam CT. Uh, one of the companies I'm working with, JD right now, they want a helical scan of the maxilla. I said, guys, it's a no-go for 99% of the dentists. They don't want to take them to the hospital, they want to use their ICAT or their ray scan or whatever, the vape tech. And they're like, well, we can segment it better, we can clean that up better. I'm like, well, okay, you know, maybe we'll send them to an uh imaging center and we'll get a helical CT, you know. Uh engage the nasal, the palatal, nasal spine, and canine eminence. Okay. He didn't have zygoma in there, you know, but we know zygoma is available. We're all there now. Maximize vocal keratinized tissue. He would probably love our lingual uh you know, scarf grafting technique there. He would love that. This is all not a really something that was being done back then. A lightweight frame, okay. You look at these frames, you know, and the stuff that's been done now, they're fascinating. Now, this one's thin, but a lot of them are really thick and they got right angles. You know, I mean, when you compare it to something like this, I mean look how thin this is. Yeah, you've got a lot of places for the perioste to reattach. Okay. So lightweight frame, you want to minimize your crossover struts. And I actually had one guy early that was lecturing on these. He says, you know, they didn't use to recess these things in the bone. And we recess our crossover struts in the bone. I'm like, first of all, you know, I was taught to recess it on my very first one in 1990. And I start looking through the literature, and I mean, it's been done since the 70s, recessed on the bone. So, you know, that's where I say, be careful who you listen to. Do your own deep dive. You know, you really need to be responsible for knowing your game. And that's why I felt like when this was a required implant for ABOI. I was the last, you know, when I got mine in 90, I had to have a sub. And they dropped it because the Oral Surgeons didn't believe in them, paradigms didn't believe in prostate, didn't believe in them. You know, it's just a bunch of dumb GPs in the Southeast doing them, you know. And so you've got this whole generation that has zero exposure to subs because it wasn't a requirement. And I get that. But my whole thing was at the time was like, we still need to know about these, we still need to teach it, we still need to let these people know how to manage the complications on this. And so I spent a lot of time teaching how to manage subperosteal complications that people call. So crossover struts, minimum of two millimeters wide. So you look at this thing, and you know, it's three or four millimeters wide going across or across the ridge three times. Whereas, you know, you look at a crossover strut here, and you know, it's two millimeters and it's recessed. So there's a big difference there. And then Lenny, he was big on his palatal strap, but uh history shows that those palatal straps uh they fitestrated, you know. So I think that uh, you know, it's just a big thing. And then with the prosthetics, you know, he was like no tissue engagement, removable zero-degree teeth over opposing dentures. If there were natural teeth on the opposing 10-degree uh maximum on your occlusion, and minimized anterior guidance. So one of the big concepts with subs was you know, the occlusal table on these is flat. If you look at the teeth, vocal cusp was the most prominent. There was actually a cutter bar in the original ones. And you know, I went through the era in the 2000s of extreme makeover, and I'm having these ladies spend 25,000 on an implant and 5,000 on a denture, and they got a metal bar, and they don't like that. So I literally had root making uh Empress teeth color match, you know, uh, without the metal bar before these became available. But um so today with occlusion, you know, everybody wants to do zirconian teeth, they want to use exacad. Uh, you know, a lot of people are using 20-degree, they're doing group function, anterior guidance, all this stuff. But with the sub, you just want it to slide without any lateral excursion, without any anterior guidance. Now, I can't give you a study, I can't give you any literature, it's all anecdotal, or you want to say it's clinical, whatever. But in practice, by doing this, and I was told this 38 years ago by my mentor who had been doing them 20 years, so they've been restored this way for 58 years successfully. Okay, and I told you I I had several hundred implants come into my clinic from Dr. Joe when he passed, Dr. Harris when he passed, Dr. Crameen when he retired. And so these patients didn't have a home, didn't have anybody that understood subs. So I would take care of all these patients, and you know, my my goal was to get them to the end game, you know, have them die with their implant. And we weren't successful. I never took one of those guys' subs out. I might have to take a posterior strut out or something, but the vast majority they get a little permucosal infection on uh ascending ramus strut, put them on around a uh Kepflex 500 TID for 10 days, and 99% of the time that maxillary denture or teeth had worn and they were locked in. And when they go in protrusive, they had anterior guidance, and when they go to lateral, they couldn't because they were locked in. So all we do is we'd replace the teeth, we call it a retread on the upper, or we just take some composite or try it at the time and just fill in the group, and they come back two weeks and they were fine, you know. So those concepts, these important things that I learned from my mentors, I think it's things that we need to take forward to the PSI world, you know, and I don't know how being integrated to bone is gonna work. Is it gonna work like a reform implant? Maybe, maybe not. But what happens if it's not bonded to bone, or what happens if it debonds? Well, we know this worked, and so you know what you want to do is have as atriumic occlusion as you can on these, and so you know that's the wonderful thing about implantology. I mean, it's it's the full game, you know, it's the occlusion, it's the soft tissue, it's the re-care. You know, I've got hygienes that's been here with 22 years. She's seen uh she sees eight implant patients a day, you know, and maintains this stuff. And I mean, she knows what's going on as well as I did. I walk in and says, Dr. Jay, we've got to get a retreat here, we've got to do this here, boom, boom, boom, you know. But uh it's it's things like that that you need to go into knowing before you get into this world of subperostero implants.

SPEAKER_01:

Yeah, I definitely think there's there's a big wave uh going along with it now. And I think that you know, in in full arch, it's like we've kind of developed this linear mentality of how one develops, right? It's it's like you you're gonna go into singles, you're gonna do some overt enters, you're gonna do your all-in four. Once you've done enough of that, you got to do your pterygoids, now you're gonna get into zygos, and maybe you're gonna get into customers, or maybe we're gonna do one of those first and some other ascending order. Just this idea that after you spend a certain amount of time, you just need to go to the next step and start doing more and more advanced stuff. And, you know, I I I agree with you that you know, we need to be looking back as as much as we're looking forward, if not more, to learn from some of these things because history does repeat itself. A lot of these things have been tried before. We've learned a lot of things. And not only have some of the things that went wrong been forgotten, but some of the good stuff has been forgotten too. And to not see that moving forward is concerning. And I think you're raising some really important points that uh people should really be considering if they're looking into getting into that customized implant world. Because I think right now it's it's it's uh it's difficult. I think when I talk to a lot of US dentists that have uh considered them, they see a lot of logistical barriers, um, you know, medical legal barriers into getting into custom subs. Not really sure um how how it's gonna cover you, you know. Yeah, right. It's it's a brand new world, my friend.

SPEAKER_00:

It's a whole new world. I mean, it's like zygos. I mean, I I think my first zygo course was at Picos, and you know, they were doing the original Nobel through the sinus flying. And you know, I I'm an archer, you know. I mean, I I I I can put an implant if I what if I wanted someplace I could do it. That's just my gift from God. And so I'm nailing all these implants, but I'm like, there's no way in hell I'm doing this in my office. And then when we got the extra maxillary, you know, and things I'm like, okay, I could do that. And I go to Vichy's office and we do a case there, and it goes great. And I come home and I got five cases lined up, and I think I got two of them successfully completed. The other three were just complete disasters. And I gotta have more reps. So I go to Brazil to Salvoni's course, and I get in eight reps, and I realize what I was doing wrong, and now you know an archer again, you know, with zygos. But you know, I mean, I put off doing zygos for over 10 years until the technique had modified enough that it was predictable and safe to do. Yeah, yeah. And I guess that's kind of my message with subs. You know, we want to do a mandibular sub, let's let's get on it, you know. But with these maxillaries, we need to be extremely selective with the patient, extremely selective with your manufacturer. And, you know, if you've got a mentor or somebody that can be there with you and help you with this and walk you through this, do it. You know, there's not a lot of us out there, you know, but uh just be careful and don't get yourself in hot water.

SPEAKER_01:

Yeah.

SPEAKER_00:

Try to get a trophy on your wall.

SPEAKER_01:

Absolutely. I think I think the trophy hunting is uh an issue. I think we've all guilt you.

SPEAKER_00:

Exactly. No one's no one I mean my credentials, my credentials, you know. I wanted to prove myself and I wanted I really haven't ever really even advertised that I'm a diplomat or a fellow. I mean, it's on my website, but I never put it in my print media, it's never on my my television stuff, you know. Um, I just didn't want to step on toes, you know, here and it wasn't necessary. I am I know it's necessary for doctors that are in big cities, you know, lots and lots of uh competition, but um, you know, now, you know, it's it's just one of those things, you know.

SPEAKER_01:

Yeah, yeah, no, I understand. So so let's say someone um, you know, is an experienced full art surgeon, um, they've done a lot of their homework, they've they've done some zygos, uh, you know, they they've done good work and they've spent some time on this, they've got a lot of recare under their belt, and but now they want to start you know tackling some customized subs. What are some principles that they should be looking for when they're considering different labs that do it, different types of designs? We've talked a little bit about the sleekness of the struts, we talked a little bit about uh surface treatment. What are some you know boxes we should be checking as we're kind of trying to vet out different sources?

SPEAKER_00:

So, first thing, you know, you've got to have your prosthetics nailed down, okay? And uh, you know, that was one of the issues Nate and I came up with with some of these cases that we were doing for other doctors. We're getting the uh prosthes seated properly, uh getting a DICOM image with that seated properly, uh getting an STL of that prosthetic, stitching all that together so that when you do design your implant, your MUAs or your meso bar and everything fit within that prosthesis. Okay. And uh, you know, even my analog guy kind of messed up on one of our implants and he he got the occlusive plane wrong on it, you know. So we had to come back in and digitally alter the maxilla and can everything up a little bit to make a little freeway space in there. So first thing is you've got to have a dialed-in prosthetic design, okay? And then you've got to be able to communicate that to it. Uh, you know, on your patient selection, I mean it's got to be a resort bridge. It's not, I don't think that you should be trying to take out teeth, cut bone, cut uh crossover strut segments, and pop it in. It's just you know, one miracle at a time, uh, you know, one step at a time. So you need to pick that carefully. And then, you know, it's just like in any implant practice, start out with what's known or more predictable. You want to do them, do them mandible. But don't do this stuff that you see where there's three per mucosal above struts from the second molar to the first premolar, and you know, big, thick, wide crossover struts, whether they're recessed or not, with 90-degree angles out into mucosa, which are all going to you know, to hits. Uh, and so that's where understanding design concepts and even talking to these manufacturers, uh, you know, I've uh got one I'm working with right now, and when I saw the design, uh I was like, wow, this guy knows what he's doing, you know. And if we could just change the workmanship of the implant itself just a little bit, you know, because he was hitting all the hobbits. He had the zygote, he went around and got your uh past the tuberosity, and and he got uh midpalatal suture. I mean, he hit all the hot spots on that, and he had four permecosal posts. Uh so you know, there are some people out there designing, but then you know, you've got all these other countries with all these other designers, and you know, they're they've got an engineer or a biotech kid that's doing it, and you know, they're they're brilliant with the software, they're brilliant with their concept, they're brilliant with their uh finite element analysis, but you know, when it comes back to what's biologically compatible in that patient's mouth, yeah, what's the tissue going to tolerate? And then I guess that's the biggest thing is you need to have quality bone for this thing to resist the forces of occlusion. And you have to have quality tissue to protect it, you know, and then you've got to have occlusion that's atraumatic. So you have to be able to find somebody who can do all that. And unfortunately, I haven't found that person yet.

SPEAKER_01:

Yeah, okay. I'm curious too, right? So, I mean, I'm thinking about, you know, what is good quality bone for a patient that needs some maxillary subperiostal? Like, how do you really assess that? I mean, these are very atrophic people, right? I mean, it's not going to be the best situation.

SPEAKER_00:

You know, Nate spends over 24 hours doing a design. You know, I've probably spent five or six hours picking out Z points and you know, the zygoma, mid-palatal suture, and saying, okay, here's where we're going to load. Okay. But you know, I'm doing the views through the lateral sinus wall, I'm doing the views through the sinus, and I've got you know 0.5 millimeter bone. Well, that's not going to resist anything. Yeah. You know, I mean, the only uh hope you have is to spread that load out. But uh it there's not, I can't give you a black and white answer. It's going to be on a case by case still. And you know, what what are you putting on it for occlusion? You know, uh, are you going anatomic teeth? Are you doing centric uh line teeth? Are you doing zirconia? Are you doing a plastic teeth or PMMA teeth? I mean, you know, there's a lot of factors to this. And you know, I've been doing it 35 years. I don't have all the answers, especially when it comes to the maxilla. Yeah, if you want a mandibular sub, you know, I can I can say, here's what you do, okay? And here's what to look out for.

SPEAKER_02:

So you're in your opinion, you think that if if somebody's getting into you know, some of the more difficult maxillary cases, you first would would do remote anchorage, um, zygos, quad zygos, and save any kind of any kind of sub um customized sub situation to like the very the patient that even that isn't gonna work for.

SPEAKER_00:

So in my lectures, you know, it's funny, I I didn't do palatal approach before 2020. Okay. So I learned palatal approach and it pissed me off because I really enjoyed doing zygote.

SPEAKER_01:

There's just so much super does so much you can do.

SPEAKER_00:

And my zygote count went down like 90% from palatal approach and transnasals and pteroids and stuff. It's like, damn it, you know. But with uh getting back, I mean, with these, you know, pick your cases, you know, start out with a with the mandible, you know, and then you know, on the maxillas, just be extremely careful, pick your patient, have a relationship with that person, and and and be very honest. Things could go south. You know, I mean, I've got a lady right now in my clinic that was done by a very good surgeon in Arkansas and restored by very good prostate honest in Arkansas, and they've both been very open, sent me everything, and she relocated to my area, and she's got bilateral uh fistulus into the sinus. Huge, huge exposure. Uh food's getting up there, they're infected. Uh, I've referred her out to an ENT that I work with. He's trying to get her cleaned up. I've got an old surgeon, you know. My old surgeon's my next door neighbor is a great guy. And we're like, you know, how are we gonna fix this lady? Because when this all comes out, she's obturator. Yeah, and there's nothing to hold event, you know, and she's in her 80s, her health is failing, and it's horrible. You know, so the devastation from these can be very, very bad. Yeah. And, you know, so you ask me, you know, are zygos first choice, uh, and these others. I think that for the maxilla, I think the sub should be the last choice. And it uh you had it on your water, you think it's controversial. That's one of the things. Because, you know, there's going to be other people that say zygos are wrought with with failure and complications and infection. And yeah, I've had all those myself, you know, and and in zygos, I respect, extremely respect those. And I do realize there are complications. But when a zygote goes south, I feel like the revision on that is easier.

SPEAKER_01:

Yeah.

SPEAKER_00:

And in one of the threads we were talking about subs this last two days, Dan Holtzlaw comes in and he goes, I got 22 references that support zygos. How many do you have that support bacterial subperosteas? And most of the case studies that I see that I've been able to research, and I even got the high dollar to chat B G Turn researching it, and it's like they're two years, yeah, 26 months, 36 months. And I got docs. Well, I've got some out five years. I'm like, okay, let's see what they look like in 10 or 15. Because you know, if you own your own practice and you stay in business long, I mean it's like I've been here 39 years, and I literally have 30 plus year old subs in my practice, yeah, you know, and you know, you see this stuff come in again and again. You really don't want to see this stuff going bad, and it's not a practice builder, right? And you know, I like to sleep at night.