SPEAKER_00: 1:19

My name is Dr. Tyler Tolbert, and I'm Dr. Storin Poppy, and you're listening to the Fix Podcast. Your source for all things implant dentistry. What other courses have you heard that you that you really like? Uh to you know, what as a general dentist, how many courses like before you do your full arch, first full arch, how many implants should you place? And I know that that's super controversial, but I'm just curious your thoughts on it, right? And then I'm curious, once you get into full arch, right? Um, I feel like there's a lot of different modalities on it. And every oral surgeon that I've talked to about general dentists going into full arch, their biggest concern and biggest issue is hey, if you can fix your problems, then I think you're good to go to do full arch. So going off of that, then when does somebody who's doing typical standard all in four start getting into advanced Patsy or, you know, like advanced zygomatic pterygoid implants? Um, what do you think is like suitable as far as those things go?

SPEAKER_03: 2:29

Okay, I don't want to be, you know, the gatekeeper, the authority behind this, you know, um, and I'm not. I'm not. I'm I'm teaching to try to help people into it. There is no number. Everyone's like, how many numbers how many implants do I have to do? 250? Is it a thousand? You know, I don't know what you know what is your comfort level. You should be comfortable doing this, and you should you should kind of know how to get in out of complications and problems, like so you can avoid them. We all have to start somewhere. I definitely don't think that you should be doing your very first implant ever in a full arch. Yeah, like I think that that's that's absurd. I think we heard we we heard that six months ago. Um people come from different backgrounds, you know. If you're a wood, if you're previously a farmer or a woodworker and then you come into dentistry, I mean, you got some, and then you're really good at the science, the biology of it, I think, you know, you've got really good hand skills, you've got good mental capacity for problem solving, probably sooner, right? I don't know. If you grew up inside of a textbook and never getting out and seeing the light of day, and then you think you're gonna get thrust into a full arch real world situation. I mean, you know, I don't know. So, like, what's your life skills? What's your background? Um, and then I think, in my opinion, you should be prepared to move at all, move quickly after standard full arch because I have, you know, I hate cantilevers and I hate short AP spread. Yeah. And the simple fact of the matter is, and I've looked at this in my own patient population, in your standard maxillary arch, your average maxillary arch, it is difficult to put the platform of your tilt much further than the first bicuspid. Okay. And sometimes half, sometimes it's between the canine and the first bicuspid. That gives you a two and a half tooth cantilever in thin bone, soft bone, shorter implants, less spacal bone anchorage, you name it, you get an AP spread of not even 10, 12 millimeters at the most in 80, 90 percent of your arches. So to say that, you know, I'm gonna do a simple maxillary arch. I mean, I'm like, I did, I think I saw one out of 350 last year, you know, like you don't get simple maxillary arches. And a simple maxillary arch would for me would be like maybe I've got a second premolar and a one-tooth cantilever. Yeah, right. That that only happens like four percent of the time. So you've got to be prepared, you know, to go and do a pterygoid or a zygomatic or do a shorter bridge. You also have to be prepared to do an FP1. Knife Sonata was just here. We just did an FP1 course with Dr. Sonata. And um, shout out to him. We had a great weekend. He and I went skydiving on Sunday. We jumped out of a plane, 13,700 feet. Oh, yeah, it was uh amazing, and he's coming back in May. Uh, I think we haven't picked the first or second weekend yet, but that guy is so brilliant, and he's probably one of the most even killed level-headed humans on the planet. I love talking to him, he's so philosophical, philosophical and deep. Um, but like he said, everyone, I'm gonna steal this from Ny from my buddy, my friend. Everybody's ready to learn zygomatics, and more people should be racing to learn FP1 because truthfully, we're gonna see more of those cases.

SPEAKER_02: 5:51

Yeah, you're right, yeah.

SPEAKER_03: 5:52

Um, for sure. Um, I see so much, I see it everywhere now. FP1. I see, you know, five years ago, everyone that came into my practice was 65. All of a sudden, I'm getting all these 30-year-olds with recovering alcohol, drug habits, you know, just sugar, never cared for their teeth. They don't have a disease of the bone, they have a disease of the teeth.

SPEAKER_02: 6:12

Yeah, right.

SPEAKER_03: 6:13

So I'm getting very long-winded here, but I think when you jump into full arts, you should be prepared to go all in. That's kind of one of the reasons the name of my podcast. You know, yeah, you gotta you gotta be like, okay, I'm gonna get to the standard course, and then soon I'm gonna take the remote, and soon I'm gonna take the FP1. Because you can't treat 100% of your maxillas unless you you know all three.

SPEAKER_02: 6:36

Yeah.

SPEAKER_03: 6:37

So and I'll I'll turn it over here in a second, but that's why we do the education with the continuum one, two, three for and three is remote anchorage, and then we do the FP1 with knife. And then if you take all four, you should have the whole scope of the project.

SPEAKER_01: 6:53

And I and I I really agree with this too. And and I think that you know, the fallacy here is the idea that you're gonna get into simple all in four, and then you're gonna get all your reps there, and then you're gonna go into more complex stuff. I think really the starting platform needs to be before you're doing your first all in four. Like you need to show that you have the didactic information, you at least understand what complications look like and what their solutions are, and show the surgical efficacy with much simpler and you know, with the types of cases that aren't gonna blow up on you and like ruin someone's life, right? Like a single implant, like a single, a single immediate. Like, if you can place a beautiful single uh immediate implant in number nine, and you have beautiful soft tissue and and all the hard and soft tissue is great, you are a very competent clinician, right? And then you can get an all in four, and then you can do everything after that, like pretty easily, because you've already got the hand skills, you've already got the knowledge, like you should be off off the off the block really fast. And I've seen so many clinicians that have really eclipsed me in terms of my growth because I kind of grew through the context of all in four personally. I was like very right off the block, like right out of school, and I grew through all in four, but the people that did all that research beforehand and they did a whole bunch of thirds and they did they were really good surgically, just didn't really have the reps all-in four. I've seen them go from just doing their first all-in-for to doing pterygoids to doing transcinus in no time. And they did it beautifully and did exemplary cases. And so it's you know, it's not about getting the reps a basic all-in four, it's about having all the foundational stuff first. And you can tell a lot about how good stuff is gonna be before they ever even do the first one. Yeah, um, so I think that's where the focus needs to mean. I totally agree. Is as soon as you get into the all-in-for world, you got to start getting into complex stuff immediately because you're gonna make your own complex cases, you know, for sure. I have a slide in my oh, sorry, go ahead.

SPEAKER_00: 8:36

Oh, yeah, yeah. I I didn't mean to clear you off. Um, I was just gonna say two things that that I really agreed with. And actually, I mentioned this on our last podcast. We had just um, I think maybe like four or five, four weeks ago, we went to the three on six guys course. Um and we've been doing one prior to that. We just wanted to see. Uh, I don't know if if you've had like those uh patients come into your door that are like three on six or nothing type of patients, but we've started to see them because they're developing like like a a following online, right?

SPEAKER_02: 9:07

Where nothing.

SPEAKER_00: 9:09

And yeah, in reality, like we and we spoke to the guys about this, right? Uh it's it's basically just standard FP1 that they segment because um yeah in their in their philosophy, Wolf's principle is where if an implant doesn't get a full load, uh, it won't have like the same potential as one that splintered, essentially. That's kind of like their their uh philosophy. But anyways, in the we did a podcast with them, and in the podcast, I said a very similar thing that you said that sure you I think that if you're you're going up the progression, standard all on four, like easy cases that um aren't super difficult, like good bone thickness, uh whatever it may be. But if you can get four implants, you can get to that second pre or that first molar, like those are awesome cases to get started with. And then I think incorporating in pterygoid implants is a neck a next next um good uh level up because you are reducing that cantilever. You're providing, I'd rather have a patient with in a pterygoid than one that's stuck with a two, three-tooth cantilever, right? So I personally like going FP1 next because you're saving a lot of that bone, right? Like you're saving a lot of those patients that have difficult cases, and then after that, like if you want to get into zygomatic, transnasal, all of these different styles to then fix all those ones that you've done prior to good treatment. Um and then the second thing I want to mention is I I totally agree with you about people's backgrounds, right? People come from all different backgrounds. For me personally, I did a one-year surgical internship where I worked under multiple surgeons for a year, and I got so much good quality basic experience that then when I jumped into implants, I was like, man, I already know all the hard stuff, right? I know how to lay big flaps, I can see all of the bone, I can take out teeth efficiently, then placing the implant, you know, is the easy part. But where I see issues, right, is where doctors they uh don't they don't reflect a full flap, right? They reflect a very tiny flap. And then they go in and they do this after it took them two hours to take all the teeth out, right? So they take them two hours to dentulate the arc, then they don't make a good flap, then they're trying to stick the implants into something that they can't see. And it's like, man, you obviously didn't get the proper basic surgical knowledge to then go into the all on four. So that's where you know, I think that if you get good at surgery, you get good at identating, you get good at laying flaps, then the full arch part could be easy for you.

SPEAKER_03: 11:54

Yeah, yeah. I have a slide, um, and I want to talk about the three on six, uh, or this the all on, what do they call it? The three on whatever three on six, yeah. Three on six, yeah, three on six. Yeah, uh, but I have a slide in my intro class, and just as we get into the introduction about when are you ready? And you know, all on four, all on X, full arch, fixed immediate load, full arch is just a combination of a lot of skills, and you have to be able to do it expediently and efficiently for the patient. And so it's like you mentioned anterior immediate load. Can I do a single anterior immediate load? Huge, yeah. Um, can I make can I do a full um arch of extractions in an immediate denture? That's like paramount, right? You can can I surgically extract teeth? Can I extract third molars, right? Sinuses, can I do a sinus lift? Okay, that's huge. You need to know in and in and around a sinus. You're gonna be in there, you're gonna be in the sinus. Yeah, for 100% sure. Can I do an overdenture? Do I know occlusion? I have so many patients or uh patients, I have so many doctors that contact me and say, I'm new to dentistry. I I I want to do fixed uh all on X because I I hate dentures. I can't do a denture. I'm like, you need to do a denture before you can do this. You have to be able to understand prosthetics, full-arch occlusion before you do this. Like, it's essential. Go make some dentures, go work in a denture clinic for like a year. It's so essential that you'll be able to have all these little tiny subsets of skills to do this, and so it's like get the training. I had a doctor come here for a one-on-one. He wanted to do a surgery, and I was watching him like try to extract a tooth. He's turning the gums into hamburger, he doesn't know how to section it. I'm like, whoa, sport, like time out, sport, you know, like we got like step aside for just a quick second. Like, we're it's been like you like you got you got two minutes to get this tooth out. Like, we gotta go. You know, like you've got like 27 more to take out. Let's spin 20 minutes on this tooth.

SPEAKER_02: 13:59

Come on, yeah.

SPEAKER_03: 14:01

Um, so you you've got that. Um, I was gonna comment about the uh three on six or whatever. So great guy, great program. They've done an excellent job marketing that I think the public knows about it all the way in here in Virginia. I'll have people in consults go, Hey, should I do all on four or should I do on three on six? I'm like, okay, look, there's way more similarities than you think. This is a marketing scheme, it's a marketing ploy. Um, I had a conversation, nice guy. I'd love to have him on the pod. And I think that he makes some kind of claim of inventing it um or trademarking it or something. Um, I mean, the fact is, when I came here to practice with Truman Baxter in Virginia Beach, Virginia in 2006, Truman was doing them already. I mean, we saw people, you know, they talked about doing these things back in the 80s, you know, and the reason they did them was for retrievability. So I've done the three-on-six procedure a whole lot of times, you know, and he was like, really, show me where, show me extra. I'm like, I'm not gonna go dig up paper charts. But, you know, we used to do like two implants, two implants, two implants, and do three just in case something failed or needed to be replaced, it wasn't all on one arch. So that was kind of something that was common. I think it's a great procedure, I think it should be done. Uh, it's very much akin to an FP1. I mean, it basically is an FP1 in three segments, so I've got nothing against it. I think it's I think it's a great treatment modality. But the bottom line is you got to be prepared to do FP1.

SPEAKER_01: 15:29

Yeah.

unknown: 15:29

Yeah.

SPEAKER_01: 15:30

No, I couldn't agree more. Couldn't agree more. And and I think too, is you know, to kind of go a little bit back to you know, our conversation on you know digital dentistry in the digital world and all the people are now coming out into a world that is fully digital and has fully embraced that, is that so we've abdigated so much of the fundamentals to labs, right? Like when you send your stage zero records to a lab, you know, all you really need to do is you take a scan of the upper, scan the lower, take a bite, take some photos. And you know, a really competent designer can make some beautiful stuff happen, and you'll have no damn idea what they did. And I think that's it's a good thing, but there's another side of that where you can skip a lot of the fundamentals and still be doing these cases. But where you're gonna get in trouble is that's a blind spot for you. You don't actually know what the lab's doing. The lab does kind of know what they're doing, but they're not actually in your practice, they're not really taking care of this patient, they're not really seeing the functional issues going on, they're just making the best of what they can with what you're sending them, you know. And so without that sort of foundational, like this was in my hands, or I had this in an articulator, I saw this patient, I understand occlusion, I understand dental principles. Um, we're kind of flying by the sea of our pants and we're advocating a lot of the actual doctor job to laboratory technicians. And eventually it will be AI as well. But it's just it's it's this is kind of a trend going on in a lot of industries, is as AI and as digital becomes more prevalent, we're kind of losing a lot of the foundational skills there. And I and I think that we're going to become less complete clinicians out of that.

SPEAKER_03: 16:52

Yeah, yeah, really careful. So, module two, I talk sorry, but module two. I talked about prosthetic seclusion a lot in our module two digital workflow class. And um, labs have we put too much trust in labs, yeah. I mean, they're hardworking individuals, they're smart people, but they don't they're not doctors, and we forget that. And a lot of dentists, I don't even think, are thinking like a doctor. You know, you have to diagnose the occlusion, you have to set it up. Don't just scan it, get it to the lab, get it back, and then just screw it in. I guarantee you, if you're objective of your prosthetic, you're probably gonna see 10 mistakes made that could be better easily. Yeah, and you've got to constantly like retrain your lab, retrain your lab. And I go through this, I know this because I have an in-office lab and I was my own lab tech for a while. So now I kind of know how they think as I train new lab techs, put way too much trust in labs. I mean, I did a um extra, I was gonna do a stackable guide course, and um I got a major national stackable guide company to come in here and do a case with me, and they were, you know, the expert. Yeah, they said, Um, okay, we got your plan ready to go, your implants are there, and I'm like, let me see them. They're like, Don't worry about it. We got the best technician on the job. You know, she's been with us for 12 or 15 years, making stackable guides. And I'm like, I want to see, let's go and let's look at these implants. I started talking to that 12, 15 year technician who does this exclusively, and I had to explain proper implant position, basal bone, palatal walls, lingual walls, angles, forces, why we use this, that, not that. And you know, she was very much like, hey, you know, she was interested. She's like, nobody's ever told me this, you know, and this is the person that 15 years offices around America and the world have been trusting to place their implants for them.

SPEAKER_02: 18:50

Yeah, yeah.

SPEAKER_03: 18:51

You know, be my message is be a doctor, like know the craft and you know, like look at it.

SPEAKER_00: 19:02

So I just did a uh it's it's funny that you say that because I just did a course, um, and I just kind of wanted a brush up on um implantitis, new new age treatments, like if anything has come out recently that is uh that has improved. Um, and so I did a whole course, and a lot of the lectures were based on uh it was like the like some World Congress of implants where they did um just a lot of periodonists come in and they go over the new improvements, right? Um and it was funny because because they a couple of lectures were about preventing, right? And it was about like what things can you do prior to your implant placement to ensure that it doesn't have these issues. And the number one cause of implantitis was was surgical placement. And it was ensuring that you have proper buckle width, ensuring that you have like all of these super basics, right? And then and then you go and you look at some people's cases, and they're like just like you said, there's a lot of doctors out there that it's just like I see bone, I place. And and there's just so many if you just really have to think about these principles to avoid, you know, you don't want over compression of the buckle plate. You want to make sure that, and and don't get me wrong, I understand that there are cases out there where you have to have you can't always do a perfect implant placement every single time. But there's a lot of cases out there that I see where I'm like, man, you could have placed that implant a hell of a lot better. And that patient probably isn't gonna be back in your chair in five years with all their buckle threads exposed. Um, so like you said, like I agree that if you're doing guided cases, I think it's important that you review the placements prior to going in there and just getting it done because um it can be the difference from you doing a revision surgery in the future. Uh for sure.

SPEAKER_03: 21:06

Yeah, for sure. And then you know, our fundamentals course talks about the best anchorage points for implants, and so oftentimes I see stuff on Instagram, and the doctor has completely missed all the anchorage points, like all of the basal bone is missed. You know, I mean, I just saw a post last week where a doctor said um the dot he said the doc the GP, I think posted and he said the surgeon got excellent torque, 30 to 40 in all the sites.

SPEAKER_00: 21:33

Wow. The lowest that you should get to love. Wow.

SPEAKER_03: 21:38

You know, and I was like, I commented, I still haven't gone back and seen if there was a reply on it, but I was like, hey, um, if you're not getting like 60 to 100 newtons on you know 90 of your implants, like DM me, like call me. Like, you know, like it's like they should be tight, tight, tight, tight. Um I I just it just blows my mind, you know, what's out there. People just trust by the surgeons, and you know, a lot of surgeons are my friends, surgeons are gonna watch this, love you guys, everybody, but just being a surgeon doesn't make you an authority on implants. Okay. I mean, case in point, like study club last night, smart, brilliant surgeon talking about how he pulls arrows out of eyes and you know, saw blades out of heads and stuff. That doesn't make you a good implant dentist, okay? You know, the title of the presentation was the zero bone loss concept. And I'm like, okay, I'm gonna take a night off my life. I want to go hear someone talk about the zero bone loss concept because I I believe in that. And I want to hear what other people's take is on that. There was nothing in this lecture that was zero bone loss concept, okay? I mean, the implants were crestal, they weren't subcrestal. Uh, he talked about having two millimeters of carotinized tissue. The rule is three, by the way. Um, didn't say anything about the buckle plate, didn't say anything about subcrestal. The third rule is um a eliminating the micro gap and having ideally a morse taper implant. The company he was speaking for does not have a morse taper implant. Like, of the top five principles of bone loss of zero bone loss concept, nothing in the lecture was zero bone loss concept. Nothing, zero, zero. And yet I look around the room and there's like 50 people. I didn't say anything because it wasn't my show. I mean, they had referral docs in there and everything. I wasn't gonna rain on the parade, but like there's like 40, 50 docs in there that are like, this guy is the authority on implants, and I'm like, you know, it does it's not don't always, it's not always true, you know, just because you have a title or you've been in the game for 35 years, it's not always true.

SPEAKER_00: 23:33

Yeah, yeah, I agree with that. I mean, Tyler and I, we we have had probably, you know, almost every single top doctor uh on the podcast, and I'll tell you that one thing that between all of them is the the ones you can tell that are are super super good at what they do are the ones that are continuously learning, right? They're just like that's that's your thing. We just had Zelig on the show, and I think of Zelig as you know, he is a beast, he does stuff that I I have like, man, that is that is impressive. I don't know if you guys just saw did you guys just see the one where he took the whole like yeah, yeah, and I was like, I would I would not have touched that. Uh anyways, but you know, he came into our podcast with just so much like spark and so much light, and about how he is constantly learning. Um and I mean I guess it does, I'm not, I'm not trying to say that there aren't implant authority figures, but what I what I do want to say is that you know, before you step on stage and lecture to a bunch of people, make sure you have your facts to it, right? It makes sure that you know that what you're talking about, if somebody rebuttals it, you can have an answer for that because there are people out there that are much further along that aren't up on that stage, and maybe that's because they're they think they're constantly learning.

SPEAKER_03: 24:50

Yeah. Oh, I mean, I'm con I'll go to any lecture. I want to hear what other people have to say. Um, but you know, throwing in that buzzword zero bone loss concept to get people to show up and then not talking about it's like the same thing as we have photogrammetry, but you don't have photogrammetry. Like the word doesn't define what you're doing just because you use the word, yeah, you know, so it's like just everyone just maybe go learn from a lot of people, you know. You can't just trust one one source, but go learn from a lot of people because there's a lot of um, I hate to steal, I hate the term on meta misinformation that's you know, just kind of my skin crawls when they say misinformation, but you know, there's a lot of misinformation out there in the uh lecture circuit and on stage. You know, I mean, I've seen it in in main podiums with like 1500 dentists in the audience, and someone's up there talking about something that's just total bullshit. Like, you know, no, you can't just like tunnel and like shove a bunch of particulate over the over the ridge. I I literally saw this one time. We're gonna cut, we're gonna tunnel, we're just gonna shove a bunch of particulate on the posterior mandible and come back in six months. And I do implants like this, and it works every single time. Like, I'm like, there are 1,500 doctors in here listening to this PS. You know, like stop, like, stop, time out. Like, you know, no, that doesn't work. You're gonna get people in trouble.

SPEAKER_01: 26:11

Yeah, right, right. Yeah, no, I I totally understand that. And we've experienced that too. Like, we've been to some, you know, I'm not, I won't drop names, but we've been to some like pretty big, you know, conferences that attract people from all over the world, and and you know, seen some of the things that get talked about, and it's like, man, I I don't really know that this is I don't see how this is reflected in reality. Like, I don't really see how what you're saying could actually be true. It's not innovative, it's nothing, you know, spectacular, but you can make a very convincing slideshow and convince people that what you're doing is just you know, gods get to earth. But um, yeah, I mean, it it's it's uh it's funny the disconnect from like the Electra Shark and and what actually works in reality.

SPEAKER_00: 26:46

Yeah, I will say that a lot of times when you see that, right? I I typically rarely see a one five-year follow-up on those type of things. Sure, you could stick a bunch of you know, alo xeno mix in an area and it's gonna look pretty on the x-ray on the day of surgery. Yeah, but what does that look like for four years from now? Even even you know, like things can things can look good at the year mark, but it's like um ensuring that you have proper follow-up before before you're posting that stuff. Because guess what? There's gonna be if 1500 doctors are in there, there's gonna be a quarter of them at least that go back to their office and they give that a shot. And who knows what's gonna happen.

SPEAKER_03: 27:25

Yeah, especially if you feel it as being easy. You're gonna everyone's gonna do it on Monday if you say it's easy. Like, oh, one incision and two stitches, okay.

SPEAKER_01: 27:34

Yeah, no problem.

SPEAKER_03: 27:37

Yeah, the the mini implant king, the like like the mini guy.

SPEAKER_01: 27:41

Yeah, you know, I think I think that's really one of the biggest issues in implant dentistry in general, is that we can celebrate really early, right? Any art you do, it's gonna screw in, you know, just fine, right? Like we are so far removed from the consequences of what we do on a daily basis because it's so far in the future, it's out of sight, out of mind. And you know, when you when you're willing to think on a very short-term basis, you can all you can think that you you're just a thousand percent successful just all the time. You're batting 1,000. Um, but the reality is that's just not how it works out over time. And uh it's just it's a lesson that gets learned probably way too late. You know, you've created way more problems than you actually have the capacity to solve by the time they come around. And uh I think that's that's uh the most insidious aspect of what full arch is, is just it's so easy to get way in over your head and you won't actually know it until you're pretty much buried. I agree.

SPEAKER_03: 28:27

Well, that's why I would you know we want to reach out. Yeah, go ahead.

SPEAKER_00: 28:30

I was just gonna I was just gonna ask, like um, you know, what uh in in the full arch world, what are kind of some of the the biggest mistakes that you see from providers? Um, and and what can providers do to fix those mistakes? I feel like that's a um there's a lot of you know clinical modalities, a lot of different things. And I'm just curious kind of what uh you know you see, what can somebody listening to this take home that that's gonna help them in their clinical abilities?

SPEAKER_03: 28:59

Well, you know, I'm gonna back up before the procedure, you know, preparedness and education and mentorship are lacking across the board. I mean, everyone thinks that they can go out and just take like a two-day class and then just go home and start slinging all on fours. Um, and you know, so because I'll say that because most of what I see come in my consultation room for revisions is just like not following very basic principles. Like, did you even learn like step one in the first place? It's like, you know, it's not hard. Like it's there, it's a cookbook procedure. You know, it's a big procedure made up of 26 little tiny procedures. And you gotta have the skill set for all of it, and you got to have a good background. Cause I think that honestly, like 95% of complications were preventable if you just did it correct in the first place. Like, like you said, periimplantitis. I agree with that. Most perictitis is a is uh occurs because of the surgical placement, you know, the platform of the implant and where it was at and the how it was placed and where. And I think the same thing goes with you know, full fixed immediate load, full large. 95% of these complications are that it wasn't done correctly in the first place. So going back and learning a stepwise approach, a methodical approach, deliberate approach to this procedure is essential. Um, but I think you were asking probably, you know, the number one um cause of complications, it's certainly in two things, really, and they're very related, I think. Understanding proper prosthetic setup and vertical dimension of occlusion, condyler-centric vertical dimension of occlusion, having an understanding of that. I think that 95% of dentists probably more don't think about condyler-centric. That's something I talk about, it's big time, especially in my module one and two classes. Understanding prescribing the proper vertical dimension of occlusion, condyler-centric, and two the alveoloplasty that's required and the bone platform interface. Where is that? All right. If doctors would understand condylar centric, vertical dimension of occlusion, proper alveoloplasty, and platform placement, 90% of their problems would go away. Just those two simple concepts. That's just what comes to mind offhand. I don't know. What do you guys think?

SPEAKER_01: 31:23

Yeah, I mean, I I think that's solid. I mean, I think the uh, you know, the the alveoloplasty and the um platform interface, I think that one's a little bit more obvious. I I think that that's something that definitely gets overlooked, but it's like a very simple, you know, uh conversion mentally that people can make and it would prevent a ton of things. And in also respect of the soft tissue too, I think we we focus way too much on hard tissue, um forgetting that the actual nutritive thing that's really going to protect and seal off that implant is not the hard tissue at all. Um that's extremely important. Um, I am curious if if you wouldn't mind expounding a little bit more on uh condyler-centric. Um, I assume this means, you know, this I'm there's so many different definitions on like central collation, right? Like the most superior, anterior position of the uh of uh the glenoid fossa and things like that. But like how that how that really turns out in the uh stage zero record taking, you know, how you're calibrating that and maybe just one simple thing that people can do at the record taking stage to maybe account a little bit better for central relation.

SPEAKER_03: 32:23

Sure. Um this is this this is big in module two, prosthetics and digital workflow. Proper record taking, you know, Keith Klaus, my buddy at digital workflow, I give a shout out to Dr. Klaus down in Mississippi, brilliant, brilliant clinician, um, smart guy, engineer turned dentist. But we teach digital workflow and we see all of the errors, 95% of the errors come back in record taking.

SPEAKER_02: 32:47

Yeah, right.

SPEAKER_03: 32:48

Are you able to and and I've narrowed it down to condylar centric vertical dimension of occlusion? Give the lab the scans at your desired vertical dimension with the conduct condyles fully seated on both sides. Okay, then there's some other occlusal things. I mean, I don't think we have the time to get into uh uh but I coach them in, I coach them into that, I get them situated, we record at the vertical where that we think that condyle-centric is. I go to my CBCT and with the putty or the bites or the bite rims or whatever in place, I check to make sure that both condyles look like they're both seated and even. All right. Um, and then you go from there, you can adjust, you can totally adjust. Um, after I put in my first prosthetics, we go take a CBCT. I check all my implant placements, but I also take a look at the condyles. And I mean, we're not able to look at soft tissue in the dental office yet. I mean, nobody can afford an MRI, nor would we expose patients to multiple MRI radiations like four or five times in a process. We're not gonna do that. But this is a a good go-to way to see if the hard structures look like they're balanced. Okay. Yeah. Guess what? When you see that, patients' faces look relaxed, they look better.

SPEAKER_02: 34:08

Yeah.

SPEAKER_03: 34:09

Um, and it's so hard to find. I talk about this so much in module two, but hammer this home. It's so hard to find general public in conductar-centric. People are in a best fit match to borrow a term from my exocad days, where their teeth just kind of interdigitate. Yeah, and you put them in full arch and you screw them down, and their midlines are kind of on on day one, and you look at them six days or six weeks later and they shift. Why? Because everything has relaxed, the whole schematic method system has relaxed, the contents have relaxed. You've basically deprogrammed them.

SPEAKER_02: 34:43

Yes.

SPEAKER_03: 34:43

People ask me all the time, do you put people like in a coist deprogrammer before treatment to get that? I'm like, no, I'm gonna take out the teeth, they're gonna get deprogrammed. Let's let's get all on four procedure, is a deprogramming procedure, you know. And I designed my lowers in a very specific way that I get to deprogram everybody, but you wouldn't believe probably 30% of people, 25% of people come back in six weeks for a wellness check with a midline shifted. And now we can go back and get condyler-centric. This is one of the biggest problems I have with anybody teaching, like the bullet-proof zirconia in three days, or you know, we'll give you final teeth in two days. Like, do you even know what's going on here? Yeah, do you are you a doctor? Do you know what's going on here? Have you how many reps have you had? This is this is huge.

SPEAKER_01: 35:29

So you're taking the CBCT. So whatever you've done, let's say you have an open the bite and you've you've jigged that somehow, a putty bite, um, you know, d uh like a uh in some sort of interior stop, whatever. You're taking a CBCT while they're locked into that and verifying the seeding of both condyles. And then you're also checking post-operatively once you deliver your temps, they're in occlusion, they're they take C BCT and you're verifying that that position is the same.

SPEAKER_03: 35:55

100%, 100%. And you know, you don't have to expose them to you know multiple too many scans. My average patient gets three scans, yeah, usually the consult scan, my record scan for condyles, and my post-surgical scan. Okay, just to verify. So most people get three. Now, if I was grossly off or the patient was uncomfortable, developed a TMD or something, acute, acute uh TMD, um, or trismus or something, I would probably be doing some more scans to look at their condyles. Yeah. But you know, the true test is symptoms. So we get it close, and 99% of the time it's great. The patient looks relaxed. They say, I've never felt better, my headaches are gone, I didn't even know it was all related to my bite. Then that 1% of the time, you know, you're it's not it's not always true, right? You gotta let's see what looks balanced on the face, see when the patient's comfortable. Symptoms are the ultimate test.

SPEAKER_01: 36:45

Yeah.

SPEAKER_03: 36:46

Ultimate test, no symptoms, and they look and feel better.

SPEAKER_01: 36:50

Yeah, no, that makes a lot of sense. And and in terms of symptoms, I mean, at what point, you know, because there's going to be some overlap between post-surgical symptomology and you know, symptomology that's secondary to the occlusion that you've put them in. Like at what point are you really paying attention to that? You know, once you're you're assured that all that inflammation has gone away and now we're just dealing with an occlusal problem.

SPEAKER_03: 37:10

Say wait, say say that again. I'm sorry, I got interrupted.

SPEAKER_01: 37:13

No, no, you're fine, you're fine. So, like post-operatively, you know, a patient may say, oh, my head is hurting or my muscles feel sore or whatever's happening. You know, how do you kind of differentiate between, you know, what's a post-operative surgical complication or maybe them just accommodating to a new bite and having gone through surgery and things versus something that's actually secondary to how their occlusion is set up.

SPEAKER_03: 37:31

Okay, well, you know, there's no secret about it. This is a major surgical procedure. Okay. Anybody who says it's simple is just not being truthful with themselves. Um, it it can take six weeks for the face to fully like settle down. You know, anybody who's had any surgery whatsoever, they know the body goes through a very, you know, slow healing process. That's that first sigma of four to six weeks is big. Nobody feels a hundred percent normal in less than four. I mean, yeah, even if it's just like I feel funny, right? Yeah. So you've got to, you know that you've you know you've got like some growing pains to do. Um, but I'm talking about that person that you see that like you can tell they've got like trismus, they've got um, you know, some spasms, they don't look or feel good. You can tell, like, you know, they come in and they look at you and they're like, you know, they're like, everything, yeah, is ever is everything okay? You're like, yeah, everything's fine. I'm like, no, your bites off. Like, you shouldn't be, you shouldn't look this stressed. Uh when you get somebody's vertical dimension and centric in and you're making adjustments, literally they'll close down and they'll be like, Oh my god, that feels better. Yeah, you know, yeah. So you're you've got to listen to prosthetics, is a huge listening game. You know, people be like, I'm having trouble with my speech. Okay, what do you think is happening? Tell me what you think is going on. You know, I know how to deal with speech. I was in speech therapy as a kid, you know. My sister-in-law is a speech therapist. We talk about it all the time because by the way, if you're a dentist out there doing prosthetics, take speech, uh take speech therapy um education, you're gonna need it. You're gonna need what the tongue does on different random movements. You need to know that. Um, so but I mean, I might already know, but I tell I ask, what do you think is happening? You know, the diagnosis oftentimes is in listening.

SPEAKER_01: 39:25

Yeah, no, I like that a lot. And that that's one of those nuances that, like, you know, I think that when people get really into say full mouth rehab, right? They're they're working with natural dentition, they're trying to open up someone's bite and re-establish a whole new smile and things like that. I mean, you you have to go really deep, right? Like you go into COIS, you go into Dawson, different, different occlusal philosophies, and like you have to go really deep and like really learn the technical aspects of it. And it seems like most people that take full mouth rehab seriously, they go and do that and they go down those continuums. But a lot of full arch people don't do that, right? Like we we do not go down, we're we're going to Orca, we're going to Clark Damon's course, we're going to Atlantic Implant Institute, we're flying all over the world, just play, you know, we're slinging titanium just all over the damn world, right? But like we don't go that deep into occlusal principles. And like we kind of throw a lot of that out because like, oh, we're taking out the teeth. You know, so much of this complexity goes away. We make it simple. But in reality, those things do still exist. They they do still very much matter. Perhaps it's more simplified, perhaps we've made a less complex system, maybe. Um, but uh, but those things still matter. And I feel like so much of the stuff that's kind of in the gray, like the problems that you just say, you know what, sometimes these things happen and patients just have to deal with it, you know, at least they have teeth, right? I I think a lot of these problems are solvable um if you if you go that deep. And I think to really last long in this and have that sort of uh patient satisfaction that I'm sure you've achieved, like you you do have to know those things and it they do matter.

SPEAKER_00: 40:43

Absolutely. Yeah, that's probably that's probably one thing I'll I'll be taking out of this conversation is you know, maybe I do need to go to like a um a speech program because that's probably one of my my biggest issues with post op complications is patients with speech issues. You know, I do my best at um after the patient come after the patient comes in, if they have a speech issue, you know, I'll go through the gambit, I'll I'll have them, you know, record them doing their different movements, I'll record them speaking, I'll record, and I'll try to to work with my lab to fix some of those issues. And usually we get it fixed, right? But sometimes it takes me three, four sets of teeth to get it fixed. Um that's probably something I could work on. Is um it'd be great if I could fix that in one or two two sets, you know, by just changing certain principles. But speech is a tough one, it's hard. Yeah, it's it's um, and it's it's one that you know it's not it's not sexy, right? It's not ready to uh nobody wants to go to a to a course like that, but it's it is fundamental for um like I would say 10, 15, 20 percent of the patients that come back with like a speech issue here.

SPEAKER_01: 41:45

There's no there's no like badass speech course, there's no course where you go out in the desert and shoot thermite, you know, to learn like speech pathology. You know, I think that's the thing, is like we're just so we like these like really hardcore uh courses where we're doing surgery and there's blood and guts everywhere, like things that like speech therapy, they're not sexy, but man, like that's the kind of stuff that solves that five percent of problems in your practice that drive you freaking nuts.

SPEAKER_03: 42:08

Oh, for sure. And it's especially bad when the patient thinks they can hear it and they can't get over it and you can't hear a thing. Um that's when you really gotta like sit down and talk about it because usually those are just like so small. Um, yeah. I mean, if you guys have worked on musicians or if you've worked on people that play like wind instruments, you know people that make their living talking, they make their living going around the country. I mean, you better be on you better be on point. I mean, I've worked on actors, and it's um, I mean, it's a really important facet of the prosthetic is how well they can talk. So, yeah, you know, be be ready for you say, like, when do you go, you know, get an all the four, you know, or how much do you go in? You go all in because you gotta you gotta be able to handle these complications. I think that goes for any any doctor whatsoever, no matter what your procedure is, if you can handle the complications, if you can address the bumps in the road, then you're ready to do it.

SPEAKER_01: 43:03

Yeah, yeah, yeah. But that I think that that's also kind of the tough thing about it, though, is like, you know, when you go through, let's say a residency, like a GPR AGD, or you know, surgeons they do um surgical residencies in hospitals, like their whole job is they work in a place where complications get sent to. So the complications just come in. They're not, they didn't treat them initially, but someone else did, and now they're dealing with complications. So it's very easy for people like that to say, oh, well, I know how to deal with these complications, so I have every right to be doing this. But if you didn't do something like that, if you've been learning through the world of CE, it's more difficult because there's not a lot of courses on complications that are live patient courses, right? It's very difficult to put that together, right? Oh, you're having this complication. Well, just hold on just a second because I'm trying to throw this course together, right? Like it doesn't, it doesn't work that well. I've seen people try to do complications courses with live patients, and it's a difficult thing to do. The ethics are questionable, right? In a in a way, like the complications you're gonna run into are gonna come from your own cases. So it's it's kind of this 22. It's like it's like when you're out in the job market and everybody wants experience, but how are you supposed to get experience if you know no one's hiring, right? Like that that's it's kind of this chicken and egg thing that happens.

SPEAKER_03: 44:02

We're we're adding a module in 2026, um, me and another doctor. So by the way, my institute's not just me, it's I've got faculty doctor as well. Um, but uh uh my next module, module six, um, is a complications weekend. We're gonna talk about complications in singles and full arch, and that's all we're gonna talk about is complications. So that's gonna be in the fall of 2026. We haven't announced it yet, but you that would be vital to go to, you know, understand, hear people like I'm gonna show you some grotesque stuff and how we managed it, how we fixed it. Um, but you know, no pictures, please. You know, anybody who says they don't have complications is probably sitting on their couch, like they're not doing anything. Yeah, yeah, yeah.

SPEAKER_00: 44:45

For sure. Well, hey Adam, I think we're uh we're coming short on time here. We usually like to to do a write-about here. Is there anything that we didn't go over? Is there anything that you want to talk about with the Atlantic Implant Institute that um you know we could find out? So what's coming? We've had a great time having this conversation. I would love to just make sure we hit anything that we didn't for you.

SPEAKER_03: 45:02

Yeah, yeah, yeah. Well, this episode brought to you by the Atlantic Intelligence. The uh let me tell you what's coming up in December.

SPEAKER_01: 45:11

Uh I said uh the Atlantic Implant Institute is now a sponsor of the fixed podcast.

SPEAKER_03: 45:16

Yeah, well, that's right. You're sponsoring me. Wait till you get my bill. I'm sponsoring you, you're sponsoring me. Um, oh, you give me your bill first. Okay.

SPEAKER_02: 45:25

Double it.

SPEAKER_03: 45:27

Okay. In oct in December, uh, my buddy Juan Gonzalez is here for uh remote anchorage, core anchorage. We've got that two days plus cadavers. We're gonna do um, by the way, all of our classes are didactic, hands-on, live surgery, observation, and usually a lab, like a cadaver course. So that's in December. So you got a chance to come learn remote anchorage. In January, I'm gonna start the continuum over um with module one. And I'd like to put a special shout out right now. Anyone that is get looking to get into full arch, you need to come to module one bootcamp core fundamentals. If you don't know if you want to take the continuum, just take module one. And we see probably three-quarters of those people add on module two and three later. So January, you want to be there. My co-faculty, Dr. Athena Ghadarzi from 4M Institute in Los Angeles, a good friend of mine. She's uh co-hosting module one with me. And then um, we've got FP1, we'll come back in May with Dr. Sonata Business of Full Arch in April as well. And then we'll have live patient experience in the fall. I do not know yet if we're gonna run the continuum twice yet for 2026, only because I'm very, very busy. Yeah.

SPEAKER_01: 46:42

So naturally, yeah.

SPEAKER_03: 46:45

Take it now while you can. It might be your only time.

SPEAKER_01: 46:47

Awesome, awesome. Yeah, that's great. And I think we got to make our way out there and and uh see all those wonderful things you got cooking. We we've been following your videos and seeing all the things that you test out. And um, I think it'd be really awesome just to uh work with you in person and see how some of that goes down. So uh I definitely want to look at that complications course, and I promise I won't tell any stories after.

SPEAKER_03: 47:05

And send your docs, your docs need training, send your docs, yeah.

SPEAKER_01: 47:08

You bet, you bet.

SPEAKER_03: 47:09

Yeah, for sure.

unknown: 47:10

Yeah.

SPEAKER_01: 47:10

Well, Dr. Hogan, thank you so much for uh coming on the Fix Podcast and also for having us on your podcast. Um, this has been a lot of fun. It's been a really easy conversation to have, and I'm sure we could have gone twice as long if we had the time. But uh, you know, I just really appreciate all the experience you bring to the forefront. And thank you so much for democratizing all this knowledge and all this experience you've had to uh so many people that want to go out and do full arch and uh get themselves in trouble, right? Um, this is just an awesome thing that uh that you're doing. And you know, I I think they need the world needs more podcasts on fixed, it needs more podcasts on implants. We need to be talking about this stuff more, the real world, the complications come along with it, all the pitfalls and things. And uh I think you're doing an excellent job with that. And uh anything we can do to help support that, we're we're more than happy to do it.

SPEAKER_03: 47:50

Thank you very much. No, it's been a pleasure talking to you. Second time we've talked, you guys are easy to chat with. I can see why you're so successful, and I can see why doctors would want to work with you too as well. Uh, my hat's off to you on the on the on the empire of offices. It's something I haven't done yet and uh often dreamed about, but yeah, not sure I'm ready to get into. Um maybe we talk offline on that more, help each other out.

SPEAKER_00: 48:11

Definitely. All right, sounds good. Thank you. You have a good one. Appreciate it.