The Fixed Podcast

Navigating Full Arch Challenges: A Talk with Dr. Sean Lan: Part 2

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Stop treating full arch like a hammer-and-nail job. We walk through how to think like a doctor first and a technician second, so your immediate wins turn into durable outcomes. From the first consult to the last suture, we frame decisions around patient values, real risk, and a plan that preserves future options rather than burning bridges.

We dig into regenerative dentistry as the quiet force behind long-term stability. Autogenous bone from routine alveolectomy, collagen membrane support, and smart use of PRF can minimize biomaterials while preserving volume. On the soft-tissue side, we show how palatal thinning and simple CTG/FGG techniques create protective keratinized bands that make hygiene easier and complications rarer. The goal isn’t “least possible” work; it’s the right amount of work—optimally invasive treatment planning that respects biology and the prosthetic you’ll be maintaining for years.

We also tackle the reality of emergencies and team culture. ACLS refreshers, mock codes, and clear role assignments turn chaos into a practiced script when vitals dip or syncope hits. That same clarity belongs in consent: immediate load versus heal-first, conventional implants versus zygomatic rescue, and how each path affects risk, cost, and reversibility. When patients choose knowingly, your surgeries run smoother and follow-ups reveal wiser decisions instead of lucky breaks.

If you’re ready to replace shortcuts with fundamentals, integrate regenerative tactics you can use Monday morning, and have cleaner consults that earn trust, this conversation is your playbook. Subscribe, share with a colleague who does full arch, and leave a review telling us which regenerative move you’ll add next.

SPEAKER_02:

My name is Dr. Tyler Tolbert. And I'm Dr. Soren Poppy. And you're listening to the Fix Podcast, your source for all things implant dentistry. And I remember Dr. Logan Locke, you know, he's he's uh one of the primary doctors there, and he teaches three on six. And he's brilliant, brilliant clinician, really, really fantastic. And uh, you know, he had this one patient he mentioned, I think it was like three or four times like throughout the course. He's like, Yep, that's that's her, you know. He's like present in his mind. He was like getting texts about it, you know, and he's like, I mean, he's one of the best like FP1 people like in the country for sure. And uh, you know, surgical stuff's gonna happen all the time, but it's just how you deal with people. And and that's uh it's something that you you can always work on, and and it will always make there's just a few things that are gonna make your life easier than just learning how to deal with um sometimes difficult people, um, for sure. So I I I think it definitely belongs in the conversation about how to survive in full arch.

SPEAKER_00:

Yeah, 100%. Yeah, 100% agreed. And you know, the thing is like these kinds, so just like reviewing kind of what we talked about, like like fitness, personal development, like these things are hard to track, right? It's harder to learn because it's harder for us to track, you know, we're we're we're used to like, oh, like in dental school, you got classical learning class two, learning class three, learning class four, you know. You it's easy to track your progression, but it's it's really hard to, it's intangible, right? How to how do you track your personal and again, it's just like you said, I think it's just constant exposure to it, constant, you're you're constantly thinking about it, getting exposed to it. So that's in the forefront of your mind, too. Um yeah. Um, but yeah, it's talking about that is you know, I I think moving to like the last point that um discuss, like well, what what are full arch dentists missing in their toolkit or maybe can strengthen is just I think a thing that we I see a lot, um, especially with younger um clinicians, but not just younger clinicians, you know, it's any kind of clinician, right? Um is just thinking more like a doctor and not just a technician, right? Um this is something that uh really picked up, you know, just from all my time with uh hanging out with the OFS guys at UF and um my training with uh with the Air Force and those attendings as well, is just like, man, like you really have to it it is you are a doctor, you know, right? You know what I mean? Um so we have to treatment plan and and critically think like one. Um you know, and especially when it comes to treatment planning, right? Like it's and this will kind of delve into uh what we're gonna talk about later, but man, if you only have um you know, if you only have a hammer, everything kind of looks like a nail, right? And when it comes to like FP3, that's the only skill, you know, and we've we've been there too, right? Like I only just started doing ones and I didn't want it any kind of FP1 case that came across my lap that I was like, yep, that's an FP1, I'm not doing that. I refer out, you know? Yeah, it's not my but it's it's about at least learning enough to know that hey, this is a case that can be done a different way, um, instead of like, yep, everyone FP3, FP3, FP3, you know. You got it. Um, and kind of like a you know, probably the most common kind of questions that you get from mentees is like, hey, how do I manage this patient? Patient has this has health history, like, what do I do? Um, and I can already tell, like, there's there's the docs that kind of just ask the question, right? Like, hey, like HBONC is 8.2, like what do I do? It's like, okay, like, what about the everything else, right? Uh, versus like sometimes I'll get docs that I know that they've maybe had some similar kind of training, like thinking more comprehensively, thinking more like a doctor is like like, hey, like it doesn't take that long. We had to present all our patients like this to 862-year-old, you know, African-American male, uh, presents with past medical history of hypertension, uh, type 2 diabetes, um, asthma, these kind of things. HPUSA is 8.2, is checked last within the last two months. Uh, patient does not bring their you know, very quick, you know, it's a very quick, straight to the point patient presentation um on the past medical history medications, allergies, social history, family history. It's it doesn't take long. Um, and that way I get you know, it's just the L I call it the elevator pitch with my with my docs. Like, hey, give me the elevator pitch um in a voice note so that I can properly help you um answer this question, right? Because little things can affect it for sure. Um so I think learning those things, not forgetting those things, um, is is really important. And um I'm I'm I'm gonna use this opportunity to get on my soapbox too for uh as far as uh uh additional training, right? Like um in the residency we all had to get ACLS uh certified because we we also were had the opportunity to get uh IV water sedation. And so I think that's a very um it's a very good thing to get, you know, if you're doing this kind of procedure day in and day out. Another stressful call that probably you've gotten a lot of times is hey, like my patient just pat like the high, like very like his blood pressure is super low, like uh they they're they're you know sweating, like what what do I do? You know what I mean? And it's like all right, let's slow down, let's let's think back to you know the most common things that can happen, you know, syncope, blah, blah, blah. Like, hey, did you get fluids? How much fluids have they gotten? All these kind of things. Um, and what kind of can give you a lot more confidence in that is taking something like ACLS. Because they run through a lot of these medical emergencies, um, especially the more serious ones. Um, and the point of it is not to learn how to deal with it, right? But it's to just increase the chance of your patient surviving until EMS arrives, right? And there's a lot that can happen between that time, um, be it 10 minutes, be it 20 minutes, um, that you can do to kind of help the patient, you know, literally support their life until more advanced care can be given, right? And it's the same thing when the EMS arrives, that they get to a hospital, you learn, um, and it's you know, say they're not a level one stroke center, and that's what they need, they need to be doing these steps to keep the pay support their life longer so that they can get to the next level of care. And so I think the you know, as as someone doing floor routinely, um getting ACLS training um is it's a must. And and um and it'll give you a lot more confidence too. Uh confidence in yourself was the comp you know the team will be way more confident in you because you're who's who are they looking to when something happens, right? You right the market salvages, exactly. Then they're freaking out, you know. So so it's a it's a great thing to to have in your tool belt, and it just helps you uh think through those kind of situations more. And and and to be honest, those that's one of the things that I haven't been able to do is is so in the military, we'd have monthly just our oral surgeon would drop a dummy anywhere in the clinic, and then that'd be like a mock code blue, and to kind of run those situations. Obviously, it's kind of harder to do in a in a private practice, but I think doing it quarterly or even you know, biannually, quarterly, whatever, I there are services I've heard that will come and do that for you and do that for the team. Obviously, you don't have to do it in front of patient care, but have a team training day where that's something maybe hey, you know, you just pop in and and they and and you have to deal with situations like that. They know it's coming, but they don't know when, you know. Um it's a good way to kind of just keep everyone on their toes and just also know that hey, like Doc really cares about this and he cares and makes them care. They're like, this is important, like this is really important. It empowers them to feel more confident in those situations, too.

SPEAKER_02:

Yeah. This reminds me of the office episode where Dwight starts a fire in the office and he's like, you got board doors to the door handles. I mean, you know, it's not architecture. You need to be prepared for these situations. But no, no, seriously. Like, I I I think that's extremely important. And you know, if you want to do full arch and you want to do this all the time, um, you know, guess what? You don't get ASA1 patients ever. You know, that's that's not that's just that's just not the ballgame. So I mean, everyone's got some risk. I mean, I see um, you know, extremely hypertensive people on a daily basis that are just you know walking around having no clue, um, you know, uncontrolled diabetes, uh, you know, people who are waiting on a you know, kidney transplant, heart transplant, whatever. So, I mean, yeah, you do have to be familiar with these things. And even if you work with, you know, say an anesthesia team that goes through and and pre-opts all your patients and you know, make sure they're surgically optimized and they're gonna be, you know, uh having IV access throughout the procedure, certainly that things makes things a lot safer, but that doesn't abdicate um the responsibility that you have as a doctor. And you have to remember, like, regardless of how you feel about your own role in in taking care of people, um, everyone in the office thinks that you know how to do it. They think that if if something happens, go get the doctor and like you're gonna be solving the problem. Like, remember, like you are the person they're gonna count on to do that. Absolutely. Um and that should make you feel a little anxious, you know, and and you can replace that anxiety with knowledge. So I totally agree. Like you have to get ACLS training and do it frequently. I mean, I I did it, you know, years and years ago, and and I recently redid it um because you know, that stuff doesn't really stick with you because it doesn't happen every day, right? Like hopefully these things never happen, but they they do. Um so uh yeah, no, I think that's a great point. And you know, so much of this really just comes down to having the fundamentals just really, really down pat, right? Everything that we're talking about comes down to fundamentals. So I think there's important points. So I know you've been itching for it, I've been itching for it. It's time to talk about regenerative dentistry. So um, you know, uh, so first of all, like I I want to talk about, you know, what is regenerative dentistry in the first place? You know, what does that what does that really mean? What does it mean in the context of Full Arch? And uh and how should we be thinking about it? You know, when I when I first got into Full Arch, I kind of alluded to this earlier, you know, when I when I was doing it, it was like regenerative just kind of got thrown out the window completely. Like we're not we're not here to graft, we're not here to socket preserve, like we're here to find bone, get implants in there and get torque and then and then throw some teeth on and let the body do its thing, right? And it's been over time that I've learned you know the value of regenerative dentistry. But how how would you define that?

SPEAKER_00:

Yeah, that's a that's a um it's a great question, a great point, because it's like um, you know, when I started Sue, and it's obviously trickled down from what you've learned as well and in education sources, but most of the course you'll see, I mean, all four is talented as a graphless solution, right? Um and that sounds great, but you know, I think um, and we'll talk about this more um in depth later, but I I like to use something, uh a term called optimally invasive treatment planning, right? Doing what's necessary um for the case, not more, not less, but you know, I'm not just doing the least amount for the sake of being conservative, right? Um, but not just going completely overboard um and finding that balance point. But um, you know, grafting is is a very general term, and grafting can involve autogenous um, you know, grafting or biomaterials. Um for me, like personally, I like the concept of minimizing, you know, minimally grafting solutions for full arch um and minimizing the amount of biomaterials used. So like, you know, for FP3 cases, uh patients that are indicated for FP3, usually you can save enough autogenous bone just through your alveolectomy. You know, I I personally it takes a little bit longer, but um, you know, mark my lines and I use a rotten double action rotten jour for the first part of my you know 70% of the alveolectomy to try to get all that you know as much bone as I can, and then then I take the rest with a literary um burr. And and usually that's enough to not even you know peck the side because why not? You have it there, right?

SPEAKER_02:

Um and then on the side, and and I I I will mention too as well, it seems like it's a lot slower, but like if you really know how to use a double action runger, as long as it's not like super cortical bone, like it can actually really speed up the procedure dramatically. It doesn't make as much of a mess, you're not throwing water all over the place. Like a runger is can do like 80% of your ovulatic pretty quickly.

SPEAKER_00:

Yeah, and and I'll say exactly I actually do. I don't have the benefit in Georgia of uh having GA for every case. Yeah, yeah. So 90% of my cases, I'd say even 90 up to 95% of my cases are general oral sedation. Like patients don't really respond when you're using the yeah, so I'm like, ah, here comes the nail clippers, and like they really some of them start coughing and stuff when the water starts coming, you know, from your yeah, no, it's it's a lot, and you get gauze helicopters and all kinds of stuff.

SPEAKER_02:

Like it's you know, it's it's a ton, and uh it's a lot for patients, and you know, uh they panic because they feel like they're being waterboarded. Like, you know, the the less water you can squirt their mouth, the better. And uh, Rogers are really powerful for that, and it is it's a source of autogenous grafting. We do that for every single case, yeah.

SPEAKER_00:

100%. And um, you know, on the on the soft tissue side, right? Oh, well, let's finish up the hard tissue. So, like yeah, uh autogenous bone 100%, you know, is usually enough to fill up most of the sockets and and maybe even some graft some buckle defects. Of course, we have a buckle defect. You can some people say you can just lay the autogenous bone on there. I still like to put uh some sort of a collagen membrane, even for a um uh within the contour defect. Um, but either way you go, you can, you know, um it's still minimizing the amount of biod materials, right? Um and then two, if you save all that uh autogenous bone, say you didn't have that much reduction, um, and you still needed to graph. Well, you still have some um autogenous bone, but instead of opening up a twocc or one cc packet of uh allograph, now you only just maybe need to use 0.5. Um, and then add it with some URF, it really increases that kind of I know it's not true volume, but it the graph itself will be stickier, easy to manipulate, blah, blah, blah. But um, it'll be able to maintain that blood clot space, right? Bigger. Yeah. Um, so you it really minimizes the amount of actual biomaterial or allograph or zenith graph that you have to use. Most of that mix is autogenous. Um so going towards that, uh, towards the soft tissue side, right? Like, especially on the maxilla, like if you're blessed with a lot of um, you know, palatal thickness, that can actually be a problem with your prost, right? Um, I know uh Dr. Clark Damon preaches this all the time. You know, you start trimming the palatal tissue so you get you know a little bit more space for your pal um for your uh for your prosthetic, and you don't have to reduce absorption bone, uh why throw it away? You know, like of course if the patient has miles of bone or miles of soft tissue, don't you know it's not worth the extra time. But if they're thin tissue phenotype, maybe you save it for the lower, especially the lower anteriors, right? Um for the lower, and you it takes not that long to tack it on the inside of the flap and you have a free CTG there, you know. Um and takes 10, 15 extra minutes, but I think it's worth it down the line when you don't have to, it's always easier to graft the time of surgery than it is after.

SPEAKER_02:

Yeah, I I that is something I do routinely um in thinning the tissue as well as obviously trimming the tissue as well. Um, you know, sometimes you have that wall of tissue and you you just you know cut that right out and then you thin everything out and try and you know dig the depth of the 15 like all the way through, get a good you know, 10 millimeter slice really thin that tissue. And you can absolutely throw that down, it could be a CTG. I also saw um it was Melanie Toe's uh presentation at Orca. She was actually um she showed one where I believe she did an FGG. So she you know took a big you know slice out of the palate and then basically made it into a poncho for like the lower um abutment. So she like threaded the straight above it right through that FGG from the palate and you know, suture all together. And like that's I mean, that couldn't be any easier, right? Like that's super, super easy. And you just did, you know, simultaneously soft tissue grafting and you know, gave your lower implants a whole lot of insurance. So, you know, it it's all there. It's free and available if you're especially if you're doing FP3, there's a fair amount of production. Like there's a lot of tissue to be had um in most cases. So yeah, I that's something I've started to do a lot more routinely. I think it's great.

SPEAKER_00:

Yeah, yeah. It says up sets the patient up for success. You know, it's it's definitely worth it. Um yeah, it's uh that that kind of like transitions to like the the concept of being optimally evasive, right? Like you hear minimally evasive all the time, and minimally evasive is a is is I think it's a relative term, right? And so is optimally evasive, but we'll talk about the difference. Like, I think minimally evasive, like people get people get too stuck on like what is the least, the less is better, right? Like I get an operative, right? Let's just start like with operatives, like D1 lesion, like if you're if you're in dental school, remit or less. There's no other discussion about like you know, like what's the carrier's risk? Like what's the what's their patient's willingness to change, what's their what's their diet like? What you know, like all these kind of things. Like what is optimally evasive for the patient? The patient that has maybe has one or two D1 lesions, like short, um, they're willing to clean up their act, they're like, oh crap, like I don't want that anymore. Like, I'll do what what do I need to do, doc? Like, yeah, for that patient, the optimally evasive thing to do would be to try to reminerize. Uh, versus you got the patient's 50s, 60s, like, yeah, doc, I'm gonna be honest with you, I ain't gonna stop smoking. I'm not gonna stop drinking, you know, I'm out and do blah, blah, blah, all these things you're talking about. I'm just not gonna do it. For that patient, the optimally evasive thing is to do the filling, right? Um, I thought you're gonna say full arch goal. Well, yeah, so it's you know, let's apply it to to to full arch, you know. Like, yeah, um, if it's just assume the patient is is indicator for FP3 and it looks like a standard all in four arch, you know. Um, you go in there, um, you know, got you know, let's just say standard for all on four, um, but you couldn't get torque on the posteriors, you know. What are you doing? You know, what you go for the nose, still no torque. Well, what are you doing?

SPEAKER_02:

Yeah, I mean that that's a good question, right? And I I think that you know what we're kind of alluding to is you know, we we talk about this on the show a lot, is like always having you know the backup plan, right? Um, so you know, in some cases, like let's say I can't get any torque on the tilted, I've tried the nose, I've tried sizing up, I've done all that kind of stuff. You know, a lot of times, you know, if I have a pterygoid, um, I'll just move anterior and just try again, right? But if none of that happens, like if I've gotten nothing in zone two, you know, of course the topic of a zygo can come up, right? And I see a lot of cases where they do the rescue zygo, right? Like they just weren't able to get um anything in the middle. They didn't exactly plan on it, but they said, you know what, there's some really good bone up there, and I really want to immediately load this case, and that's what they do. Um, and uh, you know, I think a lot of times that that may not um have been discussed before you know the case uh was taken on, and maybe someone's gotten a zygo that was kind of a surprise zygo. Um, but uh generally that tends to be the knee-jerk reaction. Like if someone can't make something happen in zone two, you know, you need to be prepared to place that inferior or posterior zygo.

SPEAKER_00:

Yeah, 100%. And you know, we're we're kind of starting our zygo journeys now, and it's um, you know, from the people that are are have been doing this a lot, it's like they they say like the yeah, obviously it's a it's more reflection, blah blah blah, but compared to teracoid, right? Technique-wise, it's a little is a little more straightforward because you can visualize everything. That aside, you know, even if you could have this in your tool belt, you know, I I just question, you know, whenever I see cases like that, you know, you'll see the the classic post I see is you know, oh, didn't get enough torque on my posterior, but good thing I know how to post you know, pivot as I go. And I'm not I'm not here to try to, I don't know the situation every time, you know, but the way that the way that's brought up and the way that's written, you know, on on Instagram or whatever, um, just kind of irks me in a way. It because I'm like, well, did sure, I'm sure that's in the in the informed concept, you know, somewhere they patients have a piece of paper, like they're good. I told them that zygos were a possibility, right? But did the patient actually really understand that this is the last resort option? Does the patient really understand that um it's that's hard to pivot from a zygo, you know, if it's especially if it's a younger patient, you know. I always try, I just think of you know, if I had to send God forbid my mom to go get FB3 and she was an indicator for it. Um standard case, she just has soft bone, but she comes home with a zygo, you know. I personally would be pissed.

SPEAKER_02:

Yeah, you know, because I know that's you know you know what she just got into, yeah.

SPEAKER_00:

Right, exactly. And um, and so what's the difference between wearing a denture for three months and you know just letting things heal, and then you uncover and then and then there you go. The way I explained to my pa, and this is um, this I know this is a bit of a tangent, but this is another kind of like thing that I'm really you know uh all all another umbrella being optimally evasive, right? It's it's how do are we giving our patients true informed consent? You know, where where I really saw this um um illustrated to me is actually one of my own experiences. You know, I had thyroid cancer, uh luckily it's the one of the best ones to get papillary thyroid carcinoma. Thank God it was that one, you know. Um but in 2022 I had to get it shocked out, and um I had a uh general surgeon that was specialized in endocrinology um do the procedure for me. And uh during the consult, he discussed, you know, hey, you know, Sean, like he's a he's a you know, nice, nice southern dude, like spoke real slow like this, but he was very thorough. And um, and he was like, you know, Sean, like I I know you're nerd about this stuff. I know you've read about this already, like because we had talked, you know, before. And um he's like, you know, you there there's a good chance that it, you know, when we're in there and there's tumor on the um the uh internal and recurrent laryngeal nerves, um, that I'm gonna cause some damage to it. Now it's gonna be paresthesia, you know, unless I cut it completely. Like um, but we have two choices here, you know. One, I go in there, I try to get it as much as I can off, you know, surgically. That will increase the chance of paresthesia and or even you know possibly anesthesia, right? Or two, I leave a comfortable amount of that tumor on these nerves, and we can try to get the rest of it with you know, chemo, with radiation, with or whatever. How would you like me to proceed in that situation? And I was like, Man, this is true consent. You know, like I was just like, Doctor Davis, thank you so much for like Yeah, I had read about it, but if it was the lay person, right, they wouldn't know. You know, and and man, what what what a great thing for a doctor to explain to their patient. Hey, what like you know, what would you rather go down? You know? Um, and so I chose the more conservative auction. And so applying that to how I give consent um for for borderline zygote cases, right? Like, let's just be very specific, is hey, uh, Ms. Jones, like you based on your scans, it looks like your bone density is really low. Like there's a good chance that I mean we have enough bone, luckily, for conventional implants, for just normal four implants. I pull up a picture, I show them they're this long, even put up to my face, it's this long. Um, if it's soft, like I said, it's just like a nail on the wall. If it sticks, then we can put a picture on it. If it doesn't stick, then we'll, you know, we can uh we have two choices. We can either one, uh, if you really, you know, one, we can wear a denture for three months, let it heal, and uncover you in three months, and you'll have a set of teeth that can attach to it just as long as it's healed. Or two, if you really, really, really care about having fixed teeth the same day and walking out with fixed teeth, we can do that option because I'm not placing zygos currently. What I'll say is if you really care about that option, I'll refer you to one of my colleagues that can place zygomatic implants. That is something they could pivot to during the surgery if that is something that is really valuable to you. How would you like to do that? Yeah, yeah.

SPEAKER_01:

That's good. That's it.

SPEAKER_00:

And two, it just does two things, right? One, it it really involves the patient in the decision process, right? We're not telling the patient to tell us how to do the surgery. Either I don't weren't, I'm not saying either one of these paths is right or wrong, but what does the patient value? You know, we're involving the patient, we're informing them correctly because they know what a zygo is. They show them, hey, look, conventional implant is this long, zygomatic implant is this long, zygomatic implant usually is you I like to save those for the end, you know. You know, if one of these shorter ones fails, that's what is likely going to happen, you know. Um, so once they explain all that, man, I haven't had a single patient yet tell me that they want a zygo. Yeah, yeah, that's that's impressive. Yeah, yeah.

SPEAKER_02:

And and I think it's it's a such a great example too, because like, you know, when you're talking about someone who's already been wearing a denture for some amount of time, the three more months is not a big deal. You know, if that if that if they have another option down the road, like they'll they'll probably just take the denture, you know. I mean, just to just to save themselves that option. Like they're not, they don't have to get teeth yesterday, you know. I think it's it's definitely different if, you know, let's say, you know, this is a person that still has all their teeth and they just got extreme perio, and the, you know, the bone is just mush and you take it all out, you try to get down a good clean bone, there's just nothing left, and now it's time for a zygo. Well, yeah, that's a patient that, you know, was trying to avoid having removable teeth, and they might, you know, say, you know, I I can't go out of here in gums. Like, do what you gotta do, give me some teeth the same day. And and you know what, no matter what happens, people can deal with the path that they chose no matter what that means. Like if they knew that that's what they were choosing to do, they're gonna be a lot nicer and a lot less likely to come after you for something if they were well informed and they chose that path and they knew what the rest were. Um I think that's extremely important.

SPEAKER_00:

Yeah, yeah, and in that situation, right? Like you they they were involved in the decision-making process. So if they chose, you know what, yeah, I would really like to get teeth, but I I also don't want to use my last resort option, you know. Like, then you know that the pressure's off you during the surgery. You're not gonna be doing crazy stuff on a 40-year-old, like place a you know, five millimeter diameter implant on it, you know, like that's also, in my opinion, not being as alchemy invasive, right? You know you're gonna have to revise that. I'd rather place the five millimeter diameter implant later on, you know. Um just put so much pressure, take so much pressure off you as a surgeon, too, right? You're like, all right, uh it's an optimal position. I'm normal, you know, 3.754 millimeter diameter implant, whatever is your workhorse. The patient said they're okay with the denture, sick. Let's move on, you know, denture for three months, graft everything else, you know, soft tissue, do all the things that we're gonna talk about to optimize them um for for your uncovery, and then there you go. You know? Yeah. They made a decision, they they're they're cool with it. Or if they really want, as I go, you get the training to places where you refer it, you know.

SPEAKER_02:

Right. Yeah. No, I I think it's great. I I actually had kind of a recent personal experience with something like this. So I I got it's probably like two years ago, um, I got consulted um for my nose. So like I have a deviated septum, it's like broken in different places, and there's not a lot of cartilage there. I can't breathe at all. Like my my you can hear me like sniffling all the time. And um, like my eyelid is completely closed when I try to breathe, especially when I'm working out and stuff, there's just no chance. And I got a consult about this a couple of years ago, and you know, the plastic surgeon that talked to me, um, it was very all or nothing, the the type of approach. It wasn't like, oh, we can just go in here and fix the deviated septum. It was like, no, no, we're gonna do anything, we have to do everything. We have to go in, we gotta take some cartilage from uh from your ear, we got to get some rib cartilage, we gotta go through, we gotta totally reconstruct your nose, we're gonna have to straighten it, do all this stuff. It's gonna be cosmetic, but it's also gonna be functional. It's gonna be great. And, you know, to me, like I kind of felt like a patient that was getting fit into an FP3 box that didn't need to be there. Like that that's literally how I felt. And uh and the cost was actually pretty similar to like a fixed floor. And I was like, yeah, I don't know. I don't know if I like this approach. Um, it maybe you're critical of my own approach. I was like, man, I really got to think about how I, you know, talk about these things. And then most recently, I think it was about you know a month ago, um, you know, I'm out in Washington now, so I gotta meet a new doctor or whatever. And the approach was totally different. You know, they're like, look, you're a young guy, your nose is fine. Owen Wilson made it just fine with his nose looking all fucked up. Like, don't worry about it, right? And he was like, look, we're wow. Like we're he's like, look, this is what we're gonna do. And like it was a much more conservative procedure. And he was like, Look, worst thing that's gonna happen is nothing, right? Like the worst thing that's gonna happen is no improvement at all. And then, you know, we can talk rhinoplasty or whatever. Um, but I won't be the one doing it because I just think that's irresponsible. I don't, I don't think you got a long life to live, and there's a lot of things that can happen. There's a lot of morbidity associated with that. And you know what? Like, I don't at this point, I don't even know what he's gonna try to do, even cost. I don't care. Like I I'm gonna go with this person because he talked me through the entire thing, gave me actual options, yeah, you know, and told me all these different paths and allowed me to choose it. You know, and I I think that that's that's what being a real doctor is about, um, and not just being a full art salesman that can play screws. Um, there's a big difference there. And I think the the doctor is the one that gets to do this a lot longer, gets to have, you know, a wealth of cases under their belt that ends up being really good at this because, you know, they practice with integrity and they and they, like you said, they act like a doctor. Um, so I think that's really important. I think engaging with your patients and treating them like people and treating them like, you know, um, like treating them like something could go wrong, and they need to know that, right? Like that's important. Now, now, granted, do I tell every patient that, you know, if things go wrong, we might place a zygote and they might end up with a hole in their face? You know, there's a more gentle way uh of of of doing that. You know, you definitely don't want to scare people. These are people that have been finding reasons not to get something done for decades, right? They've been kicking this can down the road. So it's obviously a balance. The way that you talk about these things is important. Um, but most people will gravitate towards a well-informed uh or rather a well-informed surgeon that also makes them well-informed. And and that's extremely important. Um, and yeah, you can you can have all these different consents that talk about this and that. Um, but like you said, like people don't really know what they're getting into. I mean, people I know people don't read my post op instructions because they ask me the questions that are right there in that paper all the time. So, like, why you know they're of course they're not reading their consents. Of course not. You know, they get them done in like five minutes. There's no way. I don't care who you're not reading that. Nope. Um, but yeah, all great points. I think you know, this all comes back to the expectations that we set and you know, learning how to you know communicate our treatment plans effectively and and also making sure that your team is well calibrated and understands those things as just trying to sell arches. Um you know, it's really important and you know, these things matter a lot. And I think that you know, one of the most uh insidious things about full arch is that you know there you can be very successful ignoring all of these things you know for a while, right? Like you can you can do these cases, you can drill four holes, you know, put some screws in there, attach some teeth, and like patients will love you for like a little while. Um, but it's not long before you know reckless decision making, you know, comes back around and and and shows you uh what that really does. And um, you know, it makes you question like, did I really know what I got myself into? You know?

SPEAKER_01:

Right.

SPEAKER_02:

Um and uh yeah, that's that's the seductive thing about full arts is it's very rewarding. Just what you can do in one day is extremely rewarding for everybody. Um, but it's it's on that follow-up that really you know defines you know whether or not the right choices were made. And uh, you know, it's just not fun getting in hot water. And in inevitably, if you want to be a volume full arch person, like you need to know case selection, you need to know how to talk to your patients and and set the right expectations. So I I think your points you know land really well with me.

SPEAKER_00:

Yeah, 100%. And um, you know, kind of kind of just kind of moving toward the next point of like getting kid getting to regenerative dentistry, like, hey, like um, and being optimally invasive, you know, setting patients up for success for long, you know, long the future is uh one of the things actually that I was scrolling through uh uh on my case study is like, hey, like I need to start tracking um you know the time at which patients need their first soft tissue revision or something additional, right? Is that something I haven't read and if and again there's so much literature out there if any listeners have heard of a paper that has looked at this, but like the average time that it, you know, from from initial surgery uh for full arch till when they you know they need some soft tissue revision, I would love to see and read. But that's something that I'm looking at tracking too, is like, hey, like it it I mean the theory is yes, you know, short answer, yes, it's absolutely worth it to spend the time to to do these things, especially if you already have you know, you know, this these things at your disposal, you know, you're not having to um uh you go overboard and and you know uh try to graph uh yeah, you know, uh being overly uh invasive for that.

SPEAKER_01:

Yeah.

SPEAKER_00:

But within reason, you know, uh what are things I can do easily? Yes, it'll take more time on the day of surgery, but it'll set them up for a longer amount of time.

SPEAKER_02:

Yeah, and it and it sets you up to not have as many revisions, right? Like that's another thing is like if you spend half your time doing your own revisions, like you'll burn out pretty darn quickly. Like it is so important to manage your revision rate um and do things right the first time because things are gonna go wrong whether you do it right or not, um, but they're gonna go wrong a lot more often if you don't do it right. So um that's a great point. So yeah, let's let's talk more, you know, re regenerative dentistry. Let's talk about um just kind of some basics. So let's say, you know, um let's say I'm a dentist that doesn't, you know, has been doing some full arts, I've done some all in four here and there. Um, but I've really been kind of irrespective of soft tissue. I've read zero zero boneless concepts, I know that carrot nice is important, um, but I don't know a whole lot about um, you know, what I really need to do to make sure that my implants are going to be protected. Um and I don't know anything about hard tissue. So like where do I kind of start? What are some like starter things that I should start practicing here and there um to kind of warm myself into that you know augmentation world?

SPEAKER_00:

Yeah, absolutely. And um I'll be uh if I can plug something here. But no, it really uh yeah, I wrote this article actually just um it's the the whole point of the article is just learning, it's talking about the you know high yield skills to have in in dental implantology that has nothing to do with just slinging the titanium, right? And so I wrote this article about a year ago, I think. Um shout out Steve Wolverholt for connecting me to the editor for Implant Practice US, uh, for giving me this opportunity. Um, but yeah, I essentially wrote this article for a younger me who was like, man, like what all do I need to learn to be not just good but excellent at um at dental implantology? Um and it just outlines all these high-yield skills that we can um have, and we can share the link you know in the show notes where it's gonna be but essentially, yeah, it just talks, you know, it it talks about heart tissue augmentation, and we'll talk about the varying levels of augmentation, uh the fundamental surgical skills that are associated with that. So periosteal release, uh buccalingual flat advancement. I think the the more the more I've learned about heart tissue, the more I've learned that it's actually a soft tissue gain. Uh that it and I don't mean just FPG and CTG, but it's learning how to how to mobilize and and and um and and manipulate uh the mucosa, uh the gingiva, and all that. Um yeah, fundamental suturing and membrane stabilization skills. Um then you have soft tissue augmentation, I think is another huge uh area that um that can give you a high yield uh area for success. Um just starting with the humble FGG, you know, and the different types of FGGs that harvest methods. Um FGG with aplicate position flap. Um you have connective tissue graft and the different ways that you can harvest that. Um and then you have your pedicle flaps, like your paddle pedicle or your um even on the mandible, anything that's connected that stays connected, you know, lateral rotated, pedicle fat graft, um, all the way up to your buckle fat back. Right. Yeah. Kind of like the last kind of big area is just learning, um, especially with all in four. We're working uh surfing the sinus all the time, be really close to that. Even taking out teeth close to the sinus, you know, being comfortable in the sinus. Um not just for the sake of doing a lateral sinus window, you know, a lateral sinus graph, but being able to do one to say retrieve an implant, um, or to, you know, uh say you have some pathology in there, um, doing trans sinus, like just being comfortable in in that area which many dentists are you know very uncomfortable in, you know. Yeah, those are the areas that I was like, man, like these I really need to get good at, and that will take me, you know, not all the way, but man, it'll boost me really, really quick, exponentially. Yeah.

SPEAKER_02:

Yeah. Yeah, I I definitely think it's important to uh just know how to do a call well luke, right? Because like the sinus is uh is an abyss of uncertainty for a while. Um and uh I I think most people they they learn it because they they have to do it uh you know in the moment. It's not something you can exactly practice, but um, you know, you have to get familiar with the sinus. Like you're gonna drop stuff in there, it's gonna happen, teeth are gonna go in there. Um so I definitely think that's important. Um, so yeah, uh talk to me about um, you know, okay, I'm I I'm I'm going into my case. I just listened to you know the Sean Lynn episode on the Pix podcast, and I want to try um an FTG. What's a good harvest site? Um, you know, maybe I'm I'm looking at my number 23 implant and it's got a thin band of carotenoid tissue. Um, what should I do about this before I close?

SPEAKER_00:

Yeah, uh so um essentially, so it also depends too, right? If you're doing this surgery, um uh if you're placing implants, um we call that stage uh stage one surgery. Like I would um you know have your full full thickness flaps already opened, you've done your LM4. Um I would prefer using a CTG in the in that case. Um yes, you can use FGG secured to the bone. I mean that's fine. And and and honestly, this all has to do with how thick your your donor side can be. If you have enough thick, thick enough tissue, um, I prefer to just take a um that's that's connected tissue graph. Say if you have four millimeters total of palette, you can take a two mil two millimeter thick CTG and still have um you know at least 1.5 millimeters of palette so it doesn't just necros. Um and for that, since you have the full thickness palette open, I would just take um you know the the more uh the deep half of it versus the super thick half. Take that out, and we'll talk about the difference between that too. Um where the nuance will be in the article as well. But um but yeah, this very simple, you know, you're trimming the palette anyway, likely if it's a thick palette, um, to you know, for the reasons that we discussed before, and you just tack it to the buckler lingual. Um walk me through that, like the uh yeah, I just need like it. It really is just it is the easiest time, it's the easiest way to do it. You don't have to do any kind of fancy tunnels, you don't have to do anything, any fancy like anything. It's just a simple interotid suture, essentially, um it where you you bite um the the uh uh flap. So I preferred I prefer or I prioritize the lingual flap because it's harder for me to go back and do a lingual uh aplically positioned flap um um versus on the buckle. So now um I actually prefer if I only have enough to graph you know one side, I prefer the lingual side to be honest, and I cheat more of the uh carodine issue, and uh sometimes I'll even um cut all of it and just give it to the lingual, you know, because on the bucky, I I I'm confident that I can fix it later on, you know. I'd much not rather I'd much it's easier to work when you don't have a huge lingual artery, you know, running to the ridge, right? So, um, anyways, you essentially just take your flat and you you you you purchase it with your needle, and then the next purchase will be your connective tissue. You loop it around, and then you go connective tissue out the flat, then you tie it. It's a simple, simple interruption knot. And depending on the length of it, you just do, you know, obviously you don't want to tie it too tight, you know, because you don't want to squeeze the living hell out of it. Um you want to secure it so that it doesn't really move. I like to secure it at least like a millimeter away from the flat margin because you want to leave some um uh some room for you to actually get you know prior uh closure around and not bunch up. And sometimes you if you're especially if you're suturing around an abutment, you actually want to go a little bit further away um from the flat margin because what you don't want to do is have that CTG just bunch up around the, you know, I use my cup here, but bunch up around the the verse around this. Yeah, there's no blood to that. Yeah, you you probably have enough from the overlying flat, but you know, you want to kind of you know optimize the situation, right? Um another way you can do it, right, is just like that poncher technique that um that Dr. Toe showed at Orca. Um, you know, calmor technique, you know, poncher technique, you know. Um you just kind of cut a hole into the CTG depending on how wide it is, right? And for me to make that decision is just how wide of a graph that can get, right? We have long, we have wide. If you can get a really wide one to uh to or uh wide enough, adequately wide, uh connected tissue graph to do that technique, then yeah, do a poncho, you know.

SPEAKER_02:

Yeah, um maybe I misspoke earlier. So when she did that um technique, I I said it was an FTG that she had just taken, you know, everything, the epithelium and the connector tissue, and then done the poncho. Was that was that actually a CTG? Did I misspeak on them?

SPEAKER_00:

I can't remember exactly what she did, but technically you can do either or. You can do your or yeah, and actually that's what the calamari technique is. Is you're taking uh it's actually a um I saw this from Dr. Springer. Um if you guys don't follow me, he follow him, he does great work. Him and Dr. Groger. Um, but uh there's a specific ring punch, like tissue punch that you can use. It essentially cuts like a O-ring, like what the call, the piece of calamari from the across the region, usually, and then you can just put it around your butt and you secure it that way. Um usually like for full arch, right? We're talking full arch application. Um at the time of surgery, the most straightforward thing for me for me to do in that um um situation is just good all CTG, you know. Yeah.

SPEAKER_02:

Okay, cool. Yeah, that's fantastic. And and you, I mean, you're gonna harvest that from tuberosity, from palatal tissue, wherever it's gonna be, and you're gonna get a decent amount of thickness. Is there is there a general rule about the width versus the length of that um harvested uh CTG as far as like um you know, if you're gonna go this long and you have to go this wide to have proper vascularity? Is there any rule that people need to kind of keep in mind there or no?

SPEAKER_00:

Um no, that's that's a really good question because yeah, you do have to keep that in mind for pedicled flaps. Um you're trying to maintain the yeah, okay.

SPEAKER_02:

That makes sense. Exactly.

SPEAKER_00:

Um and there's a rule for that. Um I'll I'll give the reader some homework. He can't just give out all the answers, right? Of course. Roll it that up and uh email uh email me the answers. Um but yeah, no, there is there is um um a requirement for to maintain blood supply, right? It's it's the joke in surgery, right? Like the answer is always well blood supply. Right? Yeah, it's a very important thing, right? Um, but for non-pedic uh non-pedical collapse, it doesn't matter. Yeah. Okay. You just want to make sure that it's thick enough uh and wide enough, um, you know, uh taking into account some kind of um contraction and and knowing that you it will shrink a little bit, um, especially with FGGs. Um and there's a whole nuance into that too. I don't think it's we have enough time to discuss that, but just know that you know we have to take a little bit larger, just overgraft it a little bit, right? Okay, um yeah, but there's no requirement as far as blood supply goes.