damon_1_02-17-2026_183430 0:47

So here's, here's, here's a great case. Um, you know, actually my associate, uh, sent me this picture and he was like, Hey. I need some help, right? He's like, this patient can only afford to do the upper and, and, and, and really, you know, his lower teeth aren't that bad.

ty_1_02-17-2026_163430 1:07

Yeah.

damon_1_02-17-2026_183430 1:07

always, we always do need to remember that sometimes we, we, the patient needs to be a by jaw. Um, you know, also don't forget about orthognathic surgery. We can definitely, you know, always do that as well. how do you do orthognathic surgery when the patient only has like five teeth, right? So, so just'cause you can, doesn't mean that you could, or, or, or just, or just'cause there's a treatment option out doesn't mean that it's, it's it's practical or available. So, uh, you know, geez, I mean, you know, how, how do you, how do you manage this? Right? Um, so let's go to the next slide. So, you know, here we can tell we've got the full facial profile view and we have the side facial profile view. And, and, and we can really tell his maxilla is super deficient. Really, really collapsed, right? Um, so, you know, okay, well, you know, how do we do this? We, we need to be looking at emergence profile. Are we gonna just mow down a bunch of bone to then, you know, kind of get that gap. But then how do you deal with, you know, is it gonna create a big diving board? Is it, is it gonna protrude the lip too much? And

ty_1_02-17-2026_163430 2:31

and so,

damon_1_02-17-2026_183430 2:32

one of the easier ways to gain restorative space is open up the bite,

ty_1_02-17-2026_163430 2:36

Yeah. And that's, that's gonna decrease that class three, um, characteristic as well as you do that.

damon_1_02-17-2026_183430 2:42

Totally. Yep. So let's, let's look at the next slide here. And so that's what I did. I said, okay, well, let's, you know, let's, all it takes is a little bit of flowable composite.

ty_1_02-17-2026_163430 2:55

Yeah.

damon_1_02-17-2026_183430 2:55

generally for most patients, when you wanna open'em up, long as they're not class three, you can just put it on the mandibular central incisors

ty_1_02-17-2026_163430 3:05

Yeah.

damon_1_02-17-2026_183430 3:05

cure it. Add, have'em close down, look at, look at it, add some more, you know, open'em up to where, you know, they, they feel good. generally I'll ask'em, how does, how does your jaw feel? How do your muscles feel? And, you know, when these patients are actually over closed, they'll wind up telling you, Hey, my jaw actually feels better. My, my muscles actually feel better.

ty_1_02-17-2026_163430 3:29

Hmm.

damon_1_02-17-2026_183430 3:31

Other avenues that you can do, you can use a leaf gauge to do this. I don't recommend that because how then do you evaluate the patient's facial profile? You

ty_1_02-17-2026_163430 3:41

Yeah,

damon_1_02-17-2026_183430 3:41

it's very hard to evaluate that with this big piece of plastic sticking outta their mouth.

ty_1_02-17-2026_163430 3:46

you bet. Yeah.

damon_1_02-17-2026_183430 3:47

So on, on this particular guy's gentleman's case, he had very few teeth to actually occlude on, I had to kind of put it back on his molar, uh, bo molars bilaterally to, to kind of open him up. Let's go to the next slide and then we'll probably come back. Oh, no, we didn't get the, uh,

ty_1_02-17-2026_163430 4:07

Yeah, I didn't,

damon_1_02-17-2026_183430 4:08

we missing some photos, but let's, let's go, let's go back. as, as we evaluate the patient, we're, we're then gonna look at their overall facial profile. And so this particular patient actually wound up looking, his facial profile looked better once we opened him up. And so, you know, he looked at himself in the mirror and said, yes, I really like that, you know, now, now my lower third of the face is matching the middle and the upper third. Uh, and he was, he was very happy. on on cases. On cases like that, you know, I, I know a lot of people like to just do all digital. I really think that for skeletal. Malocclusions, it is really nice to have a physical model and, and for you to mount that on an articulator and evaluate it that way, you know, you can, you can look at it in your hand and then if you want to go ahead and scan, you could scan the articulator. You know, I, I would take an intraoral scan of the patient, you know, just as he is. And then you could, you could, you could scan the, the stone models,

ty_1_02-17-2026_163430 5:27

yeah.

damon_1_02-17-2026_183430 5:28

there's, you, you, you can't do things a hundred percent digital and you can't do things a hundred percent analog. It's always gotta be a good, a good blend. And you, you need to be able to know when to kind of pivot to those. think, I think that these really big skeletal classifications, uh, or skeletal mal occlusions, articulate it, get the stone, get the stone models in your hand. You are gonna then know where to tell your lab colleagues to set the teeth. And so, you know, ob obviously here really kind of jumping that, jumping that bite and getting, getting those teeth into a normal class one occlusion is not really gonna be that difficult. You know, uh, his lip, his maxillary lip and his maxilla is already deficient. So we know he, we need to add anyways. So here, if, if we literally add. Two millimeters, uh, buckle to this guy's, uh, face and lip. It's, it's gonna look outstanding. And then that's

ty_1_02-17-2026_163430 6:31

Yeah,

damon_1_02-17-2026_183430 6:31

us back into a, a normal class one occlusion.

ty_1_02-17-2026_163430 6:35

yeah,

damon_1_02-17-2026_183430 6:36

So

ty_1_02-17-2026_163430 6:36

yeah. I,

damon_1_02-17-2026_183430 6:37

really good learning there.

ty_1_02-17-2026_163430 6:39

yeah, I'm, I'm impressed because at the, with just that initial photo, I would be convinced that you were gonna be turning this into a, a, a bi jaw surgery to, to help jump that gap.'cause it's, it is quite efficiency.

damon_1_02-17-2026_183430 6:51

Yeah. And so, you know, if, if you didn't open, open the patient up, you know, um, a I I think you're, you're putting a, you're putting a young guy in, you know, teeth are always better. Like, that's,

ty_1_02-17-2026_163430 7:07

You bet. Yeah.

damon_1_02-17-2026_183430 7:08

what everybody really needs to, to know is that, you know, teeth are always better than implants. And so at least we give'em a fighting chance, you know, on the lower to kind of keep those teeth, you know, longer, longer term. If, if you look really closely, I would, I, I definitely told this patient, Hey, I want you to plan for, we need to raise the posterior occlusion on your, on your right side. So plan for crowns on 28, 29, and 30. Uh, and then, you know, maybe we'll kinda level out, uh, you know, kind of that 23 and kind of 22 area.

ty_1_02-17-2026_163430 7:46

Yeah,

damon_1_02-17-2026_183430 7:46

but once, once we actually open'em up, it. It doesn't look, the, the lower occlusion doesn't look as canted.

ty_1_02-17-2026_163430 7:54

yeah. Which is odd. Yeah,

damon_1_02-17-2026_183430 7:56

So, lot, lot, lot of fun. I mean, these are so many things that I learned how to do, just doing analog, pre-prosthetic planning with a

ty_1_02-17-2026_163430 8:08

right?

damon_1_02-17-2026_183430 8:09

right? know,

ty_1_02-17-2026_163430 8:11

Yeah. Yeah.

damon_1_02-17-2026_183430 8:11

you know, let's, let's do a wax rim. Let's kind of play around with opening the bite. And you can, you can achieve the same thing with just some flowable composite.

ty_1_02-17-2026_163430 8:20

Yeah. That's awesome. Very cool.

damon_1_02-17-2026_183430 8:26

So here's, here's a, here's another fun case that, that presented to, uh, our, our clinic here. you know, just so many, so many things. I mean, I mean, Tyler, I've, I've talked for a while here. Why don't, uh, why don't, uh, you kind of us

ty_1_02-17-2026_163430 8:43

Yeah. Um, Yeah, it seems like the, uh, they skipped a step. Um, so we got a whole lot of maxillary bone. We almost have the distal aspect of the tuberosity, occluding on the retromolar pad. Um, so just a whole lot of excess bone there. Um, you got an implant That's right. Abutted up against the, uh, terminal tooth that was left for, you know, whatever reason. Um, not much of an, a serviceable occlusion on the lower, and this might be a, just a factor of the reconstruction of the pano, but there's not a whole lot to work against. Um, with the lower either. Um, definitely could have gotten a much better spread. I mean, there was a, uh, just a mile of bone distal to your tilted implants. Um, you know, and we're obviously missing OIDs. I know, we're in the same camp on that. So, um, there's probably a whole lot more going on outside the radiograph, but I, I see enough to, to warrant a revision.

damon_1_02-17-2026_183430 9:30

you know, you know this, this, this would be a case that may not even actually need OIDs. You could probably give this patient

ty_1_02-17-2026_163430 9:37

That's true.

damon_1_02-17-2026_183430 9:39

six implants. I mean, that

ty_1_02-17-2026_163430 9:41

Yeah.

damon_1_02-17-2026_183430 9:42

that maxillary sinus. You could, you could get after you, after you do an adequate alveolectomy, you could wind up with a posterior tilted implant in the second molar position.

ty_1_02-17-2026_163430 9:57

Yeah.

damon_1_02-17-2026_183430 9:58

You know?

ty_1_02-17-2026_163430 9:58

Oh yeah.

damon_1_02-17-2026_183430 9:58

then, I mean, this, this, this is, this is, this is one of those random cases. We don't ever see these, right? Uh, you know, if, if, if that, if that was in, in the office, you go all the way back to the second molar, and then, then I, I'd, I'd probably put an implant in the canine

ty_1_02-17-2026_163430 10:20

Mm-hmm.

damon_1_02-17-2026_183430 10:21

then I'd put it, I'd put an

ty_1_02-17-2026_163430 10:22

Yeah.

damon_1_02-17-2026_183430 10:23

in kind of that, you know, LA lateral position.

ty_1_02-17-2026_163430 10:26

Yeah. I still think a six implant configuration would be really nice. But you're right. You, you, you're not, probably not gonna need a OID here, depending on the smile line, of course. But, um, but just where that anterior sinus border is, it's very distal. Um, so yeah, you should be able to get away, uh, with getting your, your, uh, tilted in the second molar. That's great. Yeah.

damon_1_02-17-2026_183430 10:43

But you, you know what generally happens is when, when you think you can do a second molar implant tilted, you can't because the bone is just terrible.

ty_1_02-17-2026_163430 10:55

Oh, it's, yeah.

damon_1_02-17-2026_183430 10:56

even, even,

ty_1_02-17-2026_163430 10:57

D four.

damon_1_02-17-2026_183430 10:57

even, if you get to the, you know, la lateral, nasal wall, it's, you a you know, you may not even get there, but just generally that bone is, is just gonna be pretty awful.

ty_1_02-17-2026_163430 11:11

Yeah.

damon_1_02-17-2026_183430 11:11

you know, oft oftentimes I would never plan or hope for that, you know,'cause,'cause generally it's just gonna be mush. It's gonna be yellow, yellow bone.

ty_1_02-17-2026_163430 11:22

Yeah, yeah, yeah. Fatty.

damon_1_02-17-2026_183430 11:24

All right, so I think the next slide, what do we have on the next slide here? Next slide is, is basically how I would've approached the case. You

ty_1_02-17-2026_163430 11:33

Mm-hmm.

damon_1_02-17-2026_183430 11:33

mean, from a general over, you know, gen, you know, whatever, getting, getting the al, getting the alveo, getting, getting the restorative

ty_1_02-17-2026_163430 11:43

Yeah. Yeah. Absolutely.

damon_1_02-17-2026_183430 11:46

you know, take, taking out that terminal tooth, you know, like this. They need a, they need at least a lower flipper. You know, like, let's, let's, let's give, let's give them, you know, some type of a balanced occlusion,

ty_1_02-17-2026_163430 12:00

Right.

damon_1_02-17-2026_183430 12:01

you know, I mean, you know, I, I, I still will do, you know, some analog surgeries and if I'm gonna do an analog surgery, I want a nice flipper made to the new upper teeth so that I can really lock in that bite.

ty_1_02-17-2026_163430 12:14

Yeah.

damon_1_02-17-2026_183430 12:21

Yeah. You know, so, so here we go. You know, this is, uh, this is just a, this is just a absolute shit show. I mean, I think, I think on the Implant Institute, uh, you know, I said that, you know, this is what happens when you force a to be a standard.

ty_1_02-17-2026_163430 12:43

Yeah.

damon_1_02-17-2026_183430 12:44

And this is, this is truly a Patsy case. You know, if you look at that, you know, sub antral posterior bone, it's like three to four millimeters until you get to the sinus.

ty_1_02-17-2026_163430 12:57

Right.

damon_1_02-17-2026_183430 12:57

that, that should have been as zygomatic. We should have had, you know, a OIDs bilaterally. and, you know, we didn't need to penetrate the maxillary sinus like that.

ty_1_02-17-2026_163430 13:10

Do you think that. there was an attempt here at a, at a trans sinus implant?

damon_1_02-17-2026_183430 13:15

Well, you know, they're

ty_1_02-17-2026_163430 13:16

Am I giving it too much credit? Yeah. Yeah. I might be giving it a little bit too much credit. Yeah. It, it's almost, it's almost axial just going into three millimeters of, uh, a Crystals bone. And then you probably got a good, you know, 12 to 15 just hanging out here. It's a pretty long implant. To their credit, they thought that was

damon_1_02-17-2026_183430 13:31

may, maybe, maybe they were aiming for the middle atu.

ty_1_02-17-2026_163430 13:35

Yeah, yeah, yeah. Maybe, maybe, maybe it just didn't quite get there.

damon_1_02-17-2026_183430 13:39

there. There's, there's not much bone there.

ty_1_02-17-2026_163430 13:42

No, no, no, there's not.

damon_1_02-17-2026_183430 13:44

You know, people are crazy. You know, I, and

ty_1_02-17-2026_163430 13:47

Yeah.

damon_1_02-17-2026_183430 13:47

don't know why. Again, it's just seeing if, if you can only, this is why you have to do more courses. This is why you have to have a tribe. You know, like what is, what is truly amazing is if you live in Texas or Oklahoma, you can have me come into your office. I can come in and I can do advanced cases for you.

ty_1_02-17-2026_163430 14:09

Yeah.

damon_1_02-17-2026_183430 14:10

Dan Holtzclaw can, there's, there's multiple people that you can reach out to.

ty_1_02-17-2026_163430 14:15

Mm-hmm.

damon_1_02-17-2026_183430 14:16

but if, here's the deal, if you try to be too greedy if, if you try to keep the case yourself, you know, it's like, I, I don't wanna say the M word, but I mean this, this is less than ideal. I mean, it's

ty_1_02-17-2026_163430 14:35

Yeah.

damon_1_02-17-2026_183430 14:36

the standard of care. If you go into the next slide, I think that, you know, we can, we can see the, Implant is nine millimeters into the maxillary sinus

ty_1_02-17-2026_163430 14:48

Yeah.

damon_1_02-17-2026_183430 14:49

and the, and the, the, the middle one is seven millimeters into the maxillary sinus. You know,

ty_1_02-17-2026_163430 14:55

I

damon_1_02-17-2026_183430 14:55

luck, luck, luckily enough for this patient. The implant's stable and he doesn't have, there's not any sinus pathology there. So, you know, kind of, kind of dodged a bullet. You know, one, one thing. If you look at the lower pano there or the, the lower implants, do you see how buckle those are? You know, it's really kind of putting quite a bit of pressure on that anterior buckle bone on that, on that mandible.

ty_1_02-17-2026_163430 15:22

yeah, and it looked, it actually looked a little bit, uh, curious, right, right through here on the panel as well. Be curious about how that Uncle Bun's doing.

damon_1_02-17-2026_183430 15:29

don't, I don't, I don't know where that cross section was taken. I guess it would've been on that, on that particular implant. Yeah. It, it does look like that is a ailing mandibular implant. But, you know, just take people up, you know, if you don't wanna refer out the case, refer in, refer in,

ty_1_02-17-2026_163430 15:47

bring

damon_1_02-17-2026_183430 15:48

a provider, you know, I mean, I'll, I'll come, you know, I think I charge five grand an arch. You know, I can, I can come into somebody's office. You get to, you get to keep the production, you know, let's just get an anesthesiologist and then you can sit there and learn. You can sit there and learn. Okay, well this is how, you know Patsy's. Patsy's done.

ty_1_02-17-2026_163430 16:10

Right. And, and I think there's, there's a lot of people that, you know, if they just had the guidance of, you need to go here instead of here, they'd be able to accomplish the case. You know, it's just about having that sort of guiding person over your should say, Hey, let's do this instead of that. And, and you might be able to pull up the case in, in a beautiful fashion. Just if you, you know, go through that extra step at just bringing somebody into the office and then, you know, you can still make money on it, still make profit, and you've made an education course outta the case. It, it's a very doable thing.

damon_1_02-17-2026_183430 16:36

Yeah, you get, you get, you get

ty_1_02-17-2026_163430 16:38

excuse.

damon_1_02-17-2026_183430 16:38

you get free education that way.

ty_1_02-17-2026_163430 16:40

Yeah. Your patient almost pays for it in a way. You know, you, oh, yeah,

damon_1_02-17-2026_183430 16:48

So, so this, this case definitely rocked to a lot of people in the Texas Implant Institute chat.

ty_1_02-17-2026_163430 16:55

yeah, yeah. For sure. I can see why.

damon_1_02-17-2026_183430 16:58

you know, uh, you know, there's, there's a lot of talk about FP one right now. Um, I don't see Juan doing FP one. I don't, I don't see, you know, Dan Squa doing FP one. I don't see David Zelig doing FP one. Right. Uh, so, know, and you know, I'm in some other chats with some amazing worldwide clinicians and I said, Hey, can somebody give me some articles on the success rate of FP one? And it was total crickets.

ty_1_02-17-2026_163430 17:37

Yeah.

damon_1_02-17-2026_183430 17:38

There's not really very good long-term studies. So, you know, uh, you know, when I first saw this patient, I was like, does this guy really need a fixed arch? Like, do we really need to do this? Why don't we just give this guy some veneers or something? Right? Uh, but when you really get into it, I mean, he's got interproximal decay, cervical decay everywhere, and just his gums are inflamed. And so you just go down this triad of like, okay, well, you know, buddy, do you want, do you want trying to maintain these teeth and, and do you, do you want$60,000 worth of, of crown and bridge that you may or may not be able to take care of? And he was just like, not. I, I, I can't see myself doing that. And so, you know, I think this particular patient was 35, and I tell all of my patients who are really kind of under like 55 how long do you think this will last? And you know, what's really surprising is, is most of them are like, Hey, if I can get, if I can get 15 years out of this, I'll be super happy right now. I'm not, I'm not, I'm not about here to say that I want my cases to only last 15. Right. I, I would be very upset if my 3,200 arches only last 15 years, right? Like I am, I am into the. Uh, golly, how many years have been doing this? 15 years, you know, so I, I am seeing my cases from 15 years ago and they are still looking really, really good. Uh, where I have a problem with FP one is if you look at the older articles talking about what is the difference between alveolar bone and basal bone? Tyler, do you, do you know the difference?

ty_1_02-17-2026_163430 19:33

Alveolar bone and basal bone,

damon_1_02-17-2026_183430 19:35

Yeah.

ty_1_02-17-2026_163430 19:36

basal bone's harder. I get more torque out of that. I don't know. Something like that.

damon_1_02-17-2026_183430 19:41

Well, so it's actually embryological,

ty_1_02-17-2026_163430 19:45

Hmm. Okay.

damon_1_02-17-2026_183430 19:46

so so, alveolar bone is actually formed with the tooth. Basal bone is not formed with the tooth.

ty_1_02-17-2026_163430 19:55

Okay.

damon_1_02-17-2026_183430 19:56

So when the tooth is pulled, what goes away? Alveolar bone.

ty_1_02-17-2026_163430 20:02

bone. Yeah. Naturally. Yeah.

damon_1_02-17-2026_183430 20:04

so I learned a long time ago, you know, seeing cases, seeing fixed cases with just, just present to clinic. And I'm like, Hey, I can already see We didn't even do surgery just through the mucosa. We've got five millimeters of thread exposure. Right? Like, how did that happen? You know, there was no, they weren't in a denture. They weren't in a denture that rubbed against it. were in a locked in fixed. Fixed prosthesis. But you know, when you begin to start looking and you're like, and you look at the height at where the fixtures were placed, they were all placed basically, you know, maybe, maybe two to three millimeters below the crest the time of tooth extraction. And, uh, no, or very little alveolar bone was ever reduced.

ty_1_02-17-2026_163430 20:56

Right.

damon_1_02-17-2026_183430 20:58

so that's, that's where I have a big problem with FFP one. Uh, where I don't have a problem with it is if you socket shield where every single one of your implants are, and if you root bank every tooth, okay?

ty_1_02-17-2026_163430 21:13

Well,

damon_1_02-17-2026_183430 21:13

do, if you do that, I'll be perfectly happy. Why? if you keep

ty_1_02-17-2026_163430 21:18

there's something maintaining.

damon_1_02-17-2026_183430 21:20

if you keep the tooth, you keep the alveolar bone, right? So all that stays with the periodontal ligament and the tooth that all supports each other. So, um, so that's, that's, that's kind of, you know, my philosophy and, and, and, realistically, I think a lot of fp one cases could actually be veneer patients.

ty_1_02-17-2026_163430 21:44

Could be veneer patients. Yes. Yeah. I can see that. Yeah. They're fmr. Yeah. Yeah.

damon_1_02-17-2026_183430 21:50

um, so anyways, so, you know, we, uh. We gave this guy what he wanted. And that, and that's the other thing too, is you can't just judge, you can't just judge a doctor, you know, by the picture. You know, I mean, I mean, look at Michael apa,

ty_1_02-17-2026_163430 22:11

Yeah.

damon_1_02-17-2026_183430 22:12

if you were to, if you were to judge his cases that they do veneers on, you're like, golly, they had great teeth to start with, right? You know, like, like, like, like, you know, they, they didn't need to be prepped. They didn't, those teeth didn't even need to be touched. Right? They, so how is that any different?

ty_1_02-17-2026_163430 22:28

Mm-hmm.

damon_1_02-17-2026_183430 22:29

Right? Okay. Um, so just certain things to think about. It all comes down to what did you talk about with the patient? What were the patient's goals? What did they have in mind? Right? Um, so just, you know, you, you, you can't, you can't just sit there and, and, and criticize somebody, right? Like, I mean, veneers, you know, the orthodontist always tell the veneer docs like, Hey, you could have just done braces and kept their teeth all, all together and, and whatnot. I mean, I'd, I'd have a pretty hard time rolling around with braces again, at, at, you know, 42.

ty_1_02-17-2026_163430 23:03

Yeah.

damon_1_02-17-2026_183430 23:04

you know, I'd probably rather go down to smile Texas and, and get veneers. Um, but, uh, you know, so it's, it's, it's, it's, it's the same. It's the same thing, right? So we had a discussion with the patient, them their options. He's like, no, I'm done. Now this particular patient has so many red flags, right?

ty_1_02-17-2026_163430 23:24

Yeah.

damon_1_02-17-2026_183430 23:25

So Tyler, so what, what are, what are the red flags that you see on this, on this particular patient?

ty_1_02-17-2026_163430 23:30

Uh, well, glaring to me is a super, super high smile line that's above, uh, sinuses that are all the way pneumatized down. I mean, that's like, yeah, that's, that's right in front of my face. That's a really obvious one. Um, other than that, just, I mean, really, really poor OHI, I'm not, I don't really care too much about an open anterior bite if I'm, if I know I'm gonna do fp three or something like that. But, uh, I think, you know, having to deal with the science is the number one thing that I'd be concerned about. Um,'cause I know this is gonna have to be a crush or, or something like that in, in order to hide my prosthesis.

damon_1_02-17-2026_183430 24:00

Sure. But when a patient has a Mac, has a anterior open bite, you need to evaluate them for being, uh, over, uh, too far open.

ty_1_02-17-2026_163430 24:12

Oh, okay. Okay. Sure.

damon_1_02-17-2026_183430 24:13

so we need to, we need to evaluate the patient's overall facial profile. And so here he is way over opened.

ty_1_02-17-2026_163430 24:21

Mm-hmm.

damon_1_02-17-2026_183430 24:22

So, so we are, we are actually gonna close this patient down.

ty_1_02-17-2026_163430 24:26

Yeah.

damon_1_02-17-2026_183430 24:27

And that, that is gonna help with everything. So, but yeah, sinuses touching the canines red

ty_1_02-17-2026_163430 24:35

Yeah,

damon_1_02-17-2026_183430 24:36

it's only a red flag because, uh, you need to be able to execute on a trans sinus, The guy that's done 3,200 fixed arches, I have about a 70% success rate with. Trans sinus.

ty_1_02-17-2026_163430 24:51

yeah,

damon_1_02-17-2026_183430 24:51

30% of the time we're gonna need to do a, a zygomatic.

ty_1_02-17-2026_163430 24:56

yeah.

damon_1_02-17-2026_183430 24:56

So, um, you know, but, but yeah, this, this guy's sinus is below the reduction plane. we can see the muco gingival junction. So he has a high smile line, low sinus, anterior open bite, video, right? So he's got, he's got a bunch of factors that we have to, uh, uh, compete with.

ty_1_02-17-2026_163430 25:18

Yeah.

damon_1_02-17-2026_183430 25:19

So let's see what's on the next slide.

ty_1_02-17-2026_163430 25:22

Wow.

damon_1_02-17-2026_183430 25:24

Okay. So the, there, there he is. And, you know, I couldn't, I couldn't get him to smile more than that.

ty_1_02-17-2026_163430 25:30

Mm-hmm.

damon_1_02-17-2026_183430 25:31

look at that. Like, if, if you were to, if you were to preoperatively evaluate far the inci, the maxillary, incisal edge is from the lip, that's about 10, you know, maybe seven millimeters, right? And so now these, these are his surgery temps, right? These aren't, these aren't his finals. We're, we're actually in, currently in his final, uh, uh, making stage. And, and we do, we do a three step all digital final, uh, workflow.

ty_1_02-17-2026_163430 26:01

Yeah,

damon_1_02-17-2026_183430 26:01

him, I like to let him heal for three to four months.

ty_1_02-17-2026_163430 26:04

sure.

damon_1_02-17-2026_183430 26:05

tissue always changes. And, and, and, you know, you know, you know me. We are thinning the flaps. We're, we're

ty_1_02-17-2026_163430 26:10

Yeah.

damon_1_02-17-2026_183430 26:11

Everything we can. uh, I mean, he, he looks great,

ty_1_02-17-2026_163430 26:17

Yeah. It's a different person.

damon_1_02-17-2026_183430 26:19

let's see if, I gave you his pano.

ty_1_02-17-2026_163430 26:21

He even trimmed the beard a little bit. I appreciate.

damon_1_02-17-2026_183430 26:22

Yeah. Yeah. He's starting to look a little better. And, and there he is. Right. So look at that. So we readjusted his entire, uh, occlusal plane. We spent a long time scoring, scoring around his sinus and doing an entire sinus crush bilaterally. His sinuses are, are actually really nice, good, free and clear, and we were able to, uh, execute on his bilateral, trans sinus.

ty_1_02-17-2026_163430 26:58

Yeah, it's really nice. He's got this sort of, the way the sinus kicks back for you was conducive to being able to do that trans, it's really nice. Yeah.

damon_1_02-17-2026_183430 27:06

yes, yes, You know, I, I would not necessarily want to have to do a zygomatic implant on a sinus crush case.

ty_1_02-17-2026_163430 27:19

Yeah, I can see how that would be haring.

damon_1_02-17-2026_183430 27:21

That would be, that would be tough. So what, what I would, what I would prefer, would be may, know, let's, let's assume I wasn't able to nail the trans sinus, you know, maybe, maybe bring it from the kind of first premolar position bilaterally to the canine.

ty_1_02-17-2026_163430 27:39

Mm-hmm.

damon_1_02-17-2026_183430 27:40

of that heal. And I'd probably let it heal for a good year. And then I would roll back in and do, uh, zygotes bilaterally only af only after the, uh, alveoli and the basal bone is really kind of re reformed and fused.

ty_1_02-17-2026_163430 27:57

Hmm. I can see. Okay. Okay. That makes sense.

damon_1_02-17-2026_183430 28:00

So, you know, so, so the advantage to a sinus. Now your other option to do this case is you could preoperatively do bilateral sinus lifting

ty_1_02-17-2026_163430 28:12

Mm-hmm. Yeah, and, and then, you can mow it down to where you need it.

damon_1_02-17-2026_183430 28:16

and then, then, then you can mow it down to where you need it.

ty_1_02-17-2026_163430 28:19

Okay. And why did you opt for the Sinus Crush and Set? Just because it's a Single stage,

damon_1_02-17-2026_183430 28:24

single stage,

ty_1_02-17-2026_163430 28:25

Yeah.

damon_1_02-17-2026_183430 28:26

stage.

ty_1_02-17-2026_163430 28:27

I think some people will probably be very, I'm impressed as well. So the, the right oid right here. Very little tuberosity. I get asked about this a lot if you, if you just don't have a whole lot of tuberosity right here. Is a OID still doable? Well, there's always, you know, doing a trans sinusoid, of course. Right?

damon_1_02-17-2026_183430 28:44

Yeah, so that, um, what

ty_1_02-17-2026_163430 28:46

That's what it looks like.

damon_1_02-17-2026_183430 28:47

turned out to be really cool because as, as, as we in fractured the sinus,

ty_1_02-17-2026_163430 28:52

Mm-hmm.

damon_1_02-17-2026_183430 28:52

uh, was able to get that small tuberosity bone to actually kind of crush a little more anteriorly.

ty_1_02-17-2026_163430 29:02

Hmm.

damon_1_02-17-2026_183430 29:03

and so it actually was not a trans sinus, uh, oid.

ty_1_02-17-2026_163430 29:08

Cool.

damon_1_02-17-2026_183430 29:09

it,

ty_1_02-17-2026_163430 29:09

Wow.

damon_1_02-17-2026_183430 29:10

really, it actually worked really well.

ty_1_02-17-2026_163430 29:12

Very cool. And can we kind of like, I, I don't, we don't have a picture in here, um, and you described it before in a previous episode, but what is the scoring of the, um, tuberosity and the sinus and everything look like Prior to crushing it?

damon_1_02-17-2026_183430 29:24

So you, you need to score it, uh, 360 degrees, especially on the palate

ty_1_02-17-2026_163430 29:32

Yeah,

damon_1_02-17-2026_183430 29:32

that palatal bone is really dense and, and you need to score that, or else you can't get, you can't get mobility of your crush.

ty_1_02-17-2026_163430 29:42

yeah. Okay. Okay. So it's like a 360. And then do you kind of hash it throughout to, to kind of help it buckle in a little bit when you crush it or?

damon_1_02-17-2026_183430 29:51

No. We'll, I'll just, I'll just begin to just

ty_1_02-17-2026_163430 29:54

It's a circle.

damon_1_02-17-2026_183430 29:54

with the, with the BA back end into the osteotome.

ty_1_02-17-2026_163430 29:58

Cool. Very, very cool.

damon_1_02-17-2026_183430 30:00

it's like, you know, the, the only Norris product I've, I've purchased is their, their osteotomes, and I'll use the larger osteotome and, and, and, uh, hit it, you know, in reverse

ty_1_02-17-2026_163430 30:13

Okay. Very nice.

damon_1_02-17-2026_183430 30:15

the, hit the blunt end of the with the hammer so that the, the, the rounder, uh, handle portion, uh, goes in.

ty_1_02-17-2026_163430 30:26

Yes, that makes sense.

damon_1_02-17-2026_183430 30:27

Yes. So, uh, here is, um, so anyways, case worked out beautiful. Uh, you know, it's, that, that particular case was a lot of, a lot of ifs, you know, and it's like a lot, a lot of things really kind of have to work, and then if you start tipping the scales, it's, it's, uh, catastrophic ultimately.

ty_1_02-17-2026_163430 30:57

Yeah, that's for sure. Yeah, that was definitely an ambitious case.

damon_1_02-17-2026_183430 31:01

So here we are. We've, uh, I don't know, Tyler, I'll let you, I'll let you take, uh, take this or whatever you got.

ty_1_02-17-2026_163430 31:09

Yeah. So we, uh, so just questions about this slide.

damon_1_02-17-2026_183430 31:14

Yeah.

ty_1_02-17-2026_163430 31:14

Yeah. So I mean, It looks like you know, we've done this, I mean, it's very similar to the first one we saw, right? So we've done a vascularized, interpositional, you know, pedicle with the CT here. We've got a trans osseous, uh, suture to fixate it anteriorly. Um, and it looks like, I'm trying to tell, I mean, is that,

damon_1_02-17-2026_183430 31:33

It

ty_1_02-17-2026_163430 31:33

is this

damon_1_02-17-2026_183430 31:34

punched through the connective tissue. I think it was a very, a very wide,

ty_1_02-17-2026_163430 31:39

really wide, and thick?

damon_1_02-17-2026_183430 31:41

very wide, very thick. And if you notice on the anterior fixation, trans osseous kind of suture there. I actually wound up wrapping it once or twice. So you

ty_1_02-17-2026_163430 31:55

Okay.

damon_1_02-17-2026_183430 31:56

you can go through these

ty_1_02-17-2026_163430 31:57

Let's go through the same hole

damon_1_02-17-2026_183430 31:58

go through the same hole several times

ty_1_02-17-2026_163430 32:00

Oh, cool.

damon_1_02-17-2026_183430 32:01

really,

ty_1_02-17-2026_163430 32:02

Oh, that's smart. Yeah. Nice, nice. I've done that Sometimes on the low, I don't, I don't, I've never gone through it with the same suture, but sometimes I'll use the same hole for two separate sutures to kind of like bring tissue in or something like that. I've never run it through two times. It's really smart. I've never thought about that.

damon_1_02-17-2026_183430 32:18

Yeah.

ty_1_02-17-2026_163430 32:18

Very nice

damon_1_02-17-2026_183430 32:19

And, you know, I like using two oh.

ty_1_02-17-2026_163430 32:22

Yeah, I, we, we've implemented that as well. It's, like a rope. It's great.

damon_1_02-17-2026_183430 32:26

it's, it's, it, it is a game changer. You

ty_1_02-17-2026_163430 32:29

Yeah.

damon_1_02-17-2026_183430 32:30

you can get the same size needle. You may just have to go to a different supplier. I don't know if Henry Schein has the,

ty_1_02-17-2026_163430 32:36

Yeah.

damon_1_02-17-2026_183430 32:37

the, the bigger circles. But you can just reach so much deeper with these, uh, bigger, bigger sutures, and

ty_1_02-17-2026_163430 32:45

Yeah.

damon_1_02-17-2026_183430 32:46

you can pull harder. I mean, my sutures aren't ripping intraoperatively anymore. the

ty_1_02-17-2026_163430 32:51

Right.

damon_1_02-17-2026_183430 32:51

2.0 is an absolute game changer.

ty_1_02-17-2026_163430 32:54

Yeah, yeah. Highly recommend that for sure. Cool. So what I, I'm, I'm curious, you know, uh, and, and for those that are just listening in, the question here that while we're discussing this, is to use the buccal fat pad or, um, to do a scarf graft. Um, so clearly you do not use the buccal fat pad here. How do you kind of, I mean, is it really just an evaluation of the connective tissue that you have to work with, and if it's adequate, that's what you're gonna do? Is that, is that really the decision point there? Or is there anything else?

damon_1_02-17-2026_183430 33:25

Yeah. If, if you're unsuccessful or do not like the connective tissue, you know, if, if it just wasn't thick enough, you weren't able to get it where you needed to go, and if you had like a overtly vocalized zygoma,

ty_1_02-17-2026_163430 33:47

Yeah.

damon_1_02-17-2026_183430 33:48

then, then, then, then we would roll to a, a buccal fat pad.

ty_1_02-17-2026_163430 33:52

Okay. And I'm, I'm,

damon_1_02-17-2026_183430 33:54

I like saving the buccal fat pad for

ty_1_02-17-2026_163430 33:58

yeah. Of course. Yeah. Absolutely. Absolutely. Yeah. I I think what you said earlier about the, you know, doing a, a scarf graft or doing anything with a CT, that's gonna be regenerative, right? So like, but use the BFP, you're probably gonna get that one time, maybe twice.

damon_1_02-17-2026_183430 34:13

Yeah.

ty_1_02-17-2026_163430 34:14

and, and I'm noticing too here, one thing I've been thinking about recently is, you know, I've, I've been thinning my tissue for probably a little over a year now, um, because of, of your teaching. But I was curious about like, how much thickness do I actually need to leave on that palatal tissue? And I can see here it's maybe a millimeter of thick, uh, of thickness of tissue. Right. Maybe two.

damon_1_02-17-2026_183430 34:31

would say it's, it's, it's at least two. It's at

ty_1_02-17-2026_163430 34:34

two. Okay. Hard, harder to tell with a photo, but Yeah. Okay. Okay.

damon_1_02-17-2026_183430 34:37

when, whenever you can tell whenever it's too thin, you know, there's, there's not any, it's, it's just yellow and, and so, so at that point, you've, you've really taken all of the blood vasculature out of that tissue. And that can lead to some, uh, palatal necrosis, uh, postoperatively.

ty_1_02-17-2026_163430 34:58

Yeah, Yeah, That would not be ideal. Okay. Very good. And, and I like how, you know, you teach everybody to go very deep with this as well. Like it's, it's like the whole depth of like your 15 blade, like you've, you've really thinned it, you know, very far in that. I, I'm not really even sure how to call that dimension. Um, but it's, it's, a very wide graph that you're, that you're separating out there.

damon_1_02-17-2026_183430 35:19

it's, so it's, it's, it's not just the depth of the blade,

ty_1_02-17-2026_163430 35:23

Mm-hmm.

damon_1_02-17-2026_183430 35:24

Generally, I would say that the depth of the cut is at least, uh, two blades tall.

ty_1_02-17-2026_163430 35:32

Mm. Yeah.

damon_1_02-17-2026_183430 35:34

So kinda like, kinda like what you said, like you're gonna take it all the way down to like that shank where the, where

ty_1_02-17-2026_163430 35:39

the shank. Exactly. Yeah.

damon_1_02-17-2026_183430 35:41

widens out.

ty_1_02-17-2026_163430 35:42

Yeah. Not just the cutting portion, but the hole. Like you're going down to the shank there. Yeah. That's what I'm, that's what I've been doing recently.

damon_1_02-17-2026_183430 35:48

Now,

ty_1_02-17-2026_163430 35:48

lot.

damon_1_02-17-2026_183430 35:49

know, you, you are gonna get bleeders. Uh,

ty_1_02-17-2026_163430 35:54

yeah,

damon_1_02-17-2026_183430 35:54

but that, that, that, that does, that is not a contraindication, right?

ty_1_02-17-2026_163430 35:58

yeah, yeah.

damon_1_02-17-2026_183430 35:59

the be the benefits of thinning far outweigh just, just the little, uh,

ty_1_02-17-2026_163430 36:09

nuisances of,

damon_1_02-17-2026_183430 36:11

of of like a, of like a blood. So, um, and you know, I'm, I'm surprised, I'm always shocked at how many people do not have, even just like a simple electric artery device,

ty_1_02-17-2026_163430 36:22

mm-hmm. Yeah.

damon_1_02-17-2026_183430 36:23

know, 800 bucks.

ty_1_02-17-2026_163430 36:25

Yeah. It's easy.

damon_1_02-17-2026_183430 36:26

It works really well. You know, if, if your electro artery goes, goes down, um, you can just, you can just run su suture off your bleeders. That that is, that is, that is a, that is definitely another option.

ty_1_02-17-2026_163430 36:41

Mm-hmm. Yeah. No, that's really good. Yeah. I mean, I just know how to handle a bleed, right? I mean, that's just fundamental. Yeah. Absolutely.

damon_1_02-17-2026_183430 36:49

so, so, so thinning the palate allows us to have more restorative space.

ty_1_02-17-2026_163430 36:54

Yes.

damon_1_02-17-2026_183430 36:56

uh, it's actually gonna give us a stronger prosthesis because we're not gonna have these little chimneys of zirconia

ty_1_02-17-2026_163430 37:02

Yeah,

damon_1_02-17-2026_183430 37:03

that go in, that go in. I mean, we've all seen, you know, our zirconia break from time to time. And, you know, to be honest, I'm actually shocked when it does.'cause I'm like, golly, that's actually fairly thick. I'm actually surprised that broke

ty_1_02-17-2026_163430 37:17

yeah,

damon_1_02-17-2026_183430 37:17

And, and, and then I think back to all these Instagram posts I see with these like little bitty thin, zirconia little chimneys, you know,

ty_1_02-17-2026_163430 37:27

yeah.

damon_1_02-17-2026_183430 37:28

right?

ty_1_02-17-2026_163430 37:29

Yeah.

damon_1_02-17-2026_183430 37:29

increased restorative space, uh, a a stronger, thicker, longer lasting prosthesis. Uh, we are able to then advance our keratinized, gingiva, buccal two, our implants, right? And then, you know, again, it's like riding the bike. You know, if you ride your bike every day, you're gonna be really good at it. If you don't, you're not. And so then this allows, uh, to really kind of vocalize, you know, kind of like A-V-I-P-C-T and it's, it's there when, when we need it.

ty_1_02-17-2026_163430 38:03

Yeah. And you're, and you're just, you're used to doing that, you know, every time. Um, I, I definitely think with, you know, you're talking about those chimneys and that, and that's a big thing. And, and I think if you're doing, you know, direct to multiunit, especially with a printed prosthesis, Oria, what, whatever it may be, um, I, no material aside from titanium is gonna really tolerate that such a thin little protuberance. It's going away from the intaglio of your bridge going transmucosal. I can't tell You how many times I've seen like another provider's prosthesis that's, that's been the mouth for, you know, a couple years and you take that out. It's chipped almost every time. It's chipped to that interface. It's super common zirconium that does not, zir doesn't do well when it's thin. It's very brittle. It's a, it's a very brittle material. And so thinning out that pallet is huge. Getting it embedded in thelia,

damon_1_02-17-2026_183430 38:48

you know what's stronger than, uh, titanium is a cobalt chromium.

ty_1_02-17-2026_163430 38:53

uh, yeah, sure. Yeah.

damon_1_02-17-2026_183430 38:55

z zircon on has, has a cobalt chromium product. And so on occasion, I've, we've, we've milled out a, a, a cobalt, chromium,

ty_1_02-17-2026_163430 39:08

Brilliant.

damon_1_02-17-2026_183430 39:08

of bar,

ty_1_02-17-2026_163430 39:09

Yeah.

damon_1_02-17-2026_183430 39:10

super strong, super strong way, way stronger than, uh, titanium.

ty_1_02-17-2026_163430 39:15

Very nice. And is it still, does it have some malleability? Can it, can it bend a little bit? Or is it more prone to fracture?

damon_1_02-17-2026_183430 39:22

No, it's, it, it, it's, it's, I don't know. We'd have to, we'd have to pull out the eng engineering

ty_1_02-17-2026_163430 39:29

Yeah, I.

damon_1_02-17-2026_183430 39:29

on, on, all of that, but I, I would as,

ty_1_02-17-2026_163430 39:32

Hats on.

damon_1_02-17-2026_183430 39:33

yeah.

ty_1_02-17-2026_163430 39:35

That's fine with me. But yeah. that, that's a great idea. Especially if someone's, I, I've actually heard of people fracturing tie bars, which is amazing, but there's certainly indications.

damon_1_02-17-2026_183430 39:44

So, you know, let's, you know, kind of talking about, you know, the buccal fat pad. Um, it's, you know, in, in dental school, you know, the, our oral surgery colleagues, you know, talked, talked about, know, or, or, or even, or even just lay, lay people, they think, oh, well, you know, it's gonna change my face. Right?

ty_1_02-17-2026_163430 40:09

Mm-hmm.

damon_1_02-17-2026_183430 40:10

there's actually, you know, several different lobes of the buccal fat. And

ty_1_02-17-2026_163430 40:16

Yeah.

damon_1_02-17-2026_183430 40:17

I, I do not want to go into that, you know, I, I do not go through the buccinator muscle, which is where you can actually pull the buccal lobe of the buccal fat. also you're actually kind of close to, you know, stinson's duct, the, the parotid.

ty_1_02-17-2026_163430 40:33

Mm-hmm.

damon_1_02-17-2026_183430 40:34

I, I stay, I don't, I don't, I don't go there. We, I actually pull the, the buccal fat, um, out of the infra temporal fossa, right? So just kind of right there back, uh, right by the OID will just kind of

ty_1_02-17-2026_163430 40:49

Yeah.

damon_1_02-17-2026_183430 40:49

go. Go, go, go, through the, the periosteum there, and then just, you know, it's just sitting back there waiting to be pulled.

ty_1_02-17-2026_163430 40:58

Yeah.

damon_1_02-17-2026_183430 40:59

but the, uh, the, the buccal fat has its own blood supply. so, uh, it's got like, like what, like the deep temporal, it's got the buccal artery portions of the PSA, you know, there's some axillary artery branches that go into the different lobes. So it's a living, it's a living capsule. As long as you don't detach it, long as it's, you know, uh, not super thin, you know, you

ty_1_02-17-2026_163430 41:26

Yeah.

damon_1_02-17-2026_183430 41:27

to really kind of pull the whole big capsule,

ty_1_02-17-2026_163430 41:30

Yeah.

damon_1_02-17-2026_183430 41:31

how, how we approach, uh, getting it. And, know, prob probably, you know, if, if you guys will check out the Texas Implant Institute YouTube page, I'll, I'll, I actually took a video of me harvesting a buckle fat,

ty_1_02-17-2026_163430 41:48

Cool.

damon_1_02-17-2026_183430 41:49

a couple, a couple days ago. I'll, I'll post that and I'll put it on our, uh, Texas Implant Institute, WhatsApp.

ty_1_02-17-2026_163430 41:55

Yeah, sure.

damon_1_02-17-2026_183430 41:57

and you know, you, I saw a guy on Instagram yesterday, this morning, I don't know, in the past 24 hours, four, eight hours. was using a 15 blade, uh, to, to, to, to go back in there. And I

ty_1_02-17-2026_163430 42:13

blunt dissection buddy. Blunt dissection.

damon_1_02-17-2026_183430 42:15

Blunt blunt dissection. So

ty_1_02-17-2026_163430 42:17

Yeah.

damon_1_02-17-2026_183430 42:18

take, take, take, a pair of sharp dean scissors and, and, punch it in, and then spread those scissors as, as, as wide as you can. And as

ty_1_02-17-2026_163430 42:28

Yeah.

damon_1_02-17-2026_183430 42:29

it up, you're just gonna see that yellow gold back there and you get, you really get one good spread with your, with your scissors to really kind of open that up. And then beyond that, so sometimes I'll actually use the, the beaver tail end of my, uh, perote

ty_1_02-17-2026_163430 42:49

Mm.

damon_1_02-17-2026_183430 42:50

kind of, uh,

ty_1_02-17-2026_163430 42:51

Tease it.

damon_1_02-17-2026_183430 42:52

tease it, tease it out, and pull it. Um, let's, let's see what I have on the next slide here.

ty_1_02-17-2026_163430 42:59

Yeah, There we go.

damon_1_02-17-2026_183430 43:03

Yeah, so there's, there's kind of the different, uh, the, the, the different lobes, right? So different people describe'em differently. They'll, they'll kind of talk about it three lobes. Some people quote that there's four lobes, Like, uh, you know, but generally there's the buccal, the tego, the tego, palatine, and then the temporal. So the, you know, and, and the, the purpose of the buccal fat is really so that all of our muscles of mastication can kind of slide against each

ty_1_02-17-2026_163430 43:33

Lubricating. Yeah.

damon_1_02-17-2026_183430 43:35

Lubricating it. Yep. There you go. Uh, but you know, again, you know, we're gonna pull it from the fossa and so, so it's, it's not the temporal, it's not the buccal. So it'll either be the, generally, I think it's what we're pulling is this tego tego lobe. The tego palatine. You're not gonna really try to pull that lobe that's, that's, that's deep, that's

ty_1_02-17-2026_163430 44:00

Yeah,

damon_1_02-17-2026_183430 44:00

pretty high up, right up against, uh, the, the, the tego palatine fossa, which that's also where the maxillary artery enters, uh, into the, the maxilla. So

ty_1_02-17-2026_163430 44:12

yeah,

damon_1_02-17-2026_183430 44:13

stay, stay away from that. In, in one of my cadaver labs, and I'm gonna start doing this at every cadaver course, uh, whenever we're done, I wanna do a study we're gonna measure the, uh, relationship of the maxillary artery the, uh, probably just like the, the, the tuberosity. So, um, so there's, there's, there's actually kind of very few studies that have kind of outlined that. and, and one of them was a Asian study and it was a, they, they were looking at older Asian female cadavers, and so that they, they found that it was 19 millimeters, which is actually very shocking to me.

ty_1_02-17-2026_163430 44:59

yeah. That's not far.

damon_1_02-17-2026_183430 45:01

it's, it's, it's, it's not very far. But again, I mean, just think about if you have a smaller head, you know, everything's gonna be in smaller dimension.

ty_1_02-17-2026_163430 45:12

Yeah.

damon_1_02-17-2026_183430 45:12

in, in, in my cadaver courses, I've, I've measured two or three times. it's actually fairly difficult to get to'cause you have to take off the OID process. You have to take off the zygomatic arch

ty_1_02-17-2026_163430 45:23

Mm-hmm.

damon_1_02-17-2026_183430 45:24

to kind of get in there. So you really kind of gotta actually do quite a bit of dissecting to get back there.

ty_1_02-17-2026_163430 45:30

Yeah,

damon_1_02-17-2026_183430 45:30

but the time that I did it was 33 millimeters from the tuberosity to the maxillary artery.

ty_1_02-17-2026_163430 45:36

it's more like a Yeah, yeah, I started getting nervous if, if I'm drilling, I mean, I, I think I'm, we're kind of similar, like 95% of my OIDs are four by 18, you know, probably. Um, but if I start going a little bit deeper and I'm like going past like 22, 24, I'm like, okay, that's, that's a bit too far for me. We're gonna figure something out.

damon_1_02-17-2026_183430 45:57

yeah, yeah. So, you know, maybe just move your coronal entrance point a little more, uh, posterior. And then, then, then your distance

ty_1_02-17-2026_163430 46:04

You

damon_1_02-17-2026_183430 46:04

is, is definitely shorter.

ty_1_02-17-2026_163430 46:06

got it. Yeah.

damon_1_02-17-2026_183430 46:07

but you know, back to the buccal fat,

ty_1_02-17-2026_163430 46:10

Yeah.

damon_1_02-17-2026_183430 46:11

it has some, uh, mesenchymal cells and so, you know, plus that plus the blood flow, blood flow, uh, it, it really kind of helps, to, to, to weather our vocalized, uh, zy zygomatic from having any type of recession. So I.

ty_1_02-17-2026_163430 46:30

I'm curious, what do you, so we talked about how you're exposing it with the blunt dissection, you're using the beaver end of your number nine to kind of tease everything out and, and, you know, help it sort of move forward. What do you actually use something to physically grab it and pull it forward? And what do you like to use if.

damon_1_02-17-2026_183430 46:47

On a, on a on occasion, like I want, I, I really wanna make sure that once, once you pull, if, if it still is kind of not teased out,

ty_1_02-17-2026_163430 46:59

Mm-hmm.

damon_1_02-17-2026_183430 47:00

begins to tear.

ty_1_02-17-2026_163430 47:01

Yeah. That, that's what I'm getting at. Yeah.

damon_1_02-17-2026_183430 47:04

So, I, I wait until I've got good movement, you know, and then I'll grab it pretty deep

ty_1_02-17-2026_163430 47:11

Mm-hmm.

damon_1_02-17-2026_183430 47:12

be to kind of pull and then, you know, uh, I wind up suturing that down. Some, sometimes, you know, you can suture it to the anterior nasal spine. You can make some trans osseous sutures if you wish. but it really requires, you need to make a basket weave your suture. So sometimes we'll go, we'll go through it and around it five or six times to really give it, uh, where we're, we're pulling it anterior to position it from. within buckle, the buccal fat that we have teased out. So it's, it's, it's gonna be pulled from the posterior, the middle, and the anterior portion. Uh, and that allows it not to, uh, tear and become thin.

ty_1_02-17-2026_163430 48:02

Okay. Yeah. Very good. Yeah, that's when I first started doing it. Um, at the cadaver lab, that's what I was kind of running into, is I was getting a little bit too ahead of myself and I'm trying to pull it and I just tear it and it gets thin. kind of useless,

damon_1_02-17-2026_183430 48:13

Yep. Yep. Totally, totally, totally. So here's just a cool picture of, you know, just kind of, really kind of how big it is, uh, and

ty_1_02-17-2026_163430 48:23

huge.

damon_1_02-17-2026_183430 48:23

the, all the different lobes. Um, you know, it goes under, under the zygomatic arch up into the, uh, you know, where that temporal muscle is.

ty_1_02-17-2026_163430 48:33

Yeah.

damon_1_02-17-2026_183430 48:34

extension again, we're not gonna touch that, you know, let the, let the plastic surgeons take that out on our influencers and,

ty_1_02-17-2026_163430 48:42

Yeah. For the ectomies, yeah.

damon_1_02-17-2026_183430 48:44

Yeah.

ty_1_02-17-2026_163430 48:45

Yeah. Great.

damon_1_02-17-2026_183430 48:47

perfect.

ty_1_02-17-2026_163430 48:47

Yeah, I was, I was curious, do you ever see any facial change at All because you're leaving that buckle lobe, I suppose. You ever see any type of, you know, narrowing at all?

damon_1_02-17-2026_183430 48:56

just'cause everything's coming outta that fossa, right?

ty_1_02-17-2026_163430 48:59

Yeah.

damon_1_02-17-2026_183430 49:00

the infra portal fossa is bound by the, you know, zygomatic arch, the, uh, the. The OID process and you know, medially, which is kind of that, uh, the, the lateral sphenoid wing.

ty_1_02-17-2026_163430 49:18

Yeah. Okay. Okay.