September 15, 2025 • 50 mins
Mastering complex anatomy in full-arch implant cases requires both technical skill and the wisdom to know your limitations. Dr. Clark Damon joins The Fixed Podcast to share rare but invaluable techniques for challenging anatomical situations that every implant dentist will eventually encounter.
The conversation centers around two advanced procedures: sinus crushing and pterygoid implant placement. Dr. Damon reveals that despite completing 3,000 arch cases, he's only performed sinus crushes on three patients—a testament to both the rarity of proper indications and the importance of understanding when this approach is truly necessary. He walks through his precise technique, from the diamond burr scoring to the use of collagen tape rather than particulate graft, explaining how this one-surgery approach can transform cases with pneumatized sinuses that would otherwise require multiple procedures.
Perhaps most valuable is Dr. Damon's candid discussion about knowing when to collaborate with specialists. "Too many clinicians are taking on cases they really shouldn't be doing," he observes, emphasizing that revenue pressure often leads to complications that "come home to roost fairly quickly." Instead, he advocates bringing specialists into your office for complex cases—creating learning opportunities while maintaining the patient relationship.
The episode showcases Dr. Damon's pterygoid expertise, having placed over 1,000 implants with a stunning 99.5% success rate. He details precise placement techniques, including his preferred 18mm length and entry point between the second and third molar positions. Using the analogy of aiming between the "field goal posts" of the lateral and medial pterygoid plates, he demystifies this advanced technique that dramatically reduces stress on anterior implants.
Whether you're looking to expand your implant capabilities or simply understand when to call for reinforcements, this episode delivers practical wisdom from one of implant dentistry's most experienced practitioners. The techniques discussed may be advanced, but the philosophy is universal: always prioritize predictable outcomes over pushing clinical boundaries beyond your comfort zone.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren Poppy,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Hello and welcome back to theFix Podcast.
We have a special guest on today, though he's becoming somewhat
of a regular.
Today we have on Dr Clark Damon, who has graced us with his
time, and today we're going tobe doing something that looks
(00:23):
like it could be a recurringsegment for us.
So, um, for those of you whohave taken his course, uh, down
in Texas at the Texas implantInstitute, um, you get, uh, to
be a part of the tribe.
It's a WhatsApp group with allof the alums from Clark's
courses and in there, um, youget to have these really candid
conversations with all the otheralums doing Fixed for Large,
(00:46):
the good, the bad, the ugly.
We share cases in there andClark is very on top of all the
messages in there, givingfeedback, giving recommendations
, sharing his own cases whetherthey go to plan or not.
It's been a really valuablecommunity.
So we got to thinking I thinkit was actually Clark's
suggestion that we come on hereregularly and talk about some of
these topics, and so we reallyappreciate him taking out the
(01:08):
time and welcome back to theshow Clark.
Speaker 3 (01:09):
Yeah Well, thanks Well, and you know, I also
wanted you know to, you know,interview you guys and actually
let y'all be a part of you know,the tribe that you're creating
with your sure.
Sure, yeah With with yourpodcast and and maybe have
something that's a little morelaid back and you know, just
(01:32):
kind of talking about.
Like you know what's going on,you know where, where are people
headed for CE, Just kind ofjust a little more.
You know more fluff kind of what?
A little more.
You know more fluff kind ofwhat's working.
You know how your practices aremoving and just you know
there's always these seasons ina full arch practice and you
(01:55):
know the seasons can be, youknow whenever you started, or it
could literally be within youknow the quarters of the year.
You know, I think typically, youthink typically the first half
of the year, full arch practicesare busier than the latter half
, and marketing is alwayssomething that changes, and I
think that's everybody's vein orbane of existence, and so it's
(02:20):
kind of interesting to seewhat's working, just kind of
that kind of stuff.
Speaker 2 (02:26):
So yeah, absolutely.
We'd love to get some questionsfor you too, or usually on the
uh giving end, so it will benice.
Speaker 1 (02:36):
Absolutely, absolutely so, um, but yeah, I
did want to.
Uh, yeah, and you're more thanwelcome to flip the script on us
and, um, you know, it'd be thefirst time that I think either
of us have ever been interviewedon our show, so I'm I'm more
than welcome, um, for that.
But, uh, but, yeah, so I did.
I did put together just a fewtopics, um, kind of going back
through the tribe conversationsall the way back to, I think,
(02:57):
when, when we first joined, wasback in January of this year,
and, uh, there was a really um,interesting topic that came up,
and I think it actually came uparound the time that Soren um
had a case like this comethrough his clinic where, um,
you have a patient that, let'ssay, they have a high smile line
.
They may not even have aparticularly high smile line,
(03:17):
but what you deal with is youhave pneumatization of the
sinuses.
That goes so far to the pointwhere where you're trying to do
your, your alveo and and raisewhere that transition line is
going to end up being, butyou're out of runway, you don't
have enough sinus bone to takeaway, so you've got these gums
are visible and there's not anyforeseeable way to do that
(03:39):
simply with reduction, like wenormally do.
And so in the group you shareda case where you had done some
sinus crushing, so basicallyupping the sinus floor, doing
some grafting and sort ofraising that platform.
So I was hoping you can kind ofwalk us through you know
indications for that some issuesthat can come about, possibly
some alternatives for cases thatlook like that, because you
know every so often these docome through our door and that's
(04:00):
not a simple thing to treat.
Speaker 3 (04:03):
Right, yeah, so I think you know.
The first thing is you know,understand your limitations
right and and know when to referit, or really you know, now
there's there's a lot ofclinicians.
Even myself I'll go intopeople's offices in Texas and I
even recently got an Oklahomalicense and go in, go into
(04:24):
people's offices and help themout on more complex cases, you
know.
So one one issue that clinicianshave is maybe they can do the
lower arch and it's simple, butthe upper may be, you know, more
difficult, and so actuallybringing somebody in is so much
easier.
You can learn so much from thatclinician coming into your
(04:48):
office to treat your patientversus just referring them out,
like if you refer the patientout, which is obviously can be
the best thing for the patient,you miss out on that educational
opportunity.
And so consider these options.
I think Juan Gonzalez can comein and he kind of flies around.
(05:10):
I think the difference is alittle bit limited to can the
clinician actually touch thepatient, if they have a license
or not.
So that's something to takeinto consideration.
But hit me up.
(05:35):
If you're in Texas or Oklahomaand you want me to come, do a
case and you really want tolearn, I'll come and let's get
an.
I think too many clinicians aretaking on cases that they really
shouldn't be doing.
I think there's a big driverand a big push for revenue,
revenue, revenue, top line.
But when you push a standard,when you push a case to be a
(05:58):
standard, that is not a standard.
That needs to be done.
Patsy, you're going to haveproblems and these problems will
come home to roost fairlyquickly, with temps breaking,
not being able to manage a smileline.
So on a case where the sinushangs inferiorly to the
(06:20):
reduction plane, clinicians aregoing to have, you know, they
need to one, identify it, and itcan be a difficult thing to
identify.
Two, the clinicians.
You know there's no way aroundit.
You can't say, oh, we'll put aflange on it.
You can't say, oh well, we'lljust have a shortened bridge.
(06:42):
In that case, you know, becausethen it's going to be, you know
, a first premolar, you know$20,000, $25,000 implant bridge.
So again, the patient's goingto be unhappy.
So clinicians typically have twooptions when dealing with this.
One you know you have to dosomething.
(07:03):
So not doing anything is not anoption.
So option one is doingpre-surgical grafting or
pre-arch surgery grafting, andthat is a very viable
alternative.
And on certain cases we can doa sinus crush intraoperatively
(07:25):
and then that way the patientcan have one surgery.
Now I would.
So what are the indications ofa sinus crush?
I think number one the patientneeds to be a dentulist Trying
to do a sinus crush whenpatients have teeth is going to
(07:46):
be difficult Oftentimes.
And why right?
It is likely that you're goingto have some type of
communication You're going tohave.
The sinuses are going to bepneumatized, the roots are going
to be into the sinus, sooftentimes we're going to have
(08:09):
several tears there.
So I would say to do a sinuscrush indication would be
edentulous.
Speaker 1 (08:19):
Now, does that mean fully edentulous or just
edentulous in the areas whereyou would be looking to do the
crush, so you don't have allthat anatomy?
I guess that's a good point,right?
They could be partiallyedentulous or just edentulous in
the areas where you would belooking to do the crush, so you
don't have all that anatomy.
Speaker 3 (08:26):
I guess that's a good point.
They could be partiallyedentulous, as long as they're
edentulous in the area thatwe're crushing.
But again, we're talkingpneumatized sinuses.
So oftentimes if there's acanine, if they're edentulist
maybe they only have the frontsix teeth.
(08:46):
Having a canine may really bepushing it.
Always do what's predictable inyour hands.
If doing a sinus lift is morepredictable for you as long as
you can nail it and then thatway you can come back and
(09:07):
whenever you do your alveolarreduction.
Now you have sinus graftedmaterial there and you don't
have to worry about alow-hanging membrane and you
don't have to worry aboutcrushing it.
Speaker 2 (09:24):
I want to quickly go back real quick to what you were
talking about earlier abouttaking these cases on, and one
thing I want to mention foreverybody listening to this is
if you take on, like Clark wassaying, a case that should be
Patsy and you do it for acertain price, you're not only
putting the patient in thesituation where they might need
(09:47):
another surgery in the futurewith, like a zygote or something
like that, but a lot of timesyou should just keep in mind as
well that most of these patientsthat are coming to your office
at least most doctors that Iknow they're charging a set fee
for the whole surgery.
So if you do that surgery andlater it needs to end up being
(10:07):
Patsy, just remember that you'reprobably going to be the one
fronting the cost for the secondanesthesia, for another
provider coming in to do zygosand potentially, like you know,
someone coming in to dopterygoids.
So, yes, like these cases inparticular, combination syndrome
, kelly syndrome, zygocases, youknow maybe pushing the envelope
(10:31):
too far on palatal approach, ifyou start that case thinking
okay, yeah, great, like I'mgoing to test out these
different implants that I know,and that you might end up in a
situation where you're payingout $10,000 for another
anesthesia bill and anotherprovider to come into the office
by not referring that orbringing someone into your
(10:53):
office right off the bat.
Sorry, clark, from gettingaside from the crushing sinus
thing.
I just wanted to quicklymention that because I think
that's a really important point.
That because I think that's areally important point.
And when I first was likegetting into some of the more
advanced implants, it happenedto me one or two times where we
ended up having to pay foranother provider to do zygos.
(11:15):
Because I took on like a casethe cases that happened to me.
They worked out, they were justthe implants An implant failed
and I needed a zygomatic implant.
But just something to thinkabout before taking on these
challenging cases.
Speaker 3 (11:29):
Yeah, it's always better to do things right the
first time and the cost ofbringing a provider in when done
the first time, you can stillmake a fair amount of money on
that.
It's just when you've alreadylost your afternoon the first
time.
You can still make a fairamount of money on that.
It's just when you've alreadylost your afternoon the first go
and then now you have a secondanesthesia bill, you have a
(11:52):
second prosthesis bill, secondlab bill, second implant bill.
Now you have a provider bill,you know, and then you know.
So not only are you not makingmoney, but then now the
patient's like oh gosh, you hadto have somebody else come fix
it Versus.
Hey, I know where to go.
This guy's really nice and he'shooked me up with some other
guy that can come in and takecare of me.
(12:13):
That's like a win-win-win.
Speaker 1 (12:14):
You're a quarterback in that situation Looks good.
Yeah, for sure.
Speaker 2 (12:29):
Yeah, and never, you know, don't feel bad telling
your patient like, hey, I can dotraditional all-on-four, maybe
pterygoids very well, but yourcase happens to be one that
needs a little bit more advancedimplants for that.
Luckily, you know, I am goodfriends with some of the, you
know, whatever circle you're in,but I'm good friends with some
of the best implant surgeons inthe United States and I can have
them come and piggyback me onthis case so you get the best
(12:50):
possible treatment and patientsaren't going to look at you
poorly for doing that.
You're providing them supportand ensuring that they get
really good care in your office.
Speaker 1 (13:01):
And I do have a question about that too, clark.
So you know you are offering toothers that are in Texas or
Oklahoma your services.
If someone looks you to comeout for placing a Zygo, what
have you?
Obviously they're notcomfortable doing it themselves.
Well, they're probably notgoing to be feeling very
(13:21):
comfortable dealing with a Zygocomplication, should that happen
down the road right.
So is that something that youknow?
Whenever you have an agreementwith somebody like, hey, I'm
going to come out and help youout with this, you know Zygo
case, would you also beavailable to come out as well if
there's any issues with that?
Do you want to be there forfollow-up?
What does that kind of looklike?
Just to kind of paint a pictureof you know, if I'm going to
bring someone into my office,what can I expect if there's
(13:42):
ever some issues?
Speaker 3 (13:44):
Yeah, you know.
I mean, as you guys know, right, like when you start doing more
all-on-X cases, you get moreall-on-X cases and it's not
going to be, you're not going tohave the one time that you need
(14:06):
to bring an advanced providerin, right?
Like these advanced cases showup on a relative frequent basis,
right?
so um, what I, what I try to dowith.
You know the current offices.
You know one of my offices thatI go to in houston, uh, I'm
there once a month.
Um, another office you myoffices that I go to in Houston,
I'm there once a month.
Another office you know thatI'll go to in Oklahoma, I'm
(14:29):
there once a quarter, right?
So you know there's a regularcadence on that and so you know
often, oftentimes, if there'ssome issue, you know.
But going back, like I mean, Ireally try to educate these
patients like, hey, we did zygos.
(14:50):
Do not use a water pick on yourzygote.
You know sinus precautions forthe first.
You know, three weeks, don'tget on an airplane.
You know most, most, you knowpostoperative complications with
it, with a zygomatic, are goingto occur.
You know, a month, maybe maybetwo to three months down the
(15:11):
road, right, so then you knowyour cadence is kind of already
there.
And then also also when, whenyou think with an open mind
about that cadence, right thennow you're going to feel
comfortable selling more cases,right, like you know, think back
when you guys had sold, youknow, maybe under 75 arches.
(15:34):
You know, I'm sure there weresome cases where you're like,
yeah, I can, I can do this.
In the back of your mind You'relike Nope, don't do it, don't
do it.
Speaker 1 (15:43):
Right.
Speaker 3 (15:44):
But if, if you have somebody coming in on a regular
basis, boom, mrs Jones, we cando this for you.
We're going to put that on DrX's schedule.
He's going to be here in twoand a half months, no big deal,
you know.
Whatever we're going to by thetime, we, you know, send off
your medical consults, your EKG,your labs.
(16:06):
We get your teeth designed,smile designed.
You're only going to wait acouple of weeks.
I mean, you can just kind ofcreate a song and dance, so
certain things to just kind ofthink through.
That is the one challenge is,if a patient has a larger
postoperative problem, we don'twant to abandon the patient, and
(16:30):
so the clinician does need totake that into consideration.
So, whether or not you meet thepatient halfway, the patient
comes to your office, you go totheirs, vice versa, that sort of
thing.
Speaker 1 (16:45):
Yeah, so I do want to go back to the sinus crushing
just a little bit.
So, when it comes to theintraoperative sinus crush, what
does that look like?
What's the instrumentation?
How are you thinking throughthat process?
Speaker 2 (16:59):
And what complications have you seen?
Speaker 1 (17:01):
Yeah, that's great too, yeah.
Speaker 3 (17:03):
So all right, so we're just going to go back.
Indications on that.
You know, again, for a signage,crush, I want it to be
edentulous, or at leastedentulous in the site that
we're going to be crushing.
The technique you want to uselike a number eight diamond burr
(17:24):
, use like a number eightdiamond burr and you want to
score.
You want to score that 360degrees around where you're
going to tap in.
And you know, obviously theseare, these are, it's a sinus,
it's a large sinus.
So just picture, you're goingto want to crush an area that's
probably the size of your thumb.
(17:45):
Okay, so you want to make areally big elliptical scoring of
the bone and especially thepalatal bone.
So if we're going to be dealingwith the palate, we're going to
want to reflect all the waydown to the horizontal portion
of our palate.
We're going to want a largepalatal reflection, a large
(18:06):
buccal reflection, and we'regoing to want a large palatal
reflection, a large bucklereflection, and we're going to
do a 360 degrees, scoringroughly the size of your thumb,
concentrically around the sinusthat you wish to crush.
After you've scored it, then youcan take your osteotome.
You take the back end of theosteotome right, like just
(18:27):
picture the Norris 3-0 osteotome.
Okay, you don't want to choosethe pointy one, but you want to
choose the one that has theblunt tip.
Well, you're going to use it inreverse, right?
So you're going to take the fatend of the handle and you're
(18:48):
going to hammer onto the blunttip of that osteotome and so
that's going to crack andfracture in that sinus and then
you just continue to push it upand push it up.
Then you have to make sure thatyou've gotten it up beyond your
(19:08):
occlusal reduction plane.
So how do we know that?
Well, you probably need an MUAguide and with your MUA guide
you have the teeth there and youneed to measure up 12, 13, 14
millimeters.
I would measure up 14.
(19:29):
I like 14.
Make sure that the bone isreduced beyond that and so that
way we can establish ourrestorative space emergence
profile and hide our transitionline.
So to date I've done 3,000arches and the number of arches
(19:54):
that we've done sinus crushes onis 0.1%.
So I've only treated threecases with the sinus crush,
treated three cases with thesinus crush.
Now there's a lot of cases outthere.
I mean, I think probably bothof you guys have seen cases
(20:14):
where, yeah, we need to dosomething here, so it is
prevalent.
What's been interesting, though, is the patients haven't had
the money.
The ones that have needed thesinus crushes, so they actually,
you know, they haven't had themoney.
The ones that have needed thesinus crushes so they actually,
you know, they haven't movedforward with treatment, which
has been interesting, so that'swhy I only have literally three
three out of 3,000 arches.
Speaker 1 (20:35):
Yeah.
Speaker 3 (20:37):
So you know complications, you know none of
my cases had complications,because again it just kind of
goes back to case selection andthey didn't have teeth right.
So again I'm going to take outvariables that I can't manage
right.
So if, if I get a largefracture of the alveolus, if I
(21:00):
get a large sinus perforation,you know, then then then now
complications go up, right, youknow you can get the sinus to be
infected and all that sort ofstuff.
Another part of my technique isI'm not utilizing particulate
graft so we fracture the sinusin.
(21:23):
The sinus stays attached to thebone and all of that periosteum
and all that blood supply andit goes in.
And maybe I'll put one or twopieces of collar tape, no more,
and that helps hold up thematerial.
(21:44):
It establishes a really goodblood clot and then you can
utilize a nice just college andmembrane over that to help seal
it off.
And you know I'll push thesinus up.
You know all the way, kind offront to back, I'll get it
raised, you know 10 millimetersand you know, put that college
(22:06):
membrane in and everything healsreally nicely.
It takes about a year and a halfto really start to see all of
that kind of begin to ossifyfully in.
You can start seeing.
At about six months you canreally kind of start to see okay
, my sinus is clear.
(22:26):
You know, what are things wewant to see on a post-operative
basis?
No oac.
On a post-operative basis, wewant to see that the sinus uh is
healing and that the uh sinusis clear and that there's not
any um rhinosinusitis or chronicsinusitis.
What other questions you guysgot?
Speaker 1 (22:50):
Well, I think the only thing that I have left on
that one and I'll leave itbecause I know we spent some
time on it, but I guess I'm justcurious about.
So you're kind of making thisoculus of bone, right, it's like
a window of bone that's gettingcrushed up into the sinus.
I guess I'm just curious abouthow that heals.
Like, what is?
What kind of architecture doyou see in followup?
So you mentioned, like a yearbefore, everything ossifies.
(23:11):
Like what, what kind of healingare you expecting to see and
what does that look like?
Speaker 3 (23:18):
The only thing that I want to see is that we'll kind
of re ossify a floor.
Right, we left the bone and sothen it will ossify by lifting
it up and not utilizingparticulate graft the cases
(23:40):
where what I'm trying to do isI'm trying to use as much
metogenous stuff as possible.
I want the patient's blood.
I don't want to put a bunch ofdead cow bone in there, a bunch
of dead human bone in there.
I don't really want to do that.
But the sinus has such ahealing potential.
(24:01):
Anything we put to lift it upwill turn into bone eventually.
And so you know, even on, evenon, uh, zygomatics, um, you know
, when we do a nice channelalong the, the buccal alveolus,
there, I'll kind of lift up themembrane.
I do not do particulate graft,I'll just put a little um, a
(24:25):
piece of collar tape in thereand then a year later it
ossifies and you get a nice plugof bone all where that sinus
was lifted.
Speaker 1 (24:35):
Very nice, very nice.
Speaker 2 (24:38):
I think it's a great technique to have in your back
pocket for a case that maybe,like you said, you need a
minimal amount of sinus lift,case that maybe, like you said,
you, you need a minimal amountof of sinus lift, um, but uh,
you know, cause, if, if you'relifting the sinus like so, I had
a case and I I know you sawthis one, um Clark, where the
guy smiled and his sinuses wereso far down, um, and my plan on
(25:02):
that case was option one, bigsinus lifts lifts and then
coming back and attempting thecase in that manner.
But there's a lot of patientsout there that smile, you know,
and they have that Kellysyndrome, they have that
combination syndrome, but maybeit's only like four or five
millimeters that are showing forsomeone like that that once
(25:23):
they get it done in one surgerymaybe doesn't, they can't do the
whole, waiting six to eightmonths for the sinus lift to
heal and then allowing it to getit done right away rather than
waiting that long period of time.
Speaker 3 (25:39):
Yeah, the one particular case you know.
Obviously, this gentlemansmiled really high and you could
, you know, see the mucogingivaljunction bilaterally.
He had gullwing lips.
You could actually see probably5 millimeters beyond the
mucogingival junction.
In addition, he had all of histeeth and they were all just
(26:01):
rotted down to the gum line.
And so my recommendation on acase like that is edentulate,
get everything healed first.
I wouldn't even do the sinuslifts Like this would be an
ultra-staged case.
Hey, we're going to take yourteeth out, you're going to heal,
we're going to make sure yoursinuses heal.
(26:22):
I believe that patient hadsinus disease too, right, yeah?
Speaker 2 (26:26):
he did.
He had really really badsinuses heal.
I believe that patient hadsinus disease too.
Right, yeah, he did.
Speaker 3 (26:27):
He had really really bad sinuses um that's why so he
made teeth out yeah, teeth out,then maybe go get a fess and
then come back and then get asinus lift and then come back
and then get your art surgeryright.
Speaker 2 (26:41):
So um and that's, that's what I did.
A uh took the teeth out, letthose heal.
Um, he sent him to an ENT.
Uh, they, he like, kept pushingoff the fest.
Um came back into my office.
The sentences were a little bitclear, you know a little bit,
but not definitely not wherethey needed to be.
Um, and then on what we endedup deciding was he was like you
(27:04):
know, I just don't want to dothis anymore.
Uh, so we put them on the topand, uh, fixed on the bottom.
Um, and honestly that was kindof a relief for me because that
was like I would have had to.
You do a sinus lift that bigand you fill it with I don't
know, 10, 15 cc's of bone andhow long is it going to take for
(27:30):
that bone to ossify Like it'sgoing to take a long, long time
and you go in there and cuteverything down and it's going
to be mush and I just I didn't.
I honestly like wasn'tconfident that it would have
healed the way that I wanted itto.
And you know, the patientdidn't want to spend more than
our traditional all on X fee andit was a lot of surgery to do
(27:55):
with unsure prognosis.
Speaker 3 (27:58):
Right, well, but let's just assume that he wanted
to do it, that he wanted to doit.
Obviously your concern is right.
Just because we put in boneinto the sinus.
We've all seen cases where thebone just is mush, right.
So then what do you do?
(28:19):
Well, now you have a greatzygote case because you got the
sinuses way out of the way right.
Great zygote case because yougot the sinuses way out of the
way right and so now you can goin like that is, that is a great
zygote case because you're nothaving to worry about okay, well
, you know, you know is.
Is there going to be along-term oac here?
The sinuses are super high.
(28:39):
All you got to worry about isjust getting really dense,
remote anchorage into the zygoma.
So it doesn't even matter ifthat bone becomes mush, which it
may, because it is so large,because you're going to get
remote anchorage.
I was actually referred a casevery similar to that several
years ago.
(28:59):
They squeezed in an all on astandard arch on a Patsy patient
.
Lo and behold, three implantsfail.
They go in.
They add in a couple moreimplants, so the guy had his
second surgery.
They then said well, you know,things are getting really
(29:21):
constricted, you're only on like10 teeth, so let's go in and do
bilateral sinus lifts.
So he had his third surgery.
It was bilateral sinus lifts,and then they put in.
They waited for that to heal andthen they came back in and they
popped in you know, like fourimplants into the sinus and they
all torqued to like five newtoncentimeters and these
(29:44):
clinicians were like, oh my gosh, and the patient was just worn
out.
So they referred him to me.
They wanted me to just do itand actually just uncover him in
hopes that the implantsactually torqued or, you know,
osseointegrated.
(30:04):
But have me have the patientout, sedated and ready to go to
throw in zygos.
If they just backed out and Imean they backed out in a second
, all four, and so you know,which is no big deal, we'll just
, you know, roll in and do thezygos, like what we planned, and
you know the patient was very,very grateful.
I'm thankful for the patientbecause he got out of that cycle
(30:27):
right.
But again, um, just because wecan sinus lift, you know,
doesn't mean that that's theanswer to all of our, to all of
our problems, for sure.
So, uh, you know, if, if you'renot wanting to commit to a case
like that because you're afraidof mush bone after you do the
sinus lift, that needs to be inyour head.
(30:50):
You need to think you can'tjust think the sinus lift is
going to solve your problems,but roll in and do a zygote or
have somebody come and do thezygote then, and then the
patient can be a Patsy and itwill work great.
Speaker 1 (31:22):
Agreed about, every maxillary case can benefit from
the use of pterygoids, and Ithink that you, you know you've
shared some data I think weactually talked about in an
interview with Zellig about datayou've collected on pterygoids
that you've placed and thesuccess has come about that and
they were extremely impressiveand really better than standard
(31:43):
implants really, and so I washoping you could share that as
well.
And then I do have a few, youknow, minor, subtle questions
about how we place ourpterygoids and the ideal depth
and multi-unit selection andthings like that.
So could you talk a little bitabout your follow-up on your
pterygoids?
Speaker 3 (31:57):
Yeah, so, um, excuse me, Uh, you know, Wilkerson put
out an article in 2000, uh, 2021, and it was a finite elemental
analysis article and it showedthat by utilizing pterygoids it
(32:21):
took significant stress andstrain off of the middle implant
, which is your posterior tilted, comparing that to a standard
all-on-X arch without pterygoids.
And so we have data that shows,hey, we can reduce our stresses
(32:42):
and strain on our middleimplants and even on the
pterygoid implants, when youlook at the finite elemental
analysis, there's very littlestress and strain on those back
pterygoids.
So, granted, no cantilevers.
And reducing stress and strainis only one part.
(33:05):
Right.
The other part of this isocclusion and, you know, having
bilateral, simultaneous contactsand not having posterior
excursive interferences.
If you can do that, you'regoing to save yourself a lot of
trouble.
So you know I jumped in andhead into the the pterygoids.
(33:31):
I started back my my first sixpterygoid implants that I did
were back in 2017 and utilizethose for emergency cases where,
you know, I had a posteriorimplant that failed and I wanted
(33:53):
some extra anchorage.
So Vishy Broman asked me tocompile my pterygoid data, and
so the data that I have isactually already, you know,
behind.
It's probably two months behind,but as of probably the middle
(34:14):
of May, I had placed 974pterygoid implants.
So I think Vishy said that, outof the he's collecting all this
data, vishy has 8,000, has dataon 8,000 pterygoid implants.
(34:36):
And the interesting thing thathe said was that Dr Clark Damon
and Dan Holtzclaw are the numberone and two guys in the USA for
pterygoids.
Speaker 1 (34:47):
So I thought that was really kind of cool Congrats.
I assume you've hit 1,000 bynow.
Speaker 3 (34:52):
Yeah, so we're at 1,000 by now.
Fantastic, and I didn't even.
I got lazy, I didn't even lookat my 2018 or 2019 data, so
maybe there's some pterigoids inthat data as well.
But printing out a Pano andre-going over all of your cases
(35:13):
is actually a daunting feat Ican't imagine.
So let's see.
So the interesting thing hereis just kind of the ramp up.
Is just kind of the ramp up.
I started placing them in.
You know, like I said, it's2017 with six pterygoids in
(35:34):
function and I have eight-yearfollow-up on all of those and
zero failures.
In 2020, I had, from 2020 tonow, zero failures.
What's in front of me?
I don't have the number ofpterygoids I placed in 2020.
But in 2021, I placed 70pterygoids.
(35:56):
But in 2021, I placed 72.
In 2022, I placed 256, right?
So you can kind of start seeingwhere we're really ramping up
here 256, right, so you can kindof start seeing where we're
really.
There's a ramp up there, kind oframping up here.
Yeah, 23, 238, 24, 260, andcurrently in 25, I have 144, but
(36:23):
that's through May, so it'sprobably more like 175 by now.
So total failures 4.
1, 2, 3, 4 out of the 974.
I want to spend more time inthe data that I have and look at
(36:49):
the number of.
You know, I was not shy aboutif I had a pterygoid that was
only at 20 newton centimeters.
I would just carefully,carefully, put a cover screw on
it and we'd bury it If I feltthat it just had stability, just
(37:09):
not torque, right.
So I want to go through andfind, okay, well, out of the 974
, how many were loaded?
I mean, just off the cuff, Iwould say that most were loaded.
You know, maybe I couldprobably count maybe to 20 that
(37:29):
I didn't load 20.
And we would roll back in anduncover and always be able to
place an abutment.
Speaker 2 (37:37):
So if you're putting a targo in and you got like
under 20, maybe like a 10, didyou ever leave those or did you
remove those at the time?
Speaker 3 (37:47):
My dad is not that specific.
Speaker 2 (37:49):
Yeah, sure, because I've been, you know, back and
forth on some of those where, um, I'm, I'm, if I'm fairly
confident that I'm in the rightspot, you know, and that's, I
think that's the biggest hurdlewith pterygoids, right, you, you
can't see them, you don't know,know for sure.
But before I place anypterygoid I always get my probe
(38:10):
in there I'm feeling, makingsure that I have bone on all
four walls.
Yeah, making sure that I'm notthrough the lateral plate.
Or I think one of the biggest,not complications, but biggest
issues with placement that I seeare when people don't widen the
apex enough and they're kind ofdoing a trans sinus pterygoid
(38:32):
and it hits that posterior sinuswall and just slides it.
I see that quite a bit.
So if I know that I'm throughthat pterygoid, uh, the, the
through the pterygoid maxillaryjunction.
Yes, Through the junction Intothe into the pillar.
Into the pillar.
(38:52):
Then even, even at 10centimeters, I've put a cover
screw on those and I've hadsuccess doing that.
Um but uh, yeah, I was justcurious if, uh, you typically
would remove those, or if youhad a similar kind of thought
process where, if you werepretty confident it's in the
right place, you'll give it ashot at least.
Speaker 3 (39:12):
Yeah, I think, if I'm confident, now the huge concern
is just getting your coverscrew on and making sure that
you don't push it into theinfant temporal fossil, right?
Yeah, so typically kind of mygoal is is, you know, I would
like for my you know, because II place them on the contra angle
(39:37):
and I have it set to 30 and 30,30 rpms and 30 torque I would
like to hit 30 newtoncentimeters of torque on my hand
piece within and and still havefive or six millimeters of that
tear of the implant stickingout.
You know, super crustal, right?
Um, I basically will stop if,if I get like equal crustal, I'm
(40:05):
just like nope, we're gonna,we're gonna back this out and
I'm just going to kind ofreevaluate.
Um, and then, and then two tome it depends on how important
it is that we get the pterygoidback there.
Whether I'll leave it or not,um, you know like let's, let's
just say it's a, it's a quadzygote case, because I've had
one of these quad zygote case.
(40:25):
I didn't have a pterygoid, uh,get super stable, but I was like
I've got to have this.
So I left it and you know it'sin function today.
It's been in function for, youknow, three years, um.
So I do think that there issome some minor ossifying or
(40:46):
minor uh um osseointegrationpotential back there.
I don't think it's a lot.
I think most of the stabilitythat we get is from the
pyramidal process and most ofthe stability is going to be
primary.
But, that being said, probably30% said.
(41:12):
I mean you know I probably 30,30.
You know when, when it happensthat I'm getting less than 45
newton centimeters of torque,you know the first step is back
it out and and reorient rightand and reevaluate.
Um, you know, often, oftentimes, you know, when you have not
gone through that posteriorsinus wall into the
pterygomaxillary junction,because all of a sudden you're
(41:32):
going to be saying I don't thinkI drilled it at that angle,
because now all of a suddenyou're like this is a really
superior angle and I was alittle more shallow.
Well, that's when you knowyou're totally in the tuberosity
.
Well, that's when you knowyou're totally in the tuberosity
.
And the early data from Linkowand Tulsany and those people was
(41:55):
that the pterygoids they hadabout 62% success and it was
because actually a lot of themwere more tuberosity implants.
And you know, rodriguez et alsaid that the pyramidal process
is about 13.5 millimeters, andthat that is, you know, within
(42:17):
the palatine bone, 13.5millimeters high, and so we have
to get to that.
So we have to go through themaxillary tuberosity to get
there, and so what Rodriguez etal said back in 2017 was that
the minimal pterygoid implantlength should be 15 millimeters
(42:41):
so that you can get there.
And then that's obviously whenwe started seeing the pterygoid
implant success really, reallyexplode into the 90s 90% off
that 15 millimeters.
Speaker 2 (42:54):
Do you think that that is talking about?
If you don't reduce thetuberosity down?
Because now a lot of people aredoing reductions on the
tuberosity and I would imaginethat that would decrease that
number a little bit.
Speaker 3 (43:13):
Well, I mean my standard.
You know from the guy that'sdone 1,000 of them.
My standard, or my averagelength of pterygoid is 18.
My preference is, you knowagain, you run into trouble if
you're too anterior, right.
(43:34):
You run into trouble if you'retoo anterior and medial, right.
You run into trouble if you'retoo posterior and deep.
And you run into trouble ifyou're too lateral, you know.
So I like to place my coronalentrance point in between the
second and third molar, and justfrom geometry, because you're
(43:59):
already back that far, typically18 is what you need and I'm
also not looking to take out themedial pterygoid plate and I
don't necessarily want itresting on the medial pterygoid
plate either.
It doesn't have to be all theway there, it doesn't have to
brace against that.
All too often I see clinicianspost their axial cross-sections
(44:26):
of these x-rays and I'm like thetip of your implant is in black
.
Post their axial cross-sectionsof these x-rays and I'm like
the tip of your implant is inblack.
It's in black air.
You're in the nasal pharynxRight.
You've gone too medial and toodeep.
Clinicians always ask okay, Iknow where the pterygoid fossa
(44:49):
is and you know, on one side youhave the lateral, on the left
side you have the medial plate.
Where do I need to be?
And my answer to that is youget your stability in the
pyramidal process.
We're not getting our stabilityfrom the sphenoid bones and so
(45:12):
we don't need to be in themedial pterygoid plate.
Now I teach everybody aimtowards the medial pterygoid
plate, because you need to bemedial and the hamulus is a
great landmark.
That's where we want to be.
But because we're not gettingstability back there, I don't
necessarily want a 22-lengthimplant bracing against that
medial plate.
(45:32):
I can't feel that.
I don't know if we're there ornot because we're blind.
The other big thing that.
So where do you need to be?
Obviously, just view thelateral and the medial pterygoid
plate as a field goal.
As long as you're in betweenthere, you're pretty good.
(45:55):
Obviously, I want you know it'skind of good, better, best,
right, like if you're on thelateral, if you're touching that
lateral pterygoid plate butyou're still within the pillar.
Yeah that's good.
Better would be straight inbetween the uprights, right,
straight in between your, yourmedial and lateral plate, and
(46:16):
best would be hey, I aimed itand took and went straight, went
into the pyramidal process andI stopped right right at that.
That.
You know kind of that bendwhere it turns around and it
meets, uh, the, the fossa meetsthe pterygoid plate or the
medial pterygoid plate.
Speaker 2 (46:37):
That would be, you know, great because you have
almost 100 bone in contact atthat point you have lots, lots,
lots of bone implant contact now.
Speaker 3 (46:47):
Now we're not going to get any stability from the
maxillary tuberosity bone, sothat bone-to-implant contact
there really doesn't count.
Speaker 1 (47:00):
Well, that's something that really interests
me about when we sleep apterygoid, about when we sleep a
pterygoid, right.
So you know we don't expectthere to be, you know much, if
any, stability to come from theosteointegration of the tuber
osteobone, because it's mostlyfat back there, right, but we're
really just I mean, let's say,you go in between the uprights
and you go right through theparenteral process near that
(47:21):
fossa you know how much bonehave you actually passed through
that has the opportunity toosteointegrate.
It's amazing sometimes that wecan actually sleep a pterygoid
and just that you know just thatamount of bone osteointegrating
is going to, is going to grantus.
You know that that stabilitywhen we, when we go and uncover
and put a multi-unit on thereand I and I wonder, you know how
(47:43):
, in terms of how successful youcan be in sleeping a pterygoid
and letting it cook for a while.
you know how much of adifference it makes if you just
went kind of transversely,straight through um into the
fossa, versus if you, you know,engage the medial plate, um, you
know cause, obviously or atleast I would think that with
more bone implant contact downthe medial wing you're going to
have a better chance of gettingthat um, secondary stability um
(48:05):
down the road, whereas if youjust kind of just cross right
into the foster, there's not awhole lot of bone that's really
going to heal around thatimplant, I'm sure.
But but you know all that.
All that being said, I meanvery similar to your situations
where you've slept to ergoids.
I mean in times where I've donethat, it's been, you know, as
long as I'm in a relatively goodposition, it's been fairly
successful.
(48:25):
Yeah.
Speaker 3 (48:27):
And you know, I kind of feel like, on the rare
occasion that you don't achievetorque, I kind of do three
different things and I think itjust kind of depends on how I'm
feeling on the day.
Right, yeah, I may back it outand we may be like, all right,
sweetheart, you got fiveimplants, that's all you're
(48:48):
getting.
See ya, right, yeah, I maysleep it, or, you know, you know
I may say, hey, we'll see youback in three to four months and
we'll reattempt it, cause Iwant you to have a pterygoid.
So I really think it alldepends, you know, on depends on
(49:09):
that.
I've been happy on the caseswhere we didn't nail the
pterygoid and we nailed one onthe contralateral side, I've
been happy not doing an extrasurgery and then just finalizing
them and just being like that'swhat you get and then just
finalizing them and just beinglike that's that's what you get.
(49:32):
Yeah.
And you know, I've beenfrustrated on the ones where
I've kind of gone the extra mile, where it's like, okay, we'll
see you back in three to fourmonths, we'll add the pterygoid,
you know, cause then it justkind of now they're, they're
they're tooth process justextended, you know, yeah.
So it's always kind of you knowhalf of one, half of another,
and you know some.
Some days you get it right,some days, some days you don't
(49:58):
but you just got to loveyourself.
Speaker 1 (50:03):
That's right, that's good.
My name is Dr Tyler Tolbert and I'm Dr Soren Poppy,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Hello and welcome back to theFix Podcast.
We have a special guest on today, though he's becoming somewhat
of a regular.
Today we have on Dr Clark Damon, who has graced us with his
time, and today we're going tobe doing something that looks
(00:23):
like it could be a recurringsegment for us.
So, um, for those of you whohave taken his course, uh, down
in Texas at the Texas implantInstitute, um, you get, uh, to
be a part of the tribe.
It's a WhatsApp group with allof the alums from Clark's
courses and in there, um, youget to have these really candid
conversations with all the otheralums doing Fixed for Large,
(00:46):
the good, the bad, the ugly.
We share cases in there andClark is very on top of all the
messages in there, givingfeedback, giving recommendations
, sharing his own cases whetherthey go to plan or not.
It's been a really valuablecommunity.
So we got to thinking I thinkit was actually Clark's
suggestion that we come on hereregularly and talk about some of
these topics, and so we reallyappreciate him taking out the
(01:08):
time and welcome back to theshow Clark.
Speaker 3 (01:09):
Yeah Well, thanks Well, and you know, I also
wanted you know to, you know,interview you guys and actually
let y'all be a part of you know,the tribe that you're creating
with your sure.
Sure, yeah With with yourpodcast and and maybe have
something that's a little morelaid back and you know, just
(01:32):
kind of talking about.
Like you know what's going on,you know where, where are people
headed for CE, Just kind ofjust a little more.
You know more fluff kind of what?
A little more.
You know more fluff kind ofwhat's working.
You know how your practices aremoving and just you know
there's always these seasons ina full arch practice and you
(01:55):
know the seasons can be, youknow whenever you started, or it
could literally be within youknow the quarters of the year.
You know, I think typically, youthink typically the first half
of the year, full arch practicesare busier than the latter half
, and marketing is alwayssomething that changes, and I
think that's everybody's vein orbane of existence, and so it's
(02:20):
kind of interesting to seewhat's working, just kind of
that kind of stuff.
Speaker 2 (02:26):
So yeah, absolutely.
We'd love to get some questionsfor you too, or usually on the
uh giving end, so it will benice.
Speaker 1 (02:36):
Absolutely, absolutely so, um, but yeah, I
did want to.
Uh, yeah, and you're more thanwelcome to flip the script on us
and, um, you know, it'd be thefirst time that I think either
of us have ever been interviewedon our show, so I'm I'm more
than welcome, um, for that.
But, uh, but, yeah, so I did.
I did put together just a fewtopics, um, kind of going back
through the tribe conversationsall the way back to, I think,
(02:57):
when, when we first joined, wasback in January of this year,
and, uh, there was a really um,interesting topic that came up,
and I think it actually came uparound the time that Soren um
had a case like this comethrough his clinic where, um,
you have a patient that, let'ssay, they have a high smile line
.
They may not even have aparticularly high smile line,
(03:17):
but what you deal with is youhave pneumatization of the
sinuses.
That goes so far to the pointwhere where you're trying to do
your, your alveo and and raisewhere that transition line is
going to end up being, butyou're out of runway, you don't
have enough sinus bone to takeaway, so you've got these gums
are visible and there's not anyforeseeable way to do that
(03:39):
simply with reduction, like wenormally do.
And so in the group you shareda case where you had done some
sinus crushing, so basicallyupping the sinus floor, doing
some grafting and sort ofraising that platform.
So I was hoping you can kind ofwalk us through you know
indications for that some issuesthat can come about, possibly
some alternatives for cases thatlook like that, because you
know every so often these docome through our door and that's
(04:00):
not a simple thing to treat.
Speaker 3 (04:03):
Right, yeah, so I think you know.
The first thing is you know,understand your limitations
right and and know when to referit, or really you know, now
there's there's a lot ofclinicians.
Even myself I'll go intopeople's offices in Texas and I
even recently got an Oklahomalicense and go in, go into
(04:24):
people's offices and help themout on more complex cases, you
know.
So one one issue that clinicianshave is maybe they can do the
lower arch and it's simple, butthe upper may be, you know, more
difficult, and so actuallybringing somebody in is so much
easier.
You can learn so much from thatclinician coming into your
(04:48):
office to treat your patientversus just referring them out,
like if you refer the patientout, which is obviously can be
the best thing for the patient,you miss out on that educational
opportunity.
And so consider these options.
I think Juan Gonzalez can comein and he kind of flies around.
(05:10):
I think the difference is alittle bit limited to can the
clinician actually touch thepatient, if they have a license
or not.
So that's something to takeinto consideration.
But hit me up.
(05:35):
If you're in Texas or Oklahomaand you want me to come, do a
case and you really want tolearn, I'll come and let's get
an.
I think too many clinicians aretaking on cases that they really
shouldn't be doing.
I think there's a big driverand a big push for revenue,
revenue, revenue, top line.
But when you push a standard,when you push a case to be a
(05:58):
standard, that is not a standard.
That needs to be done.
Patsy, you're going to haveproblems and these problems will
come home to roost fairlyquickly, with temps breaking,
not being able to manage a smileline.
So on a case where the sinushangs inferiorly to the
(06:20):
reduction plane, clinicians aregoing to have, you know, they
need to one, identify it, and itcan be a difficult thing to
identify.
Two, the clinicians.
You know there's no way aroundit.
You can't say, oh, we'll put aflange on it.
You can't say, oh well, we'lljust have a shortened bridge.
(06:42):
In that case, you know, becausethen it's going to be, you know
, a first premolar, you know$20,000, $25,000 implant bridge.
So again, the patient's goingto be unhappy.
So clinicians typically have twooptions when dealing with this.
One you know you have to dosomething.
(07:03):
So not doing anything is not anoption.
So option one is doingpre-surgical grafting or
pre-arch surgery grafting, andthat is a very viable
alternative.
And on certain cases we can doa sinus crush intraoperatively
(07:25):
and then that way the patientcan have one surgery.
Now I would.
So what are the indications ofa sinus crush?
I think number one the patientneeds to be a dentulist Trying
to do a sinus crush whenpatients have teeth is going to
(07:46):
be difficult Oftentimes.
And why right?
It is likely that you're goingto have some type of
communication You're going tohave.
The sinuses are going to bepneumatized, the roots are going
to be into the sinus, sooftentimes we're going to have
(08:09):
several tears there.
So I would say to do a sinuscrush indication would be
edentulous.
Speaker 1 (08:19):
Now, does that mean fully edentulous or just
edentulous in the areas whereyou would be looking to do the
crush, so you don't have allthat anatomy?
I guess that's a good point,right?
They could be partiallyedentulous or just edentulous in
the areas where you would belooking to do the crush, so you
don't have all that anatomy.
Speaker 3 (08:26):
I guess that's a good point.
They could be partiallyedentulous, as long as they're
edentulous in the area thatwe're crushing.
But again, we're talkingpneumatized sinuses.
So oftentimes if there's acanine, if they're edentulist
maybe they only have the frontsix teeth.
(08:46):
Having a canine may really bepushing it.
Always do what's predictable inyour hands.
If doing a sinus lift is morepredictable for you as long as
you can nail it and then thatway you can come back and
(09:07):
whenever you do your alveolarreduction.
Now you have sinus graftedmaterial there and you don't
have to worry about alow-hanging membrane and you
don't have to worry aboutcrushing it.
Speaker 2 (09:24):
I want to quickly go back real quick to what you were
talking about earlier abouttaking these cases on, and one
thing I want to mention foreverybody listening to this is
if you take on, like Clark wassaying, a case that should be
Patsy and you do it for acertain price, you're not only
putting the patient in thesituation where they might need
(09:47):
another surgery in the futurewith, like a zygote or something
like that, but a lot of timesyou should just keep in mind as
well that most of these patientsthat are coming to your office
at least most doctors that Iknow they're charging a set fee
for the whole surgery.
So if you do that surgery andlater it needs to end up being
(10:07):
Patsy, just remember that you'reprobably going to be the one
fronting the cost for the secondanesthesia, for another
provider coming in to do zygosand potentially, like you know,
someone coming in to dopterygoids.
So, yes, like these cases inparticular, combination syndrome
, kelly syndrome, zygocases, youknow maybe pushing the envelope
(10:31):
too far on palatal approach, ifyou start that case thinking
okay, yeah, great, like I'mgoing to test out these
different implants that I know,and that you might end up in a
situation where you're payingout $10,000 for another
anesthesia bill and anotherprovider to come into the office
by not referring that orbringing someone into your
(10:53):
office right off the bat.
Sorry, clark, from gettingaside from the crushing sinus
thing.
I just wanted to quicklymention that because I think
that's a really important point.
That because I think that's areally important point.
And when I first was likegetting into some of the more
advanced implants, it happenedto me one or two times where we
ended up having to pay foranother provider to do zygos.
(11:15):
Because I took on like a casethe cases that happened to me.
They worked out, they were justthe implants An implant failed
and I needed a zygomatic implant.
But just something to thinkabout before taking on these
challenging cases.
Speaker 3 (11:29):
Yeah, it's always better to do things right the
first time and the cost ofbringing a provider in when done
the first time, you can stillmake a fair amount of money on
that.
It's just when you've alreadylost your afternoon the first
time.
You can still make a fairamount of money on that.
It's just when you've alreadylost your afternoon the first go
and then now you have a secondanesthesia bill, you have a
(11:52):
second prosthesis bill, secondlab bill, second implant bill.
Now you have a provider bill,you know, and then you know.
So not only are you not makingmoney, but then now the
patient's like oh gosh, you hadto have somebody else come fix
it Versus.
Hey, I know where to go.
This guy's really nice and he'shooked me up with some other
guy that can come in and takecare of me.
(12:13):
That's like a win-win-win.
Speaker 1 (12:14):
You're a quarterback in that situation Looks good.
Yeah, for sure.
Speaker 2 (12:29):
Yeah, and never, you know, don't feel bad telling
your patient like, hey, I can dotraditional all-on-four, maybe
pterygoids very well, but yourcase happens to be one that
needs a little bit more advancedimplants for that.
Luckily, you know, I am goodfriends with some of the, you
know, whatever circle you're in,but I'm good friends with some
of the best implant surgeons inthe United States and I can have
them come and piggyback me onthis case so you get the best
(12:50):
possible treatment and patientsaren't going to look at you
poorly for doing that.
You're providing them supportand ensuring that they get
really good care in your office.
Speaker 1 (13:01):
And I do have a question about that too, clark.
So you know you are offering toothers that are in Texas or
Oklahoma your services.
If someone looks you to comeout for placing a Zygo, what
have you?
Obviously they're notcomfortable doing it themselves.
Well, they're probably notgoing to be feeling very
(13:21):
comfortable dealing with a Zygocomplication, should that happen
down the road right.
So is that something that youknow?
Whenever you have an agreementwith somebody like, hey, I'm
going to come out and help youout with this, you know Zygo
case, would you also beavailable to come out as well if
there's any issues with that?
Do you want to be there forfollow-up?
What does that kind of looklike?
Just to kind of paint a pictureof you know, if I'm going to
bring someone into my office,what can I expect if there's
(13:42):
ever some issues?
Speaker 3 (13:44):
Yeah, you know.
I mean, as you guys know, right, like when you start doing more
all-on-X cases, you get moreall-on-X cases and it's not
going to be, you're not going tohave the one time that you need
(14:06):
to bring an advanced providerin, right?
Like these advanced cases showup on a relative frequent basis,
right?
so um, what I, what I try to dowith.
You know the current offices.
You know one of my offices thatI go to in houston, uh, I'm
there once a month.
Um, another office you myoffices that I go to in Houston,
I'm there once a month.
Another office you know thatI'll go to in Oklahoma, I'm
(14:29):
there once a quarter, right?
So you know there's a regularcadence on that and so you know
often, oftentimes, if there'ssome issue, you know.
But going back, like I mean, Ireally try to educate these
patients like, hey, we did zygos.
(14:50):
Do not use a water pick on yourzygote.
You know sinus precautions forthe first.
You know, three weeks, don'tget on an airplane.
You know most, most, you knowpostoperative complications with
it, with a zygomatic, are goingto occur.
You know, a month, maybe maybetwo to three months down the
(15:11):
road, right, so then you knowyour cadence is kind of already
there.
And then also also when, whenyou think with an open mind
about that cadence, right thennow you're going to feel
comfortable selling more cases,right, like you know, think back
when you guys had sold, youknow, maybe under 75 arches.
(15:34):
You know, I'm sure there weresome cases where you're like,
yeah, I can, I can do this.
In the back of your mind You'relike Nope, don't do it, don't
do it.
Speaker 1 (15:43):
Right.
Speaker 3 (15:44):
But if, if you have somebody coming in on a regular
basis, boom, mrs Jones, we cando this for you.
We're going to put that on DrX's schedule.
He's going to be here in twoand a half months, no big deal,
you know.
Whatever we're going to by thetime, we, you know, send off
your medical consults, your EKG,your labs.
(16:06):
We get your teeth designed,smile designed.
You're only going to wait acouple of weeks.
I mean, you can just kind ofcreate a song and dance, so
certain things to just kind ofthink through.
That is the one challenge is,if a patient has a larger
postoperative problem, we don'twant to abandon the patient, and
(16:30):
so the clinician does need totake that into consideration.
So, whether or not you meet thepatient halfway, the patient
comes to your office, you go totheirs, vice versa, that sort of
thing.
Speaker 1 (16:45):
Yeah, so I do want to go back to the sinus crushing
just a little bit.
So, when it comes to theintraoperative sinus crush, what
does that look like?
What's the instrumentation?
How are you thinking throughthat process?
Speaker 2 (16:59):
And what complications have you seen?
Speaker 1 (17:01):
Yeah, that's great too, yeah.
Speaker 3 (17:03):
So all right, so we're just going to go back.
Indications on that.
You know, again, for a signage,crush, I want it to be
edentulous, or at leastedentulous in the site that
we're going to be crushing.
The technique you want to uselike a number eight diamond burr
(17:24):
, use like a number eightdiamond burr and you want to
score.
You want to score that 360degrees around where you're
going to tap in.
And you know, obviously theseare, these are, it's a sinus,
it's a large sinus.
So just picture, you're goingto want to crush an area that's
probably the size of your thumb.
(17:45):
Okay, so you want to make areally big elliptical scoring of
the bone and especially thepalatal bone.
So if we're going to be dealingwith the palate, we're going to
want to reflect all the waydown to the horizontal portion
of our palate.
We're going to want a largepalatal reflection, a large
(18:06):
buccal reflection, and we'regoing to want a large palatal
reflection, a large bucklereflection, and we're going to
do a 360 degrees, scoringroughly the size of your thumb,
concentrically around the sinusthat you wish to crush.
After you've scored it, then youcan take your osteotome.
You take the back end of theosteotome right, like just
(18:27):
picture the Norris 3-0 osteotome.
Okay, you don't want to choosethe pointy one, but you want to
choose the one that has theblunt tip.
Well, you're going to use it inreverse, right?
So you're going to take the fatend of the handle and you're
(18:48):
going to hammer onto the blunttip of that osteotome and so
that's going to crack andfracture in that sinus and then
you just continue to push it upand push it up.
Then you have to make sure thatyou've gotten it up beyond your
(19:08):
occlusal reduction plane.
So how do we know that?
Well, you probably need an MUAguide and with your MUA guide
you have the teeth there and youneed to measure up 12, 13, 14
millimeters.
I would measure up 14.
(19:29):
I like 14.
Make sure that the bone isreduced beyond that and so that
way we can establish ourrestorative space emergence
profile and hide our transitionline.
So to date I've done 3,000arches and the number of arches
(19:54):
that we've done sinus crushes onis 0.1%.
So I've only treated threecases with the sinus crush,
treated three cases with thesinus crush.
Now there's a lot of cases outthere.
I mean, I think probably bothof you guys have seen cases
(20:14):
where, yeah, we need to dosomething here, so it is
prevalent.
What's been interesting, though, is the patients haven't had
the money.
The ones that have needed thesinus crushes, so they actually,
you know, they haven't had themoney.
The ones that have needed thesinus crushes so they actually,
you know, they haven't movedforward with treatment, which
has been interesting, so that'swhy I only have literally three
three out of 3,000 arches.
Speaker 1 (20:35):
Yeah.
Speaker 3 (20:37):
So you know complications, you know none of
my cases had complications,because again it just kind of
goes back to case selection andthey didn't have teeth right.
So again I'm going to take outvariables that I can't manage
right.
So if, if I get a largefracture of the alveolus, if I
(21:00):
get a large sinus perforation,you know, then then then now
complications go up, right, youknow you can get the sinus to be
infected and all that sort ofstuff.
Another part of my technique isI'm not utilizing particulate
graft so we fracture the sinusin.
(21:23):
The sinus stays attached to thebone and all of that periosteum
and all that blood supply andit goes in.
And maybe I'll put one or twopieces of collar tape, no more,
and that helps hold up thematerial.
(21:44):
It establishes a really goodblood clot and then you can
utilize a nice just college andmembrane over that to help seal
it off.
And you know I'll push thesinus up.
You know all the way, kind offront to back, I'll get it
raised, you know 10 millimetersand you know, put that college
(22:06):
membrane in and everything healsreally nicely.
It takes about a year and a halfto really start to see all of
that kind of begin to ossifyfully in.
You can start seeing.
At about six months you canreally kind of start to see okay
, my sinus is clear.
(22:26):
You know, what are things wewant to see on a post-operative
basis?
No oac.
On a post-operative basis, wewant to see that the sinus uh is
healing and that the uh sinusis clear and that there's not
any um rhinosinusitis or chronicsinusitis.
What other questions you guysgot?
Speaker 1 (22:50):
Well, I think the only thing that I have left on
that one and I'll leave itbecause I know we spent some
time on it, but I guess I'm justcurious about.
So you're kind of making thisoculus of bone, right, it's like
a window of bone that's gettingcrushed up into the sinus.
I guess I'm just curious abouthow that heals.
Like, what is?
What kind of architecture doyou see in followup?
So you mentioned, like a yearbefore, everything ossifies.
(23:11):
Like what, what kind of healingare you expecting to see and
what does that look like?
Speaker 3 (23:18):
The only thing that I want to see is that we'll kind
of re ossify a floor.
Right, we left the bone and sothen it will ossify by lifting
it up and not utilizingparticulate graft the cases
(23:40):
where what I'm trying to do isI'm trying to use as much
metogenous stuff as possible.
I want the patient's blood.
I don't want to put a bunch ofdead cow bone in there, a bunch
of dead human bone in there.
I don't really want to do that.
But the sinus has such ahealing potential.
(24:01):
Anything we put to lift it upwill turn into bone eventually.
And so you know, even on, evenon, uh, zygomatics, um, you know
, when we do a nice channelalong the, the buccal alveolus,
there, I'll kind of lift up themembrane.
I do not do particulate graft,I'll just put a little um, a
(24:25):
piece of collar tape in thereand then a year later it
ossifies and you get a nice plugof bone all where that sinus
was lifted.
Speaker 1 (24:35):
Very nice, very nice.
Speaker 2 (24:38):
I think it's a great technique to have in your back
pocket for a case that maybe,like you said, you need a
minimal amount of sinus lift,case that maybe, like you said,
you, you need a minimal amountof of sinus lift, um, but uh,
you know, cause, if, if you'relifting the sinus like so, I had
a case and I I know you sawthis one, um Clark, where the
guy smiled and his sinuses wereso far down, um, and my plan on
(25:02):
that case was option one, bigsinus lifts lifts and then
coming back and attempting thecase in that manner.
But there's a lot of patientsout there that smile, you know,
and they have that Kellysyndrome, they have that
combination syndrome, but maybeit's only like four or five
millimeters that are showing forsomeone like that that once
(25:23):
they get it done in one surgerymaybe doesn't, they can't do the
whole, waiting six to eightmonths for the sinus lift to
heal and then allowing it to getit done right away rather than
waiting that long period of time.
Speaker 3 (25:39):
Yeah, the one particular case you know.
Obviously, this gentlemansmiled really high and you could
, you know, see the mucogingivaljunction bilaterally.
He had gullwing lips.
You could actually see probably5 millimeters beyond the
mucogingival junction.
In addition, he had all of histeeth and they were all just
(26:01):
rotted down to the gum line.
And so my recommendation on acase like that is edentulate,
get everything healed first.
I wouldn't even do the sinuslifts Like this would be an
ultra-staged case.
Hey, we're going to take yourteeth out, you're going to heal,
we're going to make sure yoursinuses heal.
(26:22):
I believe that patient hadsinus disease too, right, yeah?
Speaker 2 (26:26):
he did.
He had really really badsinuses heal.
I believe that patient hadsinus disease too.
Right, yeah, he did.
Speaker 3 (26:27):
He had really really bad sinuses um that's why so he
made teeth out yeah, teeth out,then maybe go get a fess and
then come back and then get asinus lift and then come back
and then get your art surgeryright.
Speaker 2 (26:41):
So um and that's, that's what I did.
A uh took the teeth out, letthose heal.
Um, he sent him to an ENT.
Uh, they, he like, kept pushingoff the fest.
Um came back into my office.
The sentences were a little bitclear, you know a little bit,
but not definitely not wherethey needed to be.
Um, and then on what we endedup deciding was he was like you
(27:04):
know, I just don't want to dothis anymore.
Uh, so we put them on the topand, uh, fixed on the bottom.
Um, and honestly that was kindof a relief for me because that
was like I would have had to.
You do a sinus lift that bigand you fill it with I don't
know, 10, 15 cc's of bone andhow long is it going to take for
(27:30):
that bone to ossify Like it'sgoing to take a long, long time
and you go in there and cuteverything down and it's going
to be mush and I just I didn't.
I honestly like wasn'tconfident that it would have
healed the way that I wanted itto.
And you know, the patientdidn't want to spend more than
our traditional all on X fee andit was a lot of surgery to do
(27:55):
with unsure prognosis.
Speaker 3 (27:58):
Right, well, but let's just assume that he wanted
to do it, that he wanted to doit.
Obviously your concern is right.
Just because we put in boneinto the sinus.
We've all seen cases where thebone just is mush, right.
So then what do you do?
(28:19):
Well, now you have a greatzygote case because you got the
sinuses way out of the way right.
Great zygote case because yougot the sinuses way out of the
way right and so now you can goin like that is, that is a great
zygote case because you're nothaving to worry about okay, well
, you know, you know is.
Is there going to be along-term oac here?
The sinuses are super high.
(28:39):
All you got to worry about isjust getting really dense,
remote anchorage into the zygoma.
So it doesn't even matter ifthat bone becomes mush, which it
may, because it is so large,because you're going to get
remote anchorage.
I was actually referred a casevery similar to that several
years ago.
(28:59):
They squeezed in an all on astandard arch on a Patsy patient
.
Lo and behold, three implantsfail.
They go in.
They add in a couple moreimplants, so the guy had his
second surgery.
They then said well, you know,things are getting really
(29:21):
constricted, you're only on like10 teeth, so let's go in and do
bilateral sinus lifts.
So he had his third surgery.
It was bilateral sinus lifts,and then they put in.
They waited for that to heal andthen they came back in and they
popped in you know, like fourimplants into the sinus and they
all torqued to like five newtoncentimeters and these
(29:44):
clinicians were like, oh my gosh, and the patient was just worn
out.
So they referred him to me.
They wanted me to just do itand actually just uncover him in
hopes that the implantsactually torqued or, you know,
osseointegrated.
(30:04):
But have me have the patientout, sedated and ready to go to
throw in zygos.
If they just backed out and Imean they backed out in a second
, all four, and so you know,which is no big deal, we'll just
, you know, roll in and do thezygos, like what we planned, and
you know the patient was very,very grateful.
I'm thankful for the patientbecause he got out of that cycle
(30:27):
right.
But again, um, just because wecan sinus lift, you know,
doesn't mean that that's theanswer to all of our, to all of
our problems, for sure.
So, uh, you know, if, if you'renot wanting to commit to a case
like that because you're afraidof mush bone after you do the
sinus lift, that needs to be inyour head.
(30:50):
You need to think you can'tjust think the sinus lift is
going to solve your problems,but roll in and do a zygote or
have somebody come and do thezygote then, and then the
patient can be a Patsy and itwill work great.
Speaker 1 (31:22):
Agreed about, every maxillary case can benefit from
the use of pterygoids, and Ithink that you, you know you've
shared some data I think weactually talked about in an
interview with Zellig about datayou've collected on pterygoids
that you've placed and thesuccess has come about that and
they were extremely impressiveand really better than standard
(31:43):
implants really, and so I washoping you could share that as
well.
And then I do have a few, youknow, minor, subtle questions
about how we place ourpterygoids and the ideal depth
and multi-unit selection andthings like that.
So could you talk a little bitabout your follow-up on your
pterygoids?
Speaker 3 (31:57):
Yeah, so, um, excuse me, Uh, you know, Wilkerson put
out an article in 2000, uh, 2021, and it was a finite elemental
analysis article and it showedthat by utilizing pterygoids it
(32:21):
took significant stress andstrain off of the middle implant
, which is your posterior tilted, comparing that to a standard
all-on-X arch without pterygoids.
And so we have data that shows,hey, we can reduce our stresses
(32:42):
and strain on our middleimplants and even on the
pterygoid implants, when youlook at the finite elemental
analysis, there's very littlestress and strain on those back
pterygoids.
So, granted, no cantilevers.
And reducing stress and strainis only one part.
(33:05):
Right.
The other part of this isocclusion and, you know, having
bilateral, simultaneous contactsand not having posterior
excursive interferences.
If you can do that, you'regoing to save yourself a lot of
trouble.
So you know I jumped in andhead into the the pterygoids.
(33:31):
I started back my my first sixpterygoid implants that I did
were back in 2017 and utilizethose for emergency cases where,
you know, I had a posteriorimplant that failed and I wanted
(33:53):
some extra anchorage.
So Vishy Broman asked me tocompile my pterygoid data, and
so the data that I have isactually already, you know,
behind.
It's probably two months behind,but as of probably the middle
(34:14):
of May, I had placed 974pterygoid implants.
So I think Vishy said that, outof the he's collecting all this
data, vishy has 8,000, has dataon 8,000 pterygoid implants.
(34:36):
And the interesting thing thathe said was that Dr Clark Damon
and Dan Holtzclaw are the numberone and two guys in the USA for
pterygoids.
Speaker 1 (34:47):
So I thought that was really kind of cool Congrats.
I assume you've hit 1,000 bynow.
Speaker 3 (34:52):
Yeah, so we're at 1,000 by now.
Fantastic, and I didn't even.
I got lazy, I didn't even lookat my 2018 or 2019 data, so
maybe there's some pterigoids inthat data as well.
But printing out a Pano andre-going over all of your cases
(35:13):
is actually a daunting feat Ican't imagine.
So let's see.
So the interesting thing hereis just kind of the ramp up.
Is just kind of the ramp up.
I started placing them in.
You know, like I said, it's2017 with six pterygoids in
(35:34):
function and I have eight-yearfollow-up on all of those and
zero failures.
In 2020, I had, from 2020 tonow, zero failures.
What's in front of me?
I don't have the number ofpterygoids I placed in 2020.
But in 2021, I placed 70pterygoids.
(35:56):
But in 2021, I placed 72.
In 2022, I placed 256, right?
So you can kind of start seeingwhere we're really ramping up
here 256, right, so you can kindof start seeing where we're
really.
There's a ramp up there, kind oframping up here.
Yeah, 23, 238, 24, 260, andcurrently in 25, I have 144, but
(36:23):
that's through May, so it'sprobably more like 175 by now.
So total failures 4.
1, 2, 3, 4 out of the 974.
I want to spend more time inthe data that I have and look at
(36:49):
the number of.
You know, I was not shy aboutif I had a pterygoid that was
only at 20 newton centimeters.
I would just carefully,carefully, put a cover screw on
it and we'd bury it If I feltthat it just had stability, just
(37:09):
not torque, right.
So I want to go through andfind, okay, well, out of the 974
, how many were loaded?
I mean, just off the cuff, Iwould say that most were loaded.
You know, maybe I couldprobably count maybe to 20 that
(37:29):
I didn't load 20.
And we would roll back in anduncover and always be able to
place an abutment.
Speaker 2 (37:37):
So if you're putting a targo in and you got like
under 20, maybe like a 10, didyou ever leave those or did you
remove those at the time?
Speaker 3 (37:47):
My dad is not that specific.
Speaker 2 (37:49):
Yeah, sure, because I've been, you know, back and
forth on some of those where, um, I'm, I'm, if I'm fairly
confident that I'm in the rightspot, you know, and that's, I
think that's the biggest hurdlewith pterygoids, right, you, you
can't see them, you don't know,know for sure.
But before I place anypterygoid I always get my probe
(38:10):
in there I'm feeling, makingsure that I have bone on all
four walls.
Yeah, making sure that I'm notthrough the lateral plate.
Or I think one of the biggest,not complications, but biggest
issues with placement that I seeare when people don't widen the
apex enough and they're kind ofdoing a trans sinus pterygoid
(38:32):
and it hits that posterior sinuswall and just slides it.
I see that quite a bit.
So if I know that I'm throughthat pterygoid, uh, the, the
through the pterygoid maxillaryjunction.
Yes, Through the junction Intothe into the pillar.
Into the pillar.
(38:52):
Then even, even at 10centimeters, I've put a cover
screw on those and I've hadsuccess doing that.
Um but uh, yeah, I was justcurious if, uh, you typically
would remove those, or if youhad a similar kind of thought
process where, if you werepretty confident it's in the
right place, you'll give it ashot at least.
Speaker 3 (39:12):
Yeah, I think, if I'm confident, now the huge concern
is just getting your coverscrew on and making sure that
you don't push it into theinfant temporal fossil, right?
Yeah, so typically kind of mygoal is is, you know, I would
like for my you know, because II place them on the contra angle
(39:37):
and I have it set to 30 and 30,30 rpms and 30 torque I would
like to hit 30 newtoncentimeters of torque on my hand
piece within and and still havefive or six millimeters of that
tear of the implant stickingout.
You know, super crustal, right?
Um, I basically will stop if,if I get like equal crustal, I'm
(40:05):
just like nope, we're gonna,we're gonna back this out and
I'm just going to kind ofreevaluate.
Um, and then, and then two tome it depends on how important
it is that we get the pterygoidback there.
Whether I'll leave it or not,um, you know like let's, let's
just say it's a, it's a quadzygote case, because I've had
one of these quad zygote case.
(40:25):
I didn't have a pterygoid, uh,get super stable, but I was like
I've got to have this.
So I left it and you know it'sin function today.
It's been in function for, youknow, three years, um.
So I do think that there issome some minor ossifying or
(40:46):
minor uh um osseointegrationpotential back there.
I don't think it's a lot.
I think most of the stabilitythat we get is from the
pyramidal process and most ofthe stability is going to be
primary.
But, that being said, probably30% said.
(41:12):
I mean you know I probably 30,30.
You know when, when it happensthat I'm getting less than 45
newton centimeters of torque,you know the first step is back
it out and and reorient rightand and reevaluate.
Um, you know, often, oftentimes, you know, when you have not
gone through that posteriorsinus wall into the
pterygomaxillary junction,because all of a sudden you're
(41:32):
going to be saying I don't thinkI drilled it at that angle,
because now all of a suddenyou're like this is a really
superior angle and I was alittle more shallow.
Well, that's when you knowyou're totally in the tuberosity
.
Well, that's when you knowyou're totally in the tuberosity
.
And the early data from Linkowand Tulsany and those people was
(41:55):
that the pterygoids they hadabout 62% success and it was
because actually a lot of themwere more tuberosity implants.
And you know, rodriguez et alsaid that the pyramidal process
is about 13.5 millimeters, andthat that is, you know, within
(42:17):
the palatine bone, 13.5millimeters high, and so we have
to get to that.
So we have to go through themaxillary tuberosity to get
there, and so what Rodriguez etal said back in 2017 was that
the minimal pterygoid implantlength should be 15 millimeters
(42:41):
so that you can get there.
And then that's obviously whenwe started seeing the pterygoid
implant success really, reallyexplode into the 90s 90% off
that 15 millimeters.
Speaker 2 (42:54):
Do you think that that is talking about?
If you don't reduce thetuberosity down?
Because now a lot of people aredoing reductions on the
tuberosity and I would imaginethat that would decrease that
number a little bit.
Speaker 3 (43:13):
Well, I mean my standard.
You know from the guy that'sdone 1,000 of them.
My standard, or my averagelength of pterygoid is 18.
My preference is, you knowagain, you run into trouble if
you're too anterior, right.
(43:34):
You run into trouble if you'retoo anterior and medial, right.
You run into trouble if you'retoo posterior and deep.
And you run into trouble ifyou're too lateral, you know.
So I like to place my coronalentrance point in between the
second and third molar, and justfrom geometry, because you're
(43:59):
already back that far, typically18 is what you need and I'm
also not looking to take out themedial pterygoid plate and I
don't necessarily want itresting on the medial pterygoid
plate either.
It doesn't have to be all theway there, it doesn't have to
brace against that.
All too often I see clinicianspost their axial cross-sections
(44:26):
of these x-rays and I'm like thetip of your implant is in black
.
Post their axial cross-sectionsof these x-rays and I'm like
the tip of your implant is inblack.
It's in black air.
You're in the nasal pharynxRight.
You've gone too medial and toodeep.
Clinicians always ask okay, Iknow where the pterygoid fossa
(44:49):
is and you know, on one side youhave the lateral, on the left
side you have the medial plate.
Where do I need to be?
And my answer to that is youget your stability in the
pyramidal process.
We're not getting our stabilityfrom the sphenoid bones and so
(45:12):
we don't need to be in themedial pterygoid plate.
Now I teach everybody aimtowards the medial pterygoid
plate, because you need to bemedial and the hamulus is a
great landmark.
That's where we want to be.
But because we're not gettingstability back there, I don't
necessarily want a 22-lengthimplant bracing against that
medial plate.
(45:32):
I can't feel that.
I don't know if we're there ornot because we're blind.
The other big thing that.
So where do you need to be?
Obviously, just view thelateral and the medial pterygoid
plate as a field goal.
As long as you're in betweenthere, you're pretty good.
(45:55):
Obviously, I want you know it'skind of good, better, best,
right, like if you're on thelateral, if you're touching that
lateral pterygoid plate butyou're still within the pillar.
Yeah that's good.
Better would be straight inbetween the uprights, right,
straight in between your, yourmedial and lateral plate, and
(46:16):
best would be hey, I aimed itand took and went straight, went
into the pyramidal process andI stopped right right at that.
That.
You know kind of that bendwhere it turns around and it
meets, uh, the, the fossa meetsthe pterygoid plate or the
medial pterygoid plate.
Speaker 2 (46:37):
That would be, you know, great because you have
almost 100 bone in contact atthat point you have lots, lots,
lots of bone implant contact now.
Speaker 3 (46:47):
Now we're not going to get any stability from the
maxillary tuberosity bone, sothat bone-to-implant contact
there really doesn't count.
Speaker 1 (47:00):
Well, that's something that really interests
me about when we sleep apterygoid, about when we sleep a
pterygoid, right.
So you know we don't expectthere to be, you know much, if
any, stability to come from theosteointegration of the tuber
osteobone, because it's mostlyfat back there, right, but we're
really just I mean, let's say,you go in between the uprights
and you go right through theparenteral process near that
(47:21):
fossa you know how much bonehave you actually passed through
that has the opportunity toosteointegrate.
It's amazing sometimes that wecan actually sleep a pterygoid
and just that you know just thatamount of bone osteointegrating
is going to, is going to grantus.
You know that that stabilitywhen we, when we go and uncover
and put a multi-unit on thereand I and I wonder, you know how
(47:43):
, in terms of how successful youcan be in sleeping a pterygoid
and letting it cook for a while.
you know how much of adifference it makes if you just
went kind of transversely,straight through um into the
fossa, versus if you, you know,engage the medial plate, um, you
know cause, obviously or atleast I would think that with
more bone implant contact downthe medial wing you're going to
have a better chance of gettingthat um, secondary stability um
(48:05):
down the road, whereas if youjust kind of just cross right
into the foster, there's not awhole lot of bone that's really
going to heal around thatimplant, I'm sure.
But but you know all that.
All that being said, I meanvery similar to your situations
where you've slept to ergoids.
I mean in times where I've donethat, it's been, you know, as
long as I'm in a relatively goodposition, it's been fairly
successful.
(48:25):
Yeah.
Speaker 3 (48:27):
And you know, I kind of feel like, on the rare
occasion that you don't achievetorque, I kind of do three
different things and I think itjust kind of depends on how I'm
feeling on the day.
Right, yeah, I may back it outand we may be like, all right,
sweetheart, you got fiveimplants, that's all you're
(48:48):
getting.
See ya, right, yeah, I maysleep it, or, you know, you know
I may say, hey, we'll see youback in three to four months and
we'll reattempt it, cause Iwant you to have a pterygoid.
So I really think it alldepends, you know, on depends on
(49:09):
that.
I've been happy on the caseswhere we didn't nail the
pterygoid and we nailed one onthe contralateral side, I've
been happy not doing an extrasurgery and then just finalizing
them and just being like that'swhat you get and then just
finalizing them and just beinglike that's that's what you get.
(49:32):
Yeah.
And you know, I've beenfrustrated on the ones where
I've kind of gone the extra mile, where it's like, okay, we'll
see you back in three to fourmonths, we'll add the pterygoid,
you know, cause then it justkind of now they're, they're
they're tooth process justextended, you know, yeah.
So it's always kind of you knowhalf of one, half of another,
and you know some.
Some days you get it right,some days, some days you don't
(49:58):
but you just got to loveyourself.
Speaker 1 (50:03):
That's right, that's good.
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