September 29, 2025 • 56 mins
Dive deep into the advanced world of pterygoid implant placement with Dr. Clark as he shares game-changing insights that can transform your full-arch implant practice. This episode tackles one of the most challenging aspects of full-arch rehabilitation – achieving perfect prosthetic outcomes through precise surgical execution.
Dr. Clark challenges conventional wisdom about pterygoid implant placement depth, advocating for a more nuanced approach where anterior implants are placed first, followed by adjusting pterygoid depth to ensure all abutment platforms align perfectly. This seemingly subtle shift eliminates uneven prosthetic thickness and tissue complications. The discussion on tissue management reveals how proper thinning of tuberosity and palatal tissues creates silky smooth foundations for prosthetics, saving chairtime and preventing fractures despite initial hesitation about bleeding management.
Perhaps most revolutionary is Dr. Clark's definitive stance on implant configurations, declaring the inverted V superior to traditional axial placement. With persuasive reasoning about prosthetic flexibility and surgical contingencies, he demonstrates why angled implants provide infinitely better options for screw channel positioning. His detailed explanation of multi-unit abutment height selection challenges widespread misconceptions, showing how matching abutment height to implant depth (using 1.5mm abutments for 1mm subcrestal implants) accounts for post-surgical bone resorption and creates beautiful emergence profiles without prosthetic flanges.
For clinicians struggling with postoperative complications, Dr. Clark offers practical solutions like doxycycline protocols and bleeding management techniques using 2-0 chromic gut suture. These pearls of wisdom demonstrate why even experienced surgeons continue to learn from each visit to his courses.
Ready to transform your approach to full-arch implant cases? Listen now to gain insights that will elevate your practice and create more predictable, aesthetic outcomes for your patients. Share your experiences with these techniques and join the conversation about the evolution of implant dentistry.
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Transcript
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 Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry, let'stalk about your placement of
pterygoids, how deep you go andhow that affects your prosthesis
.
Speaker 2 (00:18):
When you have a good shelf, you know all the way back
.
And then, after that, let'stalk a little bit about M versus
V configuration and then, whenwe're finished with that, let's
go into the questions that youhave for us and we'll save some
of our other questions for thenext podcast.
And just so you guys know theaudience, we do plan on having
(00:40):
Clark on, hopefully, you know,once every month, once every two
months, and we're going tocontinue to answer some of these
more advanced cases andhopefully make this a continual
thing, cause, as everyone knows,clark's a wealth of information
and if you haven't had a chanceto go to his course, I
definitely would recommendchecking that out, because every
time we know, Tyler and I haveprobably gone what like four,
(01:01):
four four times yeah.
And every time we go it's likeyou pick up new pearls here and
there and you have a great stay.
Speaker 1 (01:10):
For the record, I almost went for my birthday.
My birthday was this pastweekend and I almost went to the
course for that, but my wifehad some plans for me, so I had
to make the smart decision there, but I was close.
Speaker 3 (01:22):
Gotcha.
Yeah, we just had the coursethis weekend and it was going to
be with Vishy and he was goingto come and he had to Zoom
lecture.
Unfortunately his mother passedaway and so he had to catch a
plane and get out of there, butwe had Dr Fayette Williams come
in.
So if you're familiar with whatFayette does, it very much
(01:49):
humbles what we do.
Fayette.
We may think that we're doinggood with teeth in a day and
Fayette is doing jaws in a day.
Jaw yeah.
And fibula teeth and so he's anamazing surgeon.
He does several days a week inthe OR doing microvasculature
(02:13):
reconstructions, head and neckcancer.
He's a guy that I work with inFort Worth and I've sent him
several of our cancer patientsand the pictures that he sends
me of these cases are justabsolutely incredible.
He's doing these free flapswhere they're doing these
(02:38):
lateral pec flaps and tunnelingthem up through the neck and
just all the kind of crazy stuff.
It's interesting we were, I wasshowing he knows about
transnasal but he had never doneone and I was showing him and
he was like oof.
And here's a guy that doeslateral neck dissections and
(03:03):
dissects down the carotid artery.
He was kind of like, I thinkmaybe the transnasal thing is
not something that I want tojump onto.
And I just told him.
I just said that's so funnybecause I would shit my pants if
I had to dissect, do a lateralneck dissection.
(03:23):
So I just said kind of to eachhis own right.
So it was just kind ofinteresting what you're
comfortable with, but thecadaver course was really great.
It was really amazing.
I can't tell you how manytransnasals we nailed.
We got lots of docs doingtransnasals and it was really
(03:47):
cool to have Fayette come inbecause he really explained and
showed how to advance a buccalfat pad.
Here's a guy that is in theface every day, so the attendees
really had a good experiencewith Dr Williams.
(04:09):
But, you know, rolling back tothe pterygoids, one of the main
problems that I see withclinicians is they're oftentimes
not placing them deep enough.
And you know, I again, you know, whenever we talk about Patsy,
you know my approach to Patsy isstill the same, exactly the
(04:32):
same.
So, but I I do say that aclinician can do the anterior,
anterior implants first and thengo back and do the pterygoid.
It doesn't necessarily changeup your sequence there, but I do
(04:52):
feel sometimes, if a clinicianstarts in the pterygoid region,
keep an open mind, because youmay need to go back after you've
placed all of your others anddeepen your pterygoid so we can
still.
we can still do patsy, we canstill do the pterygoid first
(05:14):
place.
It just don't put an abutmenton.
I think that's probably myrecommendation is don't put your
abutment on your pterygoid.
Do the abutment on yourpterygoid last.
Have your anterior and yourmiddle tilted placed and the
abutment placed, because what weall know is for biomechanical
(05:40):
success in our arches is that weneed the abutment platforms to
be all on the same level, and ifyou're not getting your
abutment platforms all on thesame level, you're having uneven
tissue thickness.
You know uneven prostheticthickness as well.
So just really pay attention tothat.
(06:03):
I want to get my abutmentplatform on the pterygoid equal
to my middle implant and so keepan open mind you may have to
deepen your pterygoid, uh to tonail that.
So, oftentimes, on the pterygoid, I'm placing um a 17 or a 30.
On the pterygoid, I'm placing a17 or a 30.
(06:24):
When I was brand new to this, Iplaced a straight, and it can
still.
You know when, if you place astraight in the back, you have
to seat your prosthesis anteriorto posterior, because it's not
going to make that curvature.
The challenge that I ran intothe ones that we did in 2017 was
(06:46):
the milling angles with astraight abutment were way too
steep, yeah, and so we stillwant to place a 17 or a 30.
That really has a very similarpath of draw to all of your
anterior ones.
So that's kind of the otherreason of why I think you need
your anterior abutments onbefore your pterygoid is because
(07:07):
then you have to also look atour path to draw.
Speaker 1 (07:10):
Yeah, that's a really good point.
And I think that's an importantnuance, especially like, if
you're a clinician, that kind oflives in this middle world
between traditional ON4 andPatsy, like, let's say, you're
sort of in that PFAS world wherea lot of us are living in Patsy
.
Like, let's say, you're sort ofin that PFAS world where a lot
of us are living, um, you know,if you're not placing, uh, zygos
, you know whether or not youget pterygoids doesn't really
inform that much of what thosefront four implants are going to
(07:33):
look like.
And so I mean, yes, you can sayyou know what Patsy says.
I got to place the pterygoidsfirst and that's going to
eventually inform whether I'mgoing to do an A-frame or
whatever with my Zygos.
If you're not doing Zygos andeven if you are, you can still
and I like your compromise thereplace your pterygoid, but don't
(07:54):
get married to your final depthof placement.
Just get it somewhere where itneeds to be.
Then go place your front four,get some multis on, and now you
can look at that plane alongthere and then figure out what
that final depth is going to be.
So you don't necessarily haveto have your pterygoid settled
before you ever tackle the frontfour.
That's something that I've donefor a long time.
In a lot of my cases mypterygoid multi units are
(08:16):
sitting inferior to where orsuperior, depending on how
you're looking at it inferior tothe front four abovements, and
you've given me that feedback ona lot of different cases.
So I've been trying to work onthat a little bit and I like
what you said there aboutsettling the final depth after
those front four have alreadybeen chosen.
Now you can really cater things.
So something I'm curious abouttoo, because we're addressing
prosthetic heights of themulti-units in comparison to
(08:38):
each other.
But what do you think aboutcrestal versus super crestal
versus subcrestal placement forthe pterygoids themselves?
What are your thought processeson that?
Because when I first learnedabout them, I was being advised
to leave them one to twomillimeter super crestal for
access.
You know if I ever had to goback and take one out or
(08:58):
something like that.
Leave it a little bit supercrestal, and I think a lot of
people are being taught that.
And now what we're seeing a lotof in terroid specific implants
are tissue collars, so like atwo millimeter polished collar
or even longer, I think.
I think Norris has up to likefive or something like that.
I could be totally wrong aboutthat, but you're seeing a lot of
polished collar implants thatyou know presumably are supposed
(09:19):
to be placed super crestally.
So I'm curious about how youweigh in about that and how you
kind of you know, cater thedesign of the implant.
What is the ideal implant?
I'm throwing a lot at you, butcan you kind of speak to the
Crestle aspect of things?
Speaker 3 (09:32):
for cleansability.
We would want to polish collarin a case that where maybe
there's tissue and not bone.
And we may want to polishcollar in a scenario where maybe
(09:57):
we expect the tuberosity boneto recede.
I think too long and kind ofatrophy.
Yeah, and my thing with that isokay, that's all, those are
good, right, so so then.
So then at that point, whatwould we be concerned about
right on a traditional, all on Ximplant we'd be concerned about
(10:18):
?
Okay, well, that stuff wouldlead to recession, thread
exposure, right.
That's kind of that longer termtriad complication.
Well, okay, I've done 1,000pterygoid implants.
I haven't seen recession on one.
Speaker 2 (10:37):
Yeah, pretty good.
I think that the reason thatthese implant companies are
doing a polished collar isbecause they're trying to make
an implant for the masses Maybepeople who aren't, who haven't
placed a thousand of them andthese doctors are having issues
with the tissue around thatimplant.
(10:58):
And what I do and I learnedthis at your course is every
time I place a pterygoid implantI am back there thinning that
thick tuberosity tissue outbecause I want my prosthetic to
sit all in one plane, kind oflike you've talked about.
And if you stick that implantand it's two millimeters super
(11:23):
crustal with a polished collaron it, the reason that I think
people are doing that is becausethey they have that really
thick tissue back there and theyhave a difficult time putting
the prosthetic on, pushingthrough, you know, like six to
eight millimeters of keratinizedtissue and this into all of
those problems, and one that'sbetter for the prosthetic is to
(11:45):
just grab that tissue with atissue forceps.
Take a a new scalpel blade,just thin that tissue out, that
connective tissue there, and allof your tissue is going to lay
much better around thatpterygoid implant and I think
the smartest way to do it is toplace it, um, you know, at the
level of the crest, or maybe alittle bit sub-crestal,
(12:06):
depending on where your implantplacements are on the anterior
fork.
Speaker 3 (12:14):
Yeah, I would 100% agree with that.
Yeah, I just think there's somelaziness there.
And then it's just kind ofhaving a different mindset,
right, because when I teachpeople at the Texas Implant
Institute courses, a lot oftimes their eyes just get huge
(12:36):
and you can just tell they'renot going to do that in the
clinic, they don't want to dothat.
But I'm like the second thattheir eyes are huge and they're
like there's going to bebleeders and all this sort of
stuff.
But then when you show them andthen you just lay that thin
(12:56):
tissue over it and you just feelhow silky and smooth and all
the restorative space that youhave, then they're like okay, I
get this.
So it's worth the extra 10minutes because it does add to
some surgical time, but it's notlike it's 20 minutes, it's a
10-minute add, but I think itresults in a beefier, temporary,
(13:22):
less fractures, so that's justgoing to save you more chair
time.
But I also to that point.
I just want to complete thethought, or I'm going to forget
it.
But I would say for thepterygoid it does not have to be
subcrestal, because we're notgoing to gain anything, we're
(13:44):
not going to get bone to growover that abutment in the
tuberosity region.
So sub-crestal is fine,equicrestal is fine, just make
sure that it aligns with theabutment.
But my other point is, if youwere to give me the Norris and
say you know, like I w, I wouldhave no way of knowing what
(14:07):
implant to select because ofthat polished collar.
You know what I mean.
Like, how do you, when, whenyou drill what, what, what are
your drills drilling to Right,like, like, is it just?
Is it just the implant depth?
Does it have the polishedcollar on that?
How then do you choose yourimplant depth?
(14:29):
So to me it adds morecomplexity to just the execution
.
Speaker 2 (14:37):
No, I agree.
A quick point too the thinningthe tissue.
Something else that I thinkthat is really powerful and I
don't know if I I think I maybegot part of it at your course
because you it was back when,you know, rick Klein was there
talking about thinning thetissue.
And something that I do a lotnow and I think it helps me
(15:01):
quite a bit, is when people aredoing restorative space.
I feel like there's not a lotof providers that factor in the
thickness of the tissue in therestorative space.
So what I mean by that is youknow you get patients that do a
high smile line and you'remeasuring from that tooth to the
top of the lip, maybe addingtwo millimeters down there,
(15:22):
using that to do your reduction.
Or you know I know Clark, you'dlike to do your multi-unit
guide or you had four.
Okay, but you know you can gainquite a bit of restorative
space too just by thinning.
You know some patients havesuper thick tissue in that
anterior region as well, and ifyou thin that tissue up, you
(15:43):
know you can sometimes save acouple millimeters of bone
having to reduce that bonebecause you can reduce down that
tissue.
Because you can reduce downthat tissue.
I don't know if that'ssomething you do too, clark, but
I find that when you pull thatpalatal tissue forward, it can
be three, four millimeters thick, and if you thin that out a
little bit it gives you a littlemore restorative space there as
(16:06):
well.
Speaker 3 (16:07):
Well, it's not only an advantage in gaining
restorative space, but it is anadvantage in being able to
buccalize our palo mucosa.
Because once you thin that, youknow and I'm not, I'm not
thinning this just in the kindof more of like the superior
portion of the palate, I'm I'mthinning it, you know, 10
(16:31):
millimeters deep right, so thatthat way it's not just on the
top portion but it's also inthat beefy kind of vertical
portion of the palate as well,so that as we pull, everything
is being buccalized and so we'regetting buccalized keratinized
gingiva from the palate, youknow, and just really avoiding
(16:57):
any type of periodontal insultswith having just the thickest
and hardest tissue around ourmultis.
And one little trick is changeout your 15 blade.
I'll see providers stillstruggling.
I'm like that blade's dull.
Just change it out.
And you know, some days myassistants they'll bet on how
(17:20):
many 15 blades we use in an archand you know, it's very
variable, depends on thethickness of the tissue.
Speaker 2 (17:30):
Yeah, yeah, yeah, so much trimming.
Speaker 3 (17:31):
Yeah.
Speaker 1 (17:32):
Yeah, yeah, so much trimming yeah.
Speaker 3 (17:36):
But don't be afraid, oftentimes I'll use one brand
new 15 for one side of thepalette and a brand new 15 for
the other.
Yeah, yeah, they're cheap,they're cheap.
And one of the challenges withthinning the palate is if you
perf it right.
But that's kind of why you usethose tissue forceps and you
(17:58):
just go straight down the middle, you allow that metal to guide
you to where you're not going toperf and you need to be ready
to tie off some bleeders, right,I think, tyler, you wanted to
talk about, um, you know, somesome bleeding things.
Yeah, uh, you know you can usea bovie or electrocardiory.
Um, I think, I think a bovieworks better than
(18:21):
electrocardiory.
But, uh, if if you don't haveeither of those I tell you what
just tying off a bleeder is waybetter than either of those
because you can just loop it andI do not control bleeding with
Epi because they're going tobleed at home and so control
(18:45):
your bleeding withoutepinephrine.
You can utilize epinephrine,say, if you're doing an analog
conversion process, just to kindof make sure that you can
reduce your heme, your ooze andyour bleed.
That's just kind of oozing,that's just natural oozing.
(19:06):
You can use epinephrine tocontrol natural oozing.
But I would not really useepinephrine to control the bleed
because it'll just rebound.
So oftentimes it's as simple asjust you have to find your
bleeder and you go posterior toit and then anterior to it and
(19:28):
then you're just going to tie aknot.
And I've had times where I'lltie a knot and I'll cut off the
tail and I'll tell the assistantdon't cut it.
We're going to wrap severalmore times around there and then
suture that down.
I've had some bleeds wherewe've wrapped them two to three
times.
Typically I find that theelectrosurge works really well
(19:51):
for kind of the more you know,as we're getting distal to those
arterioles Right, so kind ofmore in the upper coronal aspect
(20:11):
of the palatal flap.
The electrosurge works wellthere.
But if you're getting a bleedthat's a little closer down to
the greater palatine, that'sgoing to need to require a
suture.
And one of the big things thatI've done in the past two years
has been switch over to utilize2-O chromic gut suture and it is
(20:32):
so much stronger and yourneedle is a lot longer and so
you can really get to some ofthese deeper areas and you can
pull tighter and you can cinchthese things down because you
have a stronger rope.
I also use 2-0.
Speaker 1 (20:50):
Yeah, that's something.
You definitely converted me andSoren as well, on it's 2L
chromic for every Fuller's case.
It's fantastic.
Speaker 3 (20:58):
You can really get aggressive with it and it just
makes your suture so much easierand better.
And make sure you're soakingyour sutures right.
All my assistants know we havea bowl of water sterile water
and you know the start of thecase, that that chromic suture
(21:18):
is soaking and by the time we'reready to suture it is just silk
and it just it just rollsreally good, yeah, yeah,
definitely.
Speaker 1 (21:27):
And I know you know, before we start wrapping things
up here.
So I know we wanted to talkabout configuration.
So we wanted to talk about, youknow, before we start wrapping
things up here.
So I know we wanted to talkabout configurations.
So we wanted to talk about, youknow, inverted V's, m
configurations, placing youranteriors parallel pros and cons
.
I mean you see a lot ofdifferent things.
Now there's some surgicaladvantages to different
configurations.
There are prosthetic advantagesto different ones.
(21:49):
You know, at this point in yourcareer, clark, you know what
has become sort of your standardconfiguration that you will
approach your upper flourishcases with.
Speaker 3 (21:58):
Yeah.
So I mean I can saydefinitively, without a doubt,
you know, I am no longer, youknow, going to be doing an axial
anterior implant, so those aregone.
(22:19):
I want to be angling all of myimplants and I do it for a
prosthetic reason, right, I doit because I now have infinite
timing options, because I'mgoing to place an angled
abutment.
So if all we do is axillaryimplants, we only have two
(22:40):
options to correct our screwchannel axis we have a zero,
which is our straight, or wehave a 17.
So oftentimes, as we all know,sometimes we don't like the
straight and then sometimes the17 is too palatal or too buckle,
right.
But if we angle our abutments,then I can change the timing two
(23:02):
to three degrees and then placean angled abutment on there.
So all angled right.
So that knocks out axial and mypreference.
Every time that we can andactually had a case, uh, monday,
yesterday, that I could not do,it was just there was a very
large infection uh, on numbernine, right.
(23:25):
So, uh, but just in general,every case I can, I am going
nasal.
So I want to do the Vconfiguration on every implant
case out there.
Okay, uh, I, I prefer the Vconfiguration over the M right.
(23:46):
So M is is when the anteriorimplant is going into the
lateral nasal.
That, to me, the trouble thatyou get into is.
Now you're kind of having tostack your apical tips of your
implants.
It's a bunk bed, and if youdon't have a lot of bone volume
there then you're going to windup blocking your posterior
(24:08):
implant out.
And that's what Patsy teachesus, because then we can just
roll in and do a posteriorzygote no big deal.
But if if you're not ready tojust on the fly switch over to
do a zygote, then you're goingto have some trouble.
(24:28):
So if you do the Mconfiguration, you're, you are
likely going to block yourselfout on the posterior tilted.
So I prefer V on everybody.
And guess what?
Let's say you have a failure ofyour posterior implant.
Well, now you still have tonsmore room to replace that
posterior implant right, or yourmiddle implant, we'll call it
(24:52):
because you haven't blockedyourself out.
The only times that you cannottypically do a nasal crest is
when you have a very largeapical infection of your central
incisors.
And so I had a case yesterdaythat was very, very much the
case.
I nailed one nasal crest andthen the other one actually did
(25:15):
an axial.
It was literally my only option.
It was a resorbed case.
My posterior Patsy implant wasgoing to block me out and so at
that point, what's the harm inan axial implant right Like I
would?
I would not choose.
Oh, for this area on thepatient's left side where I
(25:37):
could not do a nasal crest, Idid lateral nasal and then I'm
going to block myself out andthen have to do as I go, right,
like you know, the best as I gois the one you haven't done, and
damn sure an axial implant isgoing to be way better than
having to do a zygote.
So you know just a little bitof that shucking and jiving.
It's just a.
That's a one percent one-offcase, so don't think anything
(26:00):
into it.
But but for sure, nasal crestto me, how I approach every case
, we're doing nasal crest everytime that we can.
So V configuration.
Speaker 1 (26:11):
So we're all pro V.
Establish that.
So when you're aiming for thesame spot with both these
implants, are you crossingswords?
How are you making sure thatyou're not interfering with each
other?
What's?
Speaker 2 (26:26):
your approach for that?
Speaker 1 (26:26):
inverted V, just surgically speaking.
Speaker 3 (26:32):
So I place these exactly the same every time,
right?
So so my number seven implantis going to be anterior to my
number 10.
So my number 10 is going to bedeep, is going to be posterior
to that.
So I'm actually going to anglethat you know much, you know
(26:55):
much further posterior than mynumber seven implant and that
that way you, you, you alwaysaccount for it, right.
If you do the same thing everytime, it's just it just gets
into muscle memory, whereas ifyou kind of futz around and and
you're not organized, you knowyou may do where you angled them
(27:15):
both to the same apical in yeahand that's when you wind up,
okay, well, one's going to be a13 and one's going to be a 10.
You know so my ideal, uh, so Ilike to stack them, I like to
have them cross at the nasalcrest and I prefer to do 13s
(27:40):
versus maybe try to have theapical osteotomy converge and
then you're doing 11 1⁄2s oneither Right right, so I stack
mine in the nose.
Speaker 1 (27:55):
So if we're trying to get some symmetry there, you're
saying I think you said yourseven is going to be interior to
your 10.
Is the timing going to bedifferent on that?
How is that?
How are you trying to get, howdo you get them symmetrical if
you're aiming for differentthings?
Speaker 3 (28:13):
There's still well A like you know where the
abutments are.
You won't know.
Typically on my number 10,right, it's kind of like your
pterygoid, right.
So, it not only has a medialangle, right, because we're
aiming medially to the crest.
So that's what I would say.
(28:33):
I would say the number 7 hasone angle and it's a medial
angle, Whereas number 10, notonly does it have a medial angle
, but it has a deep, you know,and a posterior tilted angle.
You're tilting it anteriorforward so often.
Speaker 2 (28:54):
Yeah, I mean the crest of the implant.
So well.
Speaker 3 (29:01):
I just go by the tip, right.
So I want the apical tip to bedeep or posterior to my apical
tip of number 7.
So oftentimes the number sevenimplant may utilize a 17 degree
abutment and the number 10implant may need to utilize a 30
(29:22):
, because I'm aiming at 30degrees posterior.
Speaker 1 (29:28):
Okay, so that answers what I was getting at.
Okay, so sometimes it's goingto be a different abutment to
account for that different.
Okay, yeah, got it, got it, yep.
Speaker 2 (29:34):
Okay, typically what's your medial angle, but
but again, you know, is it alittle bit less than your tilted
, Is it?
Is it pretty similar to yourtilted?
Speaker 3 (29:44):
Yeah, it's, it's.
It's typically nasal crests arealways less, but there's a
little bit of variability in youknow where we wind up going
based on.
I always look for just aconcept of what I call bone
shields and I want to.
(30:05):
I want to use my pilot drill inthe anterior and I I want to
find the area the most densebone, the most amount of bone,
and typically I am going toplace it, place my pilot drill,
in the medial portion of thenumber seven socket, right.
(30:31):
Like I don't necessarily wantto place it in the distal
portion of that socket, I wantmy coronal portion of my implant
to have lots of interproximalbone between eight and nine, and
that is going to help fight offlots of stuff down the road.
(30:54):
So our options are we can choosebuckle bone, the immediate
buckle bone of number eight.
We could choose the immediatebuckle bone of number seven.
I don't choose either of those.
I want to go within theinterproximal bone of number
seven and so that can be alittle bit variability based on
(31:16):
arch form.
You know if they had ortho orif they didn't have ortho.
So sometimes we may be more atlike a 17 degree angle to
midline, sometimes it may bemore of a 30 degree, so it's
definitely more variable.
And it also depends on theheight of your subnasal bone and
(31:40):
also the anatomy of the nasalfloor.
Sometimes some people have avery nice wide subnasal floor.
Sometimes it's a little moreconstricted and so all of that
kind of changes things.
But again we're aiming to thenasal crest, which is right
(32:01):
underneath that vomer bone.
But that vomer bone is furtherback it's way back there, yeah.
Not way back there, but itstarts posterior to the incisive
canal.
Speaker 1 (32:12):
Okay so you heard it here, folks, the inverted V.
That's the modality.
Now we're moving on from axialplacement.
Shame on you if you do it.
Speaker 2 (32:21):
I did it today twice.
We're with the mandible.
Speaker 1 (32:22):
Yeah, moving forward.
Speaker 2 (32:24):
Are you doing a V in the mandible every time?
Speaker 3 (32:30):
Same thing.
We prefer a V.
That angle on the anteriors is,uh, less so.
I would say it ranges from,from you know, 20 to 10, but
oftentimes I mean if you'retilted fails, you got another,
(32:51):
another so chunk of bone thatyou can move that forward one
slot and again you can.
Speaker 2 (32:57):
You can change your timing a little bit better with
multiple areas to change thattiming correct exactly, exactly.
Speaker 3 (33:11):
What about you guys?
Are you guys doing these oractually on my cases still?
Speaker 2 (33:15):
uh, but you know, I I 100 agree with everything
you're saying.
Um, patients that I'll doinverted v on are patients with
really pneumatized sinuses.
That, um, you know, I want tomake sure that I have enough
room to uh to place anotherimplant if I need to, if I have
a failed tilted implant, um.
(33:36):
But typically I'm doing axialuh, but I probably will start
doing more of these.
I think it's smart.
I don't think there's a reasonnot to, and I agree with all
your points for sure.
Speaker 1 (33:52):
Yeah, for sure, for sure, yeah, and I, I mean, I
love the prosthetic flexibilityof it.
I, you know, I always get this.
Uh, you mentioned at the verybeginning this conversation is
when you're placing axial, youusually only have like two
options and you're going to trythis straight and then you
realize maybe you're a littlebit more buckled than you had
initially intended to be.
Now you're going to be like,okay, I guess I'll put a 17 on
there, and then you end up morepalatable than you really wanted
(34:13):
to be, and so it's like there'sthere's not really a great
world in between.
Um, so by doing the inverted V,it gives you all the flexibility
in the world to figure outexactly how, how that needs to
be timed.
I am curious when you're uh,when you're timing those implant
, are you usually uh?
So I'm always looking at thedot for my timing, right?
Is that usually going to bepointing towards the midline
(34:33):
with your inverted Vconfiguration?
Is that very similar to howyou're timing your middle tilted
implants?
What are you referencing asyour timing your implant usually
?
Speaker 3 (34:45):
Well, I think in the inverted V, the most important
consideration is implant depth.
And oh, we got to talk aboutthis.
Yeah, you know, because you'reactually going to place
especially your number 10implant, or whichever implant
goes deep to the other one.
(35:08):
I measure my subcrestal desireddepth, depth which is one
millimeter subcrestal.
You know, measure that on theshallowest part.
Well, on on on the nasal crest,that's going to be not on the
buckle but on the palatal side,right, and so your, your palatal
(35:29):
wall, you know you're, you'regoing to get your implant one
millimeter subcrestal, asmeasured on the palate, but as
measured on the buckle, maybetwo, three on the buckle.
So these implants are going tofeel deeper.
So you're going to have to getin the habit of measuring your
uh abutment depth on the palate.
(35:51):
It's's the same concept as wedo on our posterior tilted.
It just feels very, very odd toplace one so deep, and so
clinicians need to take thatinto account when you're
measuring your depth.
And again, measure your depth onyour drills.
And we know exactly the depthto do because we've done a
(36:13):
subnasal lift and so we are ableto feel our drills Sometimes if
we have a wider nasal crest,sometimes we can't, but we'll
take an x-ray to account forthat.
And whenever you're doing yourmeasurements, with whatever
method you're doing yourmeasurement, make sure that you
(36:36):
are placing your implant to thedesired sub-crestal depth.
Sorry, you're taking your drill.
You want your drill to be asdeep as your desired sub-crestal
final implant depth, and sothat way there's not any
variability.
But as far as timing goes, Ialways say that the dot right.
(37:00):
Yes, for all of our implants Istart checking the timing in our
screw access channel by havingthe dot be pointing to midline.
But I always say that the teethwin and so oftentimes the dot
will help get us in the ballpark.
Speaker 1 (37:21):
Yeah, right, but.
Speaker 3 (37:23):
I'll always be double checking with your MUA guide
and and be in your posteriorimplants.
You can check with thecontralateral arch.
The only implants that wecannot check to the
contralateral arch are themaxillary anterior implants.
We have to use the MUA guideand know where the final desired
(37:44):
position of the teeth is goingto be, and that's what gets us
the right spot.
Speaker 1 (37:51):
Yeah, and I'm curious too.
Speaker 3 (37:53):
Another reason why I do not like palatal fiducial
markers.
Speaker 1 (37:58):
Oh yeah, because you're not going to have a
reference for it.
I mean, you could, but you'dhave to have like a really big
recess.
Speaker 3 (38:04):
You have to have a window.
Yeah, and you know I do bigflaps, right.
You know I'm a big proponent ofthis and so by the time I put
an MUA guide on that, has, youknow, a fiducial relief, right?
(38:26):
Yeah, well, now I've alreadydisturbed all that tissue and
it's kind of swollen and there'ssome blood in there.
So then I really question theaccuracy of that.
So you know, I know that youguys do a digital method without
fiducials.
Speaker 1 (38:45):
Yeah, correct.
Speaker 3 (38:48):
Yeah, and so it just makes it so much simpler, oh my.
Speaker 1 (38:52):
God, yeah, I still use fiducials sometimes for a
single upper or something likethat, and I suppose that you
probably could design amulti-unit, an MUA guide that
would sort of allow you toactually guide the fiducial
placement.
So you could, you know, placeit even with teeth on and maybe
it's like toothborn or somethingand it has some recesses in it
(39:13):
so you very specifically placefiduciary markers or not
fiduciary fiducial markers inspecific spots, so that when you
do get the teeth out, you couldthen put it on the MUA guide
and it would fit just over wherethose fiducial markers are.
So you don't have this likemassive window anymore, it's
like pre-planned.
But you know, this is gettinglike wait.
I mean, I don't, I don't likefiducials at all, so I'm not
(39:34):
going to go through that.
But yeah, we, we do a denturewash vest.
That it's it's, it's fantasticfor that Um.
So we can really, you know, we,we have, we can use multi-unit
guides and figure out wherethings need to be.
One thing I wanted to make surewe address too, though, and this
(39:54):
is brought up by um, I think.
I think Adil uh Khan uhmentioned this one.
Uh, yeah, he did so.
Uh, details on the multi-unitabovement height.
So you had talked about, um,you know where we're placing our
implants in relation to thecrest, what is the height of the
multi-unit that we're placingand the biologic width that gets
established there?
Um, and there's some nuancesthat you've talked about in the
group that I've never reallylike.
I obviously I've heard of thesethings, but I've never heard of
(40:16):
them really talked aboutspecifically in the context of
multi-unit abutment placement,and I feel like this is like a
really important nuance thatwe're just kind of glossing over
.
And if you look at, you know,uh, posts that people make on
Instagram of their, of theirarches, and that you show them
all the new and stuff, there isso much variability in terms of
the heights that people arechoosing and you know, is it
with respect to tissue?
Is it with respect to theimplant placement?
Speaker 3 (40:37):
Um, I really liked how you talked about um the
establishment of biologicalwidth with regards to your
multi-unit above heightselection.
So could you speak to that alittle bit?
Yeah, I think that many people,many clinicians, try to
establish biologic width at thetime of surgery and I think that
(40:57):
that is false.
I think they are missing out onthe fact that by simply raising
a flap, we are going to havesome bone resorption.
They are not taking in to thefact the bone resorption process
.
So oftentimes what I see isclinicians will be placing
(41:21):
subcrestal depth to onemillimeter and they will then
choose a 2.5 millimetermulti-unit abutment, tall and,
yes, tall, um, and that that isthat is incorrect.
If, if, if you have a multi-unitor, sorry, if you have your
(41:42):
implant that is two millimeterssubcrestal, then you should use
a two millimeter heightmulti-unit abutment.
If your implant is onemillimeter subcrestal, you
should choose a 1.5 millimetermulti-unit abutment.
And so, uh, that's that's whereI start harping on on
(42:04):
clinicians is because they didone millimeter subcrestal and
they used a two and a halfmillimeter multi-unit and it is
too tall, and so obviously we'relosing one millimeter of
restorative space just off thebat.
And now I mean, on occasion I Iget patients they complain
(42:26):
about the abutment showing andit's obviously it's not the
implant.
You know, and you know on onoccasion I mean it's, it's, it's
, it's practically unavoidableum in in in many cases, um, and
you, you're you're going tooverly pronounce that if you're
using taller multis.
(42:48):
So we want for full archbiologic width is 1.75 to 2
millimeters.
That is the appropriatebiologic width.
That is the appropriatebiologic width and we want.
So I then account for onemillimeter of post-surgical.
(43:13):
That is the appropriatebiologic width and we want.
So I then account 0.75millimeters supra-crestal, so
that after crestal we then haveestablishment of biologic width
(43:40):
and loss of roughly onemillimeters of that, that that
bone.
Three months goes by.
We then have a establishment ofbiologic Right.
(44:01):
If you're a buttments, in fact,if your abutments are too proud,
too tall, oftentimes what wesee when the final prosthetic is
made is flanges right, and sothat leads clinicians to have to
(44:24):
hide multis with flanges.
And so you know, if, if, if weall think about it from an
emergence profile standpoint,the more emergence profile we
have, the better right, so as ifwe lower our prosthetic margin,
then we're able to get a muchbetter emergence profile.
(44:46):
And so that's what I am doingwith a 1.5.
Now, that's not to say that Idon't use 2.5s.
In fact, I'll use maybe three2.5s a week, but that's just
because, for whatever reason,maybe I wanted a couple extra
turns, Maybe I needed a, youknow, an extra millimeter of
(45:08):
stability.
Speaker 2 (45:09):
Yeah.
Speaker 3 (45:10):
And, and I didn't feel like mowing a millimeter of
bone down, you know to to kindof to to make it all flow, and
so then I'll just grab a twofive 17 or a two five 30, and it
works out great.
But again, you know, all of myabutment margins are all in the
same platform, just to make sure, yeah.
Speaker 1 (45:30):
That's solid.
That's one millimeter.
Speaker 2 (45:32):
Now, when you're placing your tilted, is your one
millimeter subcrestal at themesial aspect?
Okay, yeah.
Speaker 3 (45:44):
Yes, yes, yep, and you know again, on the nasal, on
the nasal crest, it's on thepalatal.
Speaker 1 (45:52):
Yeah, yeah.
Speaker 3 (45:55):
So, and then what you're going to find is, when
you finalize your cases, you'regoing to see just beautiful, uh,
flat tissue.
Speaker 1 (46:09):
Yeah.
Speaker 3 (46:10):
Yeah.
Speaker 1 (46:11):
I mean, it's, it's these kind of you know nuances
that I think can you know, uh,really make full arch a whole
lot more predictable, even whenyou're doing it at volume.
And there's so many littlethings that are more predictable
even when you're doing it inthe post-ops with patients, and
it's like my new details, youkind of just write it off.
(46:32):
It's like oh, these, thesethings just happen.
Like sometimes patients justhave issues with this or that,
like very recently, I had apatient who you know, all of his
implants felt great, except for, like one particular spot
that's been giving him all this,all these issues.
Um, just it just feelsthrobbing.
It's been hurting.
We've taken follow-up x-rays onit and there was no effect and
just it just feels throbbing.
It's been dropped and I lookand it's all around that
multi-unit.
(46:53):
It's just like it's.
It's inflamed, um, it's gotlike it's feeling is he's, he's
reestablishing biological width.
I forced that to happen becauseI didn't pay enough attention.
I was, I was rushing, I crushedthe bone with the multi-unit
(47:13):
and now he's, or anything, thatI take his bread.
Now I have the answer as to whythat was happening and, if
anything, that I take his brickshappen and maybe it'll resolve
on its own.
So these little things, likethese very small nuances during
surgery, really shouldn't.
Just it just feels throbbing.
Thank you.
Speaker 3 (48:28):
Well, well, I wouldn't replace the multi um,
you could take it off.
You know now, now you knoweverybody, you know all my staff
knows, like we don't touchimplants until they're fully
integrated.
Right, because the second yougo back up back a buttmanment
off, you never know what's goingto happen.
(48:48):
Right, and especially theseneodent abutments.
They can be so difficult toremove because they cold well on
there, so good, and it's superfrustrating, right, like trying
to get a cold welded grand Morseabutment off your implant.
Speaker 2 (49:11):
Yeah.
Speaker 3 (49:12):
But I will take that challenge all day long because I
know that that is taking theforce off of the abutment screw.
Right, I know that we arelocking that in and and and now
we're mitigating abutment screwloosening.
You know, um, some of theseother companies, you know, when
you just kind of get themhalfway loose, I mean like the,
(49:33):
the nopel stuff, you know, thesecond you get that abutment
loose, it's, it's, it's a whileready to go um, but you know
what?
what I may just recommend is whydon't you just give him 100
milligrams of doxycycline?
Okay, and I've begun to usethat for anybody that just kind
(49:55):
of has some atypical gingivalstuff, right, like if there's
some foots going on in thegingiva, you know, a hundred
milligrams of doxycycline.
Or if you have a patient who ismaybe they're slow to heal, you
know, if they come back they'restill hurting at two weeks,
that sort of thing.
(50:15):
Um, you know, sometimes you canget some postoperative palatal
necrosis and, uh, get somepost-operative palatal necrosis.
And you know, obviously, if andwhen you have palatal necrosis,
you need to remove that deadtissue.
You know it's not going to getany better.
(50:35):
You've got to get that deadtissue out of there.
But then they all get 100milligrams of doxycycline and
that typically speeds up a lotof the a lot of the healing is
that I don't?
I don't know or what is it?
You give it BID.
Okay, 100 milligramsdoxycycline BID seven to ten
(50:57):
days, it it doesn't.
It doesn't do anything on theon the healing part, other than
it's broad-spectrum antibioticthat helps just if the body is
trying to fight off differentlittle bugs that may be impeding
your healing.
(51:17):
And then now you wipe it awaywith the doxy, then now the body
can just focus on healing.
I like that.
No, no, that's great, it's,it's, it's, it's.
It's definitely been a nicelittle thing to give.
That you know, and, andoftentimes you know, patients
just want something rightthere's just they're just
(51:39):
there's a psychological dealwhere they're just looking for
you to do something right.
Saying we can't do anything isnot reassuring to the patient.
It's hopeless.
Speaker 1 (51:48):
Yeah.
Speaker 3 (51:49):
Now, now there are cases totally, where you can
tell your patient I got you,you're fine, this is not going
to turn into an infection, it's.
It's too close to surgery.
Um, you literally need, andthere's nothing I can give you
other than time.
That also is assuring when theyknow that it's just a time
(52:15):
thing when you're prescribingtime.
Speaker 1 (52:18):
Yeah, that's solid.
Speaker 3 (52:20):
But not being able to say that and just be like, yep,
nothing I can do, but not beingable to say that and to feel
you and listen.
Speaker 1 (52:34):
That's fair.
Yeah that's fair.
Well, clark, this has reallybeen fantastic.
I think we may have gottenthrough 40% of the outline that
I made for us.
So we've at least got two partshere, and I think that may have
gotten through 40% of theoutline that I made for us.
So we've at least got, you know, two parts here, and I think
that's fantastic.
And I think we ought to save alittle bit for for next time,
because I think this is this isgoing to be a recurring series
and if not only for the audience, I think it's for Soren and I,
(52:57):
because we learned somethingevery time we sit down and talk
to you and you know, there'sgenerally a pearl that we'll
carry forward for the rest ofour careers just about every
time we talk to you.
So we certainly appreciate that.
Speaker 3 (53:06):
Awesome, Well, just kind of like, I think.
What did Elon come out?
Or it was Eric Schmidt came outand said that we've given AI
the fullest extent of all humanknowledge.
There is an extent to mine, soyou know we will reach maximal.
(53:26):
You know knowledge that Damonhas, so that could come about.
Speaker 1 (53:33):
So don't be sad when that comes, I don't think we're
at the bottom of your largelanguage model.
Once we hit that, your chatwill be reviewed.
It's back to where it was.
Speaker 2 (53:42):
It's back to where it was.
Speaker 1 (53:46):
It's funny yeah.
Speaker 2 (53:50):
Refresher Just like the canaver refresher.
Speaker 1 (53:52):
That's all it'll be, yeah.
Speaker 3 (53:54):
Awesome.
Speaker 2 (53:55):
Well.
Speaker 3 (53:55):
I really liked her interview with David Zellig.
Speaker 2 (53:59):
He is a super nice guy and super enthusiastic I I
mean, he was more excited thanhe was I actually left that
interview, like you know talkabout this stuff and I need to
be more enthusiastic about thesecases, because that guy has
been doing this way longer thanI have and he still is 100% I
(54:22):
know just stoked, yeah, yeahyeah, just overall super nice
guy.
Speaker 3 (54:31):
And you know, I mean I took, I took, I took two pages
of notes just talking withZellig and I already know all
this stuff you know yeah but uh,you know, just kind of the way
he talked and the way hepresented, I think that'll be
such a great person to have onand really we should try to get
(55:00):
Vichy or even Juan on to reallytalk about medical legal stuff.
You know, and like what, what,what do guys need to?
You know really kind of payattention to.
You know what, what are, whatare things that that that they
all can benefit from, and andyou know, I think there's a lot
(55:22):
to learn there.
Speaker 1 (55:24):
Yeah, no, I agree, I think that's a.
That's a good wrinkle that youknow I, I think there's a lot to
learn there.
Yeah, no, I agree, I, I thinkthat's a that's a good wrinkle
that you know we've never eventouched on and we've both talked
to juan before and, uh, youknow, I've been trying to get
vishy on here for quite sometime and, and, yeah, I
definitely think they can bringsome part of that conversation
that would be really interesting.
So, um, yeah, I think you'vegiven us some great ideas and
you know, we look forward to thenext time we get you sat down,
(55:46):
and either it'll beconversations with the tribe or
conversations with, uh, you know, another, um, you know
fantastic leader in full arch.
So, again, you know, we justreally appreciate your time,
clark, and we look forward tonext time.
Speaker 3 (55:57):
Awesome guys, appreciate y'all.
Thank you Always, always,always fun to talk and y'all
keep me thinking and so it'sgood.
Speaker 1 (56:07):
For sure.
My name is Dr Tyler Tolbert and I'm Dr Soren Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry, let'stalk about your placement of
pterygoids, how deep you go andhow that affects your prosthesis
.
Speaker 2 (00:18):
When you have a good shelf, you know all the way back
.
And then, after that, let'stalk a little bit about M versus
V configuration and then, whenwe're finished with that, let's
go into the questions that youhave for us and we'll save some
of our other questions for thenext podcast.
And just so you guys know theaudience, we do plan on having
(00:40):
Clark on, hopefully, you know,once every month, once every two
months, and we're going tocontinue to answer some of these
more advanced cases andhopefully make this a continual
thing, cause, as everyone knows,clark's a wealth of information
and if you haven't had a chanceto go to his course, I
definitely would recommendchecking that out, because every
time we know, Tyler and I haveprobably gone what like four,
(01:01):
four four times yeah.
And every time we go it's likeyou pick up new pearls here and
there and you have a great stay.
Speaker 1 (01:10):
For the record, I almost went for my birthday.
My birthday was this pastweekend and I almost went to the
course for that, but my wifehad some plans for me, so I had
to make the smart decision there, but I was close.
Speaker 3 (01:22):
Gotcha.
Yeah, we just had the coursethis weekend and it was going to
be with Vishy and he was goingto come and he had to Zoom
lecture.
Unfortunately his mother passedaway and so he had to catch a
plane and get out of there, butwe had Dr Fayette Williams come
in.
So if you're familiar with whatFayette does, it very much
(01:49):
humbles what we do.
Fayette.
We may think that we're doinggood with teeth in a day and
Fayette is doing jaws in a day.
Jaw yeah.
And fibula teeth and so he's anamazing surgeon.
He does several days a week inthe OR doing microvasculature
(02:13):
reconstructions, head and neckcancer.
He's a guy that I work with inFort Worth and I've sent him
several of our cancer patientsand the pictures that he sends
me of these cases are justabsolutely incredible.
He's doing these free flapswhere they're doing these
(02:38):
lateral pec flaps and tunnelingthem up through the neck and
just all the kind of crazy stuff.
It's interesting we were, I wasshowing he knows about
transnasal but he had never doneone and I was showing him and
he was like oof.
And here's a guy that doeslateral neck dissections and
(03:03):
dissects down the carotid artery.
He was kind of like, I thinkmaybe the transnasal thing is
not something that I want tojump onto.
And I just told him.
I just said that's so funnybecause I would shit my pants if
I had to dissect, do a lateralneck dissection.
(03:23):
So I just said kind of to eachhis own right.
So it was just kind ofinteresting what you're
comfortable with, but thecadaver course was really great.
It was really amazing.
I can't tell you how manytransnasals we nailed.
We got lots of docs doingtransnasals and it was really
(03:47):
cool to have Fayette come inbecause he really explained and
showed how to advance a buccalfat pad.
Here's a guy that is in theface every day, so the attendees
really had a good experiencewith Dr Williams.
(04:09):
But, you know, rolling back tothe pterygoids, one of the main
problems that I see withclinicians is they're oftentimes
not placing them deep enough.
And you know, I again, you know, whenever we talk about Patsy,
you know my approach to Patsy isstill the same, exactly the
(04:32):
same.
So, but I I do say that aclinician can do the anterior,
anterior implants first and thengo back and do the pterygoid.
It doesn't necessarily changeup your sequence there, but I do
(04:52):
feel sometimes, if a clinicianstarts in the pterygoid region,
keep an open mind, because youmay need to go back after you've
placed all of your others anddeepen your pterygoid so we can
still.
we can still do patsy, we canstill do the pterygoid first
(05:14):
place.
It just don't put an abutmenton.
I think that's probably myrecommendation is don't put your
abutment on your pterygoid.
Do the abutment on yourpterygoid last.
Have your anterior and yourmiddle tilted placed and the
abutment placed, because what weall know is for biomechanical
(05:40):
success in our arches is that weneed the abutment platforms to
be all on the same level, and ifyou're not getting your
abutment platforms all on thesame level, you're having uneven
tissue thickness.
You know uneven prostheticthickness as well.
So just really pay attention tothat.
(06:03):
I want to get my abutmentplatform on the pterygoid equal
to my middle implant and so keepan open mind you may have to
deepen your pterygoid, uh to tonail that.
So, oftentimes, on the pterygoid, I'm placing um a 17 or a 30.
On the pterygoid, I'm placing a17 or a 30.
(06:24):
When I was brand new to this, Iplaced a straight, and it can
still.
You know when, if you place astraight in the back, you have
to seat your prosthesis anteriorto posterior, because it's not
going to make that curvature.
The challenge that I ran intothe ones that we did in 2017 was
(06:46):
the milling angles with astraight abutment were way too
steep, yeah, and so we stillwant to place a 17 or a 30.
That really has a very similarpath of draw to all of your
anterior ones.
So that's kind of the otherreason of why I think you need
your anterior abutments onbefore your pterygoid is because
(07:07):
then you have to also look atour path to draw.
Speaker 1 (07:10):
Yeah, that's a really good point.
And I think that's an importantnuance, especially like, if
you're a clinician, that kind oflives in this middle world
between traditional ON4 andPatsy, like, let's say, you're
sort of in that PFAS world wherea lot of us are living in Patsy
.
Like, let's say, you're sort ofin that PFAS world where a lot
of us are living, um, you know,if you're not placing, uh, zygos
, you know whether or not youget pterygoids doesn't really
inform that much of what thosefront four implants are going to
(07:33):
look like.
And so I mean, yes, you can sayyou know what Patsy says.
I got to place the pterygoidsfirst and that's going to
eventually inform whether I'mgoing to do an A-frame or
whatever with my Zygos.
If you're not doing Zygos andeven if you are, you can still
and I like your compromise thereplace your pterygoid, but don't
(07:54):
get married to your final depthof placement.
Just get it somewhere where itneeds to be.
Then go place your front four,get some multis on, and now you
can look at that plane alongthere and then figure out what
that final depth is going to be.
So you don't necessarily haveto have your pterygoid settled
before you ever tackle the frontfour.
That's something that I've donefor a long time.
In a lot of my cases mypterygoid multi units are
(08:16):
sitting inferior to where orsuperior, depending on how
you're looking at it inferior tothe front four abovements, and
you've given me that feedback ona lot of different cases.
So I've been trying to work onthat a little bit and I like
what you said there aboutsettling the final depth after
those front four have alreadybeen chosen.
Now you can really cater things.
So something I'm curious abouttoo, because we're addressing
prosthetic heights of themulti-units in comparison to
(08:38):
each other.
But what do you think aboutcrestal versus super crestal
versus subcrestal placement forthe pterygoids themselves?
What are your thought processeson that?
Because when I first learnedabout them, I was being advised
to leave them one to twomillimeter super crestal for
access.
You know if I ever had to goback and take one out or
(08:58):
something like that.
Leave it a little bit supercrestal, and I think a lot of
people are being taught that.
And now what we're seeing a lotof in terroid specific implants
are tissue collars, so like atwo millimeter polished collar
or even longer, I think.
I think Norris has up to likefive or something like that.
I could be totally wrong aboutthat, but you're seeing a lot of
polished collar implants thatyou know presumably are supposed
(09:19):
to be placed super crestally.
So I'm curious about how youweigh in about that and how you
kind of you know, cater thedesign of the implant.
What is the ideal implant?
I'm throwing a lot at you, butcan you kind of speak to the
Crestle aspect of things?
Speaker 3 (09:32):
for cleansability.
We would want to polish collarin a case that where maybe
there's tissue and not bone.
And we may want to polishcollar in a scenario where maybe
(09:57):
we expect the tuberosity boneto recede.
I think too long and kind ofatrophy.
Yeah, and my thing with that isokay, that's all, those are
good, right, so so then.
So then at that point, whatwould we be concerned about
right on a traditional, all on Ximplant we'd be concerned about
(10:18):
?
Okay, well, that stuff wouldlead to recession, thread
exposure, right.
That's kind of that longer termtriad complication.
Well, okay, I've done 1,000pterygoid implants.
I haven't seen recession on one.
Speaker 2 (10:37):
Yeah, pretty good.
I think that the reason thatthese implant companies are
doing a polished collar isbecause they're trying to make
an implant for the masses Maybepeople who aren't, who haven't
placed a thousand of them andthese doctors are having issues
with the tissue around thatimplant.
(10:58):
And what I do and I learnedthis at your course is every
time I place a pterygoid implantI am back there thinning that
thick tuberosity tissue outbecause I want my prosthetic to
sit all in one plane, kind oflike you've talked about.
And if you stick that implantand it's two millimeters super
(11:23):
crustal with a polished collaron it, the reason that I think
people are doing that is becausethey they have that really
thick tissue back there and theyhave a difficult time putting
the prosthetic on, pushingthrough, you know, like six to
eight millimeters of keratinizedtissue and this into all of
those problems, and one that'sbetter for the prosthetic is to
(11:45):
just grab that tissue with atissue forceps.
Take a a new scalpel blade,just thin that tissue out, that
connective tissue there, and allof your tissue is going to lay
much better around thatpterygoid implant and I think
the smartest way to do it is toplace it, um, you know, at the
level of the crest, or maybe alittle bit sub-crestal,
(12:06):
depending on where your implantplacements are on the anterior
fork.
Speaker 3 (12:14):
Yeah, I would 100% agree with that.
Yeah, I just think there's somelaziness there.
And then it's just kind ofhaving a different mindset,
right, because when I teachpeople at the Texas Implant
Institute courses, a lot oftimes their eyes just get huge
(12:36):
and you can just tell they'renot going to do that in the
clinic, they don't want to dothat.
But I'm like the second thattheir eyes are huge and they're
like there's going to bebleeders and all this sort of
stuff.
But then when you show them andthen you just lay that thin
(12:56):
tissue over it and you just feelhow silky and smooth and all
the restorative space that youhave, then they're like okay, I
get this.
So it's worth the extra 10minutes because it does add to
some surgical time, but it's notlike it's 20 minutes, it's a
10-minute add, but I think itresults in a beefier, temporary,
(13:22):
less fractures, so that's justgoing to save you more chair
time.
But I also to that point.
I just want to complete thethought, or I'm going to forget
it.
But I would say for thepterygoid it does not have to be
subcrestal, because we're notgoing to gain anything, we're
(13:44):
not going to get bone to growover that abutment in the
tuberosity region.
So sub-crestal is fine,equicrestal is fine, just make
sure that it aligns with theabutment.
But my other point is, if youwere to give me the Norris and
say you know, like I w, I wouldhave no way of knowing what
(14:07):
implant to select because ofthat polished collar.
You know what I mean.
Like, how do you, when, whenyou drill what, what, what are
your drills drilling to Right,like, like, is it just?
Is it just the implant depth?
Does it have the polishedcollar on that?
How then do you choose yourimplant depth?
(14:29):
So to me it adds morecomplexity to just the execution
.
Speaker 2 (14:37):
No, I agree.
A quick point too the thinningthe tissue.
Something else that I thinkthat is really powerful and I
don't know if I I think I maybegot part of it at your course
because you it was back when,you know, rick Klein was there
talking about thinning thetissue.
And something that I do a lotnow and I think it helps me
(15:01):
quite a bit, is when people aredoing restorative space.
I feel like there's not a lotof providers that factor in the
thickness of the tissue in therestorative space.
So what I mean by that is youknow you get patients that do a
high smile line and you'remeasuring from that tooth to the
top of the lip, maybe addingtwo millimeters down there,
(15:22):
using that to do your reduction.
Or you know I know Clark, you'dlike to do your multi-unit
guide or you had four.
Okay, but you know you can gainquite a bit of restorative
space too just by thinning.
You know some patients havesuper thick tissue in that
anterior region as well, and ifyou thin that tissue up, you
(15:43):
know you can sometimes save acouple millimeters of bone
having to reduce that bonebecause you can reduce down that
tissue.
Because you can reduce downthat tissue.
I don't know if that'ssomething you do too, clark, but
I find that when you pull thatpalatal tissue forward, it can
be three, four millimeters thick, and if you thin that out a
little bit it gives you a littlemore restorative space there as
(16:06):
well.
Speaker 3 (16:07):
Well, it's not only an advantage in gaining
restorative space, but it is anadvantage in being able to
buccalize our palo mucosa.
Because once you thin that, youknow and I'm not, I'm not
thinning this just in the kindof more of like the superior
portion of the palate, I'm I'mthinning it, you know, 10
(16:31):
millimeters deep right, so thatthat way it's not just on the
top portion but it's also inthat beefy kind of vertical
portion of the palate as well,so that as we pull, everything
is being buccalized and so we'regetting buccalized keratinized
gingiva from the palate, youknow, and just really avoiding
(16:57):
any type of periodontal insultswith having just the thickest
and hardest tissue around ourmultis.
And one little trick is changeout your 15 blade.
I'll see providers stillstruggling.
I'm like that blade's dull.
Just change it out.
And you know, some days myassistants they'll bet on how
(17:20):
many 15 blades we use in an archand you know, it's very
variable, depends on thethickness of the tissue.
Speaker 2 (17:30):
Yeah, yeah, yeah, so much trimming.
Speaker 3 (17:31):
Yeah.
Speaker 1 (17:32):
Yeah, yeah, so much trimming yeah.
Speaker 3 (17:36):
But don't be afraid, oftentimes I'll use one brand
new 15 for one side of thepalette and a brand new 15 for
the other.
Yeah, yeah, they're cheap,they're cheap.
And one of the challenges withthinning the palate is if you
perf it right.
But that's kind of why you usethose tissue forceps and you
(17:58):
just go straight down the middle, you allow that metal to guide
you to where you're not going toperf and you need to be ready
to tie off some bleeders, right,I think, tyler, you wanted to
talk about, um, you know, somesome bleeding things.
Yeah, uh, you know you can usea bovie or electrocardiory.
Um, I think, I think a bovieworks better than
(18:21):
electrocardiory.
But, uh, if if you don't haveeither of those I tell you what
just tying off a bleeder is waybetter than either of those
because you can just loop it andI do not control bleeding with
Epi because they're going tobleed at home and so control
(18:45):
your bleeding withoutepinephrine.
You can utilize epinephrine,say, if you're doing an analog
conversion process, just to kindof make sure that you can
reduce your heme, your ooze andyour bleed.
That's just kind of oozing,that's just natural oozing.
(19:06):
You can use epinephrine tocontrol natural oozing.
But I would not really useepinephrine to control the bleed
because it'll just rebound.
So oftentimes it's as simple asjust you have to find your
bleeder and you go posterior toit and then anterior to it and
(19:28):
then you're just going to tie aknot.
And I've had times where I'lltie a knot and I'll cut off the
tail and I'll tell the assistantdon't cut it.
We're going to wrap severalmore times around there and then
suture that down.
I've had some bleeds wherewe've wrapped them two to three
times.
Typically I find that theelectrosurge works really well
(19:51):
for kind of the more you know,as we're getting distal to those
arterioles Right, so kind ofmore in the upper coronal aspect
(20:11):
of the palatal flap.
The electrosurge works wellthere.
But if you're getting a bleedthat's a little closer down to
the greater palatine, that'sgoing to need to require a
suture.
And one of the big things thatI've done in the past two years
has been switch over to utilize2-O chromic gut suture and it is
(20:32):
so much stronger and yourneedle is a lot longer and so
you can really get to some ofthese deeper areas and you can
pull tighter and you can cinchthese things down because you
have a stronger rope.
I also use 2-0.
Speaker 1 (20:50):
Yeah, that's something.
You definitely converted me andSoren as well, on it's 2L
chromic for every Fuller's case.
It's fantastic.
Speaker 3 (20:58):
You can really get aggressive with it and it just
makes your suture so much easierand better.
And make sure you're soakingyour sutures right.
All my assistants know we havea bowl of water sterile water
and you know the start of thecase, that that chromic suture
(21:18):
is soaking and by the time we'reready to suture it is just silk
and it just it just rollsreally good, yeah, yeah,
definitely.
Speaker 1 (21:27):
And I know you know, before we start wrapping things
up here.
So I know we wanted to talkabout configuration.
So we wanted to talk about, youknow, before we start wrapping
things up here.
So I know we wanted to talkabout configurations.
So we wanted to talk about, youknow, inverted V's, m
configurations, placing youranteriors parallel pros and cons
.
I mean you see a lot ofdifferent things.
Now there's some surgicaladvantages to different
configurations.
There are prosthetic advantagesto different ones.
(21:49):
You know, at this point in yourcareer, clark, you know what
has become sort of your standardconfiguration that you will
approach your upper flourishcases with.
Speaker 3 (21:58):
Yeah.
So I mean I can saydefinitively, without a doubt,
you know, I am no longer, youknow, going to be doing an axial
anterior implant, so those aregone.
(22:19):
I want to be angling all of myimplants and I do it for a
prosthetic reason, right, I doit because I now have infinite
timing options, because I'mgoing to place an angled
abutment.
So if all we do is axillaryimplants, we only have two
(22:40):
options to correct our screwchannel axis we have a zero,
which is our straight, or wehave a 17.
So oftentimes, as we all know,sometimes we don't like the
straight and then sometimes the17 is too palatal or too buckle,
right.
But if we angle our abutments,then I can change the timing two
(23:02):
to three degrees and then placean angled abutment on there.
So all angled right.
So that knocks out axial and mypreference.
Every time that we can andactually had a case, uh, monday,
yesterday, that I could not do,it was just there was a very
large infection uh, on numbernine, right.
(23:25):
So, uh, but just in general,every case I can, I am going
nasal.
So I want to do the Vconfiguration on every implant
case out there.
Okay, uh, I, I prefer the Vconfiguration over the M right.
(23:46):
So M is is when the anteriorimplant is going into the
lateral nasal.
That, to me, the trouble thatyou get into is.
Now you're kind of having tostack your apical tips of your
implants.
It's a bunk bed, and if youdon't have a lot of bone volume
there then you're going to windup blocking your posterior
(24:08):
implant out.
And that's what Patsy teachesus, because then we can just
roll in and do a posteriorzygote no big deal.
But if if you're not ready tojust on the fly switch over to
do a zygote, then you're goingto have some trouble.
(24:28):
So if you do the Mconfiguration, you're, you are
likely going to block yourselfout on the posterior tilted.
So I prefer V on everybody.
And guess what?
Let's say you have a failure ofyour posterior implant.
Well, now you still have tonsmore room to replace that
posterior implant right, or yourmiddle implant, we'll call it
(24:52):
because you haven't blockedyourself out.
The only times that you cannottypically do a nasal crest is
when you have a very largeapical infection of your central
incisors.
And so I had a case yesterdaythat was very, very much the
case.
I nailed one nasal crest andthen the other one actually did
(25:15):
an axial.
It was literally my only option.
It was a resorbed case.
My posterior Patsy implant wasgoing to block me out and so at
that point, what's the harm inan axial implant right Like I
would?
I would not choose.
Oh, for this area on thepatient's left side where I
(25:37):
could not do a nasal crest, Idid lateral nasal and then I'm
going to block myself out andthen have to do as I go, right,
like you know, the best as I gois the one you haven't done, and
damn sure an axial implant isgoing to be way better than
having to do a zygote.
So you know just a little bitof that shucking and jiving.
It's just a.
That's a one percent one-offcase, so don't think anything
(26:00):
into it.
But but for sure, nasal crestto me, how I approach every case
, we're doing nasal crest everytime that we can.
So V configuration.
Speaker 1 (26:11):
So we're all pro V.
Establish that.
So when you're aiming for thesame spot with both these
implants, are you crossingswords?
How are you making sure thatyou're not interfering with each
other?
What's?
Speaker 2 (26:26):
your approach for that?
Speaker 1 (26:26):
inverted V, just surgically speaking.
Speaker 3 (26:32):
So I place these exactly the same every time,
right?
So so my number seven implantis going to be anterior to my
number 10.
So my number 10 is going to bedeep, is going to be posterior
to that.
So I'm actually going to anglethat you know much, you know
(26:55):
much further posterior than mynumber seven implant and that
that way you, you, you alwaysaccount for it, right.
If you do the same thing everytime, it's just it just gets
into muscle memory, whereas ifyou kind of futz around and and
you're not organized, you knowyou may do where you angled them
(27:15):
both to the same apical in yeahand that's when you wind up,
okay, well, one's going to be a13 and one's going to be a 10.
You know so my ideal, uh, so Ilike to stack them, I like to
have them cross at the nasalcrest and I prefer to do 13s
(27:40):
versus maybe try to have theapical osteotomy converge and
then you're doing 11 1⁄2s oneither Right right, so I stack
mine in the nose.
Speaker 1 (27:55):
So if we're trying to get some symmetry there, you're
saying I think you said yourseven is going to be interior to
your 10.
Is the timing going to bedifferent on that?
How is that?
How are you trying to get, howdo you get them symmetrical if
you're aiming for differentthings?
Speaker 3 (28:13):
There's still well A like you know where the
abutments are.
You won't know.
Typically on my number 10,right, it's kind of like your
pterygoid, right.
So, it not only has a medialangle, right, because we're
aiming medially to the crest.
So that's what I would say.
(28:33):
I would say the number 7 hasone angle and it's a medial
angle, Whereas number 10, notonly does it have a medial angle
, but it has a deep, you know,and a posterior tilted angle.
You're tilting it anteriorforward so often.
Speaker 2 (28:54):
Yeah, I mean the crest of the implant.
So well.
Speaker 3 (29:01):
I just go by the tip, right.
So I want the apical tip to bedeep or posterior to my apical
tip of number 7.
So oftentimes the number sevenimplant may utilize a 17 degree
abutment and the number 10implant may need to utilize a 30
(29:22):
, because I'm aiming at 30degrees posterior.
Speaker 1 (29:28):
Okay, so that answers what I was getting at.
Okay, so sometimes it's goingto be a different abutment to
account for that different.
Okay, yeah, got it, got it, yep.
Speaker 2 (29:34):
Okay, typically what's your medial angle, but
but again, you know, is it alittle bit less than your tilted
, Is it?
Is it pretty similar to yourtilted?
Speaker 3 (29:44):
Yeah, it's, it's.
It's typically nasal crests arealways less, but there's a
little bit of variability in youknow where we wind up going
based on.
I always look for just aconcept of what I call bone
shields and I want to.
(30:05):
I want to use my pilot drill inthe anterior and I I want to
find the area the most densebone, the most amount of bone,
and typically I am going toplace it, place my pilot drill,
in the medial portion of thenumber seven socket, right.
(30:31):
Like I don't necessarily wantto place it in the distal
portion of that socket, I wantmy coronal portion of my implant
to have lots of interproximalbone between eight and nine, and
that is going to help fight offlots of stuff down the road.
(30:54):
So our options are we can choosebuckle bone, the immediate
buckle bone of number eight.
We could choose the immediatebuckle bone of number seven.
I don't choose either of those.
I want to go within theinterproximal bone of number
seven and so that can be alittle bit variability based on
(31:16):
arch form.
You know if they had ortho orif they didn't have ortho.
So sometimes we may be more atlike a 17 degree angle to
midline, sometimes it may bemore of a 30 degree, so it's
definitely more variable.
And it also depends on theheight of your subnasal bone and
(31:40):
also the anatomy of the nasalfloor.
Sometimes some people have avery nice wide subnasal floor.
Sometimes it's a little moreconstricted and so all of that
kind of changes things.
But again we're aiming to thenasal crest, which is right
(32:01):
underneath that vomer bone.
But that vomer bone is furtherback it's way back there, yeah.
Not way back there, but itstarts posterior to the incisive
canal.
Speaker 1 (32:12):
Okay so you heard it here, folks, the inverted V.
That's the modality.
Now we're moving on from axialplacement.
Shame on you if you do it.
Speaker 2 (32:21):
I did it today twice.
We're with the mandible.
Speaker 1 (32:22):
Yeah, moving forward.
Speaker 2 (32:24):
Are you doing a V in the mandible every time?
Speaker 3 (32:30):
Same thing.
We prefer a V.
That angle on the anteriors is,uh, less so.
I would say it ranges from,from you know, 20 to 10, but
oftentimes I mean if you'retilted fails, you got another,
(32:51):
another so chunk of bone thatyou can move that forward one
slot and again you can.
Speaker 2 (32:57):
You can change your timing a little bit better with
multiple areas to change thattiming correct exactly, exactly.
Speaker 3 (33:11):
What about you guys?
Are you guys doing these oractually on my cases still?
Speaker 2 (33:15):
uh, but you know, I I 100 agree with everything
you're saying.
Um, patients that I'll doinverted v on are patients with
really pneumatized sinuses.
That, um, you know, I want tomake sure that I have enough
room to uh to place anotherimplant if I need to, if I have
a failed tilted implant, um.
(33:36):
But typically I'm doing axialuh, but I probably will start
doing more of these.
I think it's smart.
I don't think there's a reasonnot to, and I agree with all
your points for sure.
Speaker 1 (33:52):
Yeah, for sure, for sure, yeah, and I, I mean, I
love the prosthetic flexibilityof it.
I, you know, I always get this.
Uh, you mentioned at the verybeginning this conversation is
when you're placing axial, youusually only have like two
options and you're going to trythis straight and then you
realize maybe you're a littlebit more buckled than you had
initially intended to be.
Now you're going to be like,okay, I guess I'll put a 17 on
there, and then you end up morepalatable than you really wanted
(34:13):
to be, and so it's like there'sthere's not really a great
world in between.
Um, so by doing the inverted V,it gives you all the flexibility
in the world to figure outexactly how, how that needs to
be timed.
I am curious when you're uh,when you're timing those implant
, are you usually uh?
So I'm always looking at thedot for my timing, right?
Is that usually going to bepointing towards the midline
(34:33):
with your inverted Vconfiguration?
Is that very similar to howyou're timing your middle tilted
implants?
What are you referencing asyour timing your implant usually
?
Speaker 3 (34:45):
Well, I think in the inverted V, the most important
consideration is implant depth.
And oh, we got to talk aboutthis.
Yeah, you know, because you'reactually going to place
especially your number 10implant, or whichever implant
goes deep to the other one.
(35:08):
I measure my subcrestal desireddepth, depth which is one
millimeter subcrestal.
You know, measure that on theshallowest part.
Well, on on on the nasal crest,that's going to be not on the
buckle but on the palatal side,right, and so your, your palatal
(35:29):
wall, you know you're, you'regoing to get your implant one
millimeter subcrestal, asmeasured on the palate, but as
measured on the buckle, maybetwo, three on the buckle.
So these implants are going tofeel deeper.
So you're going to have to getin the habit of measuring your
uh abutment depth on the palate.
(35:51):
It's's the same concept as wedo on our posterior tilted.
It just feels very, very odd toplace one so deep, and so
clinicians need to take thatinto account when you're
measuring your depth.
And again, measure your depth onyour drills.
And we know exactly the depthto do because we've done a
(36:13):
subnasal lift and so we are ableto feel our drills Sometimes if
we have a wider nasal crest,sometimes we can't, but we'll
take an x-ray to account forthat.
And whenever you're doing yourmeasurements, with whatever
method you're doing yourmeasurement, make sure that you
(36:36):
are placing your implant to thedesired sub-crestal depth.
Sorry, you're taking your drill.
You want your drill to be asdeep as your desired sub-crestal
final implant depth, and sothat way there's not any
variability.
But as far as timing goes, Ialways say that the dot right.
(37:00):
Yes, for all of our implants Istart checking the timing in our
screw access channel by havingthe dot be pointing to midline.
But I always say that the teethwin and so oftentimes the dot
will help get us in the ballpark.
Speaker 1 (37:21):
Yeah, right, but.
Speaker 3 (37:23):
I'll always be double checking with your MUA guide
and and be in your posteriorimplants.
You can check with thecontralateral arch.
The only implants that wecannot check to the
contralateral arch are themaxillary anterior implants.
We have to use the MUA guideand know where the final desired
(37:44):
position of the teeth is goingto be, and that's what gets us
the right spot.
Speaker 1 (37:51):
Yeah, and I'm curious too.
Speaker 3 (37:53):
Another reason why I do not like palatal fiducial
markers.
Speaker 1 (37:58):
Oh yeah, because you're not going to have a
reference for it.
I mean, you could, but you'dhave to have like a really big
recess.
Speaker 3 (38:04):
You have to have a window.
Yeah, and you know I do bigflaps, right.
You know I'm a big proponent ofthis and so by the time I put
an MUA guide on that, has, youknow, a fiducial relief, right?
(38:26):
Yeah, well, now I've alreadydisturbed all that tissue and
it's kind of swollen and there'ssome blood in there.
So then I really question theaccuracy of that.
So you know, I know that youguys do a digital method without
fiducials.
Speaker 1 (38:45):
Yeah, correct.
Speaker 3 (38:48):
Yeah, and so it just makes it so much simpler, oh my.
Speaker 1 (38:52):
God, yeah, I still use fiducials sometimes for a
single upper or something likethat, and I suppose that you
probably could design amulti-unit, an MUA guide that
would sort of allow you toactually guide the fiducial
placement.
So you could, you know, placeit even with teeth on and maybe
it's like toothborn or somethingand it has some recesses in it
(39:13):
so you very specifically placefiduciary markers or not
fiduciary fiducial markers inspecific spots, so that when you
do get the teeth out, you couldthen put it on the MUA guide
and it would fit just over wherethose fiducial markers are.
So you don't have this likemassive window anymore, it's
like pre-planned.
But you know, this is gettinglike wait.
I mean, I don't, I don't likefiducials at all, so I'm not
(39:34):
going to go through that.
But yeah, we, we do a denturewash vest.
That it's it's, it's fantasticfor that Um.
So we can really, you know, we,we have, we can use multi-unit
guides and figure out wherethings need to be.
One thing I wanted to make surewe address too, though, and this
(39:54):
is brought up by um, I think.
I think Adil uh Khan uhmentioned this one.
Uh, yeah, he did so.
Uh, details on the multi-unitabovement height.
So you had talked about, um,you know where we're placing our
implants in relation to thecrest, what is the height of the
multi-unit that we're placingand the biologic width that gets
established there?
Um, and there's some nuancesthat you've talked about in the
group that I've never reallylike.
I obviously I've heard of thesethings, but I've never heard of
(40:16):
them really talked aboutspecifically in the context of
multi-unit abutment placement,and I feel like this is like a
really important nuance thatwe're just kind of glossing over
.
And if you look at, you know,uh, posts that people make on
Instagram of their, of theirarches, and that you show them
all the new and stuff, there isso much variability in terms of
the heights that people arechoosing and you know, is it
with respect to tissue?
Is it with respect to theimplant placement?
Speaker 3 (40:37):
Um, I really liked how you talked about um the
establishment of biologicalwidth with regards to your
multi-unit above heightselection.
So could you speak to that alittle bit?
Yeah, I think that many people,many clinicians, try to
establish biologic width at thetime of surgery and I think that
(40:57):
that is false.
I think they are missing out onthe fact that by simply raising
a flap, we are going to havesome bone resorption.
They are not taking in to thefact the bone resorption process
.
So oftentimes what I see isclinicians will be placing
(41:21):
subcrestal depth to onemillimeter and they will then
choose a 2.5 millimetermulti-unit abutment, tall and,
yes, tall, um, and that that isthat is incorrect.
If, if, if you have a multi-unitor, sorry, if you have your
(41:42):
implant that is two millimeterssubcrestal, then you should use
a two millimeter heightmulti-unit abutment.
If your implant is onemillimeter subcrestal, you
should choose a 1.5 millimetermulti-unit abutment.
And so, uh, that's that's whereI start harping on on
(42:04):
clinicians is because they didone millimeter subcrestal and
they used a two and a halfmillimeter multi-unit and it is
too tall, and so obviously we'relosing one millimeter of
restorative space just off thebat.
And now I mean, on occasion I Iget patients they complain
(42:26):
about the abutment showing andit's obviously it's not the
implant.
You know, and you know on onoccasion I mean it's, it's, it's
, it's practically unavoidableum in in in many cases, um, and
you, you're you're going tooverly pronounce that if you're
using taller multis.
(42:48):
So we want for full archbiologic width is 1.75 to 2
millimeters.
That is the appropriatebiologic width.
That is the appropriatebiologic width and we want.
So I then account for onemillimeter of post-surgical.
(43:13):
That is the appropriatebiologic width and we want.
So I then account 0.75millimeters supra-crestal, so
that after crestal we then haveestablishment of biologic width
(43:40):
and loss of roughly onemillimeters of that, that that
bone.
Three months goes by.
We then have a establishment ofbiologic Right.
(44:01):
If you're a buttments, in fact,if your abutments are too proud,
too tall, oftentimes what wesee when the final prosthetic is
made is flanges right, and sothat leads clinicians to have to
(44:24):
hide multis with flanges.
And so you know, if, if, if weall think about it from an
emergence profile standpoint,the more emergence profile we
have, the better right, so as ifwe lower our prosthetic margin,
then we're able to get a muchbetter emergence profile.
(44:46):
And so that's what I am doingwith a 1.5.
Now, that's not to say that Idon't use 2.5s.
In fact, I'll use maybe three2.5s a week, but that's just
because, for whatever reason,maybe I wanted a couple extra
turns, Maybe I needed a, youknow, an extra millimeter of
(45:08):
stability.
Speaker 2 (45:09):
Yeah.
Speaker 3 (45:10):
And, and I didn't feel like mowing a millimeter of
bone down, you know to to kindof to to make it all flow, and
so then I'll just grab a twofive 17 or a two five 30, and it
works out great.
But again, you know, all of myabutment margins are all in the
same platform, just to make sure, yeah.
Speaker 1 (45:30):
That's solid.
That's one millimeter.
Speaker 2 (45:32):
Now, when you're placing your tilted, is your one
millimeter subcrestal at themesial aspect?
Okay, yeah.
Speaker 3 (45:44):
Yes, yes, yep, and you know again, on the nasal, on
the nasal crest, it's on thepalatal.
Speaker 1 (45:52):
Yeah, yeah.
Speaker 3 (45:55):
So, and then what you're going to find is, when
you finalize your cases, you'regoing to see just beautiful, uh,
flat tissue.
Speaker 1 (46:09):
Yeah.
Speaker 3 (46:10):
Yeah.
Speaker 1 (46:11):
I mean, it's, it's these kind of you know nuances
that I think can you know, uh,really make full arch a whole
lot more predictable, even whenyou're doing it at volume.
And there's so many littlethings that are more predictable
even when you're doing it inthe post-ops with patients, and
it's like my new details, youkind of just write it off.
(46:32):
It's like oh, these, thesethings just happen.
Like sometimes patients justhave issues with this or that,
like very recently, I had apatient who you know, all of his
implants felt great, except for, like one particular spot
that's been giving him all this,all these issues.
Um, just it just feelsthrobbing.
It's been hurting.
We've taken follow-up x-rays onit and there was no effect and
just it just feels throbbing.
It's been dropped and I lookand it's all around that
multi-unit.
(46:53):
It's just like it's.
It's inflamed, um, it's gotlike it's feeling is he's, he's
reestablishing biological width.
I forced that to happen becauseI didn't pay enough attention.
I was, I was rushing, I crushedthe bone with the multi-unit
(47:13):
and now he's, or anything, thatI take his bread.
Now I have the answer as to whythat was happening and, if
anything, that I take his brickshappen and maybe it'll resolve
on its own.
So these little things, likethese very small nuances during
surgery, really shouldn't.
Just it just feels throbbing.
Thank you.
Speaker 3 (48:28):
Well, well, I wouldn't replace the multi um,
you could take it off.
You know now, now you knoweverybody, you know all my staff
knows, like we don't touchimplants until they're fully
integrated.
Right, because the second yougo back up back a buttmanment
off, you never know what's goingto happen.
(48:48):
Right, and especially theseneodent abutments.
They can be so difficult toremove because they cold well on
there, so good, and it's superfrustrating, right, like trying
to get a cold welded grand Morseabutment off your implant.
Speaker 2 (49:11):
Yeah.
Speaker 3 (49:12):
But I will take that challenge all day long because I
know that that is taking theforce off of the abutment screw.
Right, I know that we arelocking that in and and and now
we're mitigating abutment screwloosening.
You know, um, some of theseother companies, you know, when
you just kind of get themhalfway loose, I mean like the,
(49:33):
the nopel stuff, you know, thesecond you get that abutment
loose, it's, it's, it's a whileready to go um, but you know
what?
what I may just recommend is whydon't you just give him 100
milligrams of doxycycline?
Okay, and I've begun to usethat for anybody that just kind
(49:55):
of has some atypical gingivalstuff, right, like if there's
some foots going on in thegingiva, you know, a hundred
milligrams of doxycycline.
Or if you have a patient who ismaybe they're slow to heal, you
know, if they come back they'restill hurting at two weeks,
that sort of thing.
(50:15):
Um, you know, sometimes you canget some postoperative palatal
necrosis and, uh, get somepost-operative palatal necrosis.
And you know, obviously, if andwhen you have palatal necrosis,
you need to remove that deadtissue.
You know it's not going to getany better.
(50:35):
You've got to get that deadtissue out of there.
But then they all get 100milligrams of doxycycline and
that typically speeds up a lotof the a lot of the healing is
that I don't?
I don't know or what is it?
You give it BID.
Okay, 100 milligramsdoxycycline BID seven to ten
(50:57):
days, it it doesn't.
It doesn't do anything on theon the healing part, other than
it's broad-spectrum antibioticthat helps just if the body is
trying to fight off differentlittle bugs that may be impeding
your healing.
(51:17):
And then now you wipe it awaywith the doxy, then now the body
can just focus on healing.
I like that.
No, no, that's great, it's,it's, it's, it's.
It's definitely been a nicelittle thing to give.
That you know, and, andoftentimes you know, patients
just want something rightthere's just they're just
(51:39):
there's a psychological dealwhere they're just looking for
you to do something right.
Saying we can't do anything isnot reassuring to the patient.
It's hopeless.
Speaker 1 (51:48):
Yeah.
Speaker 3 (51:49):
Now, now there are cases totally, where you can
tell your patient I got you,you're fine, this is not going
to turn into an infection, it's.
It's too close to surgery.
Um, you literally need, andthere's nothing I can give you
other than time.
That also is assuring when theyknow that it's just a time
(52:15):
thing when you're prescribingtime.
Speaker 1 (52:18):
Yeah, that's solid.
Speaker 3 (52:20):
But not being able to say that and just be like, yep,
nothing I can do, but not beingable to say that and to feel
you and listen.
Speaker 1 (52:34):
That's fair.
Yeah that's fair.
Well, clark, this has reallybeen fantastic.
I think we may have gottenthrough 40% of the outline that
I made for us.
So we've at least got two partshere, and I think that may have
gotten through 40% of theoutline that I made for us.
So we've at least got, you know, two parts here, and I think
that's fantastic.
And I think we ought to save alittle bit for for next time,
because I think this is this isgoing to be a recurring series
and if not only for the audience, I think it's for Soren and I,
(52:57):
because we learned somethingevery time we sit down and talk
to you and you know, there'sgenerally a pearl that we'll
carry forward for the rest ofour careers just about every
time we talk to you.
So we certainly appreciate that.
Speaker 3 (53:06):
Awesome, Well, just kind of like, I think.
What did Elon come out?
Or it was Eric Schmidt came outand said that we've given AI
the fullest extent of all humanknowledge.
There is an extent to mine, soyou know we will reach maximal.
(53:26):
You know knowledge that Damonhas, so that could come about.
Speaker 1 (53:33):
So don't be sad when that comes, I don't think we're
at the bottom of your largelanguage model.
Once we hit that, your chatwill be reviewed.
It's back to where it was.
Speaker 2 (53:42):
It's back to where it was.
Speaker 1 (53:46):
It's funny yeah.
Speaker 2 (53:50):
Refresher Just like the canaver refresher.
Speaker 1 (53:52):
That's all it'll be, yeah.
Speaker 3 (53:54):
Awesome.
Speaker 2 (53:55):
Well.
Speaker 3 (53:55):
I really liked her interview with David Zellig.
Speaker 2 (53:59):
He is a super nice guy and super enthusiastic I I
mean, he was more excited thanhe was I actually left that
interview, like you know talkabout this stuff and I need to
be more enthusiastic about thesecases, because that guy has
been doing this way longer thanI have and he still is 100% I
(54:22):
know just stoked, yeah, yeahyeah, just overall super nice
guy.
Speaker 3 (54:31):
And you know, I mean I took, I took, I took two pages
of notes just talking withZellig and I already know all
this stuff you know yeah but uh,you know, just kind of the way
he talked and the way hepresented, I think that'll be
such a great person to have onand really we should try to get
(55:00):
Vichy or even Juan on to reallytalk about medical legal stuff.
You know, and like what, what,what do guys need to?
You know really kind of payattention to.
You know what, what are, whatare things that that that they
all can benefit from, and andyou know, I think there's a lot
(55:22):
to learn there.
Speaker 1 (55:24):
Yeah, no, I agree, I think that's a.
That's a good wrinkle that youknow I, I think there's a lot to
learn there.
Yeah, no, I agree, I, I thinkthat's a that's a good wrinkle
that you know we've never eventouched on and we've both talked
to juan before and, uh, youknow, I've been trying to get
vishy on here for quite sometime and, and, yeah, I
definitely think they can bringsome part of that conversation
that would be really interesting.
So, um, yeah, I think you'vegiven us some great ideas and
you know, we look forward to thenext time we get you sat down,
(55:46):
and either it'll beconversations with the tribe or
conversations with, uh, you know, another, um, you know
fantastic leader in full arch.
So, again, you know, we justreally appreciate your time,
clark, and we look forward tonext time.
Speaker 3 (55:57):
Awesome guys, appreciate y'all.
Thank you Always, always,always fun to talk and y'all
keep me thinking and so it'sgood.
Speaker 1 (56:07):
For sure.
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