November 10, 2025 • 35 mins
What if the “new” thing in full-arch isn’t actually new—and the real breakthrough is remembering what already worked? We sit down with Dr. Samuel Jirk to unpack eight decades of subperiosteal design and how those lessons should guide today’s patient‑specific implants. From the first time he watched a 14‑unit FP1 delivered over 10 implants at daybreak, to building an in‑house digital lab, his path reveals how mentorship, biomechanics, and occlusion still decide who gets predictable outcomes.
We walk through the foundations laid by the Misch Institute—prosthetics before surgery, divisions of available bone, and RP1–FP4 categories—and why that structure keeps full‑arch treatment safe as complexity rises. Then we challenge the hype around PSIs: CT‑based subs have a long history, and success has always hinged on load direction and soft tissue tolerance. You’ll hear why remote anchorage to the lateral ramus and symphysis reduces crestal stress, how lattice “snowshoe” concepts translate to modern titanium, and why molar‑emerging posts invite dehiscence in thin tissue and active muscle zones. The goal isn’t thicker frameworks; it’s smarter ones—debulked, contoured, and placed where biology says yes.
Along the way, we talk real‑world fabrication—segmenting DICOMs, designing in Exocad and Blender, printing and milling, and even casting cobalt‑chrome when indicated. We also spotlight the underreported side of PSI literature, where two‑year complication rates near 26% demand humility and better design, not complacency. If you’re a surgeon or restorative dentist navigating AOX cases, zygos, or subperiosteals, this is a roadmap to pairing digital precision with time‑tested biomechanics and occlusion.
If this conversation sharpened your thinking, follow the show, share it with a colleague, and leave a review with your biggest takeaway. Your feedback helps more clinicians find practical, proven full‑arch insights.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:40):
My name is Dr.
Tyler Tolbert, and I'm Dr.
Storin Poppy, and you'relistening to the Fix Podcast.
Your stores are for all thingsin plant dentistry.
All right, and welcome back tothe Fixed Podcast.
We have another very esteemedguest on with us today.
Um took us quite a while towrangle him because he's a very
busy guy.
You're gonna hear a lot abouthis resume and his current
practice, which is still very,very busy.
(01:02):
Um we have with us Dr.
Samuel Jirak.
Um he brings a wealth ofinformation and knowledge and
experience in full archimplontology.
He's been doing this uh,frankly, longer than either uh
Soren or I have been alive.
So we're extremely humbled tohave him on here.
And, you know, one of the thingsthat I originally reached out to
him about, um, I saw that uh Ibelieve at the upcoming Orca
(01:23):
seminar, he's gonna be uhlecturing on uh customized uh
subperiospules.
And uh, you know, I know that hehad extensive, extensive
experience with that, not justthe ones that we're talking
about today, but also the onesof yesteryear, how that's been
done in the past, what we canlearn from that, the good, the
bad, the ugly, and what the nextpath forward um for customized
(01:44):
implants looks like.
And there's really not anyoneelse I could think of that would
bring a more comprehensiveexperience to speak to that
topic um than Dr.
Jarick himself.
Uh also, he's got a wealth ofinformation about all things
full arch.
He does it all, um, everythingthat we talk about.
So we're super, super excited tohave him on and uh very grateful
uh for him to spare his timewith us.
So thanks so much for coming on,Dr.
(02:04):
Jarick.
SPEAKER_02 (02:05):
Thank you very much, Tyler.
It's just a privilege to be partof it.
SPEAKER_01 (02:09):
For sure.
So uh for those who don't knowwho you are, um, we'd appreciate
if you could just kind of giveus a little bit of background
about you know your journeythrough Full Arch as a dentist,
you know, getting into implants,how things have kind of evolved
since then, and and kind ofbring us all the way up to you
know the current day.
SPEAKER_02 (02:26):
Okay.
Well, uh first of all, 1986graduate University of Tennessee
uh health center uh dentalschool.
And um, you know, when we werein dental school, you know,
dental implants were not taught.
Uh we had literally one lectureon it and had a great oral
surgery department.
Uh we did a lot of work in theoral surgery department in
(02:49):
undergrad.
But basically, the lecture washere I am the oral surgeon,
here's this dental implant doneby some cowboy over in East
Arkansas, and here I am takingit out because it's failing and
they're horrible, they don'twork.
And all I could think at thetime was, wow, if these things
work, wouldn't this be great?
You know, better than a dentureor a partial.
(03:10):
So um, you know, run out ofdental school, I mean, uh, I'm a
CE junkie, and it started fromday one.
Believe it or not, my very firstcourse, my very first CE was an
implant course, and there werefive manufacturers at it.
Uh Stereos, which later uhbecame Nobel or was bought out
by Nobel, uh, you know, wasthere.
(03:33):
Uh DB Driscoll was there, acouple others.
There were plateform implantsthere.
Of course, nobody's marketingsubs because it was all root
form, but uh, and I thinkCorvent was there, you know, and
uh took that course and then youknow kind of wandered around for
about a year, and I had anorthodontist in the clinic that
was from a small town in EastArkansas, and he kept telling me
(03:56):
you need to go uh talk to mybuddy up over there, Dr.
Liljohn, uh, where I practicepart-time, and he's he does more
implants than anybody.
And I'm like, you know, he's inthe middle of farming country,
Arkansas.
There's no way this guy's doingimplants in Arkansas, you know?
Yeah, so uh this goes on forabout a year, and I call him up,
he's and I said, Hey, yeah, Iheard you do implants.
(04:17):
Yeah, he says, and I said, Doyou mind if I come over and you
know watch you do some implantsone day?
Come on, and of course, youknow, he was working Fridays and
um he starts at seven, and uh Idrive an hour and a half over to
his office and pull up in theback, and you know, there's a
couple of Mercedes, a couple ofLincoln Town cars, a couple of
(04:39):
real nice pickup trucks, and Iwalk in the back door, and the
operatory, the main OR, wasright at the back door, and I
walk in, he's already working at7 a.m.
And he's delivering a 14 unit,which we call FP1, cemented, up
to 10 implants with bilateralsinus grafts, and I think he'd
(05:01):
done some uh tick soft tissueaugmentation.
Wow.
And I my mouth just fell open,I'd never seen anything like it,
you know.
So uh I ended up leaving hisoffice at seven that day, went
to his house, wife cooked usdinner, he said, let's go up to
the attic.
And this guy had tens ofthousands of slides, and he
(05:21):
lectured you know nationally andinternationally, even back in
the 87.
And I uh went up there and hesays, Okay, Bubby, he says, you
know, he says, obviously smartkid and everything, talented.
And he says, but you don't knowwhat you don't know.
You don't know what you don'tknow.
So at that point, you know, hewent through a bunch of stuff
(05:42):
and I said, Hey, do you mind ifI come back?
And he goes, Anytime.
So I started taking off Fridays.
I worked four days, you know,Monday through Thursday, and
then every Friday I scrubbed inwith Dr.
Liljohn and assisted him.
And we did sinus augmentations,we did subs, we did plateforms.
Uh I think he didn't do ramusframes, he didn't believe in
(06:04):
them.
Uh, but he had been in practice20 years, he started out life as
an engineer.
He was very active in AAID, hewas one of the original uh ABY
diplomates.
He was in the first class thatthey accepted, one of the first
examiners, uh, honored fellow.
And so, you know, it was veryblessed to have him in my life
(06:25):
at that time.
Um so he said, Well, we got toget you in some continued
education.
First place I went was AlabamaImplant Study Group, and at the
time they were doing a Congresswhich was attended by 120 to
1,500 doctors internationallyonce a year.
Uh, Root Lab was a big sponsor,they had a big crawfish bowl,
(06:45):
and they were showing theirimplant restorations and the
subperiosteols and everythingthere.
Um, you know, and they taughtfive courses a year, and it
would be different instructorsteaching everything from blades
to root form to sinusaugmentation.
I mean, Bill Tatum was teachingsinus aughts there.
(07:06):
I learned sinus augmentationfrom the man himself.
Uh, and then you know, they wereteaching subparaoscopes.
So uh we would have a livesurgery, it was done at Caraway
Medical Hospital.
We'd have a live surgery, uhclosed circuit TV on uh that and
uh attended all those and keptgoing back, ended up off started
(07:28):
doing some surgeries for them uhand taking some patients to
Birmingham to do that.
And uh I got into AID, uh, youknow, and that they really
weren't pushing the associatefellow fellow stuff at that
point in time yet.
Uh started going to thosemeetings and southern district
meetings, and uh you know, justhad a lot of information come
(07:48):
from a lot of different areas.
Of course, you know, this is allbefore the internet.
Uh you can't get on uh uhYouTube or TikTok and see how to
do a pterygoid or any of thisstuff like you can today.
So, you know, you had to travel,and uh, you know, I'd just
gotten married.
My wife was a pharmaceuticalrep.
We waited a while to have kids,so we were double income, no
(08:11):
kids.
I traveled the country and I wasdoing 100, 200 hours a year
continuing education, allimplantology related.
But uh the big turning point wasyou know, Carl Misch, uh Mish
Institute had just gottenstarted.
At the time it was still inDeerporn, Carl was teaching it.
His one of his wives, Lori, wasteaching the office management
(08:34):
side.
So you would literally take yourstaff to the first one, office
managers, assistants, everybody.
Uh hell, I think the hygienisteven went.
And um, it was all didactic, andLori would teach the office
management side.
Carl was all didactic, and thenwe went back five times over the
course of a year and a halftaking our own patient.
(08:57):
And we started out with the rootform, then we did a plate form,
then we did a sinusog, then weput the implants in the sinusog,
and we actually did asubperioster.
Carl was was teaching that andhe was making some
modifications, and we we did oneof his modified.
But Carl's courses compared tothe courses today, you literally
(09:19):
had two hours to do whatever youwere doing.
You had a mentor, I mean, JackHahn was one of my mentors,
Craig, his brother, was one ofmy mentors.
And just you think of anall-star, I mean, it's just
unbelievable the opportunity atthe time.
But uh, you if you didn't getdone in two hours, they pulled
you out, you went to the class,and Carl was lecturing.
And we're learning the divisionsof available bone, we're
(09:42):
learning, you know, RP1 to FP4,you know, it's just crazy.
I mean, learning all theprosthetic, all the bone
categories, and he broughteverything together.
And you know, I'm I'm pretty disI'm very dyslexic.
And so just being able tovisualize and see, uh, it just
made where any patient came in,uh, they fit a category, and you
(10:08):
it was like, you know, his hewas the first one.
I think he coined the thing thatimplant dentistry is a
prosthetic discipline with asurgical component.
And so you never put implants inunless you plan the prosthetics.
So, you know, that was just hugein in my learning.
(10:28):
But, you know, I was able to, ofcourse, do Hilt Tatum Sinus
course.
There were other courses I didback then, queries, bone
technique.
Uh, Craig Mish had a uh uhmonoblock grafting course, you
know, all sorts of courses backin the time, but Mish was the
big turning point.
Uh Hilt was trying to make uhimplantology a specialty even
(10:51):
back then.
Uh at by that time I hadreceived my fellow with AID uh
in 1998, I believe it was, andthen '99 I sat for my boards and
passed those and became adiplomate.
And at that time, Hill was like,look, I got a program starting
up at Moma Linda.
We're doing a residency program,you'll get a master's in
(11:13):
implantology, and we're we'regonna take this and we're gonna
make this a new specialty indentistry.
So I started uh doing that.
Uh and you know, it was out inCalifornia, Seventh-day
Adventist.
So, you know, we couldn't doanything on Saturday.
We started on Sunday, it wentall week, and it was once a
month, and I loved it.
(11:34):
You know, the people that werethere, the great doctors in the
course, Jaime Lazada, hisdirector now, he was in the
first class.
I was literally in the firstclass with these guys, and I did
it for six months.
We'd do the California onemonth, we'd go back to Mish
Institute, do that for onemonth.
Uh, and I did it for six months,and then my son was born, and
(11:56):
I've like I've kind of reviewedbecause Mish was so
comprehensive, so I bailed out,and that's the only thing I
regret uh is bailing out.
It would have been fun to havethat master's, you know.
Uh, but you know, as a generaldentist in learning from Mish
Institute, I was there withperidontists, prostodontists,
oral surgeons, and a few handfulof general GPs.
(12:20):
You know, this wasn't taught indental school, it wasn't taught
in any residency program.
So, you know, to get educationin implantology, you know, we
were learning from thesepractitioners like Kilt and Lil
John and Harris and Kareem andMark Davis and Mozanne, you
know, that have been doing itfor 10, 20 years already.
(12:43):
And uh, you know, there was alot of uh turf wars so far as
well, only rural surgeons shoulddo this.
Nobel would only sell theirimplants to rural surgeons
because only they could getcertified in using a Nobel
implant.
But the fun thing was, I was inMish early enough that I
actually got certified Nobel,never placed their implant at
(13:05):
the time because it was a littleinsulting that they wouldn't let
a GP place it only ruralsurgeons.
But uh, you know, it was a long,drawn-out process.
And you know, I see so manyyoung surgeons that come out of
school now one or two years in,and they're like, they're
wanting to do zygos.
And I'm like, guys, take yourtime, get your reps in, uh, take
(13:30):
and do this the right way.
And uh, you know, back then ittook a really, really long time
to do this.
But you know, I was blessed tohave some really good mentors,
you know, Dr.
Lil'John, Dr.
Mish, Tatum, Boyd Harris out ofFayetteville, Arkansas, Bill
Careen out of Marion, uh, youknow, Dan Root and Rob White and
(13:50):
Rick Baynard for Moot Live wereextremely instrumental in my
training.
You know, uh, I'd get myself inall sorts of trouble and they'd
get me out of it every time, youknow.
And Rob, especially, you know,uh I didn't like using Root
because they were so damnexpensive and it took too long,
and I could get it done for halfthe time the price twice as
(14:12):
quick, you know, from a locallab, but every time I'd get it,
you know, there'd be issues withit.
And uh, you know, what I foundout was you get what you pay
for, you know, take your time,dial things in, and uh, you
know, so they were veryinstrumental in my journey as
well.
Um, you know, other things thatI've done since then, you know,
(14:33):
early on, uh there was about 5%of the cases where the occlusion
would just be a train wreck.
And I realized I spent all thistime in surgery, and I've spent
zero time in surgery.
So I jumped in uh Frank Spearwhen he was really big uh in the
early 2000s, and he was doinghotel courses, and that'd be a
(14:54):
thousand people attending, youknow, down at the Swan in
Orlando, and I did all thosecourses, and then if you had
attended all those, he'd inviteyou uh for fee, of course, to
show up at his office, and therewas like 10 of us in there, and
you'd spend four or five dayswith him one-on-one doing cases,
(15:15):
dialing this in, and you know,Frank would, it was mainly
cosmetic aesthetic dentistry,was a light touch of
implantology, but the big thingwas you know how to uh you know
build these occlusions and theseocclusal schemes and how to dial
in that five percentage thatyou're having problems with.
So, you know, once I had Spearin, you know, it's it was really
(15:40):
uh instrumental in getting a lotof the issues that we had with
occlusion and bites and you knowthings of that nature uh down
the line.
So yeah, it was a long process.
I along the way you meet greatguys like uh you know, Dr.
Rakkowski, who you've had on.
David Leggett and I went todental school together.
(16:01):
I literally didn't see him for39 years, and he was at one of
the last orcas that I was uhteaching at.
And we got uh it was just likeyou know, we'd seen each other
yesterday.
That's cool.
And uh it's it's a greatopportunity.
I was very active in AAID, uh,you know, in my 40s, uh, was a
(16:23):
um president of the SouthernDistrict.
I was getting ready to go do thenational deal and and you know,
go up the ladder there.
And my kids had were you knowyoung teenagers, and I decided
to step back, spend more timewith my family, wait, and I told
them, I said, look, I'll comeback when the kids go to school,
(16:44):
you know, to college.
And uh I did, don't regret itall.
One of the best decisions I'veever made in my life for my
family.
Uh but the funny thing was, youknow, in that eight, nine, ten
years, uh things had moved on,you know.
Uh they didn't need me, and Ifound out that there were other
(17:04):
things to do, you know.
I was still very active, butpolitically I wasn't, you know.
Uh, but you know, AID was wasvery instrumental because you
know, I felt very um dedicatedto the diplomat and the fellow
uh credentials that's being bonafide.
I was very active in uh runningthat stuff through the legal
(17:29):
system, supporting Frank Rekkerand his efforts to make sure
that our credentials wererecognized in many states.
And we were very successful whenI was on the Board of Trustees.
Uh, you know, I really workedhard to market the AID as the
premier uh contact point forpatients to find doctors who had
(17:52):
qualifications and who had beentested.
Uh and you know that's somethingthat I felt like was very, very
important, you know.
And then of course, you know, asa board examiner for both AAID
and and for ABY and still dothat on from time to time.
Uh, but you know, it's a it wasa wonderful, wonderful career,
(18:14):
you know, so far as being ableto to be there and and see all
these guys uh early on and seethe evolution of dentistry.
And you know, the last fiveyears since two thousand since
2020, everything I do iscompletely different than I did
before.
SPEAKER_01 (18:30):
You know, it's been a fast time.
SPEAKER_02 (18:33):
It's completely different.
It's not even close.
I mean, my all on four practiceis different.
Uh, even I mean, I've I startedmy own dental lab.
Uh, I'm no longer with Route.
Uh, I've got three techniciansupstairs, I've got two
designers.
Uh, we're doing casework for uhother doctors across the
country, uh, doing AOX design,same day design.
(18:56):
We're milling for people.
Uh we're doing high-endaesthetic crowns and and and
zirconia veneers.
You know, 70% of my practice isAOX, and uh 30% is still
high-end full mouth crown andridge.
Cool.
Uh it does, it's all green tome.
I love it, you know.
Uh, and you know, prepping teethdoes not, I know it's insulting
(19:17):
for a lot of guys, but I loveit.
I still enjoy it.
SPEAKER_01 (19:20):
Still cool.
SPEAKER_02 (19:21):
Uh yeah, I mean it takes me the same amount of time
uh to prep a full arch and getthem in temps as a dozen AOX.
Uh they go out three weeks, wedial on the tents, we get new
bites, we uh mill everything outupstairs, and uh I bring them
back, sedate them one time, putit all in, tweak their bite a
(19:41):
couple times, and we're done.
Yeah, yeah, I mean it's not thateasy with AOX, you know.
So yeah, you're right.
It's still a lot of fun.
SPEAKER_01 (19:50):
Well, I I certainly appreciate that uh the storied
history you have and inimplantology all the way back to
you know really its beginnings,at least as as far as it became
widespread in the US.
Um, and and I really love thatas you tell your story, you kind
of tell it through uh all thepeople that influenced you and
helped you along the way.
And I think that speaks a lot umto you.
SPEAKER_02 (20:10):
Well, I stand on their shoulders, you know.
I would not be here withoutthese men uh in my life, you
know, and the and and thementors and all the friends that
have helped us.
And you know, the the tremendousthing now being part of oracle
and full arts masters and modinstitute is uh the social uh
threads that we're on, you know,uh WhatsApp and things like
(20:33):
that.
And I I get to mentor the kids,but you know, I learned just as
much from them.
You know, I've got a printerproblem or I've got a uh
centering of an issue, you know.
These kids are all over it, youknow, and and I get my uh
designer said, Hey, go talk toDr.
So and so.
He's got our answer over here,you know.
So it's a win-win for all of us,you know.
(20:54):
Yeah, absolutely.
SPEAKER_00 (20:55):
Absolutely.
Tyler and I talk about that allthe time, how we're we're so
lucky to be in the uh implantspace when we are, because you
know, we get to just stand onthe on the giants that came
before us.
So um, you know, it's a it's areally cool time to be a part of
implant dentistry, and wewouldn't be able to be here
without guys like you, you know.
SPEAKER_02 (21:15):
So I think this is a good lead-in to the
patient-specific implant orsub-perostal.
Okay.
I mean, it's a sub, all right.
Whether it's patient-specific oryou know, I just did an article
with Vichy Brahmont and uh NorthAmerican uh clinics of oral
surgery, uh, co-authored withhim uh on implantology, and I
(21:36):
went really heavy into thehistory and I named it classic
subperiosteal.
So we've got CSI and we've gotPSI.
And um, you know, I I attendedsome lectures with some guys
international uh that were doingthe PSIs and promoting different
companies and stuff, and verygood information.
And you know, I actually did apodcast with one of them, and
(21:59):
you know, I I was glad to handthe gauntlet off and say, you
know, go young man, do this.
And uh, but there was somethingthat was missing was all this
great information, thisresearch, and I do mean
research, publishedpeer-reviewed literature
research, RD from Root Lab andfrom doctors like little John
(22:22):
Carmeen, especially Boyd Harrisuh in Fatville, that had
perfected the mandibularsubparous.
And they were doing somemaxillary subs, but not a lot.
But we come in with this PSI andwe're like, okay, so we're doing
a CT subs.
Well, um, you know, Dr.
James did his first CT sub in1970, and from 1980 on, Loma
(22:45):
Linda only did CTs, they didn'tdo a two-stage surgery, you
know, they didn't expose theridge, uh, they didn't do the
wash impression on it, theydidn't pour that up.
They did a CT, and you know,they didn't have stereolithic
models.
They took mylar and they tookeach segment and they traced it
out, cut it, and then theystacked it, and that's how they
made the model.
SPEAKER_01 (23:05):
You know, wow, I was a much more modern application.
I did not know.
SPEAKER_02 (23:10):
Oh, yeah.
Well, I mean, literally, my lastuh lecture on subs was 2004 in
Hawaii, and uh my topic wasthree appointment subs.
They come in for records, um,you know, and literally we put
it in the next appointment, youknow, and then we took the
sutures out.
And it was 2004, it's the WorldCongress or of Oral Impactology.
(23:34):
Lenny Lincoln asked me to comedo it.
I literally flew the to Hawaii,I did my lecture, and I flew
back home the next day.
I wasn't even there 24 hours.
There were like 12 people.
The biggest thing I got fromthat was ICAT was there.
Okay.
And I'd been taking all mypatients to the hospital, to a
Helical hospital scanner, andwe're putting dowel rods on
(23:58):
them, and it's taking 45 minutesto scan them.
And you know, there was onedoctor that was hypnotizing his
patients to make them be still.
And you know, I just say, don'tmove.
And we'd tape a radio opaque rodon their face, check for
movement.
And uh there was one lab inColorado that could make a
stereolithic model, but uh youknow, I was lecturing on that in
(24:19):
2004, and nobody was interested.
Nobody, you know, so I just kindof faded off in the sunset and
said, Well, I'll still do a fewsubs here and there, you know,
and then fast forward, you know,there's an ICAT there.
I'm like, okay, so I'll buy one.
I've got the first one in thestate of Arkansas, you know, and
I start doing comb beam CTs,treatment planning, and all that
(24:42):
stuff.
And I send my DICOM data, andback then it was on a uh tape,
you know, we didn't even haveCDs to do it, much less the
internet to do it, yeah.
And uh we'd send it there, we'dget a model for a thousand
bucks, I'd send it to Root,they'd make a replica of it,
stone model, and then we'd dothe the implant.
(25:04):
It was great.
I mean, the whole first stagesurgery was gone.
Uh then you know we got to thepoint where okay, now I can do
the uh I could take the the theDICOM data and I can segment it
with my software myself.
I can print the model in my lab,and now I can send that to
(25:25):
whoever.
Uh the last ones that I've beendoing, I've been working uh with
Nate Farley, Prostatonist inPhoenix, and he and I are
literally doing it 100% digitaldesign.
We take the DICOM, we we segmentit, uh, we use mesh mixer,
exacad, blender, we set up ourdesign, uh, we milled them,
(25:48):
we've printed them, uh, youknow, whatever.
But uh they started out kind ofrudimentary because the printing
process is not as pretty, but uhwe've done a couple with the
lab, America Stental Lab in uhKansas, that uh we did the
digital design, sent him theSTL, he printed it, he invested
(26:09):
it, and he cast out a uh CobaltChrome aluminum, and it's
beautiful, the classic tripodalmandibular sub.
And uh, you know, so there'slots of things going on with the
technology, and you know, I'mcurrently working with a couple
different international dentalimplant companies that are doing
(26:29):
subparalists and said, hey, canwe tweak the design?
Uh, can we do this?
Can we do that?
And I've been very well receiveduh by you know one group, the
other, these kind of crickets,you know.
Uh but the big thing that I wantto bring in is all this stuff
(26:51):
that we learned in the 80-yearhistory of subperiosteols
doesn't just go out the windowbecause we can print it out of
titanium and put some screws inand say, oh, it bonds to bone.
Okay, yeah, but you know, theclassic sub set on top of bone,
basal bone, hard bone.
Uh settling was the big issue.
(27:12):
You know, if you were on themaxilla, it's membranous bone,
it's thin bone.
Uh, if you were on the alveolusuh on you know, division A
ridges and misclassification,they resorbed.
And so the implant settled andhad movement.
And there were a lot of designflaws early on.
(27:32):
You know, I mean, Gustav Dahldid this in 37 and he did an
interval impression, x-rays, andprobing, and he scraped that
model and he said, okay, this iswhat we're going to make a sub
on.
Uh, you know, Kerskoff and uhBergman and Goldberg, uh, 4851,
they first did the first twostage where they did a direct
(27:55):
bone impression.
And, you know, with direct boneimpressions, a lot of people
didn't reflect enough, so theydidn't get uh a good lateral
loading of the implant.
It was all crustal, so that'swhere you see the tabletop
designs on the early subs, whichall fell.
You know, they were failure, andyou know, one of the big things
(28:16):
like 1970, uh, Dr.
James from Omalinda, uh, theyhad like two different patients
who had donated their body, anduh, there was a doctor out of
Puerto Rico that had done uhhistology on it, but they saw
suspensory ligament out of densecollagenous fibers, and you
(28:40):
know, he postulated that subswere held in the suspensory
ligament and that compressiveforces or crustal loading was
you know osteoclastic, and thatit loaded the mandible laterally
on the lateral ramus or in thesymphysis, that it would be more
off-axis or tensile type loadingand it would promote bone
(29:01):
growth.
And used to the first mandibularsubs would have struts on the
lingual, and when the patient'smandible opens wide, that it's
it's it gets narrower and theywould have dehiscence there and
issues there.
So, you know, with James' uhearly theories about this, we
changed where we loaded theimplant and success rates went
(29:23):
up.
Uh, you know, we saw and todayin the current PSIs, we see a
lot of abutments coming out ofthe first and second molar
regions on the mandible.
Well, what do you have downthere?
You've got a buccinator, you'vegot the myhyoid, you've got very
low bone volume, very thinattached tissue in this area,
(29:44):
and it's uh it's a problem forrecession and infection.
Well, you know, root uh and andLincoln, funny story.
Lincoln was doing a direct boneimpression, he didn't want to
expose because he had a totallydistant nerve.
So he exposed both ramus, hespokes the symphysis, does three
different separate impressions,and then one impression of that,
(30:05):
sends it to the lab and says,make me a sub.
And at the time, you know, theframework went all the way from
ramus full.
And uh Rob got it and he looksat Danny and said, What do we
do?
And they finally decided, well,we can do a big connecting bar,
a mesobar from the ramus to andcome out of the ascending ramus
(30:26):
with one strut, come to thecanine and have your other
permeacosal strut and go around.
So it's a continuous bar all theway around.
And they just put O rings in itand an overdenture.
And um so they sent it back toLenny and Lenny.
Put it in and loved it.
Worked perfect, you know, and itgot the permucosa post out of
that molar region.
So uh Lenny was on the stagelike a couple months later at
(30:51):
one of the big implant meetingstalking about his new tripodial
sub that he designed, and Robgoes back kind of upset to
Danny.
He's like, You're gonna let himdo this, take credit for our
design?
And Dan's like, well, of courseI am.
He said, if it works, we'regonna sell a ton of them.
And he said, if it screws up,it's all Lenny's.
Well, it's all on him.
(31:13):
I mean, you know, Dan Hillarywas a very, very brilliant man,
he's a great businessman, butmoreover, he did some tremendous
work in our field, and you know,that shouldn't be lost.
So, you know, today we see very,very heavy uh thick
substructures, they run itthrough finite analysis, element
(31:33):
analysis.
And I'm not a biomaterialsexpert.
You know, we had one in AlabamaImplant Studio, Jack Lemons.
You could always run this stuffby him.
But yeah, if I could talk toJack today, I said, Jack, yeah,
how thin can I make a titaniumimplant compared to the old
chrome, cobalt, molybdium,vitatium implants?
Because you know, it's it's it'sa stronger metal and it's got
(31:55):
better flexor and all this otherstrength.
But you know, the the oldclassic subs, they were all
designed with a lattice snowshoetype structure over the ramus
and over the symphysis to spreadthe occlusal loading out on
remote areas.
And some of my lectures I talkabout subperos being the remote
(32:17):
first remote anchorage implant,you know, and so you didn't want
crestal loading, you wantedlateral ramus, you wanted
symphysis, areas like that, wellaway from your permecoastal
areas.
And you know, I literally havenot lost but one mandibular sub
or out of the approximately 100I've done.
And I chose to take it outbecause the patient was moving.
(32:38):
And uh, you know, I startedhaving better luck with shorter
root form implants, and I justpopped her in some root forms
and I sent her to Texas to befree, you know.
But you know, with the largeframeworks that we're seeing,
and they're running throughFINAT, and they say you got to
do this and you gotta do that,and and everything, I get it,
(33:00):
but there's such a thing asbiocompatibility or
biomechanical design.
And when you place an implant onbone, whether it's bonded to
bone or not, you want theperiosteum to reattach to the
bone as quickly and as well asyou can, as fast as you can.
And so, you know, those struts,uh, a lot of them that I see are
(33:24):
very bulky, they've got rodangles, they're in the mucosa.
And, you know, first lecture Isaw, PSI lecture, I was sitting
there and I'm looking at thedesign and said, it's gonna
dehys here.
One of the guys uh sitting nextto me, Bo Wright from Kentucky,
goes, How do you know that?
Just watch.
And about five slides later, weget into complications and
(33:47):
there's a dehiscence there, andthe tissue won't it won't
tolerate that bulk.
And so we really need to debulkthese things.
We need to not crestally load.
I see a lot of mandibular substhat are loaded in the molar
region with three per mucosalposts coming out of the molar
regions.
And you know, if you just take alittle look back where history
(34:10):
was and what designs proved outto be very successful, modify
the the PSI designs, usetitanium, you know, use printed
uh techniques and things likethis, uh, I think we would see
success rates uh improve.
I really think that I I I get alot of complications in my
(34:31):
clinic because I've been doingthis a while, and I've seen some
really ugly, you know, PSIs uhout there.
And I think that complicationsare definitely underreported.
And when you go to literature,you know, we're getting two-year
results.
I don't see anything long termyet, you know, with 26%
(34:51):
complication rates at two years.
And uh I just think that wereally need to take pause at
what we're doing here and seewhat used to work, see if we can
implement those uh uhdevelopments and and and
concepts into the to the newconcepts.
My name is Dr.
Tyler Tolbert, and I'm Dr.
Storin Poppy, and you'relistening to the Fix Podcast.
Your stores are for all thingsin plant dentistry.
All right, and welcome back tothe Fixed Podcast.
We have another very esteemedguest on with us today.
Um took us quite a while towrangle him because he's a very
busy guy.
You're gonna hear a lot abouthis resume and his current
practice, which is still very,very busy.
(01:02):
Um we have with us Dr.
Samuel Jirak.
Um he brings a wealth ofinformation and knowledge and
experience in full archimplontology.
He's been doing this uh,frankly, longer than either uh
Soren or I have been alive.
So we're extremely humbled tohave him on here.
And, you know, one of the thingsthat I originally reached out to
him about, um, I saw that uh Ibelieve at the upcoming Orca
(01:23):
seminar, he's gonna be uhlecturing on uh customized uh
subperiospules.
And uh, you know, I know that hehad extensive, extensive
experience with that, not justthe ones that we're talking
about today, but also the onesof yesteryear, how that's been
done in the past, what we canlearn from that, the good, the
bad, the ugly, and what the nextpath forward um for customized
(01:44):
implants looks like.
And there's really not anyoneelse I could think of that would
bring a more comprehensiveexperience to speak to that
topic um than Dr.
Jarick himself.
Uh also, he's got a wealth ofinformation about all things
full arch.
He does it all, um, everythingthat we talk about.
So we're super, super excited tohave him on and uh very grateful
uh for him to spare his timewith us.
So thanks so much for coming on,Dr.
(02:04):
Jarick.
SPEAKER_02 (02:05):
Thank you very much, Tyler.
It's just a privilege to be partof it.
SPEAKER_01 (02:09):
For sure.
So uh for those who don't knowwho you are, um, we'd appreciate
if you could just kind of giveus a little bit of background
about you know your journeythrough Full Arch as a dentist,
you know, getting into implants,how things have kind of evolved
since then, and and kind ofbring us all the way up to you
know the current day.
SPEAKER_02 (02:26):
Okay.
Well, uh first of all, 1986graduate University of Tennessee
uh health center uh dentalschool.
And um, you know, when we werein dental school, you know,
dental implants were not taught.
Uh we had literally one lectureon it and had a great oral
surgery department.
Uh we did a lot of work in theoral surgery department in
(02:49):
undergrad.
But basically, the lecture washere I am the oral surgeon,
here's this dental implant doneby some cowboy over in East
Arkansas, and here I am takingit out because it's failing and
they're horrible, they don'twork.
And all I could think at thetime was, wow, if these things
work, wouldn't this be great?
You know, better than a dentureor a partial.
(03:10):
So um, you know, run out ofdental school, I mean, uh, I'm a
CE junkie, and it started fromday one.
Believe it or not, my very firstcourse, my very first CE was an
implant course, and there werefive manufacturers at it.
Uh Stereos, which later uhbecame Nobel or was bought out
by Nobel, uh, you know, wasthere.
(03:33):
Uh DB Driscoll was there, acouple others.
There were plateform implantsthere.
Of course, nobody's marketingsubs because it was all root
form, but uh, and I thinkCorvent was there, you know, and
uh took that course and then youknow kind of wandered around for
about a year, and I had anorthodontist in the clinic that
was from a small town in EastArkansas, and he kept telling me
(03:56):
you need to go uh talk to mybuddy up over there, Dr.
Liljohn, uh, where I practicepart-time, and he's he does more
implants than anybody.
And I'm like, you know, he's inthe middle of farming country,
Arkansas.
There's no way this guy's doingimplants in Arkansas, you know?
Yeah, so uh this goes on forabout a year, and I call him up,
he's and I said, Hey, yeah, Iheard you do implants.
(04:17):
Yeah, he says, and I said, Doyou mind if I come over and you
know watch you do some implantsone day?
Come on, and of course, youknow, he was working Fridays and
um he starts at seven, and uh Idrive an hour and a half over to
his office and pull up in theback, and you know, there's a
couple of Mercedes, a couple ofLincoln Town cars, a couple of
(04:39):
real nice pickup trucks, and Iwalk in the back door, and the
operatory, the main OR, wasright at the back door, and I
walk in, he's already working at7 a.m.
And he's delivering a 14 unit,which we call FP1, cemented, up
to 10 implants with bilateralsinus grafts, and I think he'd
(05:01):
done some uh tick soft tissueaugmentation.
Wow.
And I my mouth just fell open,I'd never seen anything like it,
you know.
So uh I ended up leaving hisoffice at seven that day, went
to his house, wife cooked usdinner, he said, let's go up to
the attic.
And this guy had tens ofthousands of slides, and he
(05:21):
lectured you know nationally andinternationally, even back in
the 87.
And I uh went up there and hesays, Okay, Bubby, he says, you
know, he says, obviously smartkid and everything, talented.
And he says, but you don't knowwhat you don't know.
You don't know what you don'tknow.
So at that point, you know, hewent through a bunch of stuff
(05:42):
and I said, Hey, do you mind ifI come back?
And he goes, Anytime.
So I started taking off Fridays.
I worked four days, you know,Monday through Thursday, and
then every Friday I scrubbed inwith Dr.
Liljohn and assisted him.
And we did sinus augmentations,we did subs, we did plateforms.
Uh I think he didn't do ramusframes, he didn't believe in
(06:04):
them.
Uh, but he had been in practice20 years, he started out life as
an engineer.
He was very active in AAID, hewas one of the original uh ABY
diplomates.
He was in the first class thatthey accepted, one of the first
examiners, uh, honored fellow.
And so, you know, it was veryblessed to have him in my life
(06:25):
at that time.
Um so he said, Well, we got toget you in some continued
education.
First place I went was AlabamaImplant Study Group, and at the
time they were doing a Congresswhich was attended by 120 to
1,500 doctors internationallyonce a year.
Uh, Root Lab was a big sponsor,they had a big crawfish bowl,
(06:45):
and they were showing theirimplant restorations and the
subperiosteols and everythingthere.
Um, you know, and they taughtfive courses a year, and it
would be different instructorsteaching everything from blades
to root form to sinusaugmentation.
I mean, Bill Tatum was teachingsinus aughts there.
(07:06):
I learned sinus augmentationfrom the man himself.
Uh, and then you know, they wereteaching subparaoscopes.
So uh we would have a livesurgery, it was done at Caraway
Medical Hospital.
We'd have a live surgery, uhclosed circuit TV on uh that and
uh attended all those and keptgoing back, ended up off started
(07:28):
doing some surgeries for them uhand taking some patients to
Birmingham to do that.
And uh I got into AID, uh, youknow, and that they really
weren't pushing the associatefellow fellow stuff at that
point in time yet.
Uh started going to thosemeetings and southern district
meetings, and uh you know, justhad a lot of information come
(07:48):
from a lot of different areas.
Of course, you know, this is allbefore the internet.
Uh you can't get on uh uhYouTube or TikTok and see how to
do a pterygoid or any of thisstuff like you can today.
So, you know, you had to travel,and uh, you know, I'd just
gotten married.
My wife was a pharmaceuticalrep.
We waited a while to have kids,so we were double income, no
(08:11):
kids.
I traveled the country and I wasdoing 100, 200 hours a year
continuing education, allimplantology related.
But uh the big turning point wasyou know, Carl Misch, uh Mish
Institute had just gottenstarted.
At the time it was still inDeerporn, Carl was teaching it.
His one of his wives, Lori, wasteaching the office management
(08:34):
side.
So you would literally take yourstaff to the first one, office
managers, assistants, everybody.
Uh hell, I think the hygienisteven went.
And um, it was all didactic, andLori would teach the office
management side.
Carl was all didactic, and thenwe went back five times over the
course of a year and a halftaking our own patient.
(08:57):
And we started out with the rootform, then we did a plate form,
then we did a sinusog, then weput the implants in the sinusog,
and we actually did asubperioster.
Carl was was teaching that andhe was making some
modifications, and we we did oneof his modified.
But Carl's courses compared tothe courses today, you literally
(09:19):
had two hours to do whatever youwere doing.
You had a mentor, I mean, JackHahn was one of my mentors,
Craig, his brother, was one ofmy mentors.
And just you think of anall-star, I mean, it's just
unbelievable the opportunity atthe time.
But uh, you if you didn't getdone in two hours, they pulled
you out, you went to the class,and Carl was lecturing.
And we're learning the divisionsof available bone, we're
(09:42):
learning, you know, RP1 to FP4,you know, it's just crazy.
I mean, learning all theprosthetic, all the bone
categories, and he broughteverything together.
And you know, I'm I'm pretty disI'm very dyslexic.
And so just being able tovisualize and see, uh, it just
made where any patient came in,uh, they fit a category, and you
(10:08):
it was like, you know, his hewas the first one.
I think he coined the thing thatimplant dentistry is a
prosthetic discipline with asurgical component.
And so you never put implants inunless you plan the prosthetics.
So, you know, that was just hugein in my learning.
(10:28):
But, you know, I was able to, ofcourse, do Hilt Tatum Sinus
course.
There were other courses I didback then, queries, bone
technique.
Uh, Craig Mish had a uh uhmonoblock grafting course, you
know, all sorts of courses backin the time, but Mish was the
big turning point.
Uh Hilt was trying to make uhimplantology a specialty even
(10:51):
back then.
Uh at by that time I hadreceived my fellow with AID uh
in 1998, I believe it was, andthen '99 I sat for my boards and
passed those and became adiplomate.
And at that time, Hill was like,look, I got a program starting
up at Moma Linda.
We're doing a residency program,you'll get a master's in
(11:13):
implantology, and we're we'regonna take this and we're gonna
make this a new specialty indentistry.
So I started uh doing that.
Uh and you know, it was out inCalifornia, Seventh-day
Adventist.
So, you know, we couldn't doanything on Saturday.
We started on Sunday, it wentall week, and it was once a
month, and I loved it.
(11:34):
You know, the people that werethere, the great doctors in the
course, Jaime Lazada, hisdirector now, he was in the
first class.
I was literally in the firstclass with these guys, and I did
it for six months.
We'd do the California onemonth, we'd go back to Mish
Institute, do that for onemonth.
Uh, and I did it for six months,and then my son was born, and
(11:56):
I've like I've kind of reviewedbecause Mish was so
comprehensive, so I bailed out,and that's the only thing I
regret uh is bailing out.
It would have been fun to havethat master's, you know.
Uh, but you know, as a generaldentist in learning from Mish
Institute, I was there withperidontists, prostodontists,
oral surgeons, and a few handfulof general GPs.
(12:20):
You know, this wasn't taught indental school, it wasn't taught
in any residency program.
So, you know, to get educationin implantology, you know, we
were learning from thesepractitioners like Kilt and Lil
John and Harris and Kareem andMark Davis and Mozanne, you
know, that have been doing itfor 10, 20 years already.
(12:43):
And uh, you know, there was alot of uh turf wars so far as
well, only rural surgeons shoulddo this.
Nobel would only sell theirimplants to rural surgeons
because only they could getcertified in using a Nobel
implant.
But the fun thing was, I was inMish early enough that I
actually got certified Nobel,never placed their implant at
(13:05):
the time because it was a littleinsulting that they wouldn't let
a GP place it only ruralsurgeons.
But uh, you know, it was a long,drawn-out process.
And you know, I see so manyyoung surgeons that come out of
school now one or two years in,and they're like, they're
wanting to do zygos.
And I'm like, guys, take yourtime, get your reps in, uh, take
(13:30):
and do this the right way.
And uh, you know, back then ittook a really, really long time
to do this.
But you know, I was blessed tohave some really good mentors,
you know, Dr.
Lil'John, Dr.
Mish, Tatum, Boyd Harris out ofFayetteville, Arkansas, Bill
Careen out of Marion, uh, youknow, Dan Root and Rob White and
(13:50):
Rick Baynard for Moot Live wereextremely instrumental in my
training.
You know, uh, I'd get myself inall sorts of trouble and they'd
get me out of it every time, youknow.
And Rob, especially, you know,uh I didn't like using Root
because they were so damnexpensive and it took too long,
and I could get it done for halfthe time the price twice as
(14:12):
quick, you know, from a locallab, but every time I'd get it,
you know, there'd be issues withit.
And uh, you know, what I foundout was you get what you pay
for, you know, take your time,dial things in, and uh, you
know, so they were veryinstrumental in my journey as
well.
Um, you know, other things thatI've done since then, you know,
(14:33):
early on, uh there was about 5%of the cases where the occlusion
would just be a train wreck.
And I realized I spent all thistime in surgery, and I've spent
zero time in surgery.
So I jumped in uh Frank Spearwhen he was really big uh in the
early 2000s, and he was doinghotel courses, and that'd be a
(14:54):
thousand people attending, youknow, down at the Swan in
Orlando, and I did all thosecourses, and then if you had
attended all those, he'd inviteyou uh for fee, of course, to
show up at his office, and therewas like 10 of us in there, and
you'd spend four or five dayswith him one-on-one doing cases,
(15:15):
dialing this in, and you know,Frank would, it was mainly
cosmetic aesthetic dentistry,was a light touch of
implantology, but the big thingwas you know how to uh you know
build these occlusions and theseocclusal schemes and how to dial
in that five percentage thatyou're having problems with.
So, you know, once I had Spearin, you know, it's it was really
(15:40):
uh instrumental in getting a lotof the issues that we had with
occlusion and bites and you knowthings of that nature uh down
the line.
So yeah, it was a long process.
I along the way you meet greatguys like uh you know, Dr.
Rakkowski, who you've had on.
David Leggett and I went todental school together.
(16:01):
I literally didn't see him for39 years, and he was at one of
the last orcas that I was uhteaching at.
And we got uh it was just likeyou know, we'd seen each other
yesterday.
That's cool.
And uh it's it's a greatopportunity.
I was very active in AAID, uh,you know, in my 40s, uh, was a
(16:23):
um president of the SouthernDistrict.
I was getting ready to go do thenational deal and and you know,
go up the ladder there.
And my kids had were you knowyoung teenagers, and I decided
to step back, spend more timewith my family, wait, and I told
them, I said, look, I'll comeback when the kids go to school,
(16:44):
you know, to college.
And uh I did, don't regret itall.
One of the best decisions I'veever made in my life for my
family.
Uh but the funny thing was, youknow, in that eight, nine, ten
years, uh things had moved on,you know.
Uh they didn't need me, and Ifound out that there were other
(17:04):
things to do, you know.
I was still very active, butpolitically I wasn't, you know.
Uh, but you know, AID was wasvery instrumental because you
know, I felt very um dedicatedto the diplomat and the fellow
uh credentials that's being bonafide.
I was very active in uh runningthat stuff through the legal
(17:29):
system, supporting Frank Rekkerand his efforts to make sure
that our credentials wererecognized in many states.
And we were very successful whenI was on the Board of Trustees.
Uh, you know, I really workedhard to market the AID as the
premier uh contact point forpatients to find doctors who had
(17:52):
qualifications and who had beentested.
Uh and you know that's somethingthat I felt like was very, very
important, you know.
And then of course, you know, asa board examiner for both AAID
and and for ABY and still dothat on from time to time.
Uh, but you know, it's a it wasa wonderful, wonderful career,
(18:14):
you know, so far as being ableto to be there and and see all
these guys uh early on and seethe evolution of dentistry.
And you know, the last fiveyears since two thousand since
2020, everything I do iscompletely different than I did
before.
SPEAKER_01 (18:30):
You know, it's been a fast time.
SPEAKER_02 (18:33):
It's completely different.
It's not even close.
I mean, my all on four practiceis different.
Uh, even I mean, I've I startedmy own dental lab.
Uh, I'm no longer with Route.
Uh, I've got three techniciansupstairs, I've got two
designers.
Uh, we're doing casework for uhother doctors across the
country, uh, doing AOX design,same day design.
(18:56):
We're milling for people.
Uh we're doing high-endaesthetic crowns and and and
zirconia veneers.
You know, 70% of my practice isAOX, and uh 30% is still
high-end full mouth crown andridge.
Cool.
Uh it does, it's all green tome.
I love it, you know.
Uh, and you know, prepping teethdoes not, I know it's insulting
(19:17):
for a lot of guys, but I loveit.
I still enjoy it.
SPEAKER_01 (19:20):
Still cool.
SPEAKER_02 (19:21):
Uh yeah, I mean it takes me the same amount of time
uh to prep a full arch and getthem in temps as a dozen AOX.
Uh they go out three weeks, wedial on the tents, we get new
bites, we uh mill everything outupstairs, and uh I bring them
back, sedate them one time, putit all in, tweak their bite a
(19:41):
couple times, and we're done.
Yeah, yeah, I mean it's not thateasy with AOX, you know.
So yeah, you're right.
It's still a lot of fun.
SPEAKER_01 (19:50):
Well, I I certainly appreciate that uh the storied
history you have and inimplantology all the way back to
you know really its beginnings,at least as as far as it became
widespread in the US.
Um, and and I really love thatas you tell your story, you kind
of tell it through uh all thepeople that influenced you and
helped you along the way.
And I think that speaks a lot umto you.
SPEAKER_02 (20:10):
Well, I stand on their shoulders, you know.
I would not be here withoutthese men uh in my life, you
know, and the and and thementors and all the friends that
have helped us.
And you know, the the tremendousthing now being part of oracle
and full arts masters and modinstitute is uh the social uh
threads that we're on, you know,uh WhatsApp and things like
(20:33):
that.
And I I get to mentor the kids,but you know, I learned just as
much from them.
You know, I've got a printerproblem or I've got a uh
centering of an issue, you know.
These kids are all over it, youknow, and and I get my uh
designer said, Hey, go talk toDr.
So and so.
He's got our answer over here,you know.
So it's a win-win for all of us,you know.
(20:54):
Yeah, absolutely.
SPEAKER_00 (20:55):
Absolutely.
Tyler and I talk about that allthe time, how we're we're so
lucky to be in the uh implantspace when we are, because you
know, we get to just stand onthe on the giants that came
before us.
So um, you know, it's a it's areally cool time to be a part of
implant dentistry, and wewouldn't be able to be here
without guys like you, you know.
SPEAKER_02 (21:15):
So I think this is a good lead-in to the
patient-specific implant orsub-perostal.
Okay.
I mean, it's a sub, all right.
Whether it's patient-specific oryou know, I just did an article
with Vichy Brahmont and uh NorthAmerican uh clinics of oral
surgery, uh, co-authored withhim uh on implantology, and I
(21:36):
went really heavy into thehistory and I named it classic
subperiosteal.
So we've got CSI and we've gotPSI.
And um, you know, I I attendedsome lectures with some guys
international uh that were doingthe PSIs and promoting different
companies and stuff, and verygood information.
And you know, I actually did apodcast with one of them, and
(21:59):
you know, I I was glad to handthe gauntlet off and say, you
know, go young man, do this.
And uh, but there was somethingthat was missing was all this
great information, thisresearch, and I do mean
research, publishedpeer-reviewed literature
research, RD from Root Lab andfrom doctors like little John
(22:22):
Carmeen, especially Boyd Harrisuh in Fatville, that had
perfected the mandibularsubparous.
And they were doing somemaxillary subs, but not a lot.
But we come in with this PSI andwe're like, okay, so we're doing
a CT subs.
Well, um, you know, Dr.
James did his first CT sub in1970, and from 1980 on, Loma
(22:45):
Linda only did CTs, they didn'tdo a two-stage surgery, you
know, they didn't expose theridge, uh, they didn't do the
wash impression on it, theydidn't pour that up.
They did a CT, and you know,they didn't have stereolithic
models.
They took mylar and they tookeach segment and they traced it
out, cut it, and then theystacked it, and that's how they
made the model.
SPEAKER_01 (23:05):
You know, wow, I was a much more modern application.
I did not know.
SPEAKER_02 (23:10):
Oh, yeah.
Well, I mean, literally, my lastuh lecture on subs was 2004 in
Hawaii, and uh my topic wasthree appointment subs.
They come in for records, um,you know, and literally we put
it in the next appointment, youknow, and then we took the
sutures out.
And it was 2004, it's the WorldCongress or of Oral Impactology.
(23:34):
Lenny Lincoln asked me to comedo it.
I literally flew the to Hawaii,I did my lecture, and I flew
back home the next day.
I wasn't even there 24 hours.
There were like 12 people.
The biggest thing I got fromthat was ICAT was there.
Okay.
And I'd been taking all mypatients to the hospital, to a
Helical hospital scanner, andwe're putting dowel rods on
(23:58):
them, and it's taking 45 minutesto scan them.
And you know, there was onedoctor that was hypnotizing his
patients to make them be still.
And you know, I just say, don'tmove.
And we'd tape a radio opaque rodon their face, check for
movement.
And uh there was one lab inColorado that could make a
stereolithic model, but uh youknow, I was lecturing on that in
(24:19):
2004, and nobody was interested.
Nobody, you know, so I just kindof faded off in the sunset and
said, Well, I'll still do a fewsubs here and there, you know,
and then fast forward, you know,there's an ICAT there.
I'm like, okay, so I'll buy one.
I've got the first one in thestate of Arkansas, you know, and
I start doing comb beam CTs,treatment planning, and all that
(24:42):
stuff.
And I send my DICOM data, andback then it was on a uh tape,
you know, we didn't even haveCDs to do it, much less the
internet to do it, yeah.
And uh we'd send it there, we'dget a model for a thousand
bucks, I'd send it to Root,they'd make a replica of it,
stone model, and then we'd dothe the implant.
(25:04):
It was great.
I mean, the whole first stagesurgery was gone.
Uh then you know we got to thepoint where okay, now I can do
the uh I could take the the theDICOM data and I can segment it
with my software myself.
I can print the model in my lab,and now I can send that to
(25:25):
whoever.
Uh the last ones that I've beendoing, I've been working uh with
Nate Farley, Prostatonist inPhoenix, and he and I are
literally doing it 100% digitaldesign.
We take the DICOM, we we segmentit, uh, we use mesh mixer,
exacad, blender, we set up ourdesign, uh, we milled them,
(25:48):
we've printed them, uh, youknow, whatever.
But uh they started out kind ofrudimentary because the printing
process is not as pretty, but uhwe've done a couple with the
lab, America Stental Lab in uhKansas, that uh we did the
digital design, sent him theSTL, he printed it, he invested
(26:09):
it, and he cast out a uh CobaltChrome aluminum, and it's
beautiful, the classic tripodalmandibular sub.
And uh, you know, so there'slots of things going on with the
technology, and you know, I'mcurrently working with a couple
different international dentalimplant companies that are doing
(26:29):
subparalists and said, hey, canwe tweak the design?
Uh, can we do this?
Can we do that?
And I've been very well receiveduh by you know one group, the
other, these kind of crickets,you know.
Uh but the big thing that I wantto bring in is all this stuff
(26:51):
that we learned in the 80-yearhistory of subperiosteols
doesn't just go out the windowbecause we can print it out of
titanium and put some screws inand say, oh, it bonds to bone.
Okay, yeah, but you know, theclassic sub set on top of bone,
basal bone, hard bone.
Uh settling was the big issue.
(27:12):
You know, if you were on themaxilla, it's membranous bone,
it's thin bone.
Uh, if you were on the alveolusuh on you know, division A
ridges and misclassification,they resorbed.
And so the implant settled andhad movement.
And there were a lot of designflaws early on.
(27:32):
You know, I mean, Gustav Dahldid this in 37 and he did an
interval impression, x-rays, andprobing, and he scraped that
model and he said, okay, this iswhat we're going to make a sub
on.
Uh, you know, Kerskoff and uhBergman and Goldberg, uh, 4851,
they first did the first twostage where they did a direct
(27:55):
bone impression.
And, you know, with direct boneimpressions, a lot of people
didn't reflect enough, so theydidn't get uh a good lateral
loading of the implant.
It was all crustal, so that'swhere you see the tabletop
designs on the early subs, whichall fell.
You know, they were failure, andyou know, one of the big things
(28:16):
like 1970, uh, Dr.
James from Omalinda, uh, theyhad like two different patients
who had donated their body, anduh, there was a doctor out of
Puerto Rico that had done uhhistology on it, but they saw
suspensory ligament out of densecollagenous fibers, and you
(28:40):
know, he postulated that subswere held in the suspensory
ligament and that compressiveforces or crustal loading was
you know osteoclastic, and thatit loaded the mandible laterally
on the lateral ramus or in thesymphysis, that it would be more
off-axis or tensile type loadingand it would promote bone
(29:01):
growth.
And used to the first mandibularsubs would have struts on the
lingual, and when the patient'smandible opens wide, that it's
it's it gets narrower and theywould have dehiscence there and
issues there.
So, you know, with James' uhearly theories about this, we
changed where we loaded theimplant and success rates went
(29:23):
up.
Uh, you know, we saw and todayin the current PSIs, we see a
lot of abutments coming out ofthe first and second molar
regions on the mandible.
Well, what do you have downthere?
You've got a buccinator, you'vegot the myhyoid, you've got very
low bone volume, very thinattached tissue in this area,
(29:44):
and it's uh it's a problem forrecession and infection.
Well, you know, root uh and andLincoln, funny story.
Lincoln was doing a direct boneimpression, he didn't want to
expose because he had a totallydistant nerve.
So he exposed both ramus, hespokes the symphysis, does three
different separate impressions,and then one impression of that,
(30:05):
sends it to the lab and says,make me a sub.
And at the time, you know, theframework went all the way from
ramus full.
And uh Rob got it and he looksat Danny and said, What do we
do?
And they finally decided, well,we can do a big connecting bar,
a mesobar from the ramus to andcome out of the ascending ramus
(30:26):
with one strut, come to thecanine and have your other
permeacosal strut and go around.
So it's a continuous bar all theway around.
And they just put O rings in itand an overdenture.
And um so they sent it back toLenny and Lenny.
Put it in and loved it.
Worked perfect, you know, and itgot the permucosa post out of
that molar region.
So uh Lenny was on the stagelike a couple months later at
(30:51):
one of the big implant meetingstalking about his new tripodial
sub that he designed, and Robgoes back kind of upset to
Danny.
He's like, You're gonna let himdo this, take credit for our
design?
And Dan's like, well, of courseI am.
He said, if it works, we'regonna sell a ton of them.
And he said, if it screws up,it's all Lenny's.
Well, it's all on him.
(31:13):
I mean, you know, Dan Hillarywas a very, very brilliant man,
he's a great businessman, butmoreover, he did some tremendous
work in our field, and you know,that shouldn't be lost.
So, you know, today we see very,very heavy uh thick
substructures, they run itthrough finite analysis, element
(31:33):
analysis.
And I'm not a biomaterialsexpert.
You know, we had one in AlabamaImplant Studio, Jack Lemons.
You could always run this stuffby him.
But yeah, if I could talk toJack today, I said, Jack, yeah,
how thin can I make a titaniumimplant compared to the old
chrome, cobalt, molybdium,vitatium implants?
Because you know, it's it's it'sa stronger metal and it's got
(31:55):
better flexor and all this otherstrength.
But you know, the the oldclassic subs, they were all
designed with a lattice snowshoetype structure over the ramus
and over the symphysis to spreadthe occlusal loading out on
remote areas.
And some of my lectures I talkabout subperos being the remote
(32:17):
first remote anchorage implant,you know, and so you didn't want
crestal loading, you wantedlateral ramus, you wanted
symphysis, areas like that, wellaway from your permecoastal
areas.
And you know, I literally havenot lost but one mandibular sub
or out of the approximately 100I've done.
And I chose to take it outbecause the patient was moving.
(32:38):
And uh, you know, I startedhaving better luck with shorter
root form implants, and I justpopped her in some root forms
and I sent her to Texas to befree, you know.
But you know, with the largeframeworks that we're seeing,
and they're running throughFINAT, and they say you got to
do this and you gotta do that,and and everything, I get it,
(33:00):
but there's such a thing asbiocompatibility or
biomechanical design.
And when you place an implant onbone, whether it's bonded to
bone or not, you want theperiosteum to reattach to the
bone as quickly and as well asyou can, as fast as you can.
And so, you know, those struts,uh, a lot of them that I see are
(33:24):
very bulky, they've got rodangles, they're in the mucosa.
And, you know, first lecture Isaw, PSI lecture, I was sitting
there and I'm looking at thedesign and said, it's gonna
dehys here.
One of the guys uh sitting nextto me, Bo Wright from Kentucky,
goes, How do you know that?
Just watch.
And about five slides later, weget into complications and
(33:47):
there's a dehiscence there, andthe tissue won't it won't
tolerate that bulk.
And so we really need to debulkthese things.
We need to not crestally load.
I see a lot of mandibular substhat are loaded in the molar
region with three per mucosalposts coming out of the molar
regions.
And you know, if you just take alittle look back where history
(34:10):
was and what designs proved outto be very successful, modify
the the PSI designs, usetitanium, you know, use printed
uh techniques and things likethis, uh, I think we would see
success rates uh improve.
I really think that I I I get alot of complications in my
(34:31):
clinic because I've been doingthis a while, and I've seen some
really ugly, you know, PSIs uhout there.
And I think that complicationsare definitely underreported.
And when you go to literature,you know, we're getting two-year
results.
I don't see anything long termyet, you know, with 26%
(34:51):
complication rates at two years.
And uh I just think that wereally need to take pause at
what we're doing here and seewhat used to work, see if we can
implement those uh uhdevelopments and and and
concepts into the to the newconcepts.
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