November 24, 2025 • 36 mins
If “more titanium and more screws” sounds like a plan, this conversation may change your mind. We take you behind the curtain of subperiosteal implant design—what the classic meso bar frameworks did brilliantly, why many custom PSI trends miss critical load paths, and how occlusion often determines whether a case survives decades or fails in months. Drawing on tough lessons from early HA-coated, multi-post maxillary cases and the happiest patients who lived well with two-thirds of a frame, we unpack where repairability, segmenting, and tissue-friendly geometry still outperform shiny shortcuts.
We walk through the real differences between mandible and maxilla: cortical density, palatal and nasal spine engagement, lateral sinus walls, and the unforgiving mucosa over pneumatized spaces. You’ll hear how palatal coverage and canine eminences lifted success rates historically, and why skipping them today invites the same old complications with a digital gloss. We challenge the “ladder” mindset—singles to All-on-4 to pterygoids to zygos to PSI—and propose a more honest sequence: remote anchorage first, maxillary subs as rescue, and mandibular subs as a predictable workhorse when designed and maintained correctly.
This is a prosthetic-first blueprint. Nail the occlusal scheme, align DICOM and STL perfectly, and design frames that are thin, recessed, and biologically sensible. Use materials and guidance that absorb shock, control lateral excursions, and make revisions feasible. We share a sobering maxillary failure with sinus fistulas to underline the stakes and offer a practical checklist for vetting labs and designers who can speak both biomechanics and biology, not just software. If you want growth without trophy hunting, and long-term function your hygiene team can support, this one will sharpen your judgment.
Enjoyed the conversation? Follow, share with a colleague who’s PSI-curious, and leave a quick review telling us where you draw the line on maxillary subs.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_02 (00:40):
My name is Dr.
Tyler Tilbert, and I'm Dr.
Storin Poppy, and you'relistening to the Fix Podcast,
your source for all things inplant dentistry.
SPEAKER_01 (00:49):
Yeah, so I I'm curious too, just to kind of
simply lay out a basis of youknow what the old versus new is,
what um what is ideal and whatisn't.
Can we just kind of like brieflyillustrate, you know, uh what
are what are the mechanicalideal mechanical properties of
the classics of the classic uh Ithink you're do you mind if I
show a model?
(01:09):
Yeah, not at all.
Yeah.
SPEAKER_00 (01:12):
So so this is bear with me here, guys.
This is one of my stereolithicmodels that was done on ICAT,
sent to the lab in Colorado.
And you can see we're loadingthe lateral ramus here.
We're loading synthesis.
We've got a mesobar that comesout of the ascending ramus here,
(01:33):
canine.
There's only four posts.
SPEAKER_02 (01:35):
Yeah.
SPEAKER_00 (01:36):
Very first sub I did was at NISH, and Carl says,
Well, we've got to spread theload out.
We need nine posts, and we'lltalk about coatings.
We're gonna coat it with HA.
And my mentor and win, Dr.
Lil said, Don't do that.
And I said, I got to.
I got to deliver it at NICH.
And so we did.
And the guy was uh a classmateof mine, he was a pietodontist,
(01:59):
it was his father, and he smokedlike a train, you know, like
three packs a day.
And I said, you know, you can'tsmoke for two weeks, and we're
in Dearborn, Michigan, and I getfinished with the surgery, and
uh, I don't even think I got toclose it because it was over two
hours, you know.
It's one of these shit show typesurgeries that happens to all of
us, you know.
And so um, I'm in the didacticpart and they finally dismiss
(02:22):
him, and he's out in the parkinglot, and I go out to say goodbye
to him, and he's leaning upagainst the car and he's already
smoked a cigarette.
SPEAKER_01 (02:29):
So yeah.
SPEAKER_00 (02:31):
Incision line comes open, you know, a lot of the
stuff to hisses.
I become an expert at removingstruts, I become an expert at
soft tissue grafting.
Life uh core was just coming outwith Alloderm at the time.
Dr.
Lil John loved Perio, and he wasdoing a lot of work, and I was
learning a lot of work and doinga lot of work with him.
(02:51):
And we grafted this poor man foryears, and I think it lasted 15
years.
He actually passed away with theimplant, but it went from nine
posts, I think, down to five bythe time you know he passed
away.
So, you know, even Carl Mish isbrilliant as he was, and I think
(03:12):
he's one of the smartestimplantologists in our era.
You know, he even he had thingsthat he did that were mistakes.
And you know, I guess my bigmessage to all the young docs
that are wanting to jump rightin the middle of this PSI, just
like we all wanted to get intozygos and pterygoids and nasal
implants, and it's like a trophyup on your wall back here, you
(03:35):
know.
I did this case, I'm gonna showit here and I'm gonna show it
there.
It's on TikTok, whatever,Instagram.
You know, and that's all great,but you do your reps, be
careful, you know, because we'rein a very litigious society.
And back when I was learning, itwasn't like it is now, you know,
and patients were moreforgiving, more understanding.
(03:56):
Uh, you know, and you know, becareful.
But you know, this this implanthere, if you look at it, has a
meso bar.
And everybody wants to do screwretained teeth now.
They want uh mobile compliantMUAs coming out, they don't see
the value of the meso bar.
Well, you know, this implantactually would bond to bone, it
(04:19):
would actually be covered withbone in certain cases, or it'd
be encapsulated with softtissue, you know, that ligament
that Bob James talked about.
So it allowed for a little bitof movement, but the meso bar
kept all the struts together.
If you had one side go bad, andsometimes they did, you'd
literally cut it behind thecanine strut, take that segment
(04:44):
out, reline the overdenture onthat area.
Patient lived with two-thirds oftheir implant, and they never
missed a lick.
And these were the happiestpatients in the world, you know.
Um, we come forward to you know,the new PSI designs.
Yeah.
Here we go.
And you can see how much watereverything is, and it's all you
(05:10):
know, it's depending on screwsand that piriform reb.
You know, I love it that it'sengaging the zygoma.
You know, but like this one's intwo pieces.
Everybody wants to do it in twopieces, or you're missing the
nasal spine, which is going tobe the thickest bone in your
palate.
This one has palatal coverage.
I looked at a design uh on oneof our uh chat's rooms the other
(05:35):
just yesterday, and there was nopalatal coverage, you know, and
what you going against in themaxilla is the fact that there's
mimeritous bone, alveolar bone,very porous bone, very poor
quality bone, and you have tohave enough resistance to your
occlusal loading to prevent thatthing from setting over the
(05:56):
decades.
And just because it's titanium,just because it's all this
technology, just because youthrow a bunch of screws in it,
uh doesn't mean it's better, itdoesn't mean it's going to
resist that occlusal force thatyou put on it.
Uh people want to put zirconiateeth on it, you know.
Uh Lenny Lincoln, uh he actuallyput a study out, I think it was
(06:20):
1998, where he had done 600maxillary subs prior to
describing the problems withmaxillary subs.
He did an additional 300maxillary subs and he followed
his success rate and it wentfrom 60% to like 70-80%, okay,
with these changes.
(06:41):
And he did palatal coverage,canine eminence.
Uh, he would even uh go over theHamler knot into the uh that
area, and you know, there's alot of things that have been
tried, and a lot of errors thatwe saw from from the past that
we're replicating all thoseerrors today.
(07:01):
And uh, you know, somebody said,Well, it's titanium, it's bonded
the bone, it's better.
Where's the proof?
Where's the studies?
And and you know, let's say wemake this mandibular implant now
and make it out of titanium, andwe seed it.
(07:22):
And instead of doing a meso bar,we do MUAs.
All right, so now we've got anMUA prosthetic zert with four
you know death screws, vortex,badger, you know, you take your
choice, but four buttons screwsholding this in.
(07:42):
What happens if this segment orthis segment or this segment
come loose from the bottom?
So yeah, it's lost.
Okay, yeah.
But if you've got a meso bar,yeah, you can segment.
No, we've got 80 years of thisstuff working, so even if it's
titanium or chrome, cobalt andaluminum, we know that it can
(08:06):
survive in that suspensoryligament.
So the meso bar has has itsplace.
Now, are we working with designsnow where we're putting MUAs on
top of a meso bar in the lower?
Absolutely.
You know, so that we can do havea digital workflow because
overdentures are pain in thebutt to make.
(08:27):
You know, the labs, there's veryfew labs that still make them,
uh, and and getting the recordsfor it and having to transport
uh analog models and stuff.
I hate analog now.
I mean, I've I've literally been100% digital since 2020.
We bought pre-medit scanners,tabletop scanners, you know, uh
eye cams, everything.
And so, you know, I'm I'm all inon digital, but you know, when
(08:51):
you have to go backwards analog,uh, there's a place for it.
Like even casting the implants.
Uh, we did a digital STL and weprinted it out, but we cast it.
Uh, there's some advantages anddisadvantages to casting as
well, you know.
But um, you know, the the thebig thing here is is technology
(09:12):
is wonderful.
And I'm I'm I'm envious of youyoung men, uh, to where the next
20 years are going to lead foryour careers, you know.
As I phase out of the game andy'all go forward, you're gonna
remember this minute saying,wow, look at all what we're able
to do now.
You know, AI designs it and pusha button, they print it out, and
(09:33):
push another button, and theymill the MUAs and they polish
it, and boom, I've got teeth,you know.
Uh but uh you know, I think it'svery I'll just be nice.
I just I just knowing thesedoctors, studying from these
doctors, Luke, again, all theirhard, good, honest work.
(09:57):
I think we're really missing theboat if we don't know our
history.
You know, there's uh one who wasit said, you know, if you don't
know history, you're doomed torepeat it.
Okay, and it could be more truein what we're doing right now.
And you know, I love some ofthese young doctors that are
promoting the PSI, and I've I'veworked with them and I've done
(10:17):
demonstration surgeries withthem, but uh I do not agree with
them pushing this out andpromoting it, even over quad
zygos, you know.
I mean, I really feel like amaxillary subparaosteral should
be a rescue implant.
And uh mandibular subperoster isa whole different ballgame.
I mean, I got a hundred of themover 35 years now, and you know,
(10:40):
it's been damn near 100%success.
Uh, we've got studies fromDorsey Moore at UMKC.
There were over 20 done over orover 18 years.
They were placed by othersurgery residents, restored by
the prostodontists, prostheticresidents, 100% success rate.
(11:01):
Um, we had um John Mendochetewas doing a study on HA coding
of implants.
And I just in my research study,how he placed 20 and had a
hundred percent success rate at10 years, max later.
And you know, these are all theclassic designs, they're all
(11:22):
cast.
Uh some were uh digital records,you know, some were two-stage
surgery.
Uh, you know, even Bernardo, asmany as he's done, he was like,
segmentation is a problem, youknow, or the sinus, you know,
you can't segment that outaccurately.
And you know, you've got thesebig defects.
And you know, if you go back toLinkow's 1998 article on the
(11:45):
deficiencies, max agesubperosteals, he discusses that
very problem.
And he came up with thesolution.
He put his support over thesinus on a little finger off the
main part of the sub so that ifit gets exposed, you only had to
cut it one place and pull itout.
SPEAKER_01 (12:00):
You know.
SPEAKER_00 (12:05):
So, you know, I I just designed, I don't have
that, I I don't have the actualsub with me, but this is a
maxillary sub that we designedthat we were going to deliver
two months ago at FullArchmaster sub course that we
did, one of Ron Dunlop'spatients.
And uh, you know, I was able totake the DICOM data and uh I put
(12:27):
one of my screws in the Z point,you know.
SPEAKER_02 (12:30):
Nice, uh super Z point selling.
SPEAKER_00 (12:33):
Yeah, yeah.
SPEAKER_02 (12:35):
We just we just did that one.
SPEAKER_00 (12:37):
I know you just did.
I want I listened to it.
So, you know, that's one of myspots.
And you know, when I was doingthe uh, and I'll go ahead and
name it, it's bone easy.
Yeah, I mean, and I I did ademonstration surgery with
Bernardo and I did a podcastwith him for Larch Masters
several years back, and we wereputting the implant screws
around the the nose, you know,super thin bone, and we had
(12:59):
rescue screws, and as I'mtightening them down, it's like
I'm not getting anything here,you know, they're not fixating.
And I'm like, how much good arethese doing?
And then I'm thinking in mymind, okay, when this patient
starts functioning on this andloading this, how much
resistance are we going to get?
So, you know, there's a rightway and a wrong way to make a
maxillary sub, but I don't havethe answers.
(13:20):
You know, I've been doing this39 years, and I'm not about to
sit here and say, oh, I've gotthe answer for these.
I have a really good idea whereit should be loaded and how it
should be loaded, how it shouldbe designed.
But, you know, for a youngdoctor that's been out less than
five years and doesn't have alot of reps under his belt,
(13:40):
doesn't have good support froman ENT or an oral surgeon like I
do, uh, you know, you starthaving complications on these,
you got some splaining to do,and you don't have a lot of
literature to back you up, youknow.
And uh I just think that weshould really back up and be
very careful with what we'reseeing promoted, especially by
(14:01):
the companies and even some ofthe KOLs, you know?
And uh just this should besomething that should be a last
resort, but it's a beautifullast resort, and it can work
great, okay?
Especially on the manible, butthe maxilla, it's a complete
different animal.
SPEAKER_01 (14:20):
Yeah.
So can we just uh to kind oflike briefly summarize, what are
the main things that make itmake such a big difference
between the predictability of alower and an upper sub?
I mean, what I've heard are youknow, you have a totally
different quality of bone in theupper, the upper has much more
complex anatomy.
It can be very difficult tocreate a passive prosthesis
(14:40):
there.
Um anything else there that theycan kind of summarize why
there's such a disparity betweenthe predictability of both?
SPEAKER_00 (14:47):
Uh we'll take uh right off the slide from the
lecture from Linkow, inadequatebone support, inadequate
cortical bone, you've gotalveolar bone, you have lateral
sinus walls, you have poortissue quality, especially over
the sinus, you have mucosa, combbeam segmentation issues, and
(15:09):
you've got revisiondifficulties.
So, you know, Lincoln's featuresthat are critical to sub.
And I'm not a big Linny Lincolnfan at all.
He's from New York, I'm fromArkansas, he talks funny, I talk
funny, he's very bombastic, I'ma little less, you know.
But after reading this article,I'm like, damn it, I wish I'd
(15:30):
spent more time with this manbecause he really was brilliant,
you know.
And I hear people, oh, well,this is Link all this and that.
They don't do the deep dive inthis, they don't read this
stuff, right?
They don't study, they don'tunderstand it.
But first thing, low, densecortical bone.
Okay, there's not much up there.
You know, what do you have?
You know, you can go, yeah, headshells, you know, uh adequate
(15:55):
model, direct impression or conebeam CT.
Uh, one of the companies I'mworking with, JD right now, they
want a helical scan of themaxilla.
I said, guys, it's a no-go for99% of the dentists.
They don't want to take them tothe hospital, they want to use
their ICAT or their ray scan orwhatever, the vape tech.
And they're like, well, we cansegment it better, we can clean
that up better.
(16:15):
I'm like, well, okay, you know,maybe we'll send them to an uh
imaging center and we'll get ahelical CT, you know.
Uh engage the nasal, thepalatal, nasal spine, and canine
eminence.
Okay.
He didn't have zygoma in there,you know, but we know zygoma is
available.
We're all there now.
(16:36):
Maximize vocal keratinizedtissue.
He would probably love ourlingual uh you know, scarf
grafting technique there.
He would love that.
This is all not a reallysomething that was being done
back then.
A lightweight frame, okay.
You look at these frames, youknow, and the stuff that's been
(16:59):
done now, they're fascinating.
Now, this one's thin, but a lotof them are really thick and
they got right angles.
You know, I mean, when youcompare it to something like
this, I mean look how thin thisis.
Yeah, you've got a lot of placesfor the perioste to reattach.
Okay.
So lightweight frame, you wantto minimize your crossover
(17:22):
struts.
And I actually had one guy earlythat was lecturing on these.
He says, you know, they didn'tuse to recess these things in
the bone.
And we recess our crossoverstruts in the bone.
I'm like, first of all, youknow, I was taught to recess it
on my very first one in 1990.
And I start looking through theliterature, and I mean, it's
(17:43):
been done since the 70s,recessed on the bone.
So, you know, that's where Isay, be careful who you listen
to.
Do your own deep dive.
You know, you really need to beresponsible for knowing your
game.
And that's why I felt like whenthis was a required implant for
ABOI.
I was the last, you know, when Igot mine in 90, I had to have a
(18:04):
sub.
And they dropped it because theOral Surgeons didn't believe in
them, paradigms didn't believein prostate, didn't believe in
them.
You know, it's just a bunch ofdumb GPs in the Southeast doing
them, you know.
And so you've got this wholegeneration that has zero
exposure to subs because itwasn't a requirement.
And I get that.
But my whole thing was at thetime was like, we still need to
(18:25):
know about these, we still needto teach it, we still need to
let these people know how tomanage the complications on
this.
And so I spent a lot of timeteaching how to manage
subperosteal complications thatpeople call.
So crossover struts, minimum oftwo millimeters wide.
So you look at this thing, andyou know, it's three or four
millimeters wide going across oracross the ridge three times.
(18:48):
Whereas, you know, you look at acrossover strut here, and you
know, it's two millimeters andit's recessed.
So there's a big differencethere.
And then Lenny, he was big onhis palatal strap, but uh
history shows that those palatalstraps uh they fitestrated, you
know.
(19:09):
So I think that uh, you know,it's just a big thing.
And then with the prosthetics,you know, he was like no tissue
engagement, removablezero-degree teeth over opposing
dentures.
If there were natural teeth onthe opposing 10-degree uh
maximum on your occlusion, andminimized anterior guidance.
(19:29):
So one of the big concepts withsubs was you know, the occlusal
table on these is flat.
If you look at the teeth, vocalcusp was the most prominent.
There was actually a cutter barin the original ones.
And you know, I went through theera in the 2000s of extreme
makeover, and I'm having theseladies spend 25,000 on an
(19:53):
implant and 5,000 on a denture,and they got a metal bar, and
they don't like that.
So I literally had root makinguh Empress teeth color match,
you know, uh, without the metalbar before these became
available.
But um so today with occlusion,you know, everybody wants to do
(20:15):
zirconian teeth, they want touse exacad.
Uh, you know, a lot of peopleare using 20-degree, they're
doing group function, anteriorguidance, all this stuff.
But with the sub, you just wantit to slide without any lateral
excursion, without any anteriorguidance.
Now, I can't give you a study, Ican't give you any literature,
(20:39):
it's all anecdotal, or you wantto say it's clinical, whatever.
But in practice, by doing this,and I was told this 38 years ago
by my mentor who had been doingthem 20 years, so they've been
restored this way for 58 yearssuccessfully.
Okay, and I told you I I hadseveral hundred implants come
(21:00):
into my clinic from Dr.
Joe when he passed, Dr.
Harris when he passed, Dr.
Crameen when he retired.
And so these patients didn'thave a home, didn't have anybody
that understood subs.
So I would take care of allthese patients, and you know, my
my goal was to get them to theend game, you know, have them
die with their implant.
(21:21):
And we weren't successful.
I never took one of those guys'subs out.
I might have to take a posteriorstrut out or something, but the
vast majority they get a littlepermucosal infection on uh
ascending ramus strut, put themon around a uh Kepflex 500 TID
for 10 days, and 99% of the timethat maxillary denture or teeth
(21:41):
had worn and they were lockedin.
And when they go in protrusive,they had anterior guidance, and
when they go to lateral, theycouldn't because they were
locked in.
So all we do is we'd replace theteeth, we call it a retread on
the upper, or we just take somecomposite or try it at the time
and just fill in the group, andthey come back two weeks and
they were fine, you know.
(22:04):
So those concepts, theseimportant things that I learned
from my mentors, I think it'sthings that we need to take
forward to the PSI world, youknow, and I don't know how being
integrated to bone is gonnawork.
Is it gonna work like a reformimplant?
Maybe, maybe not.
(22:24):
But what happens if it's notbonded to bone, or what happens
if it debonds?
Well, we know this worked, andso you know what you want to do
is have as atriumic occlusion asyou can on these, and so you
know that's the wonderful thingabout implantology.
I mean, it's it's the full game,you know, it's the occlusion,
it's the soft tissue, it's there-care.
(22:46):
You know, I've got hygienesthat's been here with 22 years.
She's seen uh she sees eightimplant patients a day, you
know, and maintains this stuff.
And I mean, she knows what'sgoing on as well as I did.
I walk in and says, Dr.
Jay, we've got to get a retreathere, we've got to do this here,
boom, boom, boom, you know.
But uh it's it's things likethat that you need to go into
(23:10):
knowing before you get into thisworld of subperostero implants.
SPEAKER_01 (23:15):
Yeah, I definitely think there's there's a big wave
uh going along with it now.
And I think that you know, in infull arch, it's like we've kind
of developed this linearmentality of how one develops,
right?
It's it's like you you're gonnago into singles, you're gonna do
some overt enters, you're gonnado your all-in four.
Once you've done enough of that,you got to do your pterygoids,
now you're gonna get into zygos,and maybe you're gonna get into
customers, or maybe we're gonnado one of those first and some
(23:36):
other ascending order.
Just this idea that after youspend a certain amount of time,
you just need to go to the nextstep and start doing more and
more advanced stuff.
And, you know, I I I agree withyou that you know, we need to be
looking back as as much as we'relooking forward, if not more, to
learn from some of these thingsbecause history does repeat
itself.
A lot of these things have beentried before.
We've learned a lot of things.
And not only have some of thethings that went wrong been
(23:58):
forgotten, but some of the goodstuff has been forgotten too.
And to not see that movingforward is concerning.
And I think you're raising somereally important points that uh
people should really beconsidering if they're looking
into getting into thatcustomized implant world.
Because I think right now it'sit's it's uh it's difficult.
I think when I talk to a lot ofUS dentists that have uh
considered them, they see a lotof logistical barriers, um, you
(24:18):
know, medical legal barriersinto getting into custom subs.
Not really sure um how how it'sgonna cover you, you know.
Yeah, right.
It's it's a brand new world, myfriend.
SPEAKER_00 (24:29):
It's a whole new world.
I mean, it's like zygos.
I mean, I I think my first zygocourse was at Picos, and you
know, they were doing theoriginal Nobel through the sinus
flying.
And you know, I I'm an archer,you know.
I mean, I I I I can put animplant if I what if I wanted
someplace I could do it.
(24:49):
That's just my gift from God.
And so I'm nailing all theseimplants, but I'm like, there's
no way in hell I'm doing this inmy office.
And then when we got the extramaxillary, you know, and things
I'm like, okay, I could do that.
And I go to Vichy's office andwe do a case there, and it goes
great.
And I come home and I got fivecases lined up, and I think I
got two of them successfullycompleted.
(25:12):
The other three were justcomplete disasters.
And I gotta have more reps.
So I go to Brazil to Salvoni'scourse, and I get in eight reps,
and I realize what I was doingwrong, and now you know an
archer again, you know, withzygos.
But you know, I mean, I put offdoing zygos for over 10 years
(25:35):
until the technique had modifiedenough that it was predictable
and safe to do.
Yeah, yeah.
And I guess that's kind of mymessage with subs.
You know, we want to do amandibular sub, let's let's get
on it, you know.
But with these maxillaries, weneed to be extremely selective
with the patient, extremelyselective with your
(25:55):
manufacturer.
And, you know, if you've got amentor or somebody that can be
there with you and help you withthis and walk you through this,
do it.
You know, there's not a lot ofus out there, you know, but uh
just be careful and don't getyourself in hot water.
SPEAKER_01 (26:09):
Yeah.
SPEAKER_00 (26:10):
Try to get a trophy on your wall.
SPEAKER_01 (26:13):
Absolutely.
I think I think the trophyhunting is uh an issue.
I think we've all guilt you.
SPEAKER_00 (26:19):
Exactly.
No one's no one I mean mycredentials, my credentials, you
know.
I wanted to prove myself and Iwanted I really haven't ever
really even advertised that I'ma diplomat or a fellow.
I mean, it's on my website, butI never put it in my print
media, it's never on my mytelevision stuff, you know.
Um, I just didn't want to stepon toes, you know, here and it
(26:40):
wasn't necessary.
I am I know it's necessary fordoctors that are in big cities,
you know, lots and lots of uhcompetition, but um, you know,
now, you know, it's it's justone of those things, you know.
SPEAKER_01 (26:54):
Yeah, yeah, no, I understand.
So so let's say someone um, youknow, is an experienced full art
surgeon, um, they've done a lotof their homework, they've
they've done some zygos, uh, youknow, they they've done good
work and they've spent some timeon this, they've got a lot of
recare under their belt, and butnow they want to start you know
tackling some customized subs.
What are some principles thatthey should be looking for when
(27:15):
they're considering differentlabs that do it, different types
of designs?
We've talked a little bit aboutthe sleekness of the struts, we
talked a little bit about uhsurface treatment.
What are some you know boxes weshould be checking as we're kind
of trying to vet out differentsources?
SPEAKER_00 (27:27):
So, first thing, you know, you've got to have your
prosthetics nailed down, okay?
And uh, you know, that was oneof the issues Nate and I came up
with with some of these casesthat we were doing for other
doctors.
We're getting the uh prosthesseated properly, uh getting a
DICOM image with that seatedproperly, uh getting an STL of
(27:49):
that prosthetic, stitching allthat together so that when you
do design your implant, yourMUAs or your meso bar and
everything fit within thatprosthesis.
Okay.
And uh, you know, even my analogguy kind of messed up on one of
our implants and he he got theocclusive plane wrong on it, you
know.
So we had to come back in anddigitally alter the maxilla and
(28:14):
can everything up a little bitto make a little freeway space
in there.
So first thing is you've got tohave a dialed-in prosthetic
design, okay?
And then you've got to be ableto communicate that to it.
Uh, you know, on your patientselection, I mean it's got to be
a resort bridge.
It's not, I don't think that youshould be trying to take out
teeth, cut bone, cut uhcrossover strut segments, and
(28:38):
pop it in.
It's just you know, one miracleat a time, uh, you know, one
step at a time.
So you need to pick thatcarefully.
And then, you know, it's justlike in any implant practice,
start out with what's known ormore predictable.
You want to do them, do themmandible.
But don't do this stuff that yousee where there's three per
(28:58):
mucosal above struts from thesecond molar to the first
premolar, and you know, big,thick, wide crossover struts,
whether they're recessed or not,with 90-degree angles out into
mucosa, which are all going toyou know, to hits.
Uh, and so that's whereunderstanding design concepts
(29:20):
and even talking to thesemanufacturers, uh, you know,
I've uh got one I'm working withright now, and when I saw the
design, uh I was like, wow, thisguy knows what he's doing, you
know.
And if we could just change theworkmanship of the implant
itself just a little bit, youknow, because he was hitting all
(29:42):
the hobbits.
He had the zygote, he wentaround and got your uh past the
tuberosity, and and he got uhmidpalatal suture.
I mean, he hit all the hot spotson that, and he had four
permecosal posts.
Uh so you know, there are somepeople out there designing, but
(30:02):
then you know, you've got allthese other countries with all
these other designers, and youknow, they're they've got an
engineer or a biotech kid that'sdoing it, and you know, they're
they're brilliant with thesoftware, they're brilliant with
their concept, they're brilliantwith their uh finite element
analysis, but you know, when itcomes back to what's
(30:25):
biologically compatible in thatpatient's mouth, yeah, what's
the tissue going to tolerate?
And then I guess that's thebiggest thing is you need to
have quality bone for this thingto resist the forces of
occlusion.
And you have to have qualitytissue to protect it, you know,
and then you've got to haveocclusion that's atraumatic.
(30:47):
So you have to be able to findsomebody who can do all that.
And unfortunately, I haven'tfound that person yet.
SPEAKER_01 (30:54):
Yeah, okay.
I'm curious too, right?
So, I mean, I'm thinking about,you know, what is good quality
bone for a patient that needssome maxillary subperiostal?
Like, how do you really assessthat?
I mean, these are very atrophicpeople, right?
I mean, it's not going to be thebest situation.
SPEAKER_00 (31:07):
You know, Nate spends over 24 hours doing a
design.
You know, I've probably spentfive or six hours picking out Z
points and you know, the zygoma,mid-palatal suture, and saying,
okay, here's where we're goingto load.
Okay.
But you know, I'm doing theviews through the lateral sinus
wall, I'm doing the viewsthrough the sinus, and I've got
(31:31):
you know 0.5 millimeter bone.
Well, that's not going to resistanything.
Yeah.
You know, I mean, the only uhhope you have is to spread that
load out.
But uh it there's not, I can'tgive you a black and white
answer.
It's going to be on a case bycase still.
And you know, what what are youputting on it for occlusion?
(31:51):
You know, uh, are you goinganatomic teeth?
Are you doing centric uh lineteeth?
Are you doing zirconia?
Are you doing a plastic teeth orPMMA teeth?
I mean, you know, there's a lotof factors to this.
And you know, I've been doing it35 years.
I don't have all the answers,especially when it comes to the
(32:11):
maxilla.
Yeah, if you want a mandibularsub, you know, I can I can say,
here's what you do, okay?
And here's what to look out for.
SPEAKER_02 (32:20):
So you're in your opinion, you think that if if
somebody's getting into youknow, some of the more difficult
maxillary cases, you first wouldwould do remote anchorage, um,
zygos, quad zygos, and save anykind of any kind of sub um
customized sub situation to likethe very the patient that even
(32:41):
that isn't gonna work for.
SPEAKER_00 (32:43):
So in my lectures, you know, it's funny, I I didn't
do palatal approach before 2020.
Okay.
So I learned palatal approachand it pissed me off because I
really enjoyed doing zygote.
SPEAKER_01 (32:54):
There's just so much super does so much you can do.
SPEAKER_00 (33:00):
And my zygote count went down like 90% from palatal
approach and transnasals andpteroids and stuff.
It's like, damn it, you know.
But with uh getting back, Imean, with these, you know, pick
your cases, you know, start outwith a with the mandible, you
(33:20):
know, and then you know, on themaxillas, just be extremely
careful, pick your patient, havea relationship with that person,
and and and be very honest.
Things could go south.
You know, I mean, I've got alady right now in my clinic that
was done by a very good surgeonin Arkansas and restored by very
good prostate honest inArkansas, and they've both been
(33:41):
very open, sent me everything,and she relocated to my area,
and she's got bilateral uhfistulus into the sinus.
Huge, huge exposure.
Uh food's getting up there,they're infected.
Uh, I've referred her out to anENT that I work with.
He's trying to get her cleanedup.
I've got an old surgeon, youknow.
(34:02):
My old surgeon's my next doorneighbor is a great guy.
And we're like, you know, howare we gonna fix this lady?
Because when this all comes out,she's obturator.
Yeah, and there's nothing tohold event, you know, and she's
in her 80s, her health isfailing, and it's horrible.
You know, so the devastationfrom these can be very, very
bad.
Yeah.
And, you know, so you ask me,you know, are zygos first
(34:26):
choice, uh, and these others.
I think that for the maxilla, Ithink the sub should be the last
choice.
And it uh you had it on yourwater, you think it's
controversial.
That's one of the things.
Because, you know, there's goingto be other people that say
zygos are wrought with withfailure and complications and
(34:47):
infection.
And yeah, I've had all thosemyself, you know, and and in
zygos, I respect, extremelyrespect those.
And I do realize there arecomplications.
But when a zygote goes south, Ifeel like the revision on that
is easier.
SPEAKER_01 (35:06):
Yeah.
SPEAKER_00 (35:07):
And in one of the threads we were talking about
subs this last two days, DanHoltzlaw comes in and he goes, I
got 22 references that supportzygos.
How many do you have thatsupport bacterial subperosteas?
And most of the case studiesthat I see that I've been able
to research, and I even got thehigh dollar to chat B G Turn
(35:31):
researching it, and it's likethey're two years, yeah, 26
months, 36 months.
And I got docs.
Well, I've got some out fiveyears.
I'm like, okay, let's see whatthey look like in 10 or 15.
Because you know, if you ownyour own practice and you stay
in business long, I mean it'slike I've been here 39 years,
and I literally have 30 plusyear old subs in my practice,
(35:52):
yeah, you know, and you know,you see this stuff come in again
and again.
You really don't want to seethis stuff going bad, and it's
not a practice builder, right?
And you know, I like to sleep atnight.
My name is Dr.
Tyler Tilbert, and I'm Dr.
Storin Poppy, and you'relistening to the Fix Podcast,
your source for all things inplant dentistry.
SPEAKER_01 (00:49):
Yeah, so I I'm curious too, just to kind of
simply lay out a basis of youknow what the old versus new is,
what um what is ideal and whatisn't.
Can we just kind of like brieflyillustrate, you know, uh what
are what are the mechanicalideal mechanical properties of
the classics of the classic uh Ithink you're do you mind if I
show a model?
(01:09):
Yeah, not at all.
Yeah.
SPEAKER_00 (01:12):
So so this is bear with me here, guys.
This is one of my stereolithicmodels that was done on ICAT,
sent to the lab in Colorado.
And you can see we're loadingthe lateral ramus here.
We're loading synthesis.
We've got a mesobar that comesout of the ascending ramus here,
(01:33):
canine.
There's only four posts.
SPEAKER_02 (01:35):
Yeah.
SPEAKER_00 (01:36):
Very first sub I did was at NISH, and Carl says,
Well, we've got to spread theload out.
We need nine posts, and we'lltalk about coatings.
We're gonna coat it with HA.
And my mentor and win, Dr.
Lil said, Don't do that.
And I said, I got to.
I got to deliver it at NICH.
And so we did.
And the guy was uh a classmateof mine, he was a pietodontist,
(01:59):
it was his father, and he smokedlike a train, you know, like
three packs a day.
And I said, you know, you can'tsmoke for two weeks, and we're
in Dearborn, Michigan, and I getfinished with the surgery, and
uh, I don't even think I got toclose it because it was over two
hours, you know.
It's one of these shit show typesurgeries that happens to all of
us, you know.
And so um, I'm in the didacticpart and they finally dismiss
(02:22):
him, and he's out in the parkinglot, and I go out to say goodbye
to him, and he's leaning upagainst the car and he's already
smoked a cigarette.
SPEAKER_01 (02:29):
So yeah.
SPEAKER_00 (02:31):
Incision line comes open, you know, a lot of the
stuff to hisses.
I become an expert at removingstruts, I become an expert at
soft tissue grafting.
Life uh core was just coming outwith Alloderm at the time.
Dr.
Lil John loved Perio, and he wasdoing a lot of work, and I was
learning a lot of work and doinga lot of work with him.
(02:51):
And we grafted this poor man foryears, and I think it lasted 15
years.
He actually passed away with theimplant, but it went from nine
posts, I think, down to five bythe time you know he passed
away.
So, you know, even Carl Mish isbrilliant as he was, and I think
(03:12):
he's one of the smartestimplantologists in our era.
You know, he even he had thingsthat he did that were mistakes.
And you know, I guess my bigmessage to all the young docs
that are wanting to jump rightin the middle of this PSI, just
like we all wanted to get intozygos and pterygoids and nasal
implants, and it's like a trophyup on your wall back here, you
(03:35):
know.
I did this case, I'm gonna showit here and I'm gonna show it
there.
It's on TikTok, whatever,Instagram.
You know, and that's all great,but you do your reps, be
careful, you know, because we'rein a very litigious society.
And back when I was learning, itwasn't like it is now, you know,
and patients were moreforgiving, more understanding.
(03:56):
Uh, you know, and you know, becareful.
But you know, this this implanthere, if you look at it, has a
meso bar.
And everybody wants to do screwretained teeth now.
They want uh mobile compliantMUAs coming out, they don't see
the value of the meso bar.
Well, you know, this implantactually would bond to bone, it
(04:19):
would actually be covered withbone in certain cases, or it'd
be encapsulated with softtissue, you know, that ligament
that Bob James talked about.
So it allowed for a little bitof movement, but the meso bar
kept all the struts together.
If you had one side go bad, andsometimes they did, you'd
literally cut it behind thecanine strut, take that segment
(04:44):
out, reline the overdenture onthat area.
Patient lived with two-thirds oftheir implant, and they never
missed a lick.
And these were the happiestpatients in the world, you know.
Um, we come forward to you know,the new PSI designs.
Yeah.
Here we go.
And you can see how much watereverything is, and it's all you
(05:10):
know, it's depending on screwsand that piriform reb.
You know, I love it that it'sengaging the zygoma.
You know, but like this one's intwo pieces.
Everybody wants to do it in twopieces, or you're missing the
nasal spine, which is going tobe the thickest bone in your
palate.
This one has palatal coverage.
I looked at a design uh on oneof our uh chat's rooms the other
(05:35):
just yesterday, and there was nopalatal coverage, you know, and
what you going against in themaxilla is the fact that there's
mimeritous bone, alveolar bone,very porous bone, very poor
quality bone, and you have tohave enough resistance to your
occlusal loading to prevent thatthing from setting over the
(05:56):
decades.
And just because it's titanium,just because it's all this
technology, just because youthrow a bunch of screws in it,
uh doesn't mean it's better, itdoesn't mean it's going to
resist that occlusal force thatyou put on it.
Uh people want to put zirconiateeth on it, you know.
Uh Lenny Lincoln, uh he actuallyput a study out, I think it was
(06:20):
1998, where he had done 600maxillary subs prior to
describing the problems withmaxillary subs.
He did an additional 300maxillary subs and he followed
his success rate and it wentfrom 60% to like 70-80%, okay,
with these changes.
(06:41):
And he did palatal coverage,canine eminence.
Uh, he would even uh go over theHamler knot into the uh that
area, and you know, there's alot of things that have been
tried, and a lot of errors thatwe saw from from the past that
we're replicating all thoseerrors today.
(07:01):
And uh, you know, somebody said,Well, it's titanium, it's bonded
the bone, it's better.
Where's the proof?
Where's the studies?
And and you know, let's say wemake this mandibular implant now
and make it out of titanium, andwe seed it.
(07:22):
And instead of doing a meso bar,we do MUAs.
All right, so now we've got anMUA prosthetic zert with four
you know death screws, vortex,badger, you know, you take your
choice, but four buttons screwsholding this in.
(07:42):
What happens if this segment orthis segment or this segment
come loose from the bottom?
So yeah, it's lost.
Okay, yeah.
But if you've got a meso bar,yeah, you can segment.
No, we've got 80 years of thisstuff working, so even if it's
titanium or chrome, cobalt andaluminum, we know that it can
(08:06):
survive in that suspensoryligament.
So the meso bar has has itsplace.
Now, are we working with designsnow where we're putting MUAs on
top of a meso bar in the lower?
Absolutely.
You know, so that we can do havea digital workflow because
overdentures are pain in thebutt to make.
(08:27):
You know, the labs, there's veryfew labs that still make them,
uh, and and getting the recordsfor it and having to transport
uh analog models and stuff.
I hate analog now.
I mean, I've I've literally been100% digital since 2020.
We bought pre-medit scanners,tabletop scanners, you know, uh
eye cams, everything.
And so, you know, I'm I'm all inon digital, but you know, when
(08:51):
you have to go backwards analog,uh, there's a place for it.
Like even casting the implants.
Uh, we did a digital STL and weprinted it out, but we cast it.
Uh, there's some advantages anddisadvantages to casting as
well, you know.
But um, you know, the the thebig thing here is is technology
(09:12):
is wonderful.
And I'm I'm I'm envious of youyoung men, uh, to where the next
20 years are going to lead foryour careers, you know.
As I phase out of the game andy'all go forward, you're gonna
remember this minute saying,wow, look at all what we're able
to do now.
You know, AI designs it and pusha button, they print it out, and
(09:33):
push another button, and theymill the MUAs and they polish
it, and boom, I've got teeth,you know.
Uh but uh you know, I think it'svery I'll just be nice.
I just I just knowing thesedoctors, studying from these
doctors, Luke, again, all theirhard, good, honest work.
(09:57):
I think we're really missing theboat if we don't know our
history.
You know, there's uh one who wasit said, you know, if you don't
know history, you're doomed torepeat it.
Okay, and it could be more truein what we're doing right now.
And you know, I love some ofthese young doctors that are
promoting the PSI, and I've I'veworked with them and I've done
(10:17):
demonstration surgeries withthem, but uh I do not agree with
them pushing this out andpromoting it, even over quad
zygos, you know.
I mean, I really feel like amaxillary subparaosteral should
be a rescue implant.
And uh mandibular subperoster isa whole different ballgame.
I mean, I got a hundred of themover 35 years now, and you know,
(10:40):
it's been damn near 100%success.
Uh, we've got studies fromDorsey Moore at UMKC.
There were over 20 done over orover 18 years.
They were placed by othersurgery residents, restored by
the prostodontists, prostheticresidents, 100% success rate.
(11:01):
Um, we had um John Mendochetewas doing a study on HA coding
of implants.
And I just in my research study,how he placed 20 and had a
hundred percent success rate at10 years, max later.
And you know, these are all theclassic designs, they're all
(11:22):
cast.
Uh some were uh digital records,you know, some were two-stage
surgery.
Uh, you know, even Bernardo, asmany as he's done, he was like,
segmentation is a problem, youknow, or the sinus, you know,
you can't segment that outaccurately.
And you know, you've got thesebig defects.
And you know, if you go back toLinkow's 1998 article on the
(11:45):
deficiencies, max agesubperosteals, he discusses that
very problem.
And he came up with thesolution.
He put his support over thesinus on a little finger off the
main part of the sub so that ifit gets exposed, you only had to
cut it one place and pull itout.
SPEAKER_01 (12:00):
You know.
SPEAKER_00 (12:05):
So, you know, I I just designed, I don't have
that, I I don't have the actualsub with me, but this is a
maxillary sub that we designedthat we were going to deliver
two months ago at FullArchmaster sub course that we
did, one of Ron Dunlop'spatients.
And uh, you know, I was able totake the DICOM data and uh I put
(12:27):
one of my screws in the Z point,you know.
SPEAKER_02 (12:30):
Nice, uh super Z point selling.
SPEAKER_00 (12:33):
Yeah, yeah.
SPEAKER_02 (12:35):
We just we just did that one.
SPEAKER_00 (12:37):
I know you just did.
I want I listened to it.
So, you know, that's one of myspots.
And you know, when I was doingthe uh, and I'll go ahead and
name it, it's bone easy.
Yeah, I mean, and I I did ademonstration surgery with
Bernardo and I did a podcastwith him for Larch Masters
several years back, and we wereputting the implant screws
around the the nose, you know,super thin bone, and we had
(12:59):
rescue screws, and as I'mtightening them down, it's like
I'm not getting anything here,you know, they're not fixating.
And I'm like, how much good arethese doing?
And then I'm thinking in mymind, okay, when this patient
starts functioning on this andloading this, how much
resistance are we going to get?
So, you know, there's a rightway and a wrong way to make a
maxillary sub, but I don't havethe answers.
(13:20):
You know, I've been doing this39 years, and I'm not about to
sit here and say, oh, I've gotthe answer for these.
I have a really good idea whereit should be loaded and how it
should be loaded, how it shouldbe designed.
But, you know, for a youngdoctor that's been out less than
five years and doesn't have alot of reps under his belt,
(13:40):
doesn't have good support froman ENT or an oral surgeon like I
do, uh, you know, you starthaving complications on these,
you got some splaining to do,and you don't have a lot of
literature to back you up, youknow.
And uh I just think that weshould really back up and be
very careful with what we'reseeing promoted, especially by
(14:01):
the companies and even some ofthe KOLs, you know?
And uh just this should besomething that should be a last
resort, but it's a beautifullast resort, and it can work
great, okay?
Especially on the manible, butthe maxilla, it's a complete
different animal.
SPEAKER_01 (14:20):
Yeah.
So can we just uh to kind oflike briefly summarize, what are
the main things that make itmake such a big difference
between the predictability of alower and an upper sub?
I mean, what I've heard are youknow, you have a totally
different quality of bone in theupper, the upper has much more
complex anatomy.
It can be very difficult tocreate a passive prosthesis
(14:40):
there.
Um anything else there that theycan kind of summarize why
there's such a disparity betweenthe predictability of both?
SPEAKER_00 (14:47):
Uh we'll take uh right off the slide from the
lecture from Linkow, inadequatebone support, inadequate
cortical bone, you've gotalveolar bone, you have lateral
sinus walls, you have poortissue quality, especially over
the sinus, you have mucosa, combbeam segmentation issues, and
(15:09):
you've got revisiondifficulties.
So, you know, Lincoln's featuresthat are critical to sub.
And I'm not a big Linny Lincolnfan at all.
He's from New York, I'm fromArkansas, he talks funny, I talk
funny, he's very bombastic, I'ma little less, you know.
But after reading this article,I'm like, damn it, I wish I'd
(15:30):
spent more time with this manbecause he really was brilliant,
you know.
And I hear people, oh, well,this is Link all this and that.
They don't do the deep dive inthis, they don't read this
stuff, right?
They don't study, they don'tunderstand it.
But first thing, low, densecortical bone.
Okay, there's not much up there.
You know, what do you have?
You know, you can go, yeah, headshells, you know, uh adequate
(15:55):
model, direct impression or conebeam CT.
Uh, one of the companies I'mworking with, JD right now, they
want a helical scan of themaxilla.
I said, guys, it's a no-go for99% of the dentists.
They don't want to take them tothe hospital, they want to use
their ICAT or their ray scan orwhatever, the vape tech.
And they're like, well, we cansegment it better, we can clean
that up better.
(16:15):
I'm like, well, okay, you know,maybe we'll send them to an uh
imaging center and we'll get ahelical CT, you know.
Uh engage the nasal, thepalatal, nasal spine, and canine
eminence.
Okay.
He didn't have zygoma in there,you know, but we know zygoma is
available.
We're all there now.
(16:36):
Maximize vocal keratinizedtissue.
He would probably love ourlingual uh you know, scarf
grafting technique there.
He would love that.
This is all not a reallysomething that was being done
back then.
A lightweight frame, okay.
You look at these frames, youknow, and the stuff that's been
(16:59):
done now, they're fascinating.
Now, this one's thin, but a lotof them are really thick and
they got right angles.
You know, I mean, when youcompare it to something like
this, I mean look how thin thisis.
Yeah, you've got a lot of placesfor the perioste to reattach.
Okay.
So lightweight frame, you wantto minimize your crossover
(17:22):
struts.
And I actually had one guy earlythat was lecturing on these.
He says, you know, they didn'tuse to recess these things in
the bone.
And we recess our crossoverstruts in the bone.
I'm like, first of all, youknow, I was taught to recess it
on my very first one in 1990.
And I start looking through theliterature, and I mean, it's
(17:43):
been done since the 70s,recessed on the bone.
So, you know, that's where Isay, be careful who you listen
to.
Do your own deep dive.
You know, you really need to beresponsible for knowing your
game.
And that's why I felt like whenthis was a required implant for
ABOI.
I was the last, you know, when Igot mine in 90, I had to have a
(18:04):
sub.
And they dropped it because theOral Surgeons didn't believe in
them, paradigms didn't believein prostate, didn't believe in
them.
You know, it's just a bunch ofdumb GPs in the Southeast doing
them, you know.
And so you've got this wholegeneration that has zero
exposure to subs because itwasn't a requirement.
And I get that.
But my whole thing was at thetime was like, we still need to
(18:25):
know about these, we still needto teach it, we still need to
let these people know how tomanage the complications on
this.
And so I spent a lot of timeteaching how to manage
subperosteal complications thatpeople call.
So crossover struts, minimum oftwo millimeters wide.
So you look at this thing, andyou know, it's three or four
millimeters wide going across oracross the ridge three times.
(18:48):
Whereas, you know, you look at acrossover strut here, and you
know, it's two millimeters andit's recessed.
So there's a big differencethere.
And then Lenny, he was big onhis palatal strap, but uh
history shows that those palatalstraps uh they fitestrated, you
know.
(19:09):
So I think that uh, you know,it's just a big thing.
And then with the prosthetics,you know, he was like no tissue
engagement, removablezero-degree teeth over opposing
dentures.
If there were natural teeth onthe opposing 10-degree uh
maximum on your occlusion, andminimized anterior guidance.
(19:29):
So one of the big concepts withsubs was you know, the occlusal
table on these is flat.
If you look at the teeth, vocalcusp was the most prominent.
There was actually a cutter barin the original ones.
And you know, I went through theera in the 2000s of extreme
makeover, and I'm having theseladies spend 25,000 on an
(19:53):
implant and 5,000 on a denture,and they got a metal bar, and
they don't like that.
So I literally had root makinguh Empress teeth color match,
you know, uh, without the metalbar before these became
available.
But um so today with occlusion,you know, everybody wants to do
(20:15):
zirconian teeth, they want touse exacad.
Uh, you know, a lot of peopleare using 20-degree, they're
doing group function, anteriorguidance, all this stuff.
But with the sub, you just wantit to slide without any lateral
excursion, without any anteriorguidance.
Now, I can't give you a study, Ican't give you any literature,
(20:39):
it's all anecdotal, or you wantto say it's clinical, whatever.
But in practice, by doing this,and I was told this 38 years ago
by my mentor who had been doingthem 20 years, so they've been
restored this way for 58 yearssuccessfully.
Okay, and I told you I I hadseveral hundred implants come
(21:00):
into my clinic from Dr.
Joe when he passed, Dr.
Harris when he passed, Dr.
Crameen when he retired.
And so these patients didn'thave a home, didn't have anybody
that understood subs.
So I would take care of allthese patients, and you know, my
my goal was to get them to theend game, you know, have them
die with their implant.
(21:21):
And we weren't successful.
I never took one of those guys'subs out.
I might have to take a posteriorstrut out or something, but the
vast majority they get a littlepermucosal infection on uh
ascending ramus strut, put themon around a uh Kepflex 500 TID
for 10 days, and 99% of the timethat maxillary denture or teeth
(21:41):
had worn and they were lockedin.
And when they go in protrusive,they had anterior guidance, and
when they go to lateral, theycouldn't because they were
locked in.
So all we do is we'd replace theteeth, we call it a retread on
the upper, or we just take somecomposite or try it at the time
and just fill in the group, andthey come back two weeks and
they were fine, you know.
(22:04):
So those concepts, theseimportant things that I learned
from my mentors, I think it'sthings that we need to take
forward to the PSI world, youknow, and I don't know how being
integrated to bone is gonnawork.
Is it gonna work like a reformimplant?
Maybe, maybe not.
(22:24):
But what happens if it's notbonded to bone, or what happens
if it debonds?
Well, we know this worked, andso you know what you want to do
is have as atriumic occlusion asyou can on these, and so you
know that's the wonderful thingabout implantology.
I mean, it's it's the full game,you know, it's the occlusion,
it's the soft tissue, it's there-care.
(22:46):
You know, I've got hygienesthat's been here with 22 years.
She's seen uh she sees eightimplant patients a day, you
know, and maintains this stuff.
And I mean, she knows what'sgoing on as well as I did.
I walk in and says, Dr.
Jay, we've got to get a retreathere, we've got to do this here,
boom, boom, boom, you know.
But uh it's it's things likethat that you need to go into
(23:10):
knowing before you get into thisworld of subperostero implants.
SPEAKER_01 (23:15):
Yeah, I definitely think there's there's a big wave
uh going along with it now.
And I think that you know, in infull arch, it's like we've kind
of developed this linearmentality of how one develops,
right?
It's it's like you you're gonnago into singles, you're gonna do
some overt enters, you're gonnado your all-in four.
Once you've done enough of that,you got to do your pterygoids,
now you're gonna get into zygos,and maybe you're gonna get into
customers, or maybe we're gonnado one of those first and some
(23:36):
other ascending order.
Just this idea that after youspend a certain amount of time,
you just need to go to the nextstep and start doing more and
more advanced stuff.
And, you know, I I I agree withyou that you know, we need to be
looking back as as much as we'relooking forward, if not more, to
learn from some of these thingsbecause history does repeat
itself.
A lot of these things have beentried before.
We've learned a lot of things.
And not only have some of thethings that went wrong been
(23:58):
forgotten, but some of the goodstuff has been forgotten too.
And to not see that movingforward is concerning.
And I think you're raising somereally important points that uh
people should really beconsidering if they're looking
into getting into thatcustomized implant world.
Because I think right now it'sit's it's uh it's difficult.
I think when I talk to a lot ofUS dentists that have uh
considered them, they see a lotof logistical barriers, um, you
(24:18):
know, medical legal barriersinto getting into custom subs.
Not really sure um how how it'sgonna cover you, you know.
Yeah, right.
It's it's a brand new world, myfriend.
SPEAKER_00 (24:29):
It's a whole new world.
I mean, it's like zygos.
I mean, I I think my first zygocourse was at Picos, and you
know, they were doing theoriginal Nobel through the sinus
flying.
And you know, I I'm an archer,you know.
I mean, I I I I can put animplant if I what if I wanted
someplace I could do it.
(24:49):
That's just my gift from God.
And so I'm nailing all theseimplants, but I'm like, there's
no way in hell I'm doing this inmy office.
And then when we got the extramaxillary, you know, and things
I'm like, okay, I could do that.
And I go to Vichy's office andwe do a case there, and it goes
great.
And I come home and I got fivecases lined up, and I think I
got two of them successfullycompleted.
(25:12):
The other three were justcomplete disasters.
And I gotta have more reps.
So I go to Brazil to Salvoni'scourse, and I get in eight reps,
and I realize what I was doingwrong, and now you know an
archer again, you know, withzygos.
But you know, I mean, I put offdoing zygos for over 10 years
(25:35):
until the technique had modifiedenough that it was predictable
and safe to do.
Yeah, yeah.
And I guess that's kind of mymessage with subs.
You know, we want to do amandibular sub, let's let's get
on it, you know.
But with these maxillaries, weneed to be extremely selective
with the patient, extremelyselective with your
(25:55):
manufacturer.
And, you know, if you've got amentor or somebody that can be
there with you and help you withthis and walk you through this,
do it.
You know, there's not a lot ofus out there, you know, but uh
just be careful and don't getyourself in hot water.
SPEAKER_01 (26:09):
Yeah.
SPEAKER_00 (26:10):
Try to get a trophy on your wall.
SPEAKER_01 (26:13):
Absolutely.
I think I think the trophyhunting is uh an issue.
I think we've all guilt you.
SPEAKER_00 (26:19):
Exactly.
No one's no one I mean mycredentials, my credentials, you
know.
I wanted to prove myself and Iwanted I really haven't ever
really even advertised that I'ma diplomat or a fellow.
I mean, it's on my website, butI never put it in my print
media, it's never on my mytelevision stuff, you know.
Um, I just didn't want to stepon toes, you know, here and it
(26:40):
wasn't necessary.
I am I know it's necessary fordoctors that are in big cities,
you know, lots and lots of uhcompetition, but um, you know,
now, you know, it's it's justone of those things, you know.
SPEAKER_01 (26:54):
Yeah, yeah, no, I understand.
So so let's say someone um, youknow, is an experienced full art
surgeon, um, they've done a lotof their homework, they've
they've done some zygos, uh, youknow, they they've done good
work and they've spent some timeon this, they've got a lot of
recare under their belt, and butnow they want to start you know
tackling some customized subs.
What are some principles thatthey should be looking for when
(27:15):
they're considering differentlabs that do it, different types
of designs?
We've talked a little bit aboutthe sleekness of the struts, we
talked a little bit about uhsurface treatment.
What are some you know boxes weshould be checking as we're kind
of trying to vet out differentsources?
SPEAKER_00 (27:27):
So, first thing, you know, you've got to have your
prosthetics nailed down, okay?
And uh, you know, that was oneof the issues Nate and I came up
with with some of these casesthat we were doing for other
doctors.
We're getting the uh prosthesseated properly, uh getting a
DICOM image with that seatedproperly, uh getting an STL of
(27:49):
that prosthetic, stitching allthat together so that when you
do design your implant, yourMUAs or your meso bar and
everything fit within thatprosthesis.
Okay.
And uh, you know, even my analogguy kind of messed up on one of
our implants and he he got theocclusive plane wrong on it, you
know.
So we had to come back in anddigitally alter the maxilla and
(28:14):
can everything up a little bitto make a little freeway space
in there.
So first thing is you've got tohave a dialed-in prosthetic
design, okay?
And then you've got to be ableto communicate that to it.
Uh, you know, on your patientselection, I mean it's got to be
a resort bridge.
It's not, I don't think that youshould be trying to take out
teeth, cut bone, cut uhcrossover strut segments, and
(28:38):
pop it in.
It's just you know, one miracleat a time, uh, you know, one
step at a time.
So you need to pick thatcarefully.
And then, you know, it's justlike in any implant practice,
start out with what's known ormore predictable.
You want to do them, do themmandible.
But don't do this stuff that yousee where there's three per
(28:58):
mucosal above struts from thesecond molar to the first
premolar, and you know, big,thick, wide crossover struts,
whether they're recessed or not,with 90-degree angles out into
mucosa, which are all going toyou know, to hits.
Uh, and so that's whereunderstanding design concepts
(29:20):
and even talking to thesemanufacturers, uh, you know,
I've uh got one I'm working withright now, and when I saw the
design, uh I was like, wow, thisguy knows what he's doing, you
know.
And if we could just change theworkmanship of the implant
itself just a little bit, youknow, because he was hitting all
(29:42):
the hobbits.
He had the zygote, he wentaround and got your uh past the
tuberosity, and and he got uhmidpalatal suture.
I mean, he hit all the hot spotson that, and he had four
permecosal posts.
Uh so you know, there are somepeople out there designing, but
(30:02):
then you know, you've got allthese other countries with all
these other designers, and youknow, they're they've got an
engineer or a biotech kid that'sdoing it, and you know, they're
they're brilliant with thesoftware, they're brilliant with
their concept, they're brilliantwith their uh finite element
analysis, but you know, when itcomes back to what's
(30:25):
biologically compatible in thatpatient's mouth, yeah, what's
the tissue going to tolerate?
And then I guess that's thebiggest thing is you need to
have quality bone for this thingto resist the forces of
occlusion.
And you have to have qualitytissue to protect it, you know,
and then you've got to haveocclusion that's atraumatic.
(30:47):
So you have to be able to findsomebody who can do all that.
And unfortunately, I haven'tfound that person yet.
SPEAKER_01 (30:54):
Yeah, okay.
I'm curious too, right?
So, I mean, I'm thinking about,you know, what is good quality
bone for a patient that needssome maxillary subperiostal?
Like, how do you really assessthat?
I mean, these are very atrophicpeople, right?
I mean, it's not going to be thebest situation.
SPEAKER_00 (31:07):
You know, Nate spends over 24 hours doing a
design.
You know, I've probably spentfive or six hours picking out Z
points and you know, the zygoma,mid-palatal suture, and saying,
okay, here's where we're goingto load.
Okay.
But you know, I'm doing theviews through the lateral sinus
wall, I'm doing the viewsthrough the sinus, and I've got
(31:31):
you know 0.5 millimeter bone.
Well, that's not going to resistanything.
Yeah.
You know, I mean, the only uhhope you have is to spread that
load out.
But uh it there's not, I can'tgive you a black and white
answer.
It's going to be on a case bycase still.
And you know, what what are youputting on it for occlusion?
(31:51):
You know, uh, are you goinganatomic teeth?
Are you doing centric uh lineteeth?
Are you doing zirconia?
Are you doing a plastic teeth orPMMA teeth?
I mean, you know, there's a lotof factors to this.
And you know, I've been doing it35 years.
I don't have all the answers,especially when it comes to the
(32:11):
maxilla.
Yeah, if you want a mandibularsub, you know, I can I can say,
here's what you do, okay?
And here's what to look out for.
SPEAKER_02 (32:20):
So you're in your opinion, you think that if if
somebody's getting into youknow, some of the more difficult
maxillary cases, you first wouldwould do remote anchorage, um,
zygos, quad zygos, and save anykind of any kind of sub um
customized sub situation to likethe very the patient that even
(32:41):
that isn't gonna work for.
SPEAKER_00 (32:43):
So in my lectures, you know, it's funny, I I didn't
do palatal approach before 2020.
Okay.
So I learned palatal approachand it pissed me off because I
really enjoyed doing zygote.
SPEAKER_01 (32:54):
There's just so much super does so much you can do.
SPEAKER_00 (33:00):
And my zygote count went down like 90% from palatal
approach and transnasals andpteroids and stuff.
It's like, damn it, you know.
But with uh getting back, Imean, with these, you know, pick
your cases, you know, start outwith a with the mandible, you
(33:20):
know, and then you know, on themaxillas, just be extremely
careful, pick your patient, havea relationship with that person,
and and and be very honest.
Things could go south.
You know, I mean, I've got alady right now in my clinic that
was done by a very good surgeonin Arkansas and restored by very
good prostate honest inArkansas, and they've both been
(33:41):
very open, sent me everything,and she relocated to my area,
and she's got bilateral uhfistulus into the sinus.
Huge, huge exposure.
Uh food's getting up there,they're infected.
Uh, I've referred her out to anENT that I work with.
He's trying to get her cleanedup.
I've got an old surgeon, youknow.
(34:02):
My old surgeon's my next doorneighbor is a great guy.
And we're like, you know, howare we gonna fix this lady?
Because when this all comes out,she's obturator.
Yeah, and there's nothing tohold event, you know, and she's
in her 80s, her health isfailing, and it's horrible.
You know, so the devastationfrom these can be very, very
bad.
Yeah.
And, you know, so you ask me,you know, are zygos first
(34:26):
choice, uh, and these others.
I think that for the maxilla, Ithink the sub should be the last
choice.
And it uh you had it on yourwater, you think it's
controversial.
That's one of the things.
Because, you know, there's goingto be other people that say
zygos are wrought with withfailure and complications and
(34:47):
infection.
And yeah, I've had all thosemyself, you know, and and in
zygos, I respect, extremelyrespect those.
And I do realize there arecomplications.
But when a zygote goes south, Ifeel like the revision on that
is easier.
SPEAKER_01 (35:06):
Yeah.
SPEAKER_00 (35:07):
And in one of the threads we were talking about
subs this last two days, DanHoltzlaw comes in and he goes, I
got 22 references that supportzygos.
How many do you have thatsupport bacterial subperosteas?
And most of the case studiesthat I see that I've been able
to research, and I even got thehigh dollar to chat B G Turn
(35:31):
researching it, and it's likethey're two years, yeah, 26
months, 36 months.
And I got docs.
Well, I've got some out fiveyears.
I'm like, okay, let's see whatthey look like in 10 or 15.
Because you know, if you ownyour own practice and you stay
in business long, I mean it'slike I've been here 39 years,
and I literally have 30 plusyear old subs in my practice,
(35:52):
yeah, you know, and you know,you see this stuff come in again
and again.
You really don't want to seethis stuff going bad, and it's
not a practice builder, right?
And you know, I like to sleep atnight.
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