December 8, 2025 • 40 mins
A perfect snap-fit without a single screw will get any clinician’s heart racing—but what does that moment really mean ten years later? We take a hard look at custom subperiosteal implants and ask where they truly belong: why well-designed mandibular subs can solve brutal atrophy with durability, and why maxillary applications remain a minefield of thin bone, complex loading, and fragile claims. Along the way, we strip the shine from marketing slides and focus on what actually carries cases across the finish line—passivation, surface finishing, serviceable prosthetics, and designs that respect mucosa, biomechanics, and maintenance.
We walk through the real trade-offs between milling and DMLS, why the cheapest print can become the most expensive complication without proper finishing, and how remote frameworks, tripodial mandible designs, and meso bars distribute force where bone will accept it. We debate embedded MUAs versus removable, make the case for overdentures in extreme resorption, and share the uncomfortable truth about U.S. liability, FDA constraints, and evidence gaps that can leave clinicians exposed. Records and planning matter more than ever, and a multi-app digital pipeline only works when the data is precise and the clinician leads the design intent—not the other way around.
Credentials, community, and communication shape outcomes as much as titanium. From rescue stories to cautionary tales, we outline a professional path that prioritizes serviceability, hygiene, and legal defensibility while still embracing the progress that PSIs promise. If you’re weighing subs for your practice, this is the field guide you need: what to adopt now, what to delay, and how to prepare for the AI-enabled future without outsourcing your judgment. If this resonates, follow the show, share it with a colleague, and leave a review—then tell us: fixed or removable for the severely resorbed mandible, and why?
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:40):
My name is Dr.
Tyler Tolbert, and I'm Dr.
Soren Poppy.
And you're listening to the FixPodcast.
Your source for all thingsimplant dentistry.
I was just going to ask next,like if you are, if you are
looking to do a mandibular sub,right?
A patient that's super resorbedin the mandible, we can't do
root form implants, or if youdo, you know, they're coming out
the canines and you're gonnahave a huge cantilever.
(01:02):
What uh what are first stepsthat a doctor takes to get
proper education on um doing thesurgical side of subs?
And then what um labs or whatresources do you recommend for
the prosthetic side?
SPEAKER_04 (01:15):
So Root Lab is no longer taking new doctors for
subs, they're phasing out, andI'm sure it's probably uh
inherent to the legality of it.
They're not FDA approved.
They use FDA-approved alloys,but you know, that implant's not
FDA approved.
Uh, I do have another lab whereI have some retired employees
(01:37):
from Root Lab have lots ofexperience with uh subparol
skills that I've also put in mytwo cents on design, and you
know, they run it by me.
And I say, here, why don't we dothis or that?
Uh America's dental lab, butit's 100% analog.
You know, Nate Farley and I havebeen doing some digital designs,
(01:57):
uh, and we're working with somecompanies to uh do direct laser
metal centering.
Uh I like the milled ones.
Uh Ramsay MN has done two milledones with his lap tech.
Uh beautiful implant.
Uh the last one in particular, Iloved it.
And he had it where it wasfixed, attachable.
(02:17):
He could, you know, screw retainhis teeth on top of it.
Uh but you know, his labtechnician, I think it took him
24 hours to mill this thing.
And you know, I've spoken withseveral milling facilities, and
you know, you have to program itto mill this thing, and it's
just cost prohibitive formilling.
So direct laser metal centeringis definitely the way the most
(02:40):
cost-effective way, but then youcome up with a rougher product,
which has to be finished, andthen you know, then they come up
with well, what what are yougonna do?
You're gonna sandblast this,acid edge it.
Uh, you know, implants have tobe passivated.
Uh a lot of people don't evenknow that's a process.
They have to be passivated uh sothat they're biocompatible, uh,
(03:02):
have to have all the formmaterial and metals removed from
them.
So it's a process of acidwashing.
Uh Nate Farley does a beautifuljob.
He researched it, and he and Iprinted out a couple and
delivered uh both of them a fewmonths ago at one of the Full
Arch Masters, the firstsubcourse that we did at his
office in Phoenix.
Uh, you know, we'll probably runthat course again.
(03:25):
Uh I also teach for Orca.
I placed one last year uh as ademonstration surgery in the OR.
Uh, and it was great because wepopped this thing in, and it was
a cast chrome cobalt, uh cobaltchrome aluminum cast by America
Stenlab in Kansas.
And we snapped this thing in,and it just you could hear it
(03:48):
literally pop in.
I have no screws in it, and I'mpulling up on it, it won't come
out.
That's great.
Yeah.
And so everybody's like, yougotta have a bunch of screws in
these things, four inches vibe.
I literally put one screw in itjust to show people how to put a
screw in it.
It didn't need a screw, but JuanGonzalez is wandering around
like he is, you know, and Isaid, Juan, come take this
(04:09):
implant out.
And he starts pulling up on it,goes, I'm gonna break the jaw,
you know.
So I mean, these things can fitgreat, and screws are really
there just for primary stabilityon mandibular subs.
Yeah, and maxillary subs, it's adifferent game.
If you look at a PSI, you know,they're more in the analogy of
okay, this is what a bone platethat we use for fractures, and
(04:33):
oral surgeons understand.
Yeah, I've never I've neverplaced one in my life, okay.
I mean, I understand why theyuse them, and I think if I was
on a desert island and somebodyhad a broken jaw, I could
probably, you know, screw it uppretty bad, but get them back
together.
But you know, at what point doesthat technology and that
(04:55):
technique cross over to now I'mgonna put a strut on it attached
to it, do a permeacle as opposedto the MUA attached to it?
How does that orthopedic platefunction under load?
Okay, and how many screws in onemillimeter, half millimeter
(05:17):
thick membranous bone are gonnaresist occlusal loading?
Okay, and so when I hear peoplein the podium say it's titanium,
it's new technology, we've curedall the problems, all the old
PSI or plastic implants thatnever worked.
And this is this is great.
(05:39):
Come to my company, we're gonnamake an implant for you that
you're gonna live happily everafter.
It I think it's verydisingenuous because I don't
think we're there, especially onthe maxilla.
And a lot of the designs I seeon the mandible are very poor
designs.
You know, there's too much metaluh at the crest, there's too
(05:59):
much metal underneath themucosa, it's not remote enough
away from your mucosa.
And I think that uh, you know,call me old school.
I am, you know, I'm a boomer.
But I just think that we takewhat I gleaned from people
who've been doing it decadesbefore me and have peer-reviewed
published you know, studies onit and decades of successful
(06:25):
implementation of thesesubparalysteal implants and
bring a little bit of that intowhat we're doing today with PSI.
Don't just sweep it under thecarpet.
SPEAKER_01 (06:35):
Well, you know, I I think you know, you you uh kind
of jeer at yourself by saying,you know, I'm I'm a boomer,
right?
But I mean, as you said earlier,you've you know you've got
patients that have been inprostheses that you delivered
three decades ago.
And so your processes and yourplanning um clearly for quite
some time has been pretty sound.
I think something that'shappening with a lot of my
(06:56):
generation of full arch folks isthat we celebrate very quickly,
right?
I mean, it's literally like wewe go and make the post the same
day and we say, hey, we do thisnow.
But I, you know, I mean I did aquad zygo yesterday.
Do I say I I do quad zygos?
Well, I don't think I can reallysay that until I've got one
five, ten years out that's youknow, doing okay.
I can't say I do it because Idid it yesterday, you know.
SPEAKER_04 (07:15):
Well, yeah, you could do it.
You know, and then you know youguys keep trying to nail me
down.
I feel like a politician becauseI keep dodging your questions.
I've been an expert witness fordefense, and they try to nail
you down to yes or no.
And I'm always yes this or nothat, you know.
And and in and truly, that's theway it is with these implants.
(07:37):
Yes, this, no, that.
You know, what do you do in thisscenario?
It's all patient-specificimplementation.
There's not a black and white,there's just lots and lots of
area of gray.
Now, my hope for you guys andfor myself and dentistry is that
it becomes less gray and moreblack and white.
And I think we'll get there.
(07:59):
You know, the technology'simproving, printing of the
implants improving.
You know, we got to come up witha program to design these easy.
We can't do it easily withExacat.
We've got to take it throughthree or four different programs
to get what the result we want.
Uh, you know, I want to visitwith some of these foreign
designers and see what they'redoing, see if they've got
something better than what we'vegot.
(08:20):
But you know, you can't have aprostodont spending 24 hours
designing this thing and thenwanting to pay$5,000 for it.
Yeah.
Yeah.
You've got to be able todelegate this design technique
uh to a technician, you know.
Right.
And uh they're very expensive.
I mean, you know, uh peoplecomplain about the KLS price and
(08:41):
you know, being 20 grand, I seeit.
You know, I mean, you know, uh,we tried to start up a company,
we looked at uh FDA approval,got a consultant, and you know,
you're talking hundreds ofthousands of dollars just to get
the process started.
And you know, I'm like, I don'tneed this, you know.
(09:02):
So, you know, my thing is youknow to work with the doctors,
work with the companies, and tryto to to see what we can do to
to remedy the situation wherethere's not just one
FDA-approved implant in theUnited States.
Yeah, multiple.
And then you know, we neededucation nationally for the
(09:24):
doctors to understand it, but wehave to understand that all this
is going to be biased.
Some doctors are KLLs forcertain companies, some have a
uh you know a motive to this,you know, and and to me, I'm in
a point in my career where it'stime to pay it forward, you
know.
SPEAKER_01 (09:45):
Yeah, no, I mean I I can certainly appreciate that.
And I I think that, you know, uhas far as where you know these
uh customs will will fit intothe full arts world, is like,
you know, as we've stated manytimes, you know, the maxillary
stuff, it's it's it's as gray asgray could really be.
The mandibular stuff makes a lotof sense.
I see, I mean, I see patientsall the time where I think, man,
(10:05):
I don't have a solution for thisperson uh for their mandible,
and I don't have a lot of backupplans like we do in the Maxilla.
I know that a sub could reallywork, but at the same time, I
also understand that there'sjust not a whole lot of lab
options that really make a wholelot of economic sense for these
patients.
And I really do hope thatthat'll improve.
I do think certain advents thatwe're seeing will benefit that.
I think that one day, you know,you won't have anybody having
(10:27):
designed anything for 24 hoursbecause AI will be faster than
any of us ever could be, right?
Um, but we we do need the datato support that, right?
AI works off of data, and and Iappreciate that there's people
like yourself that you know havecases that have been in the
mouth for a long time.
You've been able to parse outsome of the you know tried and
true design aspects of these.
And hopefully uh we'll see, youknow, in the near future
(10:47):
mandibular subs at the veryleast becoming a more viable
option because there's there'sjust a huge, I think there is a
lot of opportunity for that.
There's a there's many patientsI've seen very recently that I
just told them I just don't havea solution for you.
I know it could work, but I Iit's not viable right now.
I can't do it for you, you know.
SPEAKER_04 (11:03):
Well, you know, and there are there are people
placing them and designing them,most of it's in Europe.
It's completely completelydifferent climate than it is
here in the States.
SPEAKER_03 (11:12):
Of course, yeah.
SPEAKER_04 (11:13):
We just need to really watch and really analyze
that design and really analyzethe data.
You've got to do a deep dive andsay, okay, what's your
definition of success?
You know, what what do youconsider a complication?
What do you consider a failure?
You know, uh, how many of thepatients had infections?
(11:33):
You know, how many of them didyou have to do revisions on?
What kind of revisions did youdo do?
You know, how many permecosalsites did you have?
How thick were they?
And one of the things that I'mworking with companies now is
like, okay, let's say we do adesign and and you want an MUA
coming out.
Well, the guys were having theMUA be part of the substructure
(11:55):
of the implant, okay?
So you you screw on yourzirconia or PMMA or tie bar or
whatever on top of it, and youhad the famous abutment screw
fracture inside your implant,and now you're trying to fish
that thing out and you can't getit out.
I've literally been in a coursewhere we put the implant in and
(12:16):
the MUA, we couldn't get theabutment screw to fit into it,
and it had been milled, youknow, and it's like okay.
You need to have a removable MUAto build your implant so that if
you do break the abutment screwsor what you can't.
(12:41):
And so, you know, one of thethings we're looking at is what
adding MUAs, removable genasobars, or that you need to ask
about.
And you know, uh I went to anIDS meeting in Germany in
Cologne and spoke to severalcompanies that are making them,
(13:02):
and it was amazing how manycompanies had their own sub
version of sub.
And you know, through thelanguage barrier talking to them
and stuff and and speaking aboutthese things, and then when you
say, wouldn't it be a good ideaif this was removable?
And you know, I'd get 10 reasonswhy no, it's not, you know, or
we can't do it or shouldn't doit or whatever.
(13:22):
And I'm like, Well, you're notpracticing dentistry like I do,
and see shit break, you know,and you know, you need to have a
back door on this stuff, and soit's little things like that
that you really it's that comesback, you don't know what you
don't know, you know, and sopeople want to do away with the
meso bar and go to MUA, but isit removable?
(13:44):
What happens if you break yourabutment screw?
What happens if one segment ofthe implant, if you've got it in
multiple pieces, becomesunbonded, unintegrated from the
bone, but it's say still in anice capsule and is functional.
You know, is that EMA going tohold your prosthes, or are you
(14:05):
gonna keep having abutmentscrews brain?
Right, you know, meso bar wouldhold all that together.
So on the mandible, thetripodial cell, world-famous
tripodal, it comes out of theramus, goes back into canine,
canine goes back into the ramus.
You've got wings here, you gotwings here, the meso bar holds
all three pieces apart, totallyavoids that molar region where
(14:28):
all the problems are.
Well, that meso bar serves afunction, you know.
So you really don't want to getaway from it just to go to MUAs.
SPEAKER_00 (14:38):
Can you is there can you not put MUAs on top of that
bar?
Exactly.
SPEAKER_04 (14:43):
That's what and I said that earlier.
I don't miss it, but yeah, we'reworking on MUAs on top of that.
SPEAKER_00 (14:49):
Okay.
SPEAKER_04 (14:50):
And you know, and even you can do it with MUAs
that are Nobel compliant, oreven put ball attachments on it
and go with an overdenture.
You know, and you also have toconsider what's the amount of
bone loss on a subpatient versusan AOX patient.
I mean, everybody's wanting todo FP1s now, you know?
(15:10):
And compare an FP1 patient to asubpatient who's got eight
millimeters, or like the one Idid in Guatemala, the ridge is
five millimeters tall.
I got 35 millimeters ofbilateral dehiscit nerves I got
exposed and uncovered.
And I mean, it's it's crazy.
So does that patient need afixed arch screw retained?
(15:34):
Or do they would they benefitfrom something they can remove
at home, get to it and cleanseit, and something that's got
some old rings, got someplastic, got some give to it,
that doesn't send all thatstress through your implant.
And so that was the rationale,because that's all we had back
then was over interest, but therationale was you know, get your
(15:57):
occlusion where it's nottraumatic, give plastic teeth
there, and you know, do o-ringattachments, don't screw it
down, so it has a little bit ofgive and plate to it, so you
don't overload this implant.
And so, you know, today it's apsi, it's bond of the bone.
I got 15 screws holding in.
We're gonna use 20 degree T.
(16:17):
We're gonna use zirconia, andyeah, the patient's never gonna
be able to take it out.
Maybe they'll come back and seethe hygienist once every year,
maybe they want, and hopefully,the soft tissue underneath that
subscription surviving.
SPEAKER_00 (16:29):
That's a lot of prayer.
A lot of miracles in one in onemouth.
SPEAKER_04 (16:35):
I mean, make this thing removable, they get to it,
and we didn't have sonicareswhen I started.
We had some company in BentonArkansas in uh Arkansas made
rhododenses, go around to it,and we used to have them use
that.
Sonic care came out, it's like aworld life changer, okay?
Yeah, you know, removableoverdicture.
(16:56):
Yeah, you know, just pop it on,pop it off, and then the buckle
flange helps protect the tissue,keep the food out.
It only comes out when thepatient pulls it out, right?
Yeah, I tell my students, andI'm like, overdinger is not a
problem for the patient, it'snot hard sell.
You first of all, you tell themthe benefits of it, and that
it's not gonna come out unlessyou take it out.
(17:17):
They don't have the problem withit.
People who have a problem withit is the dentist.
Yeah, and I'll be like, I've gota problem with it.
I don't want to do them becauseI can't make it my lab.
I gotta send it off to Kansas tomy guys, yeah, you know, and I
love working with them, they'regreat guys to work with, but
it's just a pain in the butt.
It'd be much easier to do MBA.
SPEAKER_01 (17:39):
Yeah, I think we're we're trying to hit a home run
where a single would do.
And I think you made a goodcomment about that patient in
Guatemala.
You know, does this personreally need screwed-in teeth?
I mean, this person has a fala,you know, does this point you
think they'd be happy just tohave teeth that last a long time
that have mitigated all theserisks?
Like, do they really need to befixed?
SPEAKER_04 (17:56):
Uh, you know, does it just put a sub with the Simon
O.
Uh, we did a uh analog design.
So it was waxed up, it waspulled off the model, it was
invested in cast, chrome cobaltballoon by the guys in uh
Kansas.
I played a little joke on him, Idid O and H in the front.
SPEAKER_03 (18:22):
He got a little nervous and he said, I can't put
that in the patient's head.
SPEAKER_04 (19:03):
So the measlebar was a little jacked up.
But it was we got it fixed, youknow.
And that's the where I say it'syou gotta get your prosthetics
right, you gotta get yourrecords to your lab right, and
it all has to be transposedright.
And that's where Nate Farleycomes in as a prosthetist.
I mean, this guy's records wereincredible.
(19:23):
He's like got the patient caughtand rolled, he's verified that
everything's seated, and thenhe's stitching everything in
Exocad, he's taking it over toBlender, he's taking it over to
mesh mixer, and I mean, the guyspends hours on these things.
I mean, his design should cost$20,000.
Yeah.
I mean, it's stupid.
SPEAKER_00 (19:45):
Um, I one one more question I have about about
subs, and you know, we've talkeda lot about how um, especially
like you know, younger doctorswho are just jumping into it,
they're they're going to theselectures and they're hearing
that you know the customized subis like the new best thing.
It's better than zygo's, betterthan this and that.
Um, and you know, you're you'repushing people uh away from
(20:06):
that, which makes total sense.
I another thing that I want tojust probably mention is
especially in in the US, andwe've talked about patients
being litigious, um, these subs,like they're if if something
happens to the patient, youknow, they there's nothing that
the doctor has a stand on,correct?
Like they're they're in in inhot water no matter what.
And and and and my understandingis that's in the mandibular subs
(20:29):
as well, correct?
SPEAKER_04 (20:31):
Yeah, well, I mean, yes, I mean there is there is
literature review, albeit old,that shows a high success rate
with properly made mandibularsubs with the proper occlusion.
You know, I can get youliterature review on that, okay?
I get you a study or two on themaxillary subs showing the
success rates on that, you know.
(20:51):
But current literature onlong-term success rate of these
new implants is just not, Idon't, I wouldn't feel
comfortable.
Put it this way (21:00):
I wouldn't want to be your defense expert and
tell you you're gonna win.
It's gonna be a lot easier to bethe plaintiff's expert and just
crucify you on the stand.
Like, how many of these done?
And where'd you learn to dothis?
And where's your loop?
And where's you know, where'swhere's the studies?
Where's all this stuff?
It's not gonna be there, youknow.
(21:21):
Is it FDA approved?
It's not, unless it's KLS.
And I'm not a fan of theirdesign at all.
So, you know, when I was yourage, you know, very aggressive,
trying to do all the latest andgreatest and newest stuff, and
I'm still pretty aggressive, youknow.
I mean, I'm a boomer and I'm100% digital.
I got a lab upstairs.
(21:42):
But my old mentor, Dr.
Joe, and he used to he's in themiddle of nowhere, Arkansas.
He used to say something on thelook on the podium.
He'd have people internationalcome in to hear him because he
was such a brilliant man.
And he said, I'm from Wynn,Arkansas.
You can't get there from here.
Okay.
I mean, yeah, he's in the middleof nowhere, but you literally
(22:04):
can't get there from whereyou're at now, you know.
Yeah, yeah.
But he would say, you know, thecutting edge, the sword of the
cutting edge cuts both ways, youknow.
So you know, you can be on thecutting edge, the leading edge
of technology, but realize youcan also get cut from that
leading edge.
Sure.
Just be prepared for that.
So, you know, my thing is is youknow, work closely with and have
(22:29):
a good community wherever youare, ENT, oral surgeon,
prostodontist, periodontists,whoever you have, to work with
Yoniks and don't just do thisfly by nine.
SPEAKER_02 (22:41):
Yeah.
SPEAKER_04 (22:42):
You know, and understand that you have to have
a relationship with thatpatient.
And that's the beautiful thingabout practice in Arkansas.
I mean, everybody's like, youknow, practice in Arkansas.
I mean, I got 3.3 million peoplein the entire state.
I have to market two-thirds ofthe state to get enough
patients.
Okay.
And I literally have patientsdrive hours to get here, you
(23:04):
know, and now with the internetand Google uh location, and it's
it's it's a nightmare marketing,you know, just these patients
and stuff.
But you know, you you deal withthese practices, and you I'm
getting losing my train ofthought here, guys.
SPEAKER_01 (23:20):
No, no, you're fine.
Um, yeah, I mean, something thatyou were kind of alluding to,
you know, when consideringgetting into this, and you know,
I think about it a lot is youkind of you know, you have to
really ask yourself uh why it isthat you would want to do this,
right?
SPEAKER_04 (23:33):
I guess that you got me back.
So my thing is have a community,have a relationship with the
patient, and you know, you'vegot to be able to let them know
that things can happen, butyou're there for them.
And you know, I have a littlesaying with my patients, we're
like the Marines here, we don'tleave anybody behind.
And even if it costs me money,I'll redo the case.
(23:56):
And you know, my thing is yougot to come in for recall and
you got to be responsible andyou got to do what we tell you
to do.
If you go away two, three, four,five years, you're done.
I mean, you own it, okay?
But if I've got a patient'scoming in every six months for
recall, even if they're outfive, ten years, I mean, I'm not
sure as hell not charging thefull fee.
And most of the time it's we'refriends, and you know, the
(24:18):
wife's bringing us browniesevery Christmas or something,
and you know, the wonderfulthing about practicing in a
state like Arkansas is thementality of the patient is not
so adversarial.
And you know, don't trust me,we've got lawyers and we all get
thumped, okay?
But especially back when I gotstarted, it wasn't as much of a
(24:42):
problem.
And you know, uh that's one ofthe things I empathize with you
guys that are in bigger states,bigger cities, with more
competition, more people tryingto pull the rug out from you.
And that's why I encouragepeople go get your fellow, go
get your ABOI, you know, and uh,you know, I have not had to go
(25:02):
to court.
I have had some records calledfor, and you know, people this
and that, but I've neversuccessfully been litigated and
sued.
Um I'll go when I say that, butI've been an expert witness, and
you know, they start saying,Well, he's a fellow of this and
diplomate of this and that, andyou know, even if it doesn't
(25:22):
mean anything to the royalsurgeon down the street from
you, it means something to thejury, okay, that you've done an
extra step.
And I'm not saying go out andget bogus credentials from you
know organizations that don'tactually test you and see what
you really do know, but get bonafide credentials, be proud of
(25:44):
them, and promote them, youknow, and they can come back and
they can help you.
I really feel like they can be,you know.
So if you're gonna do theseimplants, dot your I's, cross
your T's, have a community, havecredentials, have doctors that
are in your corner that you cango explain to.
I mean, uh, I told you guyslater, I mean, earlier today,
(26:05):
the complication for thepterygoid in Dan Heltz Claw's
book.
Infratemporal faucet.
That's me.
One of my first ones.
Yeah, I'm that guy.
SPEAKER_01 (26:15):
I was wondering if you're gonna say this on that.
SPEAKER_04 (26:18):
Hey, behavior.com.
I'm like, you're really gonna doI'll make you contributing
after.
I said, No, you can leave myname out of that one, you know.
All the adopts said, this canhappen to anybody.
I'm 30 plus years in my career,and you know, I'm I'm like,
Yeah, okay, I've seen this, Iunderstand the concept, I got
this, and I screwed it up, andit's in the infratum for fossa.
(26:43):
And you know what?
I go across the yard to my nextdoor neighbor who's moral
surgeon, and I'm like, headdown, and he's like, dude, it's
not a big deal.
I put thirds there all the time.
We got you.
Come back to my office in twoweeks, we'll get it out.
We had out five minutes, it wasa non-issue.
Told the patient immediately shehad a few little moments of
(27:05):
trismus.
It wasn't a major complication,but it could have been a really
big issue.
But if I'm a young doctor andI've got this massive bilateral
orental fistula and this failingimplant on an 80-year-old who's
gonna have to go to thehospital, go to the ENT,
probably gonna have to go to anoncological ENT and get a bone
(27:26):
graph, a flap graph, to restoremaxilla obturator.
It's a big deal.
Yeah, and I wouldn't want tohave to defend that.
You know, so yeah, there's sometrophies to get on your walls,
and there's some trophies to letsome of the people that can take
the risk and tolerate the risk.
Maybe this needs to be done ininstitutions, maybe this needs
(27:48):
to be done in foreign countries,and you know, let's get some
studies out and see where it'sat.
But yeah, I don't have all theanswers for you on the maximum.
I mean, I can tell you what todo on a mandible all day long.
But I think I know what I woulddo, but I've been 39 years and
I've only done demonstrations ofuh surgeries on other people's
(28:10):
patients.
SPEAKER_01 (28:11):
That says something.
SPEAKER_03 (28:14):
Not in your house.
Not in my house.
SPEAKER_01 (28:17):
Yeah, I mean it yeah, and I think that really I
mean it goes back to um kind ofwhat I was saying earlier, and
it that lent to your point aswell.
Is you know, you you have to askyourself, you know, why are you
interested in doing this?
Like what is really the point?
What are you after?
You know.
SPEAKER_04 (28:32):
So John Minochetti, AAID past president 10 in his
study.
He's reporting on A.
Codings, 100% success right now.
What's his definition ofsuccess?
I don't know.
He wasn't in there, you know.
Uh Arthur Mosin, another AAIDpast president.
Uh, I used some slides for him.
I said, Art, give me some oldsubslides.
(28:52):
I don't have any Max Larry subs.
Do you?
He goes, Oh shit.
I mean, that's what he said.
He goes, Oh shit.
Yeah, I did.
How'd it go?
Well, he said, I got one thatlasted 20 years.
And so we we put that one up,you know, and what do you think
he did?
It took it out and he put inquad zygot.
Yeah, you know, but how long arequad zygo cases gonna last now?
(29:15):
How long is my AOX gonna lastnow?
You know, I mean, when I gotinto this, Mish, we had
everything between the middleframe was A, B, C, D, E, five
implants.
And depending on whether you didthree, five, two, whatever, you
had locations for it, youconnected it with the meso bar,
you did an overdensure on it.
(29:36):
And then poly mola comes out andblows everything up.
And you know, we start doingAOX, and I never looked back.
Early, early adopter, you know.
And I remember I was in myactual ABOI board examination,
and there was a doctor fromKentucky, Sharon, I believe, the
(29:57):
he was a GP, and he was one ofthe first people, and he and his
partner, the Paradonist, wereteaching for Nobel, were some of
the first people, and he wastelling me what he was doing.
I'm like, you lost your mind.
You know, these are tiltedimplants, you can't load these
off axis because that was thebig thing back then.
And then when you get thinkingabout all your lateral incisors
(30:18):
and centrals and stuff, that'sall loaded off axis.
SPEAKER_02 (30:21):
Yeah.
SPEAKER_04 (30:22):
And you know, I mean, and that's what I'm
saying.
Be a student of your trade, ofyour craft, be an expert in all
aspects of it, you know.
So with these subs, don't justlet somebody blindly say, Yeah,
these works call.
Joe's Dental Lab over here, orJoe's manufacturing facility
(30:43):
over here, they've got this19-year-old from Italy that's
going to design it, or thisother 19-year-old from Portugal
that's going to design it, andit's all going to be great.
Kumbaya.
SPEAKER_02 (30:54):
Yeah.
SPEAKER_04 (30:55):
You need to be the doctor.
Same reason I don't like guides.
And I gave a lot of students,you know, that were taking their
exams and said, tell me aboutyour design on your guide.
Well, send it to the lab.
Okay.
Well, they sent it back and Itold them that it was okay.
And you know, to me, you know, Iwas, I did like 10 guides with
(31:18):
teeth in an hour when it firstcame out.
We did our first guided surgeryon TV in like 55 minutes.
Okay.
I designed those guides.
They were printed in Sweden andsent over.
Okay.
But if you're going to doguides, you need to understand
and you need to be very muchinto that.
If you're going to dosub-implants, you need to know
(31:38):
the uh the design.
You need to be able to tell thattechnician, no, we need to come
a little more interior with thatstrut.
Uh we need to put thepermeocosal post here.
Uh the substructure needs to bea little thinner, a little more
delicate.
You know, and the answers I'vebeen looking at, and I've done
some very sophisticated AIresearch on, you know, is how
(32:01):
thin can we go with titanium andit not break.
You know, and another greatthing that Dr.
Liljohn used to say isstatistics don't lie, but liars
use statistics.
Okay.
And I'm gonna I'm gonna updateit and I'm gonna say AI, or
excuse me, finite elementanalysis doesn't lie, but liars
(32:24):
use finite element analysis tojustify what they're doing, you
know?
And I've never had asubparalisteal implant break.
Now I've got a ton of examplesfrom the 70s that they had
casting defects and this andthat.
And of course, it's a harder allof it, cobalt chrome aluminum.
How thick does titanium have tobe to survive?
(32:47):
And if you use these protectedocclusal schemes that I'm
promoting here, you know, doesit really have to be as thick as
they are?
You know, so there's a lot ofthings that's gonna be really
interesting to see the next fiveand ten years how it pans out.
But I do think PSIs are here touh to stay.
(33:09):
I think they have their place.
I think that it's wonderful thatthey're coming back, but I just
want to promote a cautionarystill tell, especially if you're
early on in your career.
Yeah, you know, I'm gonna have alot better, easier time
defending myself and gettingcooperative care from other
(33:31):
specialists than a young surgeonis who's just trying to make a
name for himself.
SPEAKER_01 (33:37):
Yeah, I mean, I think that you know, sometimes
on the show when we, you know,talk about uh maybe this isn't
avant-garde, but when we starttalking about more exotic types
of implant treatment, peoplewant to listen to it so they can
learn how to do it.
Um, but you know, maybe that'snot the most valuable thing you
can come away with.
Maybe it's a lot of good reasonsnot to do it and just wait on
it, learn more, take your time,get your credentials right, and
(33:59):
and do it maybe when the time isright, when it's appropriate.
Um, but there's there's plentyof work to be done, short of
getting into these gray areasand doing you know people want
to know.
SPEAKER_04 (34:09):
I mean, literally, I was going to Nate's office to
help him put in a sub, and Ryanhad this maxillary sub, and the
patient's sick, we can't get itin.
Uh, we think she's not gonnamake it, but uh, we're gonna put
in two subs.
But then one of the oralsurgeons says, Hey man, I got
one I needed to have done.
I was like, Well, there's threesubs.
It's like Ryan, you need to do acourse.
(34:30):
Yeah, so he literally put itonline, and within a day and a
half, it was full.
Wow.
Okay.
And everybody came to Phoenixtonight, it's got a great
facility, and we had closecircuit TV, and you know, we we
put in two of the three that wehad scheduled, and it was great.
And like Orca, you know, there'sa need and there's a want, but
(34:55):
it's the ability to get thepatients to the residents, to
get the records, to get thedesigns, and they've even got
manufacturers that will donate.
I've got two right now that willjump right in the middle of
this.
And so, you know, we're intalks, or Simon and them are in
talks.
I'm not part of the board there,but you know, there's been
(35:15):
discussion of bringingsubairoster course to ORCA.
Okay.
You know, but you guys thatwatching the podcast, it's going
to be the same message there,and it was the same message at
Full Archmasters.
There's safe things to do, andthere's not some there's not
proven things to do yet.
Just see where you are in yourcareer and how much risk are you
(35:39):
willing to assume for aparticular patient.
You know, if you're your mom ordad or aunt or uncle, you know,
or sister or whatever, then youknow, you can assume more risk.
But uh, yeah, if it's a full feepaying patient that you have no
connection with, you need to bevery careful.
Yeah.
SPEAKER_01 (35:59):
Yeah.
No, that that makes a lot ofsense.
Well, well, Dr.
Jerry, uh, you know, we have uhcovered you know decades of of
learning in the uh world ofCSIs, PSIs, um, and and learned
so much from your experience.
And uh, you know, I'm leavingwith more questions than
answers, I think, in a very goodway.
I have a lot more that I need tolearn um about this modality,
(36:22):
and uh, I really appreciate youspending the time to come on and
and talk about it.
You know, I was just curious ifyou had any other you know,
closing thoughts or encouraginguh sentiments for you know other
full art surgeons out here,anyone listening to the podcast
that might be interested umlearning more about your work or
whatever else that it is thatyou do with Orca and all those
good things.
SPEAKER_04 (36:39):
Well, uh, you know, I'm I'm available, uh, I'm on a
lot of uh different threads andstuff, but uh I'm more than
willing to look at some thingsand and help point people in the
right directions, hopefully.
Uh, you know, uh there are otherdoctors that have done this.
Dr.
Picos, I know he's done 200.
I think he and I are gonna dosomething.
(37:00):
We're gonna be speaking at theupcoming Orca Symposium in Las
Vegas in January.
Be there.
Yeah.
Okay.
Thank you.
Uh, you know, uh Ramsey Amin hasdone several subs.
He's I think speaking at the AIDmeeting uh that's coming up in
November.
I don't know what the topic ison that or what what he's
(37:22):
covering, but uh we're if he'sgonna go in the PSIs or what,
but he's got some materialthere.
And you know, we're looking totry to bring this more to uh you
know to to the pup to the otherto the dentist group, you know,
one group or the other.
And you know, I don't have alecture facility or
(37:44):
organization.
Uh I'm a heart gun.
You know, I mean I I enjoy doingthis.
I don't need to run the show.
Uh I I love giving back.
I love being with the young docsand and and meeting new people
and making the connections.
And you know, uh just uh keep onFacebook, look at your Orca,
(38:05):
look at your Full Archmasters,Adam Hogan.
He may do something with hisstuff, you know.
Uh I've even been in talks withMaud Institute, you know, we may
do something with these guys.
So there's lots of good learningopportunities.
Vichy Berman uh has done anumber of subs, and his uh
experience with the PSIs is morethan mine.
(38:28):
And again, you know, he's he'sthe expert of experts, KOL.
Uh he can weather the storms ofthe failures, and you know,
let's see what happens with thework that Vichy.
But you know, he and I worked inthe past very closely on
designs.
Even he and I and Nate have donesome implants together.
You know, that that's how we allgot tied up together.
(38:48):
Nate had a patient that neededan implant, and so we we did
that.
But uh I wish I had betterresources we did that, but uh I
wish I had the orca uh just foreverybody.
But uh, you know, come to Ramseyand uh we'll get some
information.
We'll I'm sure there'll be acourse come up and we'll get the
information out there andeverybody comes come see us.
SPEAKER_01 (39:57):
Yes, sir.
Well we appreciate your time.
Thank you so much.
My name is Dr.
Tyler Tolbert, and I'm Dr.
Soren Poppy.
And you're listening to the FixPodcast.
Your source for all thingsimplant dentistry.
I was just going to ask next,like if you are, if you are
looking to do a mandibular sub,right?
A patient that's super resorbedin the mandible, we can't do
root form implants, or if youdo, you know, they're coming out
the canines and you're gonnahave a huge cantilever.
(01:02):
What uh what are first stepsthat a doctor takes to get
proper education on um doing thesurgical side of subs?
And then what um labs or whatresources do you recommend for
the prosthetic side?
SPEAKER_04 (01:15):
So Root Lab is no longer taking new doctors for
subs, they're phasing out, andI'm sure it's probably uh
inherent to the legality of it.
They're not FDA approved.
They use FDA-approved alloys,but you know, that implant's not
FDA approved.
Uh, I do have another lab whereI have some retired employees
(01:37):
from Root Lab have lots ofexperience with uh subparol
skills that I've also put in mytwo cents on design, and you
know, they run it by me.
And I say, here, why don't we dothis or that?
Uh America's dental lab, butit's 100% analog.
You know, Nate Farley and I havebeen doing some digital designs,
(01:57):
uh, and we're working with somecompanies to uh do direct laser
metal centering.
Uh I like the milled ones.
Uh Ramsay MN has done two milledones with his lap tech.
Uh beautiful implant.
Uh the last one in particular, Iloved it.
And he had it where it wasfixed, attachable.
(02:17):
He could, you know, screw retainhis teeth on top of it.
Uh but you know, his labtechnician, I think it took him
24 hours to mill this thing.
And you know, I've spoken withseveral milling facilities, and
you know, you have to program itto mill this thing, and it's
just cost prohibitive formilling.
So direct laser metal centeringis definitely the way the most
(02:40):
cost-effective way, but then youcome up with a rougher product,
which has to be finished, andthen you know, then they come up
with well, what what are yougonna do?
You're gonna sandblast this,acid edge it.
Uh, you know, implants have tobe passivated.
Uh a lot of people don't evenknow that's a process.
They have to be passivated uh sothat they're biocompatible, uh,
(03:02):
have to have all the formmaterial and metals removed from
them.
So it's a process of acidwashing.
Uh Nate Farley does a beautifuljob.
He researched it, and he and Iprinted out a couple and
delivered uh both of them a fewmonths ago at one of the Full
Arch Masters, the firstsubcourse that we did at his
office in Phoenix.
Uh, you know, we'll probably runthat course again.
(03:25):
Uh I also teach for Orca.
I placed one last year uh as ademonstration surgery in the OR.
Uh, and it was great because wepopped this thing in, and it was
a cast chrome cobalt, uh cobaltchrome aluminum cast by America
Stenlab in Kansas.
And we snapped this thing in,and it just you could hear it
(03:48):
literally pop in.
I have no screws in it, and I'mpulling up on it, it won't come
out.
That's great.
Yeah.
And so everybody's like, yougotta have a bunch of screws in
these things, four inches vibe.
I literally put one screw in itjust to show people how to put a
screw in it.
It didn't need a screw, but JuanGonzalez is wandering around
like he is, you know, and Isaid, Juan, come take this
(04:09):
implant out.
And he starts pulling up on it,goes, I'm gonna break the jaw,
you know.
So I mean, these things can fitgreat, and screws are really
there just for primary stabilityon mandibular subs.
Yeah, and maxillary subs, it's adifferent game.
If you look at a PSI, you know,they're more in the analogy of
okay, this is what a bone platethat we use for fractures, and
(04:33):
oral surgeons understand.
Yeah, I've never I've neverplaced one in my life, okay.
I mean, I understand why theyuse them, and I think if I was
on a desert island and somebodyhad a broken jaw, I could
probably, you know, screw it uppretty bad, but get them back
together.
But you know, at what point doesthat technology and that
(04:55):
technique cross over to now I'mgonna put a strut on it attached
to it, do a permeacle as opposedto the MUA attached to it?
How does that orthopedic platefunction under load?
Okay, and how many screws in onemillimeter, half millimeter
(05:17):
thick membranous bone are gonnaresist occlusal loading?
Okay, and so when I hear peoplein the podium say it's titanium,
it's new technology, we've curedall the problems, all the old
PSI or plastic implants thatnever worked.
And this is this is great.
(05:39):
Come to my company, we're gonnamake an implant for you that
you're gonna live happily everafter.
It I think it's verydisingenuous because I don't
think we're there, especially onthe maxilla.
And a lot of the designs I seeon the mandible are very poor
designs.
You know, there's too much metaluh at the crest, there's too
(05:59):
much metal underneath themucosa, it's not remote enough
away from your mucosa.
And I think that uh, you know,call me old school.
I am, you know, I'm a boomer.
But I just think that we takewhat I gleaned from people
who've been doing it decadesbefore me and have peer-reviewed
published you know, studies onit and decades of successful
(06:25):
implementation of thesesubparalysteal implants and
bring a little bit of that intowhat we're doing today with PSI.
Don't just sweep it under thecarpet.
SPEAKER_01 (06:35):
Well, you know, I I think you know, you you uh kind
of jeer at yourself by saying,you know, I'm I'm a boomer,
right?
But I mean, as you said earlier,you've you know you've got
patients that have been inprostheses that you delivered
three decades ago.
And so your processes and yourplanning um clearly for quite
some time has been pretty sound.
I think something that'shappening with a lot of my
(06:56):
generation of full arch folks isthat we celebrate very quickly,
right?
I mean, it's literally like wewe go and make the post the same
day and we say, hey, we do thisnow.
But I, you know, I mean I did aquad zygo yesterday.
Do I say I I do quad zygos?
Well, I don't think I can reallysay that until I've got one
five, ten years out that's youknow, doing okay.
I can't say I do it because Idid it yesterday, you know.
SPEAKER_04 (07:15):
Well, yeah, you could do it.
You know, and then you know youguys keep trying to nail me
down.
I feel like a politician becauseI keep dodging your questions.
I've been an expert witness fordefense, and they try to nail
you down to yes or no.
And I'm always yes this or nothat, you know.
And and in and truly, that's theway it is with these implants.
(07:37):
Yes, this, no, that.
You know, what do you do in thisscenario?
It's all patient-specificimplementation.
There's not a black and white,there's just lots and lots of
area of gray.
Now, my hope for you guys andfor myself and dentistry is that
it becomes less gray and moreblack and white.
And I think we'll get there.
(07:59):
You know, the technology'simproving, printing of the
implants improving.
You know, we got to come up witha program to design these easy.
We can't do it easily withExacat.
We've got to take it throughthree or four different programs
to get what the result we want.
Uh, you know, I want to visitwith some of these foreign
designers and see what they'redoing, see if they've got
something better than what we'vegot.
(08:20):
But you know, you can't have aprostodont spending 24 hours
designing this thing and thenwanting to pay$5,000 for it.
Yeah.
Yeah.
You've got to be able todelegate this design technique
uh to a technician, you know.
Right.
And uh they're very expensive.
I mean, you know, uh peoplecomplain about the KLS price and
(08:41):
you know, being 20 grand, I seeit.
You know, I mean, you know, uh,we tried to start up a company,
we looked at uh FDA approval,got a consultant, and you know,
you're talking hundreds ofthousands of dollars just to get
the process started.
And you know, I'm like, I don'tneed this, you know.
(09:02):
So, you know, my thing is youknow to work with the doctors,
work with the companies, and tryto to to see what we can do to
to remedy the situation wherethere's not just one
FDA-approved implant in theUnited States.
Yeah, multiple.
And then you know, we neededucation nationally for the
(09:24):
doctors to understand it, but wehave to understand that all this
is going to be biased.
Some doctors are KLLs forcertain companies, some have a
uh you know a motive to this,you know, and and to me, I'm in
a point in my career where it'stime to pay it forward, you
know.
SPEAKER_01 (09:45):
Yeah, no, I mean I I can certainly appreciate that.
And I I think that, you know, uhas far as where you know these
uh customs will will fit intothe full arts world, is like,
you know, as we've stated manytimes, you know, the maxillary
stuff, it's it's it's as gray asgray could really be.
The mandibular stuff makes a lotof sense.
I see, I mean, I see patientsall the time where I think, man,
(10:05):
I don't have a solution for thisperson uh for their mandible,
and I don't have a lot of backupplans like we do in the Maxilla.
I know that a sub could reallywork, but at the same time, I
also understand that there'sjust not a whole lot of lab
options that really make a wholelot of economic sense for these
patients.
And I really do hope thatthat'll improve.
I do think certain advents thatwe're seeing will benefit that.
I think that one day, you know,you won't have anybody having
(10:27):
designed anything for 24 hoursbecause AI will be faster than
any of us ever could be, right?
Um, but we we do need the datato support that, right?
AI works off of data, and and Iappreciate that there's people
like yourself that you know havecases that have been in the
mouth for a long time.
You've been able to parse outsome of the you know tried and
true design aspects of these.
And hopefully uh we'll see, youknow, in the near future
(10:47):
mandibular subs at the veryleast becoming a more viable
option because there's there'sjust a huge, I think there is a
lot of opportunity for that.
There's a there's many patientsI've seen very recently that I
just told them I just don't havea solution for you.
I know it could work, but I Iit's not viable right now.
I can't do it for you, you know.
SPEAKER_04 (11:03):
Well, you know, and there are there are people
placing them and designing them,most of it's in Europe.
It's completely completelydifferent climate than it is
here in the States.
SPEAKER_03 (11:12):
Of course, yeah.
SPEAKER_04 (11:13):
We just need to really watch and really analyze
that design and really analyzethe data.
You've got to do a deep dive andsay, okay, what's your
definition of success?
You know, what what do youconsider a complication?
What do you consider a failure?
You know, uh, how many of thepatients had infections?
(11:33):
You know, how many of them didyou have to do revisions on?
What kind of revisions did youdo do?
You know, how many permecosalsites did you have?
How thick were they?
And one of the things that I'mworking with companies now is
like, okay, let's say we do adesign and and you want an MUA
coming out.
Well, the guys were having theMUA be part of the substructure
(11:55):
of the implant, okay?
So you you screw on yourzirconia or PMMA or tie bar or
whatever on top of it, and youhad the famous abutment screw
fracture inside your implant,and now you're trying to fish
that thing out and you can't getit out.
I've literally been in a coursewhere we put the implant in and
(12:16):
the MUA, we couldn't get theabutment screw to fit into it,
and it had been milled, youknow, and it's like okay.
You need to have a removable MUAto build your implant so that if
you do break the abutment screwsor what you can't.
(12:41):
And so, you know, one of thethings we're looking at is what
adding MUAs, removable genasobars, or that you need to ask
about.
And you know, uh I went to anIDS meeting in Germany in
Cologne and spoke to severalcompanies that are making them,
(13:02):
and it was amazing how manycompanies had their own sub
version of sub.
And you know, through thelanguage barrier talking to them
and stuff and and speaking aboutthese things, and then when you
say, wouldn't it be a good ideaif this was removable?
And you know, I'd get 10 reasonswhy no, it's not, you know, or
we can't do it or shouldn't doit or whatever.
(13:22):
And I'm like, Well, you're notpracticing dentistry like I do,
and see shit break, you know,and you know, you need to have a
back door on this stuff, and soit's little things like that
that you really it's that comesback, you don't know what you
don't know, you know, and sopeople want to do away with the
meso bar and go to MUA, but isit removable?
(13:44):
What happens if you break yourabutment screw?
What happens if one segment ofthe implant, if you've got it in
multiple pieces, becomesunbonded, unintegrated from the
bone, but it's say still in anice capsule and is functional.
You know, is that EMA going tohold your prosthes, or are you
(14:05):
gonna keep having abutmentscrews brain?
Right, you know, meso bar wouldhold all that together.
So on the mandible, thetripodial cell, world-famous
tripodal, it comes out of theramus, goes back into canine,
canine goes back into the ramus.
You've got wings here, you gotwings here, the meso bar holds
all three pieces apart, totallyavoids that molar region where
(14:28):
all the problems are.
Well, that meso bar serves afunction, you know.
So you really don't want to getaway from it just to go to MUAs.
SPEAKER_00 (14:38):
Can you is there can you not put MUAs on top of that
bar?
Exactly.
SPEAKER_04 (14:43):
That's what and I said that earlier.
I don't miss it, but yeah, we'reworking on MUAs on top of that.
SPEAKER_00 (14:49):
Okay.
SPEAKER_04 (14:50):
And you know, and even you can do it with MUAs
that are Nobel compliant, oreven put ball attachments on it
and go with an overdenture.
You know, and you also have toconsider what's the amount of
bone loss on a subpatient versusan AOX patient.
I mean, everybody's wanting todo FP1s now, you know?
(15:10):
And compare an FP1 patient to asubpatient who's got eight
millimeters, or like the one Idid in Guatemala, the ridge is
five millimeters tall.
I got 35 millimeters ofbilateral dehiscit nerves I got
exposed and uncovered.
And I mean, it's it's crazy.
So does that patient need afixed arch screw retained?
(15:34):
Or do they would they benefitfrom something they can remove
at home, get to it and cleanseit, and something that's got
some old rings, got someplastic, got some give to it,
that doesn't send all thatstress through your implant.
And so that was the rationale,because that's all we had back
then was over interest, but therationale was you know, get your
(15:57):
occlusion where it's nottraumatic, give plastic teeth
there, and you know, do o-ringattachments, don't screw it
down, so it has a little bit ofgive and plate to it, so you
don't overload this implant.
And so, you know, today it's apsi, it's bond of the bone.
I got 15 screws holding in.
We're gonna use 20 degree T.
(16:17):
We're gonna use zirconia, andyeah, the patient's never gonna
be able to take it out.
Maybe they'll come back and seethe hygienist once every year,
maybe they want, and hopefully,the soft tissue underneath that
subscription surviving.
SPEAKER_00 (16:29):
That's a lot of prayer.
A lot of miracles in one in onemouth.
SPEAKER_04 (16:35):
I mean, make this thing removable, they get to it,
and we didn't have sonicareswhen I started.
We had some company in BentonArkansas in uh Arkansas made
rhododenses, go around to it,and we used to have them use
that.
Sonic care came out, it's like aworld life changer, okay?
Yeah, you know, removableoverdicture.
(16:56):
Yeah, you know, just pop it on,pop it off, and then the buckle
flange helps protect the tissue,keep the food out.
It only comes out when thepatient pulls it out, right?
Yeah, I tell my students, andI'm like, overdinger is not a
problem for the patient, it'snot hard sell.
You first of all, you tell themthe benefits of it, and that
it's not gonna come out unlessyou take it out.
(17:17):
They don't have the problem withit.
People who have a problem withit is the dentist.
Yeah, and I'll be like, I've gota problem with it.
I don't want to do them becauseI can't make it my lab.
I gotta send it off to Kansas tomy guys, yeah, you know, and I
love working with them, they'regreat guys to work with, but
it's just a pain in the butt.
It'd be much easier to do MBA.
SPEAKER_01 (17:39):
Yeah, I think we're we're trying to hit a home run
where a single would do.
And I think you made a goodcomment about that patient in
Guatemala.
You know, does this personreally need screwed-in teeth?
I mean, this person has a fala,you know, does this point you
think they'd be happy just tohave teeth that last a long time
that have mitigated all theserisks?
Like, do they really need to befixed?
SPEAKER_04 (17:56):
Uh, you know, does it just put a sub with the Simon
O.
Uh, we did a uh analog design.
So it was waxed up, it waspulled off the model, it was
invested in cast, chrome cobaltballoon by the guys in uh
Kansas.
I played a little joke on him, Idid O and H in the front.
SPEAKER_03 (18:22):
He got a little nervous and he said, I can't put
that in the patient's head.
SPEAKER_04 (19:03):
So the measlebar was a little jacked up.
But it was we got it fixed, youknow.
And that's the where I say it'syou gotta get your prosthetics
right, you gotta get yourrecords to your lab right, and
it all has to be transposedright.
And that's where Nate Farleycomes in as a prosthetist.
I mean, this guy's records wereincredible.
(19:23):
He's like got the patient caughtand rolled, he's verified that
everything's seated, and thenhe's stitching everything in
Exocad, he's taking it over toBlender, he's taking it over to
mesh mixer, and I mean, the guyspends hours on these things.
I mean, his design should cost$20,000.
Yeah.
I mean, it's stupid.
SPEAKER_00 (19:45):
Um, I one one more question I have about about
subs, and you know, we've talkeda lot about how um, especially
like you know, younger doctorswho are just jumping into it,
they're they're going to theselectures and they're hearing
that you know the customized subis like the new best thing.
It's better than zygo's, betterthan this and that.
Um, and you know, you're you'repushing people uh away from
(20:06):
that, which makes total sense.
I another thing that I want tojust probably mention is
especially in in the US, andwe've talked about patients
being litigious, um, these subs,like they're if if something
happens to the patient, youknow, they there's nothing that
the doctor has a stand on,correct?
Like they're they're in in inhot water no matter what.
And and and and my understandingis that's in the mandibular subs
(20:29):
as well, correct?
SPEAKER_04 (20:31):
Yeah, well, I mean, yes, I mean there is there is
literature review, albeit old,that shows a high success rate
with properly made mandibularsubs with the proper occlusion.
You know, I can get youliterature review on that, okay?
I get you a study or two on themaxillary subs showing the
success rates on that, you know.
(20:51):
But current literature onlong-term success rate of these
new implants is just not, Idon't, I wouldn't feel
comfortable.
Put it this way (21:00):
I wouldn't want to be your defense expert and
tell you you're gonna win.
It's gonna be a lot easier to bethe plaintiff's expert and just
crucify you on the stand.
Like, how many of these done?
And where'd you learn to dothis?
And where's your loop?
And where's you know, where'swhere's the studies?
Where's all this stuff?
It's not gonna be there, youknow.
(21:21):
Is it FDA approved?
It's not, unless it's KLS.
And I'm not a fan of theirdesign at all.
So, you know, when I was yourage, you know, very aggressive,
trying to do all the latest andgreatest and newest stuff, and
I'm still pretty aggressive, youknow.
I mean, I'm a boomer and I'm100% digital.
I got a lab upstairs.
(21:42):
But my old mentor, Dr.
Joe, and he used to he's in themiddle of nowhere, Arkansas.
He used to say something on thelook on the podium.
He'd have people internationalcome in to hear him because he
was such a brilliant man.
And he said, I'm from Wynn,Arkansas.
You can't get there from here.
Okay.
I mean, yeah, he's in the middleof nowhere, but you literally
(22:04):
can't get there from whereyou're at now, you know.
Yeah, yeah.
But he would say, you know, thecutting edge, the sword of the
cutting edge cuts both ways, youknow.
So you know, you can be on thecutting edge, the leading edge
of technology, but realize youcan also get cut from that
leading edge.
Sure.
Just be prepared for that.
So, you know, my thing is is youknow, work closely with and have
(22:29):
a good community wherever youare, ENT, oral surgeon,
prostodontist, periodontists,whoever you have, to work with
Yoniks and don't just do thisfly by nine.
SPEAKER_02 (22:41):
Yeah.
SPEAKER_04 (22:42):
You know, and understand that you have to have
a relationship with thatpatient.
And that's the beautiful thingabout practice in Arkansas.
I mean, everybody's like, youknow, practice in Arkansas.
I mean, I got 3.3 million peoplein the entire state.
I have to market two-thirds ofthe state to get enough
patients.
Okay.
And I literally have patientsdrive hours to get here, you
(23:04):
know, and now with the internetand Google uh location, and it's
it's it's a nightmare marketing,you know, just these patients
and stuff.
But you know, you you deal withthese practices, and you I'm
getting losing my train ofthought here, guys.
SPEAKER_01 (23:20):
No, no, you're fine.
Um, yeah, I mean, something thatyou were kind of alluding to,
you know, when consideringgetting into this, and you know,
I think about it a lot is youkind of you know, you have to
really ask yourself uh why it isthat you would want to do this,
right?
SPEAKER_04 (23:33):
I guess that you got me back.
So my thing is have a community,have a relationship with the
patient, and you know, you'vegot to be able to let them know
that things can happen, butyou're there for them.
And you know, I have a littlesaying with my patients, we're
like the Marines here, we don'tleave anybody behind.
And even if it costs me money,I'll redo the case.
(23:56):
And you know, my thing is yougot to come in for recall and
you got to be responsible andyou got to do what we tell you
to do.
If you go away two, three, four,five years, you're done.
I mean, you own it, okay?
But if I've got a patient'scoming in every six months for
recall, even if they're outfive, ten years, I mean, I'm not
sure as hell not charging thefull fee.
And most of the time it's we'refriends, and you know, the
(24:18):
wife's bringing us browniesevery Christmas or something,
and you know, the wonderfulthing about practicing in a
state like Arkansas is thementality of the patient is not
so adversarial.
And you know, don't trust me,we've got lawyers and we all get
thumped, okay?
But especially back when I gotstarted, it wasn't as much of a
(24:42):
problem.
And you know, uh that's one ofthe things I empathize with you
guys that are in bigger states,bigger cities, with more
competition, more people tryingto pull the rug out from you.
And that's why I encouragepeople go get your fellow, go
get your ABOI, you know, and uh,you know, I have not had to go
(25:02):
to court.
I have had some records calledfor, and you know, people this
and that, but I've neversuccessfully been litigated and
sued.
Um I'll go when I say that, butI've been an expert witness, and
you know, they start saying,Well, he's a fellow of this and
diplomate of this and that, andyou know, even if it doesn't
(25:22):
mean anything to the royalsurgeon down the street from
you, it means something to thejury, okay, that you've done an
extra step.
And I'm not saying go out andget bogus credentials from you
know organizations that don'tactually test you and see what
you really do know, but get bonafide credentials, be proud of
(25:44):
them, and promote them, youknow, and they can come back and
they can help you.
I really feel like they can be,you know.
So if you're gonna do theseimplants, dot your I's, cross
your T's, have a community, havecredentials, have doctors that
are in your corner that you cango explain to.
I mean, uh, I told you guyslater, I mean, earlier today,
(26:05):
the complication for thepterygoid in Dan Heltz Claw's
book.
Infratemporal faucet.
That's me.
One of my first ones.
Yeah, I'm that guy.
SPEAKER_01 (26:15):
I was wondering if you're gonna say this on that.
SPEAKER_04 (26:18):
Hey, behavior.com.
I'm like, you're really gonna doI'll make you contributing
after.
I said, No, you can leave myname out of that one, you know.
All the adopts said, this canhappen to anybody.
I'm 30 plus years in my career,and you know, I'm I'm like,
Yeah, okay, I've seen this, Iunderstand the concept, I got
this, and I screwed it up, andit's in the infratum for fossa.
(26:43):
And you know what?
I go across the yard to my nextdoor neighbor who's moral
surgeon, and I'm like, headdown, and he's like, dude, it's
not a big deal.
I put thirds there all the time.
We got you.
Come back to my office in twoweeks, we'll get it out.
We had out five minutes, it wasa non-issue.
Told the patient immediately shehad a few little moments of
(27:05):
trismus.
It wasn't a major complication,but it could have been a really
big issue.
But if I'm a young doctor andI've got this massive bilateral
orental fistula and this failingimplant on an 80-year-old who's
gonna have to go to thehospital, go to the ENT,
probably gonna have to go to anoncological ENT and get a bone
(27:26):
graph, a flap graph, to restoremaxilla obturator.
It's a big deal.
Yeah, and I wouldn't want tohave to defend that.
You know, so yeah, there's sometrophies to get on your walls,
and there's some trophies to letsome of the people that can take
the risk and tolerate the risk.
Maybe this needs to be done ininstitutions, maybe this needs
(27:48):
to be done in foreign countries,and you know, let's get some
studies out and see where it'sat.
But yeah, I don't have all theanswers for you on the maximum.
I mean, I can tell you what todo on a mandible all day long.
But I think I know what I woulddo, but I've been 39 years and
I've only done demonstrations ofuh surgeries on other people's
(28:10):
patients.
SPEAKER_01 (28:11):
That says something.
SPEAKER_03 (28:14):
Not in your house.
Not in my house.
SPEAKER_01 (28:17):
Yeah, I mean it yeah, and I think that really I
mean it goes back to um kind ofwhat I was saying earlier, and
it that lent to your point aswell.
Is you know, you you have to askyourself, you know, why are you
interested in doing this?
Like what is really the point?
What are you after?
You know.
SPEAKER_04 (28:32):
So John Minochetti, AAID past president 10 in his
study.
He's reporting on A.
Codings, 100% success right now.
What's his definition ofsuccess?
I don't know.
He wasn't in there, you know.
Uh Arthur Mosin, another AAIDpast president.
Uh, I used some slides for him.
I said, Art, give me some oldsubslides.
(28:52):
I don't have any Max Larry subs.
Do you?
He goes, Oh shit.
I mean, that's what he said.
He goes, Oh shit.
Yeah, I did.
How'd it go?
Well, he said, I got one thatlasted 20 years.
And so we we put that one up,you know, and what do you think
he did?
It took it out and he put inquad zygot.
Yeah, you know, but how long arequad zygo cases gonna last now?
(29:15):
How long is my AOX gonna lastnow?
You know, I mean, when I gotinto this, Mish, we had
everything between the middleframe was A, B, C, D, E, five
implants.
And depending on whether you didthree, five, two, whatever, you
had locations for it, youconnected it with the meso bar,
you did an overdensure on it.
(29:36):
And then poly mola comes out andblows everything up.
And you know, we start doingAOX, and I never looked back.
Early, early adopter, you know.
And I remember I was in myactual ABOI board examination,
and there was a doctor fromKentucky, Sharon, I believe, the
(29:57):
he was a GP, and he was one ofthe first people, and he and his
partner, the Paradonist, wereteaching for Nobel, were some of
the first people, and he wastelling me what he was doing.
I'm like, you lost your mind.
You know, these are tiltedimplants, you can't load these
off axis because that was thebig thing back then.
And then when you get thinkingabout all your lateral incisors
(30:18):
and centrals and stuff, that'sall loaded off axis.
SPEAKER_02 (30:21):
Yeah.
SPEAKER_04 (30:22):
And you know, I mean, and that's what I'm
saying.
Be a student of your trade, ofyour craft, be an expert in all
aspects of it, you know.
So with these subs, don't justlet somebody blindly say, Yeah,
these works call.
Joe's Dental Lab over here, orJoe's manufacturing facility
(30:43):
over here, they've got this19-year-old from Italy that's
going to design it, or thisother 19-year-old from Portugal
that's going to design it, andit's all going to be great.
Kumbaya.
SPEAKER_02 (30:54):
Yeah.
SPEAKER_04 (30:55):
You need to be the doctor.
Same reason I don't like guides.
And I gave a lot of students,you know, that were taking their
exams and said, tell me aboutyour design on your guide.
Well, send it to the lab.
Okay.
Well, they sent it back and Itold them that it was okay.
And you know, to me, you know, Iwas, I did like 10 guides with
(31:18):
teeth in an hour when it firstcame out.
We did our first guided surgeryon TV in like 55 minutes.
Okay.
I designed those guides.
They were printed in Sweden andsent over.
Okay.
But if you're going to doguides, you need to understand
and you need to be very muchinto that.
If you're going to dosub-implants, you need to know
(31:38):
the uh the design.
You need to be able to tell thattechnician, no, we need to come
a little more interior with thatstrut.
Uh we need to put thepermeocosal post here.
Uh the substructure needs to bea little thinner, a little more
delicate.
You know, and the answers I'vebeen looking at, and I've done
some very sophisticated AIresearch on, you know, is how
(32:01):
thin can we go with titanium andit not break.
You know, and another greatthing that Dr.
Liljohn used to say isstatistics don't lie, but liars
use statistics.
Okay.
And I'm gonna I'm gonna updateit and I'm gonna say AI, or
excuse me, finite elementanalysis doesn't lie, but liars
(32:24):
use finite element analysis tojustify what they're doing, you
know?
And I've never had asubparalisteal implant break.
Now I've got a ton of examplesfrom the 70s that they had
casting defects and this andthat.
And of course, it's a harder allof it, cobalt chrome aluminum.
How thick does titanium have tobe to survive?
(32:47):
And if you use these protectedocclusal schemes that I'm
promoting here, you know, doesit really have to be as thick as
they are?
You know, so there's a lot ofthings that's gonna be really
interesting to see the next fiveand ten years how it pans out.
But I do think PSIs are here touh to stay.
(33:09):
I think they have their place.
I think that it's wonderful thatthey're coming back, but I just
want to promote a cautionarystill tell, especially if you're
early on in your career.
Yeah, you know, I'm gonna have alot better, easier time
defending myself and gettingcooperative care from other
(33:31):
specialists than a young surgeonis who's just trying to make a
name for himself.
SPEAKER_01 (33:37):
Yeah, I mean, I think that you know, sometimes
on the show when we, you know,talk about uh maybe this isn't
avant-garde, but when we starttalking about more exotic types
of implant treatment, peoplewant to listen to it so they can
learn how to do it.
Um, but you know, maybe that'snot the most valuable thing you
can come away with.
Maybe it's a lot of good reasonsnot to do it and just wait on
it, learn more, take your time,get your credentials right, and
(33:59):
and do it maybe when the time isright, when it's appropriate.
Um, but there's there's plentyof work to be done, short of
getting into these gray areasand doing you know people want
to know.
SPEAKER_04 (34:09):
I mean, literally, I was going to Nate's office to
help him put in a sub, and Ryanhad this maxillary sub, and the
patient's sick, we can't get itin.
Uh, we think she's not gonnamake it, but uh, we're gonna put
in two subs.
But then one of the oralsurgeons says, Hey man, I got
one I needed to have done.
I was like, Well, there's threesubs.
It's like Ryan, you need to do acourse.
(34:30):
Yeah, so he literally put itonline, and within a day and a
half, it was full.
Wow.
Okay.
And everybody came to Phoenixtonight, it's got a great
facility, and we had closecircuit TV, and you know, we we
put in two of the three that wehad scheduled, and it was great.
And like Orca, you know, there'sa need and there's a want, but
(34:55):
it's the ability to get thepatients to the residents, to
get the records, to get thedesigns, and they've even got
manufacturers that will donate.
I've got two right now that willjump right in the middle of
this.
And so, you know, we're intalks, or Simon and them are in
talks.
I'm not part of the board there,but you know, there's been
(35:15):
discussion of bringingsubairoster course to ORCA.
Okay.
You know, but you guys thatwatching the podcast, it's going
to be the same message there,and it was the same message at
Full Archmasters.
There's safe things to do, andthere's not some there's not
proven things to do yet.
Just see where you are in yourcareer and how much risk are you
(35:39):
willing to assume for aparticular patient.
You know, if you're your mom ordad or aunt or uncle, you know,
or sister or whatever, then youknow, you can assume more risk.
But uh, yeah, if it's a full feepaying patient that you have no
connection with, you need to bevery careful.
Yeah.
SPEAKER_01 (35:59):
Yeah.
No, that that makes a lot ofsense.
Well, well, Dr.
Jerry, uh, you know, we have uhcovered you know decades of of
learning in the uh world ofCSIs, PSIs, um, and and learned
so much from your experience.
And uh, you know, I'm leavingwith more questions than
answers, I think, in a very goodway.
I have a lot more that I need tolearn um about this modality,
(36:22):
and uh, I really appreciate youspending the time to come on and
and talk about it.
You know, I was just curious ifyou had any other you know,
closing thoughts or encouraginguh sentiments for you know other
full art surgeons out here,anyone listening to the podcast
that might be interested umlearning more about your work or
whatever else that it is thatyou do with Orca and all those
good things.
SPEAKER_04 (36:39):
Well, uh, you know, I'm I'm available, uh, I'm on a
lot of uh different threads andstuff, but uh I'm more than
willing to look at some thingsand and help point people in the
right directions, hopefully.
Uh, you know, uh there are otherdoctors that have done this.
Dr.
Picos, I know he's done 200.
I think he and I are gonna dosomething.
(37:00):
We're gonna be speaking at theupcoming Orca Symposium in Las
Vegas in January.
Be there.
Yeah.
Okay.
Thank you.
Uh, you know, uh Ramsey Amin hasdone several subs.
He's I think speaking at the AIDmeeting uh that's coming up in
November.
I don't know what the topic ison that or what what he's
(37:22):
covering, but uh we're if he'sgonna go in the PSIs or what,
but he's got some materialthere.
And you know, we're looking totry to bring this more to uh you
know to to the pup to the otherto the dentist group, you know,
one group or the other.
And you know, I don't have alecture facility or
(37:44):
organization.
Uh I'm a heart gun.
You know, I mean I I enjoy doingthis.
I don't need to run the show.
Uh I I love giving back.
I love being with the young docsand and and meeting new people
and making the connections.
And you know, uh just uh keep onFacebook, look at your Orca,
(38:05):
look at your Full Archmasters,Adam Hogan.
He may do something with hisstuff, you know.
Uh I've even been in talks withMaud Institute, you know, we may
do something with these guys.
So there's lots of good learningopportunities.
Vichy Berman uh has done anumber of subs, and his uh
experience with the PSIs is morethan mine.
(38:28):
And again, you know, he's he'sthe expert of experts, KOL.
Uh he can weather the storms ofthe failures, and you know,
let's see what happens with thework that Vichy.
But you know, he and I worked inthe past very closely on
designs.
Even he and I and Nate have donesome implants together.
You know, that that's how we allgot tied up together.
(38:48):
Nate had a patient that neededan implant, and so we we did
that.
But uh I wish I had betterresources we did that, but uh I
wish I had the orca uh just foreverybody.
But uh, you know, come to Ramseyand uh we'll get some
information.
We'll I'm sure there'll be acourse come up and we'll get the
information out there andeverybody comes come see us.
SPEAKER_01 (39:57):
Yes, sir.
Well we appreciate your time.
Thank you so much.
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