Episode Transcript
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Speaker 1 (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
And welcome back to the FixPodcast.
I am super excited abouttoday's episode.
I know I say that every time,but this time I mean it a little
bit more than I usually do.
So today we have an absolutepowerhouse of speakers in here.
(00:23):
If you combine the number oforches that have been done
between these four people,myself included, I'm sure you'd
be somewhere in the thousand,maybe five digits, I don't even
know.
But today we have Dr ClarkDamon who is returning to the
show.
Welcome back, clark.
And he has graciously brought onhis good friend and colleague
and mentor to all of us, drDavid Zellig, who instructed me
(00:47):
not to call him doctor, but youknow, I'm from the South.
It's going to be hard for me toavoid the formalities.
But just as a brief intro forDavid, as he likes to be called,
he is a board certified oraland maxillofacial surgeon and a
nationally recognized leader inimplant industry.
Surgeon and a nationallyrecognized leader in implant
dentistry.
Dr Zellig, excuse me.
David earned a bachelor'sdegree from the University of
(01:10):
Memphis, followed by his DDSfrom the University of Tennessee
College of Dentistry andcompleted his residency in oral
maxillofacial surgery at theLong Island Jewish Medical
Center.
His years practicing in Memphis, david served as an associate
professor in his department oforal and maxillofacial surgery
at the University of Tennessee.
He was an active member of hiscraniofacial surgery team,
specializing in orthodontic andTMJ reconstruction, alongside
his implantology practice.
Since relocating to New York,he has held key roles with Clear
(01:33):
Choice Dental Implant Centers,among several other centers,
where he leads advanced implantsurgical programs, including
full arch, zygomatic andpterygoid implant procedures and
a host of other procedureswe're going to be talking about
today.
David has zygomatic andpterygoid implant procedures and
a host of other procedureswe're going to be talking about
today.
David is also a contributingauthor in the textbook Remote
Anchorage Implant Leave noTrophic Maxilla Behind quite a
(01:53):
title there which focuses onzygomatic, pterygoid, transnasal
nasopalatine and trans sinusimplant techniques, featuring
case contributions and protocolsfrom leading surgeons in the
field, including himself, ofcourse.
So, david, welcome to the show.
That ended up being a whole lotmore jumbo than I ever planned
on and I think it was stillabbreviated from your actual
career.
But again, welcome to the show.
Thank you so much for sparingyour time.
(02:14):
I'm so excited to learn fromyou today.
Speaker 2 (02:15):
It's actually pretty cool to hear a eulogy about
oneself and to be able to speakafterwards.
But thank you for those words.
Speaker 1 (02:25):
Of course, of course, of course.
Now did that more or lesssummarize your career.
I'd be interested in how youwould add to it what sort of uh
things you hang your hat on?
Speaker 2 (02:32):
how would you define your career as well, just to
give uh the listeners somebackground well, I, you know, I
came out of out of residency andstarted my own practice in
memphis.
Um, I'm, you know, the southernthe Southern part of me is
still polite but I?
Um it turned into a full scopepractice and I was very proud of
that.
Um coming back to New Yorkyears, years later, after 20
(02:56):
plus years of private practice,back to New York, um, I got
really very active in traumasurgery and we'll talk about it
later.
I think that helped.
I got really very active intrauma surgery and we'll talk
about it later.
I think that helped.
That just the more you can domakes you a better surgeon.
So I just everything you do,even if it, even if you distill
your life down to arches,anything you can do to make
yourself a better surgeon helps,and my life is distilled my
(03:23):
professional life is distilleddown to arches, of course.
Speaker 1 (03:25):
That's what happens.
Yeah, absolutely.
And can you tell us a littlebit about your current clinical
practice?
We were talking a little bitbefore we turned on recording.
It sounds like you're goingaround to tons of centers
helping folks out with remoteencourage cases, still getting
yourself bloody and helpingpeople out of trouble and, you
know, putting out fires all overthe place.
What does that look like foryou?
Speaker 2 (03:45):
Well, you know, putting out fires all over the
place.
What does that look like foryou?
Well, I was an early.
I drank Palo Malo's Kool-Aidkind of early in my career and,
you know, brought that deal onfour idea to Memphis years ago.
And then when I came here, keptthat up and after a lot of
trauma, surgery and orthodonticsand others still doing art is
(04:07):
at the same time I wasapproached by.
It was a clear choice to open acouple of their centers and it
was pretty much focused onarches.
And when that got so busy Istarted mentoring some juniors
and when they got proficient Iwas left with only the extreme
arches, and that's where I am.
So you can't have enoughextreme arches in one place.
(04:29):
So I'm running around to a lotof different places doing their
extreme arches.
That's what's happened.
Speaker 1 (04:36):
So you're the fixer.
Speaker 3 (04:37):
Well, that's really cool.
So I just have a question sowhen did you go to the Mollo
Clinic, like what kind of talkedto me about that path.
Speaker 2 (04:48):
Yeah, first I drank his Kool-Aid in this country
first.
Actually, one of his earlystudents started teaching it in
Kentucky and I went to I thinkit was Lexington way back when,
back when, and then, and thenlearned from Milo after that and
(05:09):
just I don't know what to say.
When, when I think it was BoRangert that kind of convinced
me to say that wow, I'm usingengineering principles here and
we're bringing engineering intodentistry.
And when I say it's a bridge,it's a bridge like going over a
river and how many abutments youneed is based on how thick the
(05:31):
roadway is.
That kind of thing.
It was engineering principles.
It just hit me.
I guess I was a physics majorin college.
Not that I remember anythingabout physics anymore, but it
resonated with me.
Speaker 3 (05:43):
It made sense, right anymore, but that they're kind
of it.
It resonated with me.
It made sense, right, so so didyou.
Did you wait until the uh 20,uh 2011 article came out, where
he kind of published like hisfirst 245 cases, or were you
doing it um sooner than that?
Speaker 2 (05:57):
No, I was, I was um, I was early, early 2000.
Speaker 4 (06:02):
It was before it was cool.
Yeah yeah, david, can you talkto us a little bit about um?
You know how you've seen fromthe early 2000s Cause you're
probably one of the first guysin the U S you know to to really
take it on Maybe not the first,but like in the in that first
realm Um and maybe you know whatthings you've seen change over
(06:24):
the last two decades.
Uh, you know pros, cons, kindof thing would be great.
Speaker 2 (06:29):
Uh well, uh, two things really.
First of all, we all came fromdental school and we all respect
bone and the idea of bonereduction was anathema to all of
us and that's what that was.
The big thing that we had towas anathema to all of us and
that was the big thing that wehad to the big river to cross to
(06:49):
get to effective all-on-Xtreatment was that amount of
bone reduction.
So we I think all of us were alittle hesitant at the beginning
doing the bone reduction thatwe really needed.
And I don't mean just to hide atransition line.
I'm talking about to get a goodall-on-four-shelf table, to be
able to get implants in solidbone, to apply the other
(07:12):
principles that other giantsgave us, like Dennis Tarnow, a
couple of millimeters of bonebuckle around the implant.
So that was one thing that'schanged.
The other thing that changed, Ithink that, well, prosthetic
materials certainly.
You know the initial acrylicbridges that we were using
(07:33):
worked nicely and maybe did havethe idea of some
shock-absorbing effect on theimplant, but they ended up
looking horrible after a year orso.
So moving into ceramics,zirconium, certainly was a big
deal.
I think those are the realadvances as we went along.
Speaker 3 (07:54):
It's amazing because I was doing arches probably 2013
is whenever I started and, youknow, hit them pretty heavy and,
looking back from really 2013,which I felt like I was, you
know, fairly new I mean, Iwasn't, you know, one of the
(08:15):
first, but you know, still in2013, I was having to deal with,
you know, the dogma of bonereduction with you know the
dogma of bone reduction, right,the dogma of, you know, taking
out a few healthy teeth, and youknow the dogma that was also
like, hey, these are all goingto fail really, really soon.
And you know it's amazing tosee where we are today.
(08:41):
And you know, I really kind ofthink, like right around COVID
and and maybe a touch before, itreally seemed like the implants
got so much better, like 2019,2020, the implants that we have
in the abutments just seemedlike everything got so much
better.
Do you kind of feel similarly?
Speaker 2 (09:04):
it's interesting because I'm looking back at.
Unfortunately, when I firststarted learning all on four, I
said, wow, I need to go to acourse to learn how to put in
implants that aren't parallel.
All of my implants wereparallel.
You know, it was the learningcurve.
All my implants looked horribleand I look back at them.
What the idea of doing fewerimplants as opposed to arches of
(09:27):
eight and ten implants was wasanother river to cross and you
look at the failures of thosearches with the titanium
overdoses and and that kind ofthing, and when they fail, they
fail miserably.
Yeah, even if this, even if animplant fails in an all-on-x,
it's, it's you at least havemore bone because you haven't
(09:50):
occupied the entire arch withtitanium.
So I think that was a benefittoo early.
You know, listen, I was doingimplants when they were machine
surfaces, brown marks and thenlater hydroxyapatite coated
implants and that didn't workout.
You know, I did press fits.
We went through the whole.
Yeah, I went through the whole.
Wow, I'm sounding like um, god,I'm sounding like I'm tating to
(10:13):
something right now you'rebullshit or something.
Wow, I don't know how thathappened so fast, but I went
through that and yeah, so theimplants did get better, but I
think, uh, we also just theunderstanding of the principles.
It finally clicked.
Speaker 1 (10:30):
Yeah, I think the general trend has been that you
know, through clinical practicewe've kind of discovered you
know what works and what doesn't, and we've had a lot of people
doing that hard work to gothrough all the things that
didn't work and now it's gettingdown to the actual product
level where you know amulti-unit is shaped in such a
way that we don't have to boneprofile as often you know.
(10:53):
Just all the little nuances isnow we're not going to
programmed in to make full archa whole lot more predictable.
And there was a lot of gruntwork that happened in the past
20 years or so to get us to thepoint where you know we have
things that just work and I'mnot sure that you know people
like myself and Soren that haveyou know, come out in the last,
you know, half decade or so, andthen doing this, I don't know
that we can fully appreciate allthe things that came and went
um to get where we're at.
And it's, you know, we lovetalking about not not just the
(11:14):
things that guys hear but wherewe're going.
But we certainly appreciatethat we're coming into the game
after people have already spentso much time figuring out all
the things that didn't work.
So we do appreciate, you know,you guys contributing to that
body of work.
Speaker 2 (11:25):
Of course, Well, that's actually a very you know.
They say that there are threekinds of people Some people can
learn from a book, and somepeople can learn from other
people's mistakes, and somepeople got to pee on the
electric fence themselves and itwould be preferable to learn
from someone else's mistakes.
That's right, that's right.
Speaker 3 (11:42):
That's right, that's right that's right, yeah, I mean
, I remember uh using the, thenobel, the nobel system, and you
know you had to what one.
The abutments didn't always, youknow, fit very well onto the
internal connection and then youhad to profile every single one
of those and what's?
What's kind of a funny story is,in 2017, I bought a ton of
(12:07):
Nobel implants and then I think18 or 19 switched over to Neodem
, so I didn't have to boneprofile anymore and I just left,
literally, I think in myAmarillo office I left 500 Nobel
implants and so, rolling into2021, I was like these things
(12:27):
are all going to expire.
So I had to do probably, Idon't know 60 or 70 arches all
with Nobel and it's and I mean,it's so frustrating because you
have a bone profile surgical kit.
You have, like you know,several.
You have to have so manysurgical kits out to you know to
(12:48):
do a case and then you know, loand behold, if you want to do a
4.0, well, then you got toreach for a speedy, groovy kit
and then that has its own boneprofilers and different
abutments.
I mean it is my assistantshated 2021 because we were using
all these antiquated systemsand it's really hard doing
(13:10):
pterygoids and having the boneprofile back there.
And you know if you're concerned, is your abutment seated all
the way, you know, because thatNobel multi-unit abutment
doesn't have a full 360 degreesconnection.
So it's really interesting, you, you know all these things that
we take for granted now, thatreally speed up our surgeries
yeah, absolutely the.
Speaker 4 (13:31):
I'm sure your assistants weren't too happy if
they forgot to sterilize one,one thing during your kit.
And then you're well, or?
Speaker 3 (13:37):
if they, if they lost the bone profiler, the, the
little, the little guide thatsits on top of the implant once
it's placed, and you know ifit's a speedy groovy compared to
a Nobel active.
You know, they're like.
These things look like healingabutments too.
Oh, they look like enough.
Speaker 1 (13:53):
Yeah, there's way too many yeah.
Speaker 2 (13:56):
You missed the Nobel's egg almonds, though,
didn't you?
Speaker 3 (14:01):
Yeah, I got, I got, I got, I got a bunch of them
right up, right up here, okayyeah.
Speaker 2 (14:04):
I got a bunch of them right up here.
Okay, that was another one witha mount.
That was impossible.
Speaker 3 (14:08):
Yeah, we'll try my first quad that I ever did after
in like 2016 or something or 15.
I broke the mount inside of the45 degree abutment and so
there's a whole screw in thereand you know you're trying to
back a screw out after you knowyour first quad psychoma case.
(14:29):
Luckily I had a colleague thatwas there who was like, hey, you
did the case, let me back outthe screw for you, and so
luckily he navigated that.
Speaker 4 (14:40):
But yeah, lots, lots of uh great time, lots of
frustrating things, it's forsure I'm kidding, so go ahead
all right, I was just going tosay we uh have gone through,
like you know, with clarkpreviously a lot of the um zero
to 100 when it comes to fullarch, uh basics, what you need
(15:02):
to do to get started, goodprotocols to learn prior to, you
know, tackling your firstarches.
So today I think what we wantedto go over was a lot more of
the remote anchorage transnasalquad zygoma stuff that you excel
in.
So I'd love to kind of startour discussion on that with um
(15:26):
talking about transnasal, youknow, like the Z point and that
kind of thing, and uh, go overyour expertise on what, if
doctors are looking to get intotransnasal, maybe what
continuing education you'drecommend um key anatomical
points, that kind of thing wouldbe very very helpful for our
listeners.
Speaker 1 (15:43):
And I think, starting first, we should just go with
definitions Like what?
What is a trans nasal?
Speaker 3 (15:47):
what is the point, so we know what we're doing.
Speaker 2 (15:49):
A good start all right well, you know, the first
thing that came out and and malowrote about it, only jensen
wrote about it, others wroteabout was the trans sinus
implant, was the idea of using,if a to get whether it's because
the sinus anatomy is such thatthe anterior sinus wall is
anterior to ideal position orjust to extend the AP spread.
(16:14):
A trans-sinus implant is onethat has crestal anchorage
underneath the sinus and apicalanchorage at the lateral nasal
wall, with nothing in betweengoing through the sinus, with
the membrane lifted ideally, butplus minus lifted membrane but
crestal anchorage under thesinus and apical anchorage at
(16:35):
the lateral nasal wall.
And the idea here is in atransnasal is going to go
bypassing the lateral nasal wall, having crestal anchorage
underneath the nose and subnasalbone and apical anchorage at
the lateral nasal wall.
Well, in this case the implantis at the lateral incisor
(16:55):
position, just as anteriorzygoma would be, or an anterior
implant.
But if you don't have enoughsubnasal bone to put in whether
it's endpoint or towards thenasal crest of the maxilla bone
to put in whether it's endpointor towards the nasal crest of
the maxilla, the alternative isto use the subnasal bone if you
have at least three millimetersplus of subnasal bone and then
(17:15):
get into the lateral nasal wallat this junction of and I call
it the confluence of the lateralnasal wall, lateral maxillary
wall anterior to the nasalacromal duct, at the level of
the inferior turbinate.
You got that.
It's kind of three-dimensional.
Speaker 1 (17:30):
We triangulated it, yeah.
Speaker 2 (17:32):
And that is the target that some people have
called the Z-point.
I can't call it that.
Speaker 3 (17:40):
So where do you think that name comes from?
The Z-point.
Speaker 2 (17:44):
Yeah, I think Dan Hulsklaw did that for me.
He calls me the pioneer.
I don't want to be a pioneer, Ijust want to follow giants that
I stand on their shoulders.
But that's the idea.
So the apex of the implant isin the lateral nasal wall, at
(18:06):
this confluence of lateral nasaland lateral maxillary wall, and
the posterior margin is a nasallacrimal duct and fortunately
the ENT literature has done ourwork for us to help define where
that is and where we can findthat preoperatively on CT scans.
(18:26):
And there's in two-thirds ofthe population there's adequate
bone for this implant.
The apical anchorage I'mtalking about two-thirds of the
population has it where there'senough bone anterior and enough
thickness anterior to the nasalacromal duct.
As far as training to see ittechnically, the way I teach
(18:49):
remote anchorage, except for thepterygoid, is visualize
everything.
So there's no minimal invasivesurgery for a zygoma in my
opinion, not because you can'tget the zygoma in the right
place, but it helps you avoidsome of the complications.
So wide exposure, seeing theentrance and the exit points.
(19:10):
Do exactly the same thing withthe transnasal visualize.
What made it reasonable for meas an oral surgeon is because
you know I've been there beforefor orthodontic surgery, so
you're in the nose a lot.
You know what you're looking at, you know what to avoid, but
it's eminently teachable.
You know, this is pretty clean,direct dissection.
(19:35):
As far as education, yes, whereyou can get this, where you can
learn this, well, you can learnit in books, but you got to see
it and do it.
So, fortunately, well,unfortunately, early days, when
I had dark hair, there weren't alot of courses and there
certainly weren't books for anyof this, and then you just had
to base what you did onprinciples that existed before.
(19:57):
So that's generally what I'vedone is use previous principles
and kind of expand on them.
In this case, now there arecadaver courses, there are live
surgery courses, there'smentorship to a bunch of us guys
that are willing to go aroundand look over your shoulder and
hold your hand.
(20:17):
It just didn't exist in ourfield.
It didn't exist 10, 20 yearsago, but it existed in medical
education.
Medical education is reallyinteresting If you think about
the way internships andresidencies there's someone
holding your hand at thebeginning, like riding a bike
with training wheels, and slowly, as you get proficient, they're
(20:38):
watching you holding your handsalmost literally.
And then they let go of yourhand and they're still watching.
They're still holding thebicycle seat as they're running
down the driveway and eventuallythey let go of your hand and
they're still watching.
They're still holding thebicycle seat as they're running
down the driveway and eventuallythey let go and you're flying
on your own and we finally havethat in dentistry.
We just didn't have this beforeand it's nice to be able to say
(20:59):
we got cadaver courses and livesurgery courses and mentorships
and it's all out there.
Cadaver courses and livesurgery courses and mentorships,
and it's all out there.
Back in back in the day, backin the day, I flew all over the
world to watch people do thesethings Um, literally all over
the world.
It was crazy because there wasno place to go officially, just
(21:21):
nice guys that let me watch.
Speaker 1 (21:23):
And, um, eventually you just got to a point where
you say I gotta do it and that'swhat it was that's, that's
really incredible um, david,just just the lengths that you
had to go to following it'sfortunately we're living in
better times and for some things, for some things not, but for
this we have, we have podcastsnow you can speak, speak
(21:43):
yourself.
Speaker 2 (21:44):
Now the transnasal.
Back to the transnasal.
So it really is an alternativein many patients for a quad, for
the anterior zygoma of a quadzygoma, and this is something
I'm curious too about, david andI.
Speaker 1 (21:56):
Actually I took the liberty of messaging a few
friends that we were going to beinterviewing you and got some
questions back, and so my goodfriend, dr Sean Lan, out of
Atlanta, georgia.
He had been reading throughyour 2025 paper on the placate
guidelines and he's asking withregards to the Z-point implant
(22:17):
we've been talking about, hesaid would engaging the lateral
nasal wall be a viablealternative or would you go
straight to an anterior superiorzygote?
So I guess what he's saying is,if you had difficulty engaging
the Z Z point or if it wereinsufficient, is there a world
where you would go through thatsubnasal bone and just engage
the lateral nasal wall, asopposed to finding that conflict
.
Speaker 2 (22:36):
Yes, there is one type Well, in a way that is
still the it is lateral nasalwall that this is engaging even
in that world.
But so here's the thing thelateral nasal wall, that this is
engaging even in the world.
But, um, so here's the thing.
The lateral nasal wall in abouta third of the population is
what simon daniel simonclassified as a type three,
where there's a lot of spacebetween the late nasal lacrimal
(22:56):
duct and the anterior edge ofthe lateral nasal wall.
But it's very thin and in thosecases I term it exteriorized.
As you're going up the thelateral nasal wall, you're
hugging the lateral nasal wall,but because it's so thin, it's
dehiscence on the nasal side,not through the nasomycosis.
It's still deep to thenasomycosis and on the facial
(23:18):
side as well, halfway up, butthe apex is still in solid bone.
So the answer is yeah, you cando that.
That lateral nasal wall is isas long as it's surrounded by
bone, and the higher you go itgets thicker as you go.
As long as you know, you canknow, you can locate where that
nasal acromal duct isradiographically.
So the answer is yes.
(23:39):
The only place where you reallyshould not do it is in what
simmon called the type one wherethere is no space between the
nasal acromal duct right andthat and that edge of the
lateral nasal wall, and also invery hypoplastic maxillas, not
just severely atrophic buthypoplastic, where there's a
real class 3 ap relationshipbecause that this implant is
(24:00):
palatal to the crest as opposedto a interzygoma, that's on the
facial aspect of the, of the ofthe of the crest right.
You would actually make your apdiscrepancy worse yeah, that's.
Speaker 1 (24:12):
That's actually something that uh simon made a
post about I think it was maybethree weeks ago, and he was
talking about disadvantage ofthe transnasal versus doing
anterior superior.
Zygote is that you have a lotmore prosthetic flexibility, uh,
when it comes to doing interiorsuperior, whereas with that
transnasal you might just fixateinto that palatal position.
Speaker 2 (24:30):
But in a non-hypoplastic maxilla, in a
normal position maxilla.
I would say that 90% of mytransnasals have a 17 degree
multi-unit abutment comingforward and it puts it right
over the the lower incisors.
Speaker 1 (24:47):
So that's generally where I go, great, generally
where it goes.
Speaker 3 (24:51):
Yeah, so and and this was, uh, one of the questions
that I had.
Uh for you, david, in regardsto some prosthetic challenges,
um is is with the class 3patient.
Um, so you know, obviously wewant to avoid a significant
anterior cantilever, and youknow my question there is, you
(25:13):
know, if you have a veryhypoplastic mandible, oftentimes
let's also say maybe theirzygoma is, you know, not very
tall, maybe.
Let's just say it's, you know,15 millimeters, right, I don't
know if I've seen a zygoma thatshort, but let's say there's one
where it precludes you fromthat.
So you're almost forced intodoing this on a class three.
(25:35):
Would you then prostheticallyrecommend that we maybe bring
the mandibular teeth back andkind of retrocline and just kind
of pull everything back in, soit's not as anterior.
Speaker 2 (25:50):
Yeah, I think there are a couple of things.
First of all, there's still aplace in the world for
orthomatic surgery and if we allme, you, the patient, everybody
understands that in an idealworld we would fix your skeletal
deformity before we didanything else, if we're
accepting that, we're not goingto do that and we're going to
(26:11):
camouflage or we're going tocompromise, then sometimes you
have to compromise yourocclusion as well.
That end-to-end, edge-to-edgeocclusion may be the best you
can get and ling, linguallydecline the lower anteriors to
get back as an orthodontistwould do camouflage,
(26:32):
non-surgical orthodontics.
So that is a possibility.
There's really no otheralternative.
I mean, the alternative, ofcourse, is grafting, major
grafting, but I've been thatgamut and long term that just is
not a good answer.
Right?
Well, in my hands, even thepatient-specific implants, these
(26:54):
subs, you can't correct thatmuch that way either.
Well, you're still on the samebase of bone.
Speaker 1 (27:02):
So I'm curious about this too, because I think it was
Dr Zach Brown that presented onthis recently at the last ORCA
symposium.
He talked about prosthicmathics right, so this thing
that we're able to camouflageand compensate for these things
with prosthetics.
You know, when you'reevaluating these hyperplastic
cases severe class discrepancieswhere do you kind of draw the
(27:24):
line?
And how do you draw the linebetween this really is an
orthognathic case or no?
This is something we couldaccomplish with just some
prosthetic black magic.
Speaker 2 (27:33):
So I mean age of the patient realistically is one
thing we really have to thinkabout.
What's realistic for thepatient?
We can explain it to thepatient, give these options out
there, but that's a that's awhole lot to expect anybody to
go through nowadays, especiallyin this age of instant
gratification.
you know, like finals, finalarches, final teeth in 24 hours.
(27:57):
We can discuss that in a minutetoo, but I think that that's.
That's a big thing.
You know a patient can be, can,can explain all.
You can explain everything tothe patient ahead of time, and
smile design is critical aheadof time.
Really, get a smile design.
Show a patient what you can do,even if it means in plastic.
Just show them what you can do,what's realistic and what's not
(28:18):
.
I think that these hugeanterior cantilevers are just as
bad as a huge posteriorcantilever.
Anterior cantilevers are justas bad as a huge posterior
cantilever.
There's only so much you can dowith a nasal palatine implant
to try and avoid an anteriorcantilever.
It just doesn't go as far asyou want it to.
So these are things you have toconsider for long-term
solutions.
Speaker 1 (28:40):
Definitely, definitely.
So, as far as when you're doingthese transnasals, is there
ever an indication to do anygrafting?
So if you were to elevate themembrane, is there any reason
that you would want to pack somebone in there?
Is there any possibility you'dget some bone back?
Speaker 2 (28:56):
There's a Professor Almeida who did the first
English article on this.
He showed grafting on his casesand I did one after a while.
Here's my thinking.
The area of the mucosa thatcovers this implant on the nasal
(29:19):
side is pretty robust.
It's pretty thick mucosa.
It's not like a sinus membraneat all.
It's not mobile mucosa.
It's not like a sinus membraneat all.
Right, it's not mobile mucosa.
In fact, you know the way Idescribe it in courses if you
pick your nose you don't evenget to the bony nose.
You're in the soft tissue nose.
You don't even get back there.
So you're not in area mobilemucosa.
(29:40):
Nothing's hitting it.
It's not being compressed.
However, the idea was to graphthat to cover the threads of the
implant there, not necessarilyfor osteointegration, but to
protect the navel mucosa.
The problem with that is thisimplant is not and this is my
argument against it, by the way,that part of the implant is not
(30:00):
in the narrowest part of thenose.
The narrowest part of the nosefirst of all is in the soft
tissue nose, not in the bonynose.
And the narrowest part of thenose first of all is in the soft
tissue nose, not in the bonynose.
And the narrowest part of thebony nose is on the medial most
aspect of the inferior turbinateright and we're lateral to the
medial most aspect of theinferior turbinate.
So we're not in the narrowestpart of the nose.
So I don't see us narrowingairway space unless you graft.
(30:21):
If you graft you couldpotentially bulk that out too
much and narrow the airway spaceand then you are compressing
that mucosa.
Now there's a new implant that Ihelped design that has a bald,
non-threaded portion on the midshaft of that implant so that
you can and it's timed such thatthe hex works that the medial
(30:42):
aspect underneath the mucosathere does not have threads.
So it does away with that wholeargument.
And as far as grafting forincreased stability, I'm getting
typically 60 newton centimetertorques on these.
It's cortical bone, it's hardbone.
Um, that's generally what I'mlooking at.
So I see graft.
Speaker 4 (31:02):
I see, can you talk a little bit about, um, your
indications as far as and maybeeven mentioned to like, trans
sinus?
I know we've gone through thison the podcast before, but when
you're doing a trans sinus, whenyou're doing a trans nasal, um,
how much crustal bone do youlike to have?
How much apical bone do youlike to have?
(31:22):
When you're doing a trans sinus, um, are you typically, um, you
know, lifting the membrane?
Are you going through themembrane?
Um, what are your indicationsfor doing both of those?
Speaker 2 (31:34):
I think that's great, you guys are great, you guys
are great, these are great.
So, first of all, yeah, I dolift the membrane.
It's not that big a deal, youknow it's.
It's uh, almost like an asideto get a good round diamond burr
and get through the bone andlift the membrane.
Um, can you do it without it?
Sure, but what can happen?
(31:55):
I don't know.
We saw a lot of sinusitis fromthe, the og method of, of
zygomas.
So why not stay outside thesinus, just like we do with
zygomas now?
So, um, as far as the amount ofbone, so the literature
supports and that's that's um.
Ollie jensen wrote about it,like I said, and milo also that
(32:16):
you need greater than threemillimeters of sub antral bone
to not need to graft, to notneed to do a sinus lift.
So I I use the same thing.
I want more than threemillimeters of subnasal bone as
my crestal anchorage.
The literature on the transsinus suggests that you need two
millimeter thickness of lateralnasal wall and generally, yeah,
(32:40):
that's what you have.
I just double it kind ofempirically.
I just said empirically if wecan do two millimeters of
lateral nasal wall thickness fora trans sinus implant which
goes through the lateral nasalwall more perpendicular.
This is going more parallelalong the lateral nasal wall.
So I'm just going to say I cando double that easily.
(33:03):
So I aim for four millimeters.
I'll hit that inferiorterminate point and then enter
four millimeters superiorly forapical anchorage of at least
four millimeters.
So I got an eight millimeterimplant, essentially four
millimeters at the apex and fourmillimeters at the crest, and I
got good stability.
Speaker 1 (33:21):
And in order to, because I want to make sure
everyone's appreciating what youjust said.
So you're saying you're doingthe trans sinus and you're
actually targeting the Z pointitself for your ankle anchorage?
Is that what you're saying?
Speaker 2 (33:34):
No, no, no, no, that's really hard to that's
hard to aim for that.
That's why I'm Anytime you gofrom the trans sinus, you're
going through the sinus.
What bone are you going to hit?
You're going to hit the lateralnasal wall.
Of course.
I suppose you could, if you'rethat much of a sniper, expose
the lateral nasal wall andtriangulate.
Yomi could do it.
Speaker 1 (33:58):
Yeah, let's get Clark starting on Yomi.
Speaker 2 (34:00):
Yomi, good, but I don't.
You know that you have twomillimeters of thickness.
You already looked at your CTscans.
You know what you have and,like I said, you're hitting that
more perpendicular.
You're not really tangentiallyhitting that lateral nasal wall.
That's not really the apex.
It's nice if you could hit it,but that's not part of that.
(34:23):
But that's not part of that.
Speaker 3 (34:33):
Yeah, I was going to ask your opinion on a trans
sinus that goes up to the Zpoint there.
I've always avoided that, yeah,for fear of it's much easier to
hit the NLD from a posteriorapproach than it is directly
visualizing that.
So I wondered if you felt thesame.
Speaker 2 (34:51):
Absolutely.
I think that the idea here is,especially if you've opened the
sinus window, is to hit thatcurvature of the anterior wall
of the sinus where it meets thelateral nasal wall, and you can
almost see it if you need to.
If it's really thin, you couldactually watch it come through,
the facial aspect of that bone,the apex, coming through if you
(35:12):
need it correct um, I haveanother question for you.
Speaker 3 (35:19):
Uh, you know, I've I've probably completed 20, uh
transnasal implants and maybe atouch more, but probably about
20.
You know, if I liked calling it, you call it crystal or you
could call it the coronalentrance point point.
(35:45):
So kind of walk me through.
There's a little bit of alearning curve because you
almost have to not over widenyour osteotomy at the crestal
aspect but you need to have alittle bit of degrees of freedom
to really kind of get yourpilot drill, an initial prep.
Speaker 2 (35:58):
Yeah, sure, um, so first of all, I generally will
mark lateral incisor andjunction of second premolar,
first molar.
I'll mark that on the alveolus.
(36:18):
That's going to be my idealpositions for the four of all
on-on-x, all-on-four, part of anall-on-x, and I'm going to keep
that.
I know that Vandalum talksabout.
If you need, depending on thelateral wall thickness, he moves
that laterally or medially, butI'm going to idealize that
position lateral and sizer.
(36:38):
Let my axis hold me in thecingulum of that lateral.
They all look alike that wayand I'm going to start my
osteotomy with a, with a Lancepilot drill.
Uh, the near dent, twomillimeter, um, sharp pilot.
Um, the beauty of that burr isthat it only cuts in the in the,
(37:02):
the part of the tip that hassharp sides, flat sides.
So the in the, the part of thetip that has sharp sides, flat
sides.
So the shaft, the long shaft,doesn't cut, so you just get
through.
Again, you got to be palatal tothe crest at this point.
You get through into the nose.
It almost doesn't matter whereyou end up in the nose, you just
want to see it underneath themucosa and once, once you're up
there, then you start directinglaterally, visualizing that
(37:27):
point that you're aiming for,aiming, aiming, coming in and
out of that osteotomy because itonly takes.
It's the only part you candirect it or change.
The direction is down on thetip of that burr as you go in
and out until you get rightwhere you want.
Now the same thing goes foranteroclosteroly Same thing
You're just using that twomillimeter drill out until you
get right where you want.
Now the same thing goes foranthero posteriorly same thing
you're just using that twomillimeter drill.
(37:48):
Once you get to that and youreally have to direct the burr
because it's going to want toskim along the medial aspect of
the nose.
Once you get into that pointagain, you hit it.
You can see where the lines areon that burr and just go
another four millimeters foryour apex and then switch to
what I use that burr and just goanother four millimeters for
your apex and then switch towhat I use.
I.
I've used the, the heel, theneodent helix long burr until,
(38:13):
actually for a long time, untilthe norris pterygoid kit came
out.
Norris pterygoid kit has a, hasa second as an implant specific
kit, has a second, has animplant-specific burr and that
one is a conical burr the wholeway.
That cuts the whole way Again,not just the tip.
I'll use that Once I use thatpilot drill, I'll use that next
(38:34):
drill as my final drill and I'llgo right again watching it hit
that apical target, thatosteotomy that I made at the at
the target spot, go in anotherfour millimeters and that's my
osteotomy, so it's a highlytapered uh yes
Speaker 4 (38:53):
drill right, so that that way you're able to.
Speaker 2 (38:57):
You know kind of, you have some freedom there on your
right again, I think I really Ireally form that direction with
that pilot drill, first the twomillimeter, and then I go to a
it's a two, two, three, two,three, two, I think, is what it
is, um, and then just follow itwith that, but again it's, it's
(39:18):
got to be under directvisualization.
Oh, totally, I think that.
I think that directvisualization thing is so key in
not just this zygos as wellyeah, I'm always interested with
how, how lazy people can be.
Speaker 3 (39:33):
Um, you know every, every, every case and you know I
, I teach and encourageeverybody.
You know, on, on, even on your,your standard easy case, still
still lift the nasal mucosa.
I feel that I have so much morecontrol of my case when I know
exactly where all of my drilltips are.
Speaker 2 (39:55):
I think that I'm going to use this kind of
symbolically when I say that thething that's important for an
archer, for an arch surgeon, isto lose the loops.
I mean you could use the loopsDon't get me wrong, I don't use
them but lose the loops becauseyou've got to see the whole
picture and it's not just evenseeing the whole arch.
It's when you strip the nasalmucosa and you're seeing this
(40:19):
just like your model.
I mean it looks exactly likethat, you know what you're
looking at.
You just model.
I mean it looks exactly likethat, you know what you're
looking at.
You just see so much more.
So it's almost likesymbolically losing loops,
seeing the whole picture.
Speaker 1 (40:32):
I think that's important, yeah, so something I
I've struggled a little bit withintraoperatively, and I
couldn't agree more aboutvisualization, illumination, you
know all of that is what reallymakes full arch doable and fun,
frankly?
And but something I've struggledwith is I routinely lift nasal
mucosa to ensure engagementwhenever I'm trying to do that
(40:52):
with traditional all in four Um.
But I've many times gonehunting to figure out you know
where, where's my Z point out,and I've tried to you know kind
of go up that lateral nasal walland figure out where I'm at,
and I have a harder time with it.
Do you have any tips about howto expose that intraoperatively,
identify that anatomy?
Are there some things that justkind of help us find our way
(41:12):
through the dark there?
Speaker 2 (41:13):
Yeah, I think so.
I think that first of all youshould study your your CAT scan
first.
Speaker 4 (41:20):
You can almost measure where that is.
Speaker 2 (41:27):
Now the tendency is not to go deep enough and you
don't need to go very deep.
You don't want to go very deepbecause you don't want to
encounter nasal acromal duct.
You want to be anterior to that, no matter what as you start to
strip.
I'm also, by the way, when whenyou strip, I tend to want to
strip widely and then go deep asI'm wide.
So, in other words, I don'twant to tunnel.
So I'm going to strip the nasalcrest of the maxilla straight
(41:49):
along the floor up the side ofthe nose as high as I feel like
I need to go, and then go alittle deeper each time.
So I have the floor of the noseexposed and then as I come up
the side, I can go a little bitdeeper and my periosteal is
going to stop.
Or in my case, I use a nasalfreer.
My freer is going to stop whenI get to that widening at that
(42:10):
turbinate.
So the anterior most point, ifyou're too far anterior, you
didn't hit the turbinate yetyou're going to go as high as
you want because there's nothingto stop you superficially or
not deep in the nose Go a littledeeper, you'll get to that
widening I see.
Speaker 3 (42:28):
I've also kind of found that if you find your
infraorbital framing, it'stypically right.
About that same line, would youagree?
Speaker 2 (42:39):
Yeah, it is, but that's a variable point to me.
So the other thing, by the way,is Cesar Guerrero, by the way,
has an atlas from years ago andhe did a series on infraorbital
using the ligoma implant withinfraorbital rim anchorage.
(43:01):
Not something that I would do,but the idea is that you can go
higher along that lateral nasalwall and still avoid the nasal
acromal duct.
To get to that point.
You can go higher if you needto, if that's where the
thickness is.
In fact, I was at a live surgerycourse in Brazil and I was
tasked to do a revision on apatient that came back with
(43:24):
failures and there really was noway to get anchorage at the
typical transnasal point and Ijust had to go up as close as I
could to the infraorbital rim toget anchorage.
So there's nothing there tostop me, as long as you see it
on the scan ahead of time.
What you're avoiding to stop me, as long as you see it on the
on the scan ahead of time, whatyou're avoiding but yeah,
(43:45):
generally that's at the level ofthe inferior turbinate is is
parallel with that you know.
Speaker 3 (43:50):
Also in that book you referenced there's uh zygoma
implants in the mandible yes,yeah, yeah, yeah oh boy you know
it's counting on apicalanchorage, isn't it?
Speaker 1 (44:04):
Yeah, no kidding.
So actually I fortunately had askull on hand just to kind of
be steady.
I don't know if I can get thecamera to focus on it, but I did
look because what you just saidwas very interesting, clark.
You said the infrarobal beingright at the same level as that
terminal, at least in this model.
Speaker 3 (44:22):
That's fairly accurate.
I mean, I think it'd be in theneighborhood.
Speaker 1 (44:27):
It's a reference point, right.
It's something just to kind ofgive us a little bit of
geolocation.
Oh, he, dave is getting hisskull.
Speaker 4 (44:32):
I'm sure, david, I did that one.
Speaker 1 (44:35):
Oh, look at this you got the t1000 and he really has
it too.
Oh, that's fantastic.
Um, but I also I mean, justjust looking at this, I mean it
all comes back.
Speaker 2 (44:48):
Just knowing your anatomy, I can tell too, is you
know, a lot of times when I'vebeen looking for this, I'm not
going posterior enough, right itall feels really smooth and I'm
like oh, I guess anatomy is notthere, but it's, it's back
there but look at it, look, ifyou look at it on on axial
slices, you can see just how farback you really have to go to
even involve the nasal lacrimalduct.
(45:09):
So when simon said that theaverage of the anterior part of
the, of the inferior turbinateto the to the nasal lacrimal
duct, on average is 15millimeters.
You know, you got some leeway.
Not every patient, no patient,is average.
Um, all of our kids are aboveaverage, but uh, in this case
you just you should look aheadof time and you'll know where it
(45:30):
is.
But that is, it's deeper, it isdeeper.
Speaker 4 (45:34):
I see, I see Can you, can you talk about some of the
complications um, around your uh, transnasal and like what
you've seen, seen what you'vehad to fix, and maybe just some
like key points?
of absolute no goes, and I knowyou just talked about how class,
the class one, is typically onethat you shouldn't do, but for
(45:57):
you know, as we're seeing moreand more people venture into
remote Anchorage, and maybepeople that shouldn't be
venturing into remote anchorage,I'm sure you're seeing more and
more things that are big no-nosthat I would love to go over.
Speaker 2 (46:14):
Well, I'll say I really think I only had one
transnasal implant that failedand it turns out it was a
patient that I couldn't getanything to stick on.
I finally ended up with a quadthat so far, so good is working.
But you know, it was likesometimes it really is the
(46:36):
patient you know you throw thesame thing at everybody and
sometimes usually it sticksright.
So I mean it, it sticks right.
Yes, so I mean it was a smoker.
I'm not blaming that, it's justnothing seemed to stick on this
guy.
As far as complications, I havenot seen any epiphyllum.
I've not seen any damage tonasal acrymal duct, nor have I
(46:59):
had to treat that.
But I know that that's outthere, certainly from trauma it
exists.
But as far as nasal fromtransnasal implants really it's
failures I've not seen.
I have seen.
I have seen tears and nasalmucosa dehiscence that I was
able to treat with local flapsand not GBR but just membranes
(47:25):
and that worked out fine.
Really, you can hug as long asyou stick with the principles.
Like everything else in life,if you stick with the principles
, you hug the lateral nasal wallso that you're not far off of
that, you're not expandingagainst the nasal mucosa and
your anterior to nasal acromalduct.
This is an implant.
(47:45):
This is a good, solid implantand use the right implant.
By the way, it's important touse the right implant.
So the aggressively threadedimplants are not made for this.
They're just not good.
The bone is extremely corticalbone.
It'll crack.
It'll crack the maxilla.
You'll be sorry you did it.
So there are implants out there.
You know there's just from a,from a company standpoint.
(48:07):
You know, neodent, helix Longwas.
This was the gold standard.
Norris now has one that'sspecific for this.
I think that as long as youhave a finally threaded implant
with a narrow apex, you're good.
My name is Dr Tyler Tolbert and I'm Dr Soren Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
And welcome back to the FixPodcast.
I am super excited abouttoday's episode.
I know I say that every time,but this time I mean it a little
bit more than I usually do.
So today we have an absolutepowerhouse of speakers in here.
(00:23):
If you combine the number oforches that have been done
between these four people,myself included, I'm sure you'd
be somewhere in the thousand,maybe five digits, I don't even
know.
But today we have Dr ClarkDamon who is returning to the
show.
Welcome back, clark.
And he has graciously brought onhis good friend and colleague
and mentor to all of us, drDavid Zellig, who instructed me
(00:47):
not to call him doctor, but youknow, I'm from the South.
It's going to be hard for me toavoid the formalities.
But just as a brief intro forDavid, as he likes to be called,
he is a board certified oraland maxillofacial surgeon and a
nationally recognized leader inimplant industry.
Surgeon and a nationallyrecognized leader in implant
dentistry.
Dr Zellig, excuse me.
David earned a bachelor'sdegree from the University of
(01:10):
Memphis, followed by his DDSfrom the University of Tennessee
College of Dentistry andcompleted his residency in oral
maxillofacial surgery at theLong Island Jewish Medical
Center.
His years practicing in Memphis, david served as an associate
professor in his department oforal and maxillofacial surgery
at the University of Tennessee.
He was an active member of hiscraniofacial surgery team,
specializing in orthodontic andTMJ reconstruction, alongside
his implantology practice.
Since relocating to New York,he has held key roles with Clear
(01:33):
Choice Dental Implant Centers,among several other centers,
where he leads advanced implantsurgical programs, including
full arch, zygomatic andpterygoid implant procedures and
a host of other procedureswe're going to be talking about
today.
David has zygomatic andpterygoid implant procedures and
a host of other procedureswe're going to be talking about
today.
David is also a contributingauthor in the textbook Remote
Anchorage Implant Leave noTrophic Maxilla Behind quite a
(01:53):
title there which focuses onzygomatic, pterygoid, transnasal
nasopalatine and trans sinusimplant techniques, featuring
case contributions and protocolsfrom leading surgeons in the
field, including himself, ofcourse.
So, david, welcome to the show.
That ended up being a whole lotmore jumbo than I ever planned
on and I think it was stillabbreviated from your actual
career.
But again, welcome to the show.
Thank you so much for sparingyour time.
(02:14):
I'm so excited to learn fromyou today.
Speaker 2 (02:15):
It's actually pretty cool to hear a eulogy about
oneself and to be able to speakafterwards.
But thank you for those words.
Speaker 1 (02:25):
Of course, of course, of course.
Now did that more or lesssummarize your career.
I'd be interested in how youwould add to it what sort of uh
things you hang your hat on?
Speaker 2 (02:32):
how would you define your career as well, just to
give uh the listeners somebackground well, I, you know, I
came out of out of residency andstarted my own practice in
memphis.
Um, I'm, you know, the southernthe Southern part of me is
still polite but I?
Um it turned into a full scopepractice and I was very proud of
that.
Um coming back to New Yorkyears, years later, after 20
(02:56):
plus years of private practice,back to New York, um, I got
really very active in traumasurgery and we'll talk about it
later.
I think that helped.
I got really very active intrauma surgery and we'll talk
about it later.
I think that helped.
That just the more you can domakes you a better surgeon.
So I just everything you do,even if it, even if you distill
your life down to arches,anything you can do to make
yourself a better surgeon helps,and my life is distilled my
(03:23):
professional life is distilleddown to arches, of course.
Speaker 1 (03:25):
That's what happens.
Yeah, absolutely.
And can you tell us a littlebit about your current clinical
practice?
We were talking a little bitbefore we turned on recording.
It sounds like you're goingaround to tons of centers
helping folks out with remoteencourage cases, still getting
yourself bloody and helpingpeople out of trouble and, you
know, putting out fires all overthe place.
What does that look like foryou?
Speaker 2 (03:45):
Well, you know, putting out fires all over the
place.
What does that look like foryou?
Well, I was an early.
I drank Palo Malo's Kool-Aidkind of early in my career and,
you know, brought that deal onfour idea to Memphis years ago.
And then when I came here, keptthat up and after a lot of
trauma, surgery and orthodonticsand others still doing art is
(04:07):
at the same time I wasapproached by.
It was a clear choice to open acouple of their centers and it
was pretty much focused onarches.
And when that got so busy Istarted mentoring some juniors
and when they got proficient Iwas left with only the extreme
arches, and that's where I am.
So you can't have enoughextreme arches in one place.
(04:29):
So I'm running around to a lotof different places doing their
extreme arches.
That's what's happened.
Speaker 1 (04:36):
So you're the fixer.
Speaker 3 (04:37):
Well, that's really cool.
So I just have a question sowhen did you go to the Mollo
Clinic, like what kind of talkedto me about that path.
Speaker 2 (04:48):
Yeah, first I drank his Kool-Aid in this country
first.
Actually, one of his earlystudents started teaching it in
Kentucky and I went to I thinkit was Lexington way back when,
back when, and then, and thenlearned from Milo after that and
(05:09):
just I don't know what to say.
When, when I think it was BoRangert that kind of convinced
me to say that wow, I'm usingengineering principles here and
we're bringing engineering intodentistry.
And when I say it's a bridge,it's a bridge like going over a
river and how many abutments youneed is based on how thick the
(05:31):
roadway is.
That kind of thing.
It was engineering principles.
It just hit me.
I guess I was a physics majorin college.
Not that I remember anythingabout physics anymore, but it
resonated with me.
Speaker 3 (05:43):
It made sense, right anymore, but that they're kind
of it.
It resonated with me.
It made sense, right, so so didyou.
Did you wait until the uh 20,uh 2011 article came out, where
he kind of published like hisfirst 245 cases, or were you
doing it um sooner than that?
Speaker 2 (05:57):
No, I was, I was um, I was early, early 2000.
Speaker 4 (06:02):
It was before it was cool.
Yeah yeah, david, can you talkto us a little bit about um?
You know how you've seen fromthe early 2000s Cause you're
probably one of the first guysin the U S you know to to really
take it on Maybe not the first,but like in the in that first
realm Um and maybe you know whatthings you've seen change over
(06:24):
the last two decades.
Uh, you know pros, cons, kindof thing would be great.
Speaker 2 (06:29):
Uh well, uh, two things really.
First of all, we all came fromdental school and we all respect
bone and the idea of bonereduction was anathema to all of
us and that's what that was.
The big thing that we had towas anathema to all of us and
that was the big thing that wehad to the big river to cross to
(06:49):
get to effective all-on-Xtreatment was that amount of
bone reduction.
So we I think all of us were alittle hesitant at the beginning
doing the bone reduction thatwe really needed.
And I don't mean just to hide atransition line.
I'm talking about to get a goodall-on-four-shelf table, to be
able to get implants in solidbone, to apply the other
(07:12):
principles that other giantsgave us, like Dennis Tarnow, a
couple of millimeters of bonebuckle around the implant.
So that was one thing that'schanged.
The other thing that changed, Ithink that, well, prosthetic
materials certainly.
You know the initial acrylicbridges that we were using
(07:33):
worked nicely and maybe did havethe idea of some
shock-absorbing effect on theimplant, but they ended up
looking horrible after a year orso.
So moving into ceramics,zirconium, certainly was a big
deal.
I think those are the realadvances as we went along.
Speaker 3 (07:54):
It's amazing because I was doing arches probably 2013
is whenever I started and, youknow, hit them pretty heavy and,
looking back from really 2013,which I felt like I was, you
know, fairly new I mean, Iwasn't, you know, one of the
(08:15):
first, but you know, still in2013, I was having to deal with,
you know, the dogma of bonereduction with you know the
dogma of bone reduction, right,the dogma of, you know, taking
out a few healthy teeth, and youknow the dogma that was also
like, hey, these are all goingto fail really, really soon.
And you know it's amazing tosee where we are today.
(08:41):
And you know, I really kind ofthink, like right around COVID
and and maybe a touch before, itreally seemed like the implants
got so much better, like 2019,2020, the implants that we have
in the abutments just seemedlike everything got so much
better.
Do you kind of feel similarly?
Speaker 2 (09:04):
it's interesting because I'm looking back at.
Unfortunately, when I firststarted learning all on four, I
said, wow, I need to go to acourse to learn how to put in
implants that aren't parallel.
All of my implants wereparallel.
You know, it was the learningcurve.
All my implants looked horribleand I look back at them.
What the idea of doing fewerimplants as opposed to arches of
(09:27):
eight and ten implants was wasanother river to cross and you
look at the failures of thosearches with the titanium
overdoses and and that kind ofthing, and when they fail, they
fail miserably.
Yeah, even if this, even if animplant fails in an all-on-x,
it's, it's you at least havemore bone because you haven't
(09:50):
occupied the entire arch withtitanium.
So I think that was a benefittoo early.
You know, listen, I was doingimplants when they were machine
surfaces, brown marks and thenlater hydroxyapatite coated
implants and that didn't workout.
You know, I did press fits.
We went through the whole.
Yeah, I went through the whole.
Wow, I'm sounding like um, god,I'm sounding like I'm tating to
(10:13):
something right now you'rebullshit or something.
Wow, I don't know how thathappened so fast, but I went
through that and yeah, so theimplants did get better, but I
think, uh, we also just theunderstanding of the principles.
It finally clicked.
Speaker 1 (10:30):
Yeah, I think the general trend has been that you
know, through clinical practicewe've kind of discovered you
know what works and what doesn't, and we've had a lot of people
doing that hard work to gothrough all the things that
didn't work and now it's gettingdown to the actual product
level where you know amulti-unit is shaped in such a
way that we don't have to boneprofile as often you know.
(10:53):
Just all the little nuances isnow we're not going to
programmed in to make full archa whole lot more predictable.
And there was a lot of gruntwork that happened in the past
20 years or so to get us to thepoint where you know we have
things that just work and I'mnot sure that you know people
like myself and Soren that haveyou know, come out in the last,
you know, half decade or so, andthen doing this, I don't know
that we can fully appreciate allthe things that came and went
um to get where we're at.
And it's, you know, we lovetalking about not not just the
(11:14):
things that guys hear but wherewe're going.
But we certainly appreciatethat we're coming into the game
after people have already spentso much time figuring out all
the things that didn't work.
So we do appreciate, you know,you guys contributing to that
body of work.
Speaker 2 (11:25):
Of course, Well, that's actually a very you know.
They say that there are threekinds of people Some people can
learn from a book, and somepeople can learn from other
people's mistakes, and somepeople got to pee on the
electric fence themselves and itwould be preferable to learn
from someone else's mistakes.
That's right, that's right.
Speaker 3 (11:42):
That's right, that's right that's right, yeah, I mean
, I remember uh using the, thenobel, the nobel system, and you
know you had to what one.
The abutments didn't always, youknow, fit very well onto the
internal connection and then youhad to profile every single one
of those and what's?
What's kind of a funny story is,in 2017, I bought a ton of
(12:07):
Nobel implants and then I think18 or 19 switched over to Neodem
, so I didn't have to boneprofile anymore and I just left,
literally, I think in myAmarillo office I left 500 Nobel
implants and so, rolling into2021, I was like these things
(12:27):
are all going to expire.
So I had to do probably, Idon't know 60 or 70 arches all
with Nobel and it's and I mean,it's so frustrating because you
have a bone profile surgical kit.
You have, like you know,several.
You have to have so manysurgical kits out to you know to
(12:48):
do a case and then you know, loand behold, if you want to do a
4.0, well, then you got toreach for a speedy, groovy kit
and then that has its own boneprofilers and different
abutments.
I mean it is my assistantshated 2021 because we were using
all these antiquated systemsand it's really hard doing
(13:10):
pterygoids and having the boneprofile back there.
And you know if you're concerned, is your abutment seated all
the way, you know, because thatNobel multi-unit abutment
doesn't have a full 360 degreesconnection.
So it's really interesting, you, you know all these things that
we take for granted now, thatreally speed up our surgeries
yeah, absolutely the.
Speaker 4 (13:31):
I'm sure your assistants weren't too happy if
they forgot to sterilize one,one thing during your kit.
And then you're well, or?
Speaker 3 (13:37):
if they, if they lost the bone profiler, the, the
little, the little guide thatsits on top of the implant once
it's placed, and you know ifit's a speedy groovy compared to
a Nobel active.
You know, they're like.
These things look like healingabutments too.
Oh, they look like enough.
Speaker 1 (13:53):
Yeah, there's way too many yeah.
Speaker 2 (13:56):
You missed the Nobel's egg almonds, though,
didn't you?
Speaker 3 (14:01):
Yeah, I got, I got, I got, I got a bunch of them
right up, right up here, okayyeah.
Speaker 2 (14:04):
I got a bunch of them right up here.
Okay, that was another one witha mount.
That was impossible.
Speaker 3 (14:08):
Yeah, we'll try my first quad that I ever did after
in like 2016 or something or 15.
I broke the mount inside of the45 degree abutment and so
there's a whole screw in thereand you know you're trying to
back a screw out after you knowyour first quad psychoma case.
(14:29):
Luckily I had a colleague thatwas there who was like, hey, you
did the case, let me back outthe screw for you, and so
luckily he navigated that.
Speaker 4 (14:40):
But yeah, lots, lots of uh great time, lots of
frustrating things, it's forsure I'm kidding, so go ahead
all right, I was just going tosay we uh have gone through,
like you know, with clarkpreviously a lot of the um zero
to 100 when it comes to fullarch, uh basics, what you need
(15:02):
to do to get started, goodprotocols to learn prior to, you
know, tackling your firstarches.
So today I think what we wantedto go over was a lot more of
the remote anchorage transnasalquad zygoma stuff that you excel
in.
So I'd love to kind of startour discussion on that with um
(15:26):
talking about transnasal, youknow, like the Z point and that
kind of thing, and uh, go overyour expertise on what, if
doctors are looking to get intotransnasal, maybe what
continuing education you'drecommend um key anatomical
points, that kind of thing wouldbe very very helpful for our
listeners.
Speaker 1 (15:43):
And I think, starting first, we should just go with
definitions Like what?
What is a trans nasal?
Speaker 3 (15:47):
what is the point, so we know what we're doing.
Speaker 2 (15:49):
A good start all right well, you know, the first
thing that came out and and malowrote about it, only jensen
wrote about it, others wroteabout was the trans sinus
implant, was the idea of using,if a to get whether it's because
the sinus anatomy is such thatthe anterior sinus wall is
anterior to ideal position orjust to extend the AP spread.
(16:14):
A trans-sinus implant is onethat has crestal anchorage
underneath the sinus and apicalanchorage at the lateral nasal
wall, with nothing in betweengoing through the sinus, with
the membrane lifted ideally, butplus minus lifted membrane but
crestal anchorage under thesinus and apical anchorage at
(16:35):
the lateral nasal wall.
And the idea here is in atransnasal is going to go
bypassing the lateral nasal wall, having crestal anchorage
underneath the nose and subnasalbone and apical anchorage at
the lateral nasal wall.
Well, in this case the implantis at the lateral incisor
(16:55):
position, just as anteriorzygoma would be, or an anterior
implant.
But if you don't have enoughsubnasal bone to put in whether
it's endpoint or towards thenasal crest of the maxilla bone
to put in whether it's endpointor towards the nasal crest of
the maxilla, the alternative isto use the subnasal bone if you
have at least three millimetersplus of subnasal bone and then
(17:15):
get into the lateral nasal wallat this junction of and I call
it the confluence of the lateralnasal wall, lateral maxillary
wall anterior to the nasalacromal duct, at the level of
the inferior turbinate.
You got that.
It's kind of three-dimensional.
Speaker 1 (17:30):
We triangulated it, yeah.
Speaker 2 (17:32):
And that is the target that some people have
called the Z-point.
I can't call it that.
Speaker 3 (17:40):
So where do you think that name comes from?
The Z-point.
Speaker 2 (17:44):
Yeah, I think Dan Hulsklaw did that for me.
He calls me the pioneer.
I don't want to be a pioneer, Ijust want to follow giants that
I stand on their shoulders.
But that's the idea.
So the apex of the implant isin the lateral nasal wall, at
(18:06):
this confluence of lateral nasaland lateral maxillary wall, and
the posterior margin is a nasallacrimal duct and fortunately
the ENT literature has done ourwork for us to help define where
that is and where we can findthat preoperatively on CT scans.
(18:26):
And there's in two-thirds ofthe population there's adequate
bone for this implant.
The apical anchorage I'mtalking about two-thirds of the
population has it where there'senough bone anterior and enough
thickness anterior to the nasalacromal duct.
As far as training to see ittechnically, the way I teach
(18:49):
remote anchorage, except for thepterygoid, is visualize
everything.
So there's no minimal invasivesurgery for a zygoma in my
opinion, not because you can'tget the zygoma in the right
place, but it helps you avoidsome of the complications.
So wide exposure, seeing theentrance and the exit points.
(19:10):
Do exactly the same thing withthe transnasal visualize.
What made it reasonable for meas an oral surgeon is because
you know I've been there beforefor orthodontic surgery, so
you're in the nose a lot.
You know what you're looking at, you know what to avoid, but
it's eminently teachable.
You know, this is pretty clean,direct dissection.
(19:35):
As far as education, yes, whereyou can get this, where you can
learn this, well, you can learnit in books, but you got to see
it and do it.
So, fortunately, well,unfortunately, early days, when
I had dark hair, there weren't alot of courses and there
certainly weren't books for anyof this, and then you just had
to base what you did onprinciples that existed before.
(19:57):
So that's generally what I'vedone is use previous principles
and kind of expand on them.
In this case, now there arecadaver courses, there are live
surgery courses, there'smentorship to a bunch of us guys
that are willing to go aroundand look over your shoulder and
hold your hand.
(20:17):
It just didn't exist in ourfield.
It didn't exist 10, 20 yearsago, but it existed in medical
education.
Medical education is reallyinteresting If you think about
the way internships andresidencies there's someone
holding your hand at thebeginning, like riding a bike
with training wheels, and slowly, as you get proficient, they're
(20:38):
watching you holding your handsalmost literally.
And then they let go of yourhand and they're still watching.
They're still holding thebicycle seat as they're running
down the driveway and eventuallythey let go of your hand and
they're still watching.
They're still holding thebicycle seat as they're running
down the driveway and eventuallythey let go and you're flying
on your own and we finally havethat in dentistry.
We just didn't have this beforeand it's nice to be able to say
(20:59):
we got cadaver courses and livesurgery courses and mentorships
and it's all out there.
Cadaver courses and livesurgery courses and mentorships,
and it's all out there.
Back in back in the day, backin the day, I flew all over the
world to watch people do thesethings Um, literally all over
the world.
It was crazy because there wasno place to go officially, just
(21:21):
nice guys that let me watch.
Speaker 1 (21:23):
And, um, eventually you just got to a point where
you say I gotta do it and that'swhat it was that's, that's
really incredible um, david,just just the lengths that you
had to go to following it'sfortunately we're living in
better times and for some things, for some things not, but for
this we have, we have podcastsnow you can speak, speak
(21:43):
yourself.
Speaker 2 (21:44):
Now the transnasal.
Back to the transnasal.
So it really is an alternativein many patients for a quad, for
the anterior zygoma of a quadzygoma, and this is something
I'm curious too about, david andI.
Speaker 1 (21:56):
Actually I took the liberty of messaging a few
friends that we were going to beinterviewing you and got some
questions back, and so my goodfriend, dr Sean Lan, out of
Atlanta, georgia.
He had been reading throughyour 2025 paper on the placate
guidelines and he's asking withregards to the Z-point implant
(22:17):
we've been talking about, hesaid would engaging the lateral
nasal wall be a viablealternative or would you go
straight to an anterior superiorzygote?
So I guess what he's saying is,if you had difficulty engaging
the Z Z point or if it wereinsufficient, is there a world
where you would go through thatsubnasal bone and just engage
the lateral nasal wall, asopposed to finding that conflict
.
Speaker 2 (22:36):
Yes, there is one type Well, in a way that is
still the it is lateral nasalwall that this is engaging even
in that world.
But so here's the thing thelateral nasal wall, that this is
engaging even in the world.
But, um, so here's the thing.
The lateral nasal wall in abouta third of the population is
what simon daniel simonclassified as a type three,
where there's a lot of spacebetween the late nasal lacrimal
(22:56):
duct and the anterior edge ofthe lateral nasal wall.
But it's very thin and in thosecases I term it exteriorized.
As you're going up the thelateral nasal wall, you're
hugging the lateral nasal wall,but because it's so thin, it's
dehiscence on the nasal side,not through the nasomycosis.
It's still deep to thenasomycosis and on the facial
(23:18):
side as well, halfway up, butthe apex is still in solid bone.
So the answer is yeah, you cando that.
That lateral nasal wall is isas long as it's surrounded by
bone, and the higher you go itgets thicker as you go.
As long as you know, you canknow, you can locate where that
nasal acromal duct isradiographically.
So the answer is yes.
(23:39):
The only place where you reallyshould not do it is in what
simmon called the type one wherethere is no space between the
nasal acromal duct right andthat and that edge of the
lateral nasal wall, and also invery hypoplastic maxillas, not
just severely atrophic buthypoplastic, where there's a
real class 3 ap relationshipbecause that this implant is
(24:00):
palatal to the crest as opposedto a interzygoma, that's on the
facial aspect of the, of the ofthe of the crest right.
You would actually make your apdiscrepancy worse yeah, that's.
Speaker 1 (24:12):
That's actually something that uh simon made a
post about I think it was maybethree weeks ago, and he was
talking about disadvantage ofthe transnasal versus doing
anterior superior.
Zygote is that you have a lotmore prosthetic flexibility, uh,
when it comes to doing interiorsuperior, whereas with that
transnasal you might just fixateinto that palatal position.
Speaker 2 (24:30):
But in a non-hypoplastic maxilla, in a
normal position maxilla.
I would say that 90% of mytransnasals have a 17 degree
multi-unit abutment comingforward and it puts it right
over the the lower incisors.
Speaker 1 (24:47):
So that's generally where I go, great, generally
where it goes.
Speaker 3 (24:51):
Yeah, so and and this was, uh, one of the questions
that I had.
Uh for you, david, in regardsto some prosthetic challenges,
um is is with the class 3patient.
Um, so you know, obviously wewant to avoid a significant
anterior cantilever, and youknow my question there is, you
(25:13):
know, if you have a veryhypoplastic mandible, oftentimes
let's also say maybe theirzygoma is, you know, not very
tall, maybe.
Let's just say it's, you know,15 millimeters, right, I don't
know if I've seen a zygoma thatshort, but let's say there's one
where it precludes you fromthat.
So you're almost forced intodoing this on a class three.
(25:35):
Would you then prostheticallyrecommend that we maybe bring
the mandibular teeth back andkind of retrocline and just kind
of pull everything back in, soit's not as anterior.
Speaker 2 (25:50):
Yeah, I think there are a couple of things.
First of all, there's still aplace in the world for
orthomatic surgery and if we allme, you, the patient, everybody
understands that in an idealworld we would fix your skeletal
deformity before we didanything else, if we're
accepting that, we're not goingto do that and we're going to
(26:11):
camouflage or we're going tocompromise, then sometimes you
have to compromise yourocclusion as well.
That end-to-end, edge-to-edgeocclusion may be the best you
can get and ling, linguallydecline the lower anteriors to
get back as an orthodontistwould do camouflage,
(26:32):
non-surgical orthodontics.
So that is a possibility.
There's really no otheralternative.
I mean, the alternative, ofcourse, is grafting, major
grafting, but I've been thatgamut and long term that just is
not a good answer.
Right?
Well, in my hands, even thepatient-specific implants, these
(26:54):
subs, you can't correct thatmuch that way either.
Well, you're still on the samebase of bone.
Speaker 1 (27:02):
So I'm curious about this too, because I think it was
Dr Zach Brown that presented onthis recently at the last ORCA
symposium.
He talked about prosthicmathics right, so this thing
that we're able to camouflageand compensate for these things
with prosthetics.
You know, when you'reevaluating these hyperplastic
cases severe class discrepancieswhere do you kind of draw the
(27:24):
line?
And how do you draw the linebetween this really is an
orthognathic case or no?
This is something we couldaccomplish with just some
prosthetic black magic.
Speaker 2 (27:33):
So I mean age of the patient realistically is one
thing we really have to thinkabout.
What's realistic for thepatient?
We can explain it to thepatient, give these options out
there, but that's a that's awhole lot to expect anybody to
go through nowadays, especiallyin this age of instant
gratification.
you know, like finals, finalarches, final teeth in 24 hours.
(27:57):
We can discuss that in a minutetoo, but I think that that's.
That's a big thing.
You know a patient can be, can,can explain all.
You can explain everything tothe patient ahead of time, and
smile design is critical aheadof time.
Really, get a smile design.
Show a patient what you can do,even if it means in plastic.
Just show them what you can do,what's realistic and what's not
(28:18):
.
I think that these hugeanterior cantilevers are just as
bad as a huge posteriorcantilever.
Anterior cantilevers are justas bad as a huge posterior
cantilever.
There's only so much you can dowith a nasal palatine implant
to try and avoid an anteriorcantilever.
It just doesn't go as far asyou want it to.
So these are things you have toconsider for long-term
solutions.
Speaker 1 (28:40):
Definitely, definitely.
So, as far as when you're doingthese transnasals, is there
ever an indication to do anygrafting?
So if you were to elevate themembrane, is there any reason
that you would want to pack somebone in there?
Is there any possibility you'dget some bone back?
Speaker 2 (28:56):
There's a Professor Almeida who did the first
English article on this.
He showed grafting on his casesand I did one after a while.
Here's my thinking.
The area of the mucosa thatcovers this implant on the nasal
(29:19):
side is pretty robust.
It's pretty thick mucosa.
It's not like a sinus membraneat all.
It's not mobile mucosa.
It's not like a sinus membraneat all.
Right, it's not mobile mucosa.
In fact, you know the way Idescribe it in courses if you
pick your nose you don't evenget to the bony nose.
You're in the soft tissue nose.
You don't even get back there.
So you're not in area mobilemucosa.
(29:40):
Nothing's hitting it.
It's not being compressed.
However, the idea was to graphthat to cover the threads of the
implant there, not necessarilyfor osteointegration, but to
protect the navel mucosa.
The problem with that is thisimplant is not and this is my
argument against it, by the way,that part of the implant is not
(30:00):
in the narrowest part of thenose.
The narrowest part of the nosefirst of all is in the soft
tissue nose, not in the bonynose.
And the narrowest part of thenose first of all is in the soft
tissue nose, not in the bonynose.
And the narrowest part of thebony nose is on the medial most
aspect of the inferior turbinateright and we're lateral to the
medial most aspect of theinferior turbinate.
So we're not in the narrowestpart of the nose.
So I don't see us narrowingairway space unless you graft.
(30:21):
If you graft you couldpotentially bulk that out too
much and narrow the airway spaceand then you are compressing
that mucosa.
Now there's a new implant that Ihelped design that has a bald,
non-threaded portion on the midshaft of that implant so that
you can and it's timed such thatthe hex works that the medial
(30:42):
aspect underneath the mucosathere does not have threads.
So it does away with that wholeargument.
And as far as grafting forincreased stability, I'm getting
typically 60 newton centimetertorques on these.
It's cortical bone, it's hardbone.
Um, that's generally what I'mlooking at.
So I see graft.
Speaker 4 (31:02):
I see, can you talk a little bit about, um, your
indications as far as and maybeeven mentioned to like, trans
sinus?
I know we've gone through thison the podcast before, but when
you're doing a trans sinus, whenyou're doing a trans nasal, um,
how much crustal bone do youlike to have?
How much apical bone do youlike to have?
(31:22):
When you're doing a trans sinus, um, are you typically, um, you
know, lifting the membrane?
Are you going through themembrane?
Um, what are your indicationsfor doing both of those?
Speaker 2 (31:34):
I think that's great, you guys are great, you guys
are great, these are great.
So, first of all, yeah, I dolift the membrane.
It's not that big a deal, youknow it's.
It's uh, almost like an asideto get a good round diamond burr
and get through the bone andlift the membrane.
Um, can you do it without it?
Sure, but what can happen?
(31:55):
I don't know.
We saw a lot of sinusitis fromthe, the og method of, of
zygomas.
So why not stay outside thesinus, just like we do with
zygomas now?
So, um, as far as the amount ofbone, so the literature
supports and that's that's um.
Ollie jensen wrote about it,like I said, and milo also that
(32:16):
you need greater than threemillimeters of sub antral bone
to not need to graft, to notneed to do a sinus lift.
So I I use the same thing.
I want more than threemillimeters of subnasal bone as
my crestal anchorage.
The literature on the transsinus suggests that you need two
millimeter thickness of lateralnasal wall and generally, yeah,
(32:40):
that's what you have.
I just double it kind ofempirically.
I just said empirically if wecan do two millimeters of
lateral nasal wall thickness fora trans sinus implant which
goes through the lateral nasalwall more perpendicular.
This is going more parallelalong the lateral nasal wall.
So I'm just going to say I cando double that easily.
(33:03):
So I aim for four millimeters.
I'll hit that inferiorterminate point and then enter
four millimeters superiorly forapical anchorage of at least
four millimeters.
So I got an eight millimeterimplant, essentially four
millimeters at the apex and fourmillimeters at the crest, and I
got good stability.
Speaker 1 (33:21):
And in order to, because I want to make sure
everyone's appreciating what youjust said.
So you're saying you're doingthe trans sinus and you're
actually targeting the Z pointitself for your ankle anchorage?
Is that what you're saying?
Speaker 2 (33:34):
No, no, no, no, that's really hard to that's
hard to aim for that.
That's why I'm Anytime you gofrom the trans sinus, you're
going through the sinus.
What bone are you going to hit?
You're going to hit the lateralnasal wall.
Of course.
I suppose you could, if you'rethat much of a sniper, expose
the lateral nasal wall andtriangulate.
Yomi could do it.
Speaker 1 (33:58):
Yeah, let's get Clark starting on Yomi.
Speaker 2 (34:00):
Yomi, good, but I don't.
You know that you have twomillimeters of thickness.
You already looked at your CTscans.
You know what you have and,like I said, you're hitting that
more perpendicular.
You're not really tangentiallyhitting that lateral nasal wall.
That's not really the apex.
It's nice if you could hit it,but that's not part of that.
(34:23):
But that's not part of that.
Speaker 3 (34:33):
Yeah, I was going to ask your opinion on a trans
sinus that goes up to the Zpoint there.
I've always avoided that, yeah,for fear of it's much easier to
hit the NLD from a posteriorapproach than it is directly
visualizing that.
So I wondered if you felt thesame.
Speaker 2 (34:51):
Absolutely.
I think that the idea here is,especially if you've opened the
sinus window, is to hit thatcurvature of the anterior wall
of the sinus where it meets thelateral nasal wall, and you can
almost see it if you need to.
If it's really thin, you couldactually watch it come through,
the facial aspect of that bone,the apex, coming through if you
(35:12):
need it correct um, I haveanother question for you.
Speaker 3 (35:19):
Uh, you know, I've I've probably completed 20, uh
transnasal implants and maybe atouch more, but probably about
20.
You know, if I liked calling it, you call it crystal or you
could call it the coronalentrance point point.
(35:45):
So kind of walk me through.
There's a little bit of alearning curve because you
almost have to not over widenyour osteotomy at the crestal
aspect but you need to have alittle bit of degrees of freedom
to really kind of get yourpilot drill, an initial prep.
Speaker 2 (35:58):
Yeah, sure, um, so first of all, I generally will
mark lateral incisor andjunction of second premolar,
first molar.
I'll mark that on the alveolus.
(36:18):
That's going to be my idealpositions for the four of all
on-on-x, all-on-four, part of anall-on-x, and I'm going to keep
that.
I know that Vandalum talksabout.
If you need, depending on thelateral wall thickness, he moves
that laterally or medially, butI'm going to idealize that
position lateral and sizer.
(36:38):
Let my axis hold me in thecingulum of that lateral.
They all look alike that wayand I'm going to start my
osteotomy with a, with a Lancepilot drill.
Uh, the near dent, twomillimeter, um, sharp pilot.
Um, the beauty of that burr isthat it only cuts in the in the,
(37:02):
the part of the tip that hassharp sides, flat sides.
So the in the, the part of thetip that has sharp sides, flat
sides.
So the shaft, the long shaft,doesn't cut, so you just get
through.
Again, you got to be palatal tothe crest at this point.
You get through into the nose.
It almost doesn't matter whereyou end up in the nose, you just
want to see it underneath themucosa and once, once you're up
there, then you start directinglaterally, visualizing that
(37:27):
point that you're aiming for,aiming, aiming, coming in and
out of that osteotomy because itonly takes.
It's the only part you candirect it or change.
The direction is down on thetip of that burr as you go in
and out until you get rightwhere you want.
Now the same thing goes foranteroclosteroly Same thing
You're just using that twomillimeter drill out until you
get right where you want.
Now the same thing goes foranthero posteriorly same thing
you're just using that twomillimeter drill.
(37:48):
Once you get to that and youreally have to direct the burr
because it's going to want toskim along the medial aspect of
the nose.
Once you get into that pointagain, you hit it.
You can see where the lines areon that burr and just go
another four millimeters foryour apex and then switch to
what I use that burr and just goanother four millimeters for
your apex and then switch towhat I use.
I.
I've used the, the heel, theneodent helix long burr until,
(38:13):
actually for a long time, untilthe norris pterygoid kit came
out.
Norris pterygoid kit has a, hasa second as an implant specific
kit, has a second, has animplant-specific burr and that
one is a conical burr the wholeway.
That cuts the whole way Again,not just the tip.
I'll use that Once I use thatpilot drill, I'll use that next
(38:34):
drill as my final drill and I'llgo right again watching it hit
that apical target, thatosteotomy that I made at the at
the target spot, go in anotherfour millimeters and that's my
osteotomy, so it's a highlytapered uh yes
Speaker 4 (38:53):
drill right, so that that way you're able to.
Speaker 2 (38:57):
You know kind of, you have some freedom there on your
right again, I think I really Ireally form that direction with
that pilot drill, first the twomillimeter, and then I go to a
it's a two, two, three, two,three, two, I think, is what it
is, um, and then just follow itwith that, but again it's, it's
(39:18):
got to be under directvisualization.
Oh, totally, I think that.
I think that directvisualization thing is so key in
not just this zygos as wellyeah, I'm always interested with
how, how lazy people can be.
Speaker 3 (39:33):
Um, you know every, every, every case and you know I
, I teach and encourageeverybody.
You know, on, on, even on your,your standard easy case, still
still lift the nasal mucosa.
I feel that I have so much morecontrol of my case when I know
exactly where all of my drilltips are.
Speaker 2 (39:55):
I think that I'm going to use this kind of
symbolically when I say that thething that's important for an
archer, for an arch surgeon, isto lose the loops.
I mean you could use the loopsDon't get me wrong, I don't use
them but lose the loops becauseyou've got to see the whole
picture and it's not just evenseeing the whole arch.
It's when you strip the nasalmucosa and you're seeing this
(40:19):
just like your model.
I mean it looks exactly likethat, you know what you're
looking at.
You just model.
I mean it looks exactly likethat, you know what you're
looking at.
You just see so much more.
So it's almost likesymbolically losing loops,
seeing the whole picture.
Speaker 1 (40:32):
I think that's important, yeah, so something I
I've struggled a little bit withintraoperatively, and I
couldn't agree more aboutvisualization, illumination, you
know all of that is what reallymakes full arch doable and fun,
frankly?
And but something I've struggledwith is I routinely lift nasal
mucosa to ensure engagementwhenever I'm trying to do that
(40:52):
with traditional all in four Um.
But I've many times gonehunting to figure out you know
where, where's my Z point out,and I've tried to you know kind
of go up that lateral nasal walland figure out where I'm at,
and I have a harder time with it.
Do you have any tips about howto expose that intraoperatively,
identify that anatomy?
Are there some things that justkind of help us find our way
(41:12):
through the dark there?
Speaker 2 (41:13):
Yeah, I think so.
I think that first of all youshould study your your CAT scan
first.
Speaker 4 (41:20):
You can almost measure where that is.
Speaker 2 (41:27):
Now the tendency is not to go deep enough and you
don't need to go very deep.
You don't want to go very deepbecause you don't want to
encounter nasal acromal duct.
You want to be anterior to that, no matter what as you start to
strip.
I'm also, by the way, when whenyou strip, I tend to want to
strip widely and then go deep asI'm wide.
So, in other words, I don'twant to tunnel.
So I'm going to strip the nasalcrest of the maxilla straight
(41:49):
along the floor up the side ofthe nose as high as I feel like
I need to go, and then go alittle deeper each time.
So I have the floor of the noseexposed and then as I come up
the side, I can go a little bitdeeper and my periosteal is
going to stop.
Or in my case, I use a nasalfreer.
My freer is going to stop whenI get to that widening at that
(42:10):
turbinate.
So the anterior most point, ifyou're too far anterior, you
didn't hit the turbinate yetyou're going to go as high as
you want because there's nothingto stop you superficially or
not deep in the nose Go a littledeeper, you'll get to that
widening I see.
Speaker 3 (42:28):
I've also kind of found that if you find your
infraorbital framing, it'stypically right.
About that same line, would youagree?
Speaker 2 (42:39):
Yeah, it is, but that's a variable point to me.
So the other thing, by the way,is Cesar Guerrero, by the way,
has an atlas from years ago andhe did a series on infraorbital
using the ligoma implant withinfraorbital rim anchorage.
(43:01):
Not something that I would do,but the idea is that you can go
higher along that lateral nasalwall and still avoid the nasal
acromal duct.
To get to that point.
You can go higher if you needto, if that's where the
thickness is.
In fact, I was at a live surgerycourse in Brazil and I was
tasked to do a revision on apatient that came back with
(43:24):
failures and there really was noway to get anchorage at the
typical transnasal point and Ijust had to go up as close as I
could to the infraorbital rim toget anchorage.
So there's nothing there tostop me, as long as you see it
on the scan ahead of time.
What you're avoiding to stop me, as long as you see it on the
on the scan ahead of time, whatyou're avoiding but yeah,
(43:45):
generally that's at the level ofthe inferior turbinate is is
parallel with that you know.
Speaker 3 (43:50):
Also in that book you referenced there's uh zygoma
implants in the mandible yes,yeah, yeah, yeah oh boy you know
it's counting on apicalanchorage, isn't it?
Speaker 1 (44:04):
Yeah, no kidding.
So actually I fortunately had askull on hand just to kind of
be steady.
I don't know if I can get thecamera to focus on it, but I did
look because what you just saidwas very interesting, clark.
You said the infrarobal beingright at the same level as that
terminal, at least in this model.
Speaker 3 (44:22):
That's fairly accurate.
I mean, I think it'd be in theneighborhood.
Speaker 1 (44:27):
It's a reference point, right.
It's something just to kind ofgive us a little bit of
geolocation.
Oh, he, dave is getting hisskull.
Speaker 4 (44:32):
I'm sure, david, I did that one.
Speaker 1 (44:35):
Oh, look at this you got the t1000 and he really has
it too.
Oh, that's fantastic.
Um, but I also I mean, justjust looking at this, I mean it
all comes back.
Speaker 2 (44:48):
Just knowing your anatomy, I can tell too, is you
know, a lot of times when I'vebeen looking for this, I'm not
going posterior enough, right itall feels really smooth and I'm
like oh, I guess anatomy is notthere, but it's, it's back
there but look at it, look, ifyou look at it on on axial
slices, you can see just how farback you really have to go to
even involve the nasal lacrimalduct.
(45:09):
So when simon said that theaverage of the anterior part of
the, of the inferior turbinateto the to the nasal lacrimal
duct, on average is 15millimeters.
You know, you got some leeway.
Not every patient, no patient,is average.
Um, all of our kids are aboveaverage, but uh, in this case
you just you should look aheadof time and you'll know where it
(45:30):
is.
But that is, it's deeper, it isdeeper.
Speaker 4 (45:34):
I see, I see Can you, can you talk about some of the
complications um, around your uh, transnasal and like what
you've seen, seen what you'vehad to fix, and maybe just some
like key points?
of absolute no goes, and I knowyou just talked about how class,
the class one, is typically onethat you shouldn't do, but for
(45:57):
you know, as we're seeing moreand more people venture into
remote Anchorage, and maybepeople that shouldn't be
venturing into remote anchorage,I'm sure you're seeing more and
more things that are big no-nosthat I would love to go over.
Speaker 2 (46:14):
Well, I'll say I really think I only had one
transnasal implant that failedand it turns out it was a
patient that I couldn't getanything to stick on.
I finally ended up with a quadthat so far, so good is working.
But you know, it was likesometimes it really is the
(46:36):
patient you know you throw thesame thing at everybody and
sometimes usually it sticksright.
So I mean it, it sticks right.
Yes, so I mean it was a smoker.
I'm not blaming that, it's justnothing seemed to stick on this
guy.
As far as complications, I havenot seen any epiphyllum.
I've not seen any damage tonasal acrymal duct, nor have I
(46:59):
had to treat that.
But I know that that's outthere, certainly from trauma it
exists.
But as far as nasal fromtransnasal implants really it's
failures I've not seen.
I have seen.
I have seen tears and nasalmucosa dehiscence that I was
able to treat with local flapsand not GBR but just membranes
(47:25):
and that worked out fine.
Really, you can hug as long asyou stick with the principles.
Like everything else in life,if you stick with the principles
, you hug the lateral nasal wallso that you're not far off of
that, you're not expandingagainst the nasal mucosa and
your anterior to nasal acromalduct.
This is an implant.
(47:45):
This is a good, solid implantand use the right implant.
By the way, it's important touse the right implant.
So the aggressively threadedimplants are not made for this.
They're just not good.
The bone is extremely corticalbone.
It'll crack.
It'll crack the maxilla.
You'll be sorry you did it.
So there are implants out there.
You know there's just from a,from a company standpoint.
(48:07):
You know, neodent, helix Longwas.
This was the gold standard.
Norris now has one that'sspecific for this.
I think that as long as youhave a finally threaded implant
with a narrow apex, you're good.
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