August 18, 2025 • 59 mins
Remote anchorage techniques have revolutionized what's possible in full arch restoration, and few clinicians have as much experience implementing these advanced approaches as Dr. David Zelig. With nearly 1,000 pterygoid implant placements and decades of surgical experience, Dr. Zellig shares the hard-earned wisdom that can only come from extensive clinical practice.
The conversation begins with a detailed exploration of pterygoid implant technique, where Dr. Zelig reveals his systematic approach to navigating this complex anatomical region. From precisely identifying the hamular notch to utilizing the pyramidal process of the palatine bone for primary anchorage, listeners gain valuable insights that go well beyond textbook knowledge. "The real stability is along that path in the palatine bone," Dr. Zelig explains, demystifying a placement that many clinicians find intimidating.
When discussing potential complications, particularly bleeding management in the pterygoid region, Dr. Zelig provides practical solutions while emphasizing preventative measures through proper technique. His thoughtful approach to zygomatic implants similarly balances clinical efficacy with tissue management, revealing his preference for extra-maxillary approaches in most cases and innovative soft tissue handling techniques that minimize dehiscence.
Perhaps most valuable for practicing clinicians is Dr. Zelig's candid discussion of surgical ergonomics and professional longevity. Rather than slowing down after decades of practice, he remains passionate about advancing the field and mentoring the next generation of implant surgeons. "I feel like it is spring again," he shares, describing how these advanced techniques maintain his enthusiasm for patient care.
As full arch restoration continues evolving, Dr. Zelig anticipates further advances in patient-specific implants and prosthetic design while cautioning against unrealistic expectations regarding maintenance-free restorations. His balanced perspective, combining cutting-edge innovation with pragmatic clinical wisdom, offers listeners a roadmap for incorporating these advanced techniques into their own practices.
Ready to elevate your implant practice? Subscribe to the Fixed Podcast for more conversations with leaders who are pushing the boundaries of what's possible in implant dentistry.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Tyler Tolbert (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren
Poppy, and you're listening tothe Fix Podcast, your source for
all things implant dentistry.
Dr. Clark Damon (00:10):
So what is the talk about the Norris?
Is this like a 375 or a 35?
Dr. David Zelig (00:17):
What's its size ?
On the Norris it's a 375.
It's a 375 with a narrow apex.
To me it's a nicely taperedapex and the rest of it is
threaded to the crest.
Same exact thread the whole way.
It's not aggressively threadedand it has that added benefit of
(00:40):
the bold surface.
Dr. Tyler Tolbert (00:42):
the non-threaded portion, uh,
mid-shaft yeah, do you thinkthat that would have any
indication for use?
Dr. David Zelig (00:53):
uh, with trans sinus as well, yes, yeah, yeah,
definitely, it's um, um, yeah, Imean it's.
It's really.
You don't need thatnon-threaded surface in the
trans sinus, but it doesn't.
You don't need threads in thetrans sinus portion either.
So, yeah, it certainly can be.
Dr. Tyler Tolbert (01:11):
Okay.
Dr. David Zelig (01:12):
Yeah.
Dr. Tyler Tolbert (01:13):
Fair, fair.
So one thing I don't thinkwe've put a lot of attention to
is pterygoid implants as well,right?
So of course we've talked aboutthe full gamut of you know of
remote anchorage and things.
So you know, I'm curious whatkind of you know tips might you
have for applying pterygoids insomeone's practice?
What kind of implant designsare you looking for there?
(01:33):
And are you a drill guy,osteotome guy?
A little bit of both, greatquestion.
Dr. David Zelig (01:40):
It's really funny because I did the same
thing.
By the way, I flew around thecountry watching people do this
too.
It was really no, no definedtechniques around and no real
defined anatomical landmarks touse, and so it's funny that that
I'm.
I'm not going to call myselfone of the mentors here, but
(02:02):
there are a few of us thatstarted teaching this a while
back.
Each one of us is kind ofadopted points of the others and
and we've each one is distilled, their own, their own technique
.
So I generally use I'll startwith an osteotomy I use, I
really use every landmark that Ican.
(02:22):
I use the hamulus.
Hamulus is the medial mostpoint of the, the inferior most
point of the medial pterygoidplate.
That's going to be my end point.
Typically, I'll just imagine apoint 20 millimeters above.
That is going to be my, myaiming point for this and the.
Depending on how much bonethere is under the sinus, I'll
(02:44):
start as far forward as I canunderneath the sinus or in the
posterior maxilla.
So typically, let's say, acentimeter in front of the
hemular notch, which, by the way, you really do need to reduce
the tuberosity to make sureyou're not losing all that
wasted bone.
There's a wasted height, lengthof an implant.
(03:06):
But once you do that you caneven even feel it.
The other trick that I've beendoing most recently is I'll take
the the two millimeter sharposteotome and dissect, well with
a with a periosteal dissect,the posterior to the hamular
notch and a little bit furtherposteriorly to see the fibers of
(03:26):
the musculature.
Then I'll take the point, theosteotome, and put it between
those two plates in the musclejust a few millimeters and use
medial lateral movement toactually I'm hitting the medial
plate, I'm hitting the lateralplate and it really directs me
to that medial plate so thatthat gives me a little bit more.
Every possible clue that I canget out of this patient I'm
(03:51):
going to use to get me in theright direction.
You know we have a very healthyrespect for the pterygoid
region, all the bleeding thingsthat are back there.
So medial is the way to go andI'll use that sharp osteotome
(04:11):
first just to get through themaxilla, hit the pyramidal
process of the palatine bone,stop right there and then go to
the same burrs that I'll use forthe transnasal, the sharp two
millimeter long pilot, and thenfollowed by that implant
specific drill and that's reallyit.
But I use that.
I use that, by the way, in thezygoma handpiece, the, the
straight handpiece that I don'tuse for zygomas it's hard to use
(04:35):
that for posterior zygoma, bythe way, but it should be called
the pterygoid handpiece becauseyou're standing behind the
patient.
Whatever you're doing, the samedirection as the osteotome goes
, the handpiece goes.
And I use that handpiece withboth of those drills, the pilot
drill and the implant-specificdrill, almost as an osteotome.
I'm sounding as I go boom, boom, boom, boom, boom, boom, and
(04:58):
then I'll go to the.
I definitely use theRosen-Smiler driver.
I think that's a clutch.
I like saying I make fun ofmyself, but I was almost
self-defecating, not justself-deprecating.
When you lose an implant there,you'll lose more than an
implant.
(05:19):
You know what I mean.
It's the worst.
So it's a very scary moment.
So that Rosen-Smiler driver hasjust locked the implant in place
.
There's one for for theinternal hex connection is one
for the neodymium connection,which is sin.
I mean you, you don't need togo without it and it's just a
way to stay safe and that's it.
I mean it's from an implantchoice.
(05:40):
I like something moreaggressively threaded and
generally I will leave the flathex or the dot, depending on
what implant company I'm using,facing forward so that, um, ever
so slightly a 17 degreetypically 17 degree or 30 degree
multi-unit will will come everso slightly in an anterior
(06:03):
vector and ever so slightly in afacial vector so that I can get
a driver in there.
If it's right over the lowercusps or lower central groove of
a second molar, it's impossibleto get a driver in there.
Dr. Soren Paape (06:17):
Yeah, I would say too, by doing that a lot of
times we're angling our anteriorimplants forward to get that
proper prosthetic right behindthe iso edge, so it prevents a
divergence.
Yeah, um which luckily now Imean I don't know what, if you
guys are doing photogrammetry atall or anything but something
(06:38):
that's been very helpful in myoffice is our photogrammetry
unit specifically will tell youthe divergence.
So you know that day like, okay,I need to make a quick
adjustment on my multi-unit.
But by having that anteriormulti-unit it matches the
anteriors a little bit better aswell.
And a little tip too forlisteners that I've been doing
(07:01):
is when I have a case of apatient who you know their teeth
are flared forward quite a bitand I'm doing my angled, my
anterior implants angled forwardquite a bit, I will not angle
my posterior ones as much maybea little bit less than 30,
because that will pull thoseforward as well, specifically
(07:23):
when I'm doing pterygoids, sothat everything's in line and I
get much less divergence onthose implants.
A question that I have for youabout your medial angle for your
pterygoid implants is are youcommonly trying to get full bone
in contact, going throughdirectly at the medial plate, or
(07:44):
what are your opinions on, youknow, popping through the that
process into the, the fossathere?
Dr. David Zelig (07:51):
Yeah, sure, okay, let me just say that the
greatest thing, the greatestthing about you know, one of the
things I would suggest toanybody is just don't stay alone
in your office and stay in yourlittle world.
Just, social media is great andthis is a great.
Just to share this passion thatwe all have, it's wonderful.
(08:12):
I believe that the I believethat the real anchorage of a
pterygoid implant is thepyramidal process of the
palatine bone.
If you hit a plate, a medialplate, in most cases you're
going to hit it in an area whereit's a thin plate.
It's really not going to giveyou much.
(08:33):
Maybe it'll give you anothercortex, another little bit of
stability.
But I think most of thestability is really that
pyramidal process, so thatgetting through into the, if you
get into the pterygoid fossabetween the plates, once you're
past that you're gaining nothingexcept maybe causing some
trismus for a while, but you'renot gaining anything.
(08:55):
So extra length once you dothat is not gaining anything.
So I don't see a benefit there.
If you can aim, sure, ideallyaim towards the medial plate and
if you hit it, then you'll getsome more.
But most of the real stabilityis along that path in the
(09:15):
palatine bone.
And if you look at if you lookat, look at an anatomy book and
and the kind that separateseverything out, and look what
that palatine bone is, it's,it's a nice thick, solid bone.
Um, you got to be pretty luckyand this is a blind placement.
I mean, unless you're, unlessyou're doing it guided which you
(09:37):
owe me another discussion, youowe me all fans of that.
It's another discussion.
But unless you're doing a guy,you know it is a blind procedure
.
So you're using the landmarksthat you have and you're gaining
the stability as you go.
So I'm not necessarily tryingto pop through.
If I do pop through, I surehope it's after 18 millimeters.
You know at least I have 18millimeters of implant before I
(09:58):
pop through.
That's my goal.
Dr. Clark Damon (10:01):
That's my goal.
Yeah, I would say that I wouldnever know if I was right into
the pterygoid fossa, right?
So just solid anchorage in thepalatine bone, versus if we
nailed the complete medial wingthere, right, I wouldn't know.
(10:23):
There's really no way toactually tell.
And, and to be honest, if youpop through the medial wing of
this, the pterygoid, you're,you're into the nasal fossa,
right You're, you're in thenasal pharynx.
And so I've seen other people'saxial um slices and I'm like
(10:45):
that tip of that implant is inair.
You know, like if they ever getintubated or whatever.
You know nasally, that implantmay puncture the tube.
Dr. Tyler Tolbert (10:57):
And this is something too.
And I've done this, clark, I'vegone, I mean I'll just, you
know, I'll put myself out there.
I mean I'm always going forthat medial wing and just like
David was describing earlierwith putting his osteotome
between the plates, I did thesame thing with my Lance drill.
Right, I like to get in betweenthere and actually move the
head physically and I'm alwaysshooting for that medial plate
(11:22):
and I've had a few times littlebit more medial and like, yeah,
I mean I've got a few that start, you know, edging into that
nasal cavity and I've beencurious.
I mean they've torqued outwonderfully every time, of
course, but I've been curious ifthere's anything, any negative
sequela that could come fromthat.
I'm not, I'm not entirely sure.
I've never taken anything outjust because of that, yeah.
Dr. David Zelig (11:40):
It's, it's way back there.
I mean, it really isn't nasalpharynx, so there's good thick
mucosa over it, so it shouldn'tdehist through.
But, like what Clark was saying, I wonder what happens in a
nasal intubation or some othertrauma or something like that.
Right, but generally, how farare you going to poke through?
I mean, I would probably saypoking through a millimeter or
(12:00):
two into the nasal floor is alsono consequence.
Dr. Tyler Tolbert (12:03):
Yeah, yeah, I mean generally, if I'm deeper
than I don't know if I'm goingto play something longer than
2022 millimeters I need toreally know where I'm at and
have a good idea why?
Um, most of mine are just 18.
Dr. David Zelig (12:13):
So I mean they're not going to go that far
.
Dr. Tyler Tolbert (12:15):
Um, but, uh.
But something I was curiousabout too is, uh, you know, you
mentioned how, um, your, I guessyour anterior, posterior entry
point with relation to thehamlet or notch, is dependent on
how much bone you have backthere, right?
So I'm curious.
I mean, I have some cases wherethere's really not any runway
at all.
I mean, I got a shell of boneall the way back, does that?
(12:38):
I mean I've done some of thesecases where you know,
essentially what I'm doing is atrans sinus, right?
You know?
I mean I'm curious of yourthoughts on that, if there's a
way to circumvent that, if it'sa non-issue, you know, how do
you view?
Dr. David Zelig (12:51):
it.
So the way to circumvent it I'mnot recommending it, but the
way to circumvent it is the lessbone you have under the sinus,
the more vertical that implantbecomes, more posterior, but
then it becomes prostheticallyuseless.
Yes, so you have to play thegame.
On the other hand, how manycases do we see that your
reduction plane is already inthe sinus, whether you have to
(13:14):
lift or crush the sinus floor,whatever you got to do, even at
the posterior maxilla, at thetuberosity.
So if you're already at sinus,okay, ideally you've lifted the
membrane there and you canactually see the posterior
wallilla at the tuberosity.
So if you're already at sinus,okay, ideally you've lifted the
membrane there and you canactually see the posterior wall
at that point, which is not abad thing, you can see the
posterior wall, you can seewhere your medial plate is and
you're you're already inpyramidal process.
(13:36):
Yeah, that's great if you can doit, but it does, you know.
It leaves a good bit of implanthanging in midair, not not in
the sinus, but in midair.
What that does long-term do weknow.
You know, it's not like azygoma.
You have a lot less stability,it's less of a bony anchorage
(14:00):
Less of a bending motion Right.
There's less of a long arm there, that's true, um, and it is the
posterior it eliminates.
You can't deliver.
So there is a benefit.
Um, I didn't.
I started this business as aall-on-four purist.
You know, clark, you probablydid too, you know you.
(14:20):
You come out of there andsaying any more than four is an
emotional implant.
That fifth implant is an amaze.
You feel better, but it doesn'tdo anything.
Well, we know that it does dosomething.
I mean, at least the territoryis eliminated, and you can't
believe it does have a benefit.
But I came.
I came to it a little later.
You know, I used it as anemergency for years and
(14:42):
eventually it's.
It's not necessarily every case, but it's most of my cases.
Dr. Tyler Tolbert (14:48):
Yeah, I think of the less emergency.
More insurance, yeah.
Dr. Clark Damon (14:52):
Yeah, and I think, go into surgery that
you're only going to do it onceand do it the best you can.
I don't understand otherclinicians who say, well, we
want to save bone, we want tosave this for when we have to
redo it, like if, if that's yourthinking, then why?
Why even do it?
Because when you have to redoit, it's on you and it's even
(15:15):
harder, you know, um, so youknow, in in my practice,
everybody gets a pterygoid.
Uh, I'm, we're doing nocantilevers and I actually
compiled my data for vichy andI've got, over the past five
years, I've got nine hundred andsixty four pterygoid implants
(15:36):
completed, with only four failsso.
So it's interesting, you know, Ireally, it really is Getting
all that data.
But yeah, you know, when you goto Nobel, they told you that
the fifth implant, like you said, emotional implant or it's the
boat payment right.
(15:56):
And you know I've got a lot ofcases where, yeah, they're doing
great at you know eight, tenyears on four, where, yeah,
they're doing great at you knoweight, ten years on four, but
man, if we could have eliminatedsome cantilevers or given
patients extra teeth.
You know, one thing that Ilearned a long time ago is when
you're treating Indian patients,or you know patients from you
(16:20):
know the East, what do theyoften have that many of
caucasian americans don't?
They often have third molars,and so when you give them a
all-on-four on 12 teeth, youknow they, they are upset,
they're like where's my molars?
Oh, you've, we gave you a molarand they're like where's the
(16:44):
other four?
um, so you know, just, youalways have to think of that.
That was, that was a big aha,you know, moment of my, you know
american americanism, uh, sojust think that through and
that's that's you know you wantto make sure that you're doing
teriquids on them.
I have have one.
Dr. Soren Paape (17:03):
I have one patient right now that, uh, I
did.
You know I try to doretroframenol on every one of my
cases as well to get those backmolars and um, it was an Indian
patient and I the didn't gettorque on that, so I just put a
cover screw.
I usually come back at threemonths, especially in that in
the posterior mandibleible.
Um, sometimes I'll get thosewhere you know, I come back at
(17:24):
three months, expose it and thenadd it to my.
My case at that point, and herbiggest complaint over and over
and over again was that rightside, was that she was missing
two molars back there and nowfor the three months that was
the worst thing that I ever didto her.
Uh, luckily went back in and youknow it would torque fine.
Everything looked good, butexact same thing that you were
(17:45):
talking about yeah, it's just,you know the learning curve of
forage, david.
Dr. Clark Damon (17:51):
I wanted to ask you, um you know, often times
you know when we're talkingabout pterygoids and when you
talk about patsy protocol.
All right, posterior, anterior,um you?
Dr. David Zelig (18:03):
know middle.
Dr. Clark Damon (18:04):
I, I kind of like Pam, right?
Um, that's that's what Juan'sbeen saying lately.
If he could rename it, he wouldrename it as Pam posterior,
anterior and middle.
Um, I don't like doing mypterygoids first.
Um, now, if, if I know off thebat, hey, this is going to be a
bilateral zygoma case, then sureI will.
(18:25):
I will roll in and do thepterygoid first, but just on my
run-of-the-mill standard arch.
Let's say it's relatively easyin complexity.
I actually like doing theanterior four implants first
before I do the pterygoid, sothat I can make sure that I get
(18:48):
the platform all on the samelevel right.
Whenever we're talking aboutimplant depth, I prefer to have
my anterior four abutments onbefore I place the pterygoid.
I find that that really helpsme get the correct depth versus
having to go back in and forthand take an abutment off because
(19:11):
you didn't get your pterygoiddeep enough.
That's kind of one of thethings I typically find in the
learning curve is not placingyour pterygoid deep enough.
And then when you have yourabutment on, it's too shallow
and so you kind of get like ayou know your bar, your
prosthesis kind of dips downwhere that pterygoid is because
(19:31):
you didn't get it prostheticallyin the right spot.
Dr. David Zelig (19:35):
So yeah, it makes sense.
That does make sense.
So AMP instead of PAM, Okay.
Dr. Clark Damon (19:40):
That's how I approach some of my cases right
now, the hard ones, you know.
We're doing the posterior,we're doing the posterior, we're
doing the pterygoid first, or Iactually may do the anterior
first on a really hard case.
I'll do the two anterior onesjust to kind of get a good rep
(20:01):
and then I'll do the pterygoidand then finish up with my
zygoma.
Dr. David Zelig (20:02):
The logic of the pterygoid first is to help
you position your tilted orzygoma to have that posterior
implant.
For example, if you don't getthe pterygoid, then your
zygomatic implant needs to be alittle further posterior just to
limit the cantilever.
(20:23):
I mean, I understand that logicbut assuming that you're going
to get them all, your logic isgood.
Your logic is good.
Dr. Tyler Tolbert (20:36):
I'm curious too, david.
So when it comes to so, let'ssay you're in that situation
where you haven't been able toget the pterygoid If you don't
get it, the patient probablyjust doesn't have pterygoids,
they're just an anomaly haven'tbeen able to get the pterygoid
patient.
If you don't get it, thepatient probably doesn't have
pterygoids, they're just ananomaly.
But um, let's say you don'thave that.
Now you're trying to establishthat posterior stop and you're
going to do that with azygomatic implant.
(20:56):
Are you incorporating thehessian zygo, that sort of
infant temporal zygo that goesall the way back to the first
molar?
Are you trying to do that, oris it more just like a
traditional a-frame coming outin the first, second premolar?
How are you going about it?
Dr. David Zelig (21:11):
I generally.
I generally go to an a-frameand go back as far back as I can
, hessian.
I've done them.
I've done them.
Um, it's interesting, I've doneit in a case.
It was a I remember one.
The first time I did was arevision case failed zygomas
from elsewhere and the onlything the only zygoma I can get
was back there.
But I started with thepterygoid first, so that the
(21:34):
zygoma and the pterygoid was soclose they ended up burying the
pterygoid, not even using it atthe end of the day.
So really it really was a wayposterior zygoma.
So there's a lot of leeway upthere there really is is a lot
of freedom once you can get backbehind the infratemporal fossil
like that.
I think it's very useful, um,but generally I'm able to with
(21:55):
an a-frame limit, the cantilever.
The same way are you, tyler Iwould.
Dr. Clark Damon (21:59):
I would say on your characterization there uh,
hessian would be more in thepterygoid spot and a a-frame
would be more in the pterygoidspot and a frame would be more
in the first or even secondmolar spot.
The traditional Braziliantechnique is where they're a
little more parallel.
(22:20):
They're parallel, okay.
And that's more in the premolarposition.
I appreciate that.
Dr. David Zelig (22:26):
And, by the way , that's a great use for a
zygomatic handpiece when you, ifyou're doing parallel or an
anterior zygoma I love thathandpiece yeah, I love that
handpiece, but I love it morefor pterygoids now yeah that
makes sense are you in asituation where you you aren't
getting a pterygoid but you are,you can't you do get the
standard four in the front?
Dr. Soren Paape (22:48):
At what point would you consider putting a
zygomatic implant in, becauseyour tilted implants are too far
forward?
If you're coming out canine,are you putting a zygomatic
implant back there?
If you come out first pre, whatis your logic?
Dr. David Zelig (23:06):
The biggest cantilever I want is going to be
a 10 millimeter cantilever.
So if I can get to secondpremolar, first molar junction,
I'm happy.
Ideally I want to be at thefirst molar exit point.
Um, that's, that's my ideal, um, especially if I don't have a
pterygoid.
If not, if I'm at firstpremolar or something like that,
I'll put as I go in to get backthere, got it.
Dr. Soren Paape (23:29):
And then the second question I had was more
for people who are venturinginto the pterygoid space.
If, let's say, you get a reallybad bleed back there, I would
love to hear how you, how youmanage that, what you know.
Just some tips for doctors ifthey run into that situation.
What are the steps that you'dtake?
Dr. David Zelig (23:50):
So the really bad bleed.
You should never get it backinto meaning the pterygoid
plexus or the internal maxillary.
If you're there, you reallyshouldn't have been there to
begin with.
So you're going the wrong way.
So you really have to followyour, your anatomy, follow your
landmarks.
And assuming that you'refollowing your landmarks, I mean
(24:11):
it's like saying you know whatif you poke in the eyeball, I
mean you just shouldn't havebeen there.
I mean there are ways to dealwith it, of course, but you got
to pack the hell out of it.
You should have some toolsavailable to help you.
Avertine is something thatshould be in your office
microfibrillar collagen to helpthe first stage of clots.
(24:32):
And, by the way, the best wayto use that Avitine is if you
take a TB syringe, a 1cc syringe.
I do the same thing with bone.
You just take a 1cc syringe andcut off the tip, the lower lock
tip or the catheter tip.
Cut that off and you could useit as a bone syringe too.
You take your bone in yourDappen dish and just fill it up
(24:53):
from the bottom, like we used todo with impression material.
Just fill it up that way andthen you can use it.
You can do the same thing withAvertine Make little Avertine
balls, put it in the syringe andthat way you can direct it as
you take your pack away direct,and that way you can direct it
as you take your pack away,direct that syringe into where
it's bleeding and start packingthat.
So packing obviously is the wayto do it.
(25:17):
In the case of the realisticbleed, which is one that you're
going too far, medial, and youget descending palatine artery,
there are two things you can do.
First, you can try it dependson where you hit it.
You can try and get the palate,compress the palate on the
palatal side of the, of theincision, try and get it.
If you, if you got that low, ifit's high, then you have to get
into that, into that foramen.
(25:37):
Today, just let me.
I told you I did a, just helpeda guy out with a zygote case
and patient was complaining ofsome pain, flap was open and he
was trying to get a v2 block andsometimes you can hit it and
sometimes you can't.
I said, well, hey, let's cheat,just dissect that palate a
little bit, you can see wherethe periosteum starts to get
(25:57):
into the, the greater palatineforamen, and just once you know
where that is.
Now you can cheat, put the flapback and you go through there.
So I'm saying, do the samething, get into the foramen and
use some epi there.
And then the next thing is toget into the osteotomy that
you've created that caused thebleeding and pack it.
Pack it there, pack it withavatine, pack it with gauze and
(26:19):
then get an implant in there.
I mean, that's really those arethe only ways.
Um, bovi is not particularlybeneficial at that depth.
You're not going to get there.
It's great, by the way, bovi isa great tool to have.
I think some electrocautery isimportant.
It's most important when youstart punching the mucosa around
(26:40):
your palatal multiunits and youget these little arteriolar
bleeds kind that you can stopfor a moment with epi, but then
it starts bleeding again whenthe patient goes home.
So use a bovie when you seethose, or the posterior superior
alveolar artery intraosseousbranch that you see it across
the lateral maxillary wallbefore you get into it with a
(27:01):
zygoma burr or a sinus lift,just zap it, touch the bone and
it'll burn that too.
But the DPA bleeds are notamenable to bovies.
And then the last thing isdon't just let a patient bleed
out and die.
There is interventionalradiology for these things.
(27:22):
So pack it if you're really introuble.
Before you get to that levelthere is, you know, pack it,
stabilize the patient, get intoa hospital that has IR and that
can be fixed.
But again, the real trouble oneis internal max and you just
shouldn't be there.
There's no reason to be there.
Dr. Clark Damon (27:42):
I mean on the internal max, you're not going
to have time to go to thehospital.
Dr. David Zelig (27:45):
Interesting it depends, I mean, if you really
max, you're not going to havetime to go to the hospital.
Interesting, it depends, I mean, if you really get it, that's
true, if you really get it,that's true.
But I've seen some bad bleeds.
I have seen a human being bleedout from a face by the way,
coincidentally, I was finishingsurgery in the operating room
(28:05):
this was in Memphis and thechief of surgery comes running
up Zellig, we need you in the ER.
And I'm like you'll never needme like that.
But he's no.
This guy got brought in in ahelicopter, ejected from a car.
They intubated him in the field.
He essentially had a split faceand I packed everything that
you could possibly pack.
It turns out there wereinternal carotid bleeds,
(28:30):
ethmoidals.
He literally just unfortunately, watched the guy bleed out.
It was just terrible.
The argument you can't bleedout from your face is just not
true.
Wow.
Dr. Clark Damon (28:41):
Let's get off this topic.
I have a Zygo question for you.
What do you think about for you?
What do you think about Zygo?
And or do you do everythingextra maxillary?
Dr. David Zelig (29:03):
That's a great question.
So let's just take a Zy zero orone.
We have a straight wall becauseeverything else, everything
else, is pretty much going to beextra max light, sure?
So the only one that could beintra max, intra alveolus anyway
, is going to be a zaga zero orone.
And on those cases the bigquestion to me is what am I
(29:27):
gaining from saving that littlemillimeter or two?
You know, I mean I'm not goingto debate Carlos Aparicio on
this, but you know in my ownmind what am I really gaining?
The only thing I gain from thatis preventing some dehiscence
of soft tissue over the shaft ofthe implant, at the crest To me
(29:51):
.
To me, because I'm not using athreaded implant, so I'm not
going to get osteointegration inthat crest, so that's the only
thing I'm saving.
It makes it technically morelikely to me to perforate the
sinus membrane low, I'm talkingat the crest.
(30:14):
So, although I've done it inthese cases, you've got this
really beautiful, thick alveolusand it would be a crime to
grind through it.
I've done that, but at the sametime I've made a window, a long
enough window in the side ofthe membrane to be able to lift
everything.
Not that I'm an impatientsurgeon because I think I got
patients to do it right if ittakes it, but I just I question
(30:36):
the benefit.
I question the benefit.
So, yes, I've done in somecases.
I don't see a lot of those fullalveolus cases, so almost all
of them are ground down.
Use that lateral extra sinusburr.
Dr. Clark Damon (30:50):
So let's just say it's a zaga three.
You know, you have two options,right.
You can either tunnel orchannel, right, so um I channel.
Okay, there you go all rightwell what do you do?
I'm more flexible, I'm a littlemore open-minded, I tend to be
(31:21):
more Zaga versus extra maxillary, but you're a big Norris guy,
right.
Dr. David Zelig (31:25):
So Norris likes to.
That's true too.
Today was a near that case, butum, I don't, I don't, um, I
don't know.
I just I wonder.
I think that the soft tissuemanagement, I just don't see a
lot of the dehiscence.
If I'm gonna see it, you know,I can generally predict it a
(31:46):
smoker or something like that,and I use thick tissue and, by
the way, I started on edentulouscases I really went back to a
vestibular incision, like aLaforte incision, and bring all
that you know, really punch thetissue so that my incision is
far from the crest.
Dr. Clark Damon (32:14):
So you're going .
What 10 millimeters?
Dr. David Zelig (32:15):
beyond, or 10 millimeters apical to the… Into
mucosa, into mucosa, into mucosa, and bring the whole thing over
.
It makes, I mean, in aconventional case, in
conventional not necessarilyzygoma cases, but in
conventional cases it just endsup looking like, wow, this is
healed already.
You know, as soon as you finishyour case, it's just, it's so.
It just makes it so clean andthen you don't worry about your
(32:35):
incision line.
The only thing I worry about indoing it that way with zygomas
is is there going to bedehiscence along the shaft?
And I'm using fat, I'm thickand covered, so I really have
not seen that.
Dr. Clark Damon (32:49):
So now do you pull fat on every zygoma case or
will you do like a scarf graft?
I do both.
Dr. David Zelig (32:59):
I do both.
Not on every case, but I willdo both.
Non-smokers with good thicktissue I don't always do, and if
it's a Zaga 1 or so then Idon't necessarily.
Dr. Clark Damon (33:12):
Yeah, I tend to hold the fat, to reserve the
fat and harvest as muchpedicalized CT when possible
Makes sense.
Dr. David Zelig (33:24):
Makes sense.
Dr. Tyler Tolbert (33:26):
So I'm curious about this vestibular
approach, because that's notsomething I'm super familiar
with.
So does that?
Is that to say that you'reincising into the actual
vestibulum and then Not that,not quite.
Dr. David Zelig (33:36):
It's called the vestibular incision, but it's
not.
It's essentially it's what'sused for a Laforte osteotomy.
You're, you're leaving all theattached gingiva, attached in
this case to the palate, um, andyou know again, normally you do
some little forward osteotomy.
There are teeth that stay there, so the attached gingiva stays
(33:57):
there.
It's not stripped.
In this case it's an edentulousarch.
So um into the free gingiva,okay, at the attached gingiva,
free gingiva junction, almost orfurther apical than that, and
then strip the entire flap overpallet, okay, so you go past the
end of the j and then you comeback over and now, when you
(34:19):
close, it's then I punch through.
I essentially am punchingthrough the crest yeah, wow, wow
.
Dr. Clark Damon (34:25):
One of the drawbacks, though, is that you
can't thin the palate.
But, um, on the edentulous case, it's really just edentulous
cases.
Yeah, it'd have to be a casewhere you don't have to do any
tuberosity reduction or thinningor anything like that.
Dr. David Zelig (34:41):
Good, um, nice question.
So I do.
I do when I, because how areyou going to get your pterygoid
in Same problem?
So I do change that incision.
I'll have to show you one day.
It's towards the crest and thengoes vestibular At the
tuberosity.
It's crestal over thetuberosity and then comes over.
Dr. Clark Damon (35:01):
Yeah.
Dr. Tyler Tolbert (35:02):
I think I can see that yeah.
Dr. Clark Damon (35:03):
Just looks like a denture almost.
It kind of goes up and has aflame.
Yeah, that, yeah, just lookslike a denture almost.
It kind of goes up and has aflame.
Yeah, yeah, yeah, nice, nice,wow, that's great.
Now one other question, um, youknow, you, you brought up in one
(35:24):
of the chat, chat groups thatwe're in about, uh, basically
bracing your zygoma shaft alongthe palatal wall.
And you know, one thing that Iwill often do is because, on a
scenario like what you'retalking about, where you've got
a channel right along thatalveolar wall and like, let's
(35:44):
say, it's a, that case would belike a, like a zaga, maybe one
or two, something like that.
Right, I, uh, chu, I think, ishis name, he's out of hong kong,
he's got a great article.
It's an older article, um, buthe, he lifts the entire membrane
and actually does particulategrafting there.
(36:06):
I don't like particulategrafting with zygos, but
oftentimes what I'll do is,whenever I lift, I'll put in
maybe some collar tape orsomething like that, so that I
actually will wind up gettingsome type of bone formation
several years after this is allsaid and done.
(36:28):
So I'll still kind of prefer torest it along that palatal
channel, but I'll lift mymembrane and then I'll put in a
collar tape so that it stays inplace and hopefully we get some
bone formation later.
Dr. David Zelig (36:48):
Alternative.
Again, these are cases that youhave to do so much bone
reduction that you're past thesinus floor, right?
That's what we're talking about, those kind of cases.
So what I'd like to do is startyour reductions until you start
to see that membrane andthere's still bone over it and
just infracture that floor sothat there is bone on that inner
(37:10):
aspect of your implant still,but it's still it's it's too
palatable.
I mean, it's still palatable tothe ideal, um, but that was the
alternative.
Speaking of using some kind ofmembrane is um, I toyed with
using volumax thick ossexmembrane.
When ossex first came out,their big claim to fame was that
(37:32):
the membrane itself ossifies,so that the thickness of that
membrane.
You go back in there sometimesand you see the texture of the
membrane still now bone.
So Volumax, the argument is yougot this thick membrane that
will ossify in theory.
So I started using that,actually on the facial of some
(37:57):
zygomas as well.
Dr. Clark Damon (37:58):
Let's see what happens.
Well, it's easier than a ramusgraft.
Yes, it sure is.
Dr. David Zelig (38:04):
So that's an alternative is to use something
like that, a good thick membrane.
Certainly it'll help with anyoral-antral communication, but
it might help with someossification too.
Dr. Clark Damon (38:14):
I think that's a really good thought there.
Dr. Soren Paape (38:17):
the ossic exfoliants Just changing topics
a little bit.
I'm curious, david, what yourthoughts are on the best
practices for general dentistsdoing remote anchorage just for,
like, protection from boardcomplaints and being compliant
(38:39):
and making sure and I don't knowif you've seen it happen or
anything but like a generaldentist who perhaps had a board
complaint or something for aremote Anchorage based implant.
Is there anything that you'veseen dentists do to protect
themselves from that, to ensurethat and not not I'm not talking
(38:59):
about cases where they weredoing something that they
shouldn't have been doing orlike in a location they
shouldn't have been, but just toensure that they're staying up
to par with someone, like likean oral surgeon, oral
maxillofacial surgeon.
If they came across the boardand just said, oh, he's a
general dentist, he shouldn't bedoing this, so you know, we, we
had, we have the same issue, ifyou think about it.
Dr. David Zelig (39:20):
You know, when I, when I wanted a well, so I
trained in a training programwhere we did our own hips, we,
we took our own hip bone andmost of us do today I went to
Memphis, a very conservativetown, and they didn't want to
let me do it, and so I spoke tothe chief of surgery.
The chief of surgery was anorthopedist who trained the
Jackson Memorial, where BobMarks was, and they wrote the
(39:43):
book on grafting from the hip,and he knew that and he actually
supported me.
So bottom line is I had thetraining and I had the support
of an orthopedist to suggestthat I'm right and it worked.
So in this case it's the samething A general dentist should
get the training, and we justdiscussed what that is.
(40:04):
It's the same thing thatmedical education letting go of
the hands and slowly taking thetraining wheels off it's a
learning curve.
It clearly is, and probablymore of a learning curve for a
general dentist that didn't havea surgical residency.
So take your time, have thebacking of the people that
trained you and go out and do it.
I don't think that you stay inyour lane, so to speak, do what
(40:30):
you're trained and well-trainedto do, and I think you should
have some backup, somebody tocall.
Well, you know David some of thethings that I see is just in
record keeping.
Dr. Clark Damon (40:48):
That's a good point.
It's very technical, yeah,absolutely well, sure, but, um,
very simple.
You know, everybody who's goingto undergo anesthesia just get
a medical consult.
Right, it's not a medicalclearance, it's just a medical
consult.
So we get that on everybody andwhat you get back from the
physicians is their entiremedical history, right, like
(41:09):
I've seen people get dingedbecause they didn't put an ASA
classification, you know, on oneof their notes.
You know, or something, orsomething crazy.
But if you in your part of yourrecord is the patient's record
from the medical doctor, you aremore than covered.
You know, and I you know.
I think it's also importantthat you know the our medical
(41:31):
colleagues.
They don't give us clearance,right.
We are the ones who aredeciding to work on.
So, and it's just having havinga very, a very nice medical
consultation letter that you arejust asking is this patient
medically optimized and do youhave any objections?
Dr. Soren Paape (41:56):
is.
You know you've been doing full, I mean practicing oral surgery
and then getting into the fullarch dentistry.
I would love to hear kind ofyour tips as far as what you do
to for your own personal health,to ensure that you can, you
know, keep doing these things,because right now, you know me,
I'm like leaned over upside downin the patient and I don't
(42:21):
think that that's the best forlongevity right, our dogs are
okay and I would love to hearyour tips.
I know some guys do it sittingdown like I'm just oh, here's
what?
Dr. David Zelig (42:31):
here's what I started with.
First of all, I think that allof us are all front anterior
chain in physical therapy terms.
We're all anterior deltoids andpecs and everything's in the
front All right.
So our backs are critical.
So I came.
Before I started this, I was apowerlifter First, it was
(42:54):
martial, I was a nut, I waswrestling team in college and
power lifting and all thisnonsense.
So because of that, by now Ihave a total shoulder
replacement, two hips and a kneereplaced.
That's aside, but I'm stilldoing all this.
I'm still lifting.
I'm still doing the rest of ittoo good so I think that staying
, staying fit and stretched andall that stuff is really
(43:15):
critical.
I really think that's veryimportant, which opens up the
other thing balance in life.
Because we can I think I was, Ihad a better balance in life
before I became a full arch guy,but that's another discussion
you start to get down in therabbit hole.
Um, I do sit.
Uh, in the last 10 yearsprobably I started sitting and I
use years probably I startedsitting and I use a sit stand
(43:43):
stool.
I use a sally stool, which islike you're, you're almost
standing, so you can feel like asurgeon.
And, um, no, I'm seriously,because that was the big thing
oral surgeons, here you don'tsit.
What are you a dentist?
You know that kind of thing isridiculous, but but that was it,
was the thing.
So, and everybody in theoperating room stands.
So this thing is you, you'realmost standing, your feet are
almost straight, but you're in astool.
Sally's stool, great for men,has a pudendal groove to let
(44:08):
your prostate be healthy andkeep the boys from being asleep,
so anyhow, so that's, I dorecommend that.
I do recommend sitting andsitting in a stool.
If you're in a horse's saddleyou can't slouch, so you really
are maintaining a good, a goodposture.
So I think that's important, um, but sitting high so that
you're still looking down andable to see what you need to see
(44:31):
.
Headlight, like I said, I don'tuse the loops, um, um, I used to
use it for a lot in surgery,but not in arches.
You really, I feel like you gotto see the whole headlight.
What's that?
What headlight do you like touse?
I have the kls martin, the, theuh med led chrome, okay, um,
(44:53):
but I've tried them all.
I have another one that sits onmy glasses.
Oh, I just recently I'm notwearing them now, but I just got
somebody bought me a giftcertificate, gave me a gift
certificate for the Ray-Ban Metaglasses.
You know the AI glasses.
Yeah, I put the camera in there.
I actually started using it forfilming in surgery.
(45:16):
It's great.
Dr. Tyler Tolbert (45:17):
Someone suggested this to me on
Instagram and I was curious.
Yeah, it's great.
Dr. David Zelig (45:21):
You just.
There's something.
You just.
You can't use your headlightwhen you're doing that, though,
it's too bright, but once youyou take the headlight off, it's
great.
It really is very useful it's ahigh quality video is high
resolution.
They it's a high qualityresolution.
They're limited.
You can do live stream by the.
You can do live stream, by theway.
You can do live stream with it,but the video length is limited
(45:43):
to like three minutes.
Dr. Clark Damon (45:44):
But you know you want to show somebody,
something.
Dr. David Zelig (45:47):
You can take pictures and you can do little
snippets.
Oh, that's cool.
Dr. Soren Paape (45:52):
When you're doing the.
Actually, you know, I was justgoing to ask about the three
minute thing, cause when Tylerand I, previous to our current,
what we're currently doing, wewere doing a lot of a clinical
director like helping peoplewith their first surgery, so we
were taking a lot of video andit's always a pain in the butt
to have this video camera likeabove and it's like focusing in
and out every time you leanforward, you know.
Dr. David Zelig (46:13):
Um, uh, what's that?
There is a camera that is onthe on the overhead light
fujiden, I forget what it'scalled, but there's one that
does well.
But the other one I got that umheadlight camera.
I have that too five thousanddollar, yeah it was.
You know, what else am I goingto do with the money, you know,
(46:34):
but anyway, I it's veryuncomfortable and, um, heavy.
You're like a lot.
Dr. Soren Paape (46:39):
Right, there's a lot of this going on, so, um,
I haven't found the secret sowhen you're doing your um, when
you're on your, your sally stool, and you're, you're, you're
doing it, you're at the 12o'clock position.
Are you doing your mandiblesfrom the 12 o'clock position?
Dr. David Zelig (46:55):
Yeah, mandible, more of the mandible.
So 12 o'clock to 3 o'clock.
I mean I'm to the side of thepatient as well, but I try.
More I can do from behind, thebetter.
Patient is flat, that's.
The other thing is, you know,when I did, when I'm doing my
own sedation, my own deepsedation, the worst position for
a patient when they're in openairway is flat.
(47:17):
So you know, but it's the rightway for us to do surgery.
It's the easiest way for us tosee the maxilla and the mandible
.
So I do fight it.
When I'm doing my own sedation,I often use a nasopharyngeal
airway to help with that.
When I'm elsewhere not my owncenter, I have an
anesthesiologist, the patient'sintubated, that's beautiful.
(47:38):
So I have no airway issues.
Um, and when I'm doing themandible, I'll just sit the
patient up a little bit.
So I'm looking down, but I tryto be from the standpoint of
when I'm doing the osteotomies.
Dr. Soren Paape (47:50):
I'm behind the patient, which just makes
everything symmetrical I havetried doing that so many times
and I keep.
I always come around to thefront of the patient to do mine,
but it's just one of thosethings that you gotta, you gotta
, but as long as I mean, if yourback is straight, that's the
main thing.
Dr. David Zelig (48:08):
Yeah, you just keep your back straight and look
down, keep the patient low andjust look them down and good
well, hey, I appreciate thosetips, that's great yeah, we need
something, something that a lotof people don't think about,
but I'm hoping a long careerahead and get out there and play
pickleball or something.
Dr. Tyler Tolbert (48:28):
Oh man.
But yeah, maybe I'll just startwearing one of the powerlifting
suits, you know, with the thoseare beautiful.
Dr. Soren Paape (48:35):
Just the belt during the surgery.
Dr. Tyler Tolbert (48:37):
Yeah, I have done that actually, but uh, but
no, that that's great, and soyou know I mean that that
question kind of alludes to youknow, you know how long you've
been doing this and your abilityto continue to do it.
I'm curious about you, know,looking forward for yourself
professionally.
Obviously you've been doingarches a long time.
You're practicing at the top ofwhat we can really do.
(48:59):
Um, you know, what are youlooking forward to for the rest
of your career?
I mean, do you see moreadvancement, more growth in your
clinical uh pursuits?
I mean, what do you?
Dr. David Zelig (49:07):
see for yourself.
It's so funny.
You know everybody I havefriends that some have retired,
some are retiring, some areslowing down, some of everybody
else, and I'm like I'm still onfire on this.
I love it.
Um, yeah, it's great.
You know, there was a.
There's an old singer that wasthe other thing I did was I was,
(49:29):
I was in a choir, but anyhow,this guy, we did this opera
together and the old man sang inthe winter of my life.
I feel like it is spring again,is what he's saying.
I'm not in the winter of mylife or anything, but I feel
like this is keeping me going,excited in this every day.
(49:50):
I love what we're able to dofor patients.
It's a privilege, it's a realprivilege and I love it.
So do I want?
Yeah, yeah, I definitely wantto do more.
I want to keep teaching, I wantto help the next generation and
, um, just keep doing the rightthings for patients, you know
yeah, yeah, and looking forward.
Dr. Tyler Tolbert (50:11):
For you know, obviously you you've had the
wisdom and the experience to seehow far full Arch has come, all
the way going back to whenPaula Malone was first talking
about this kind of stuff.
So you have probably as muchauthority as anybody to say what
does it look like for the next10 years?
Where do you think Full Arch isgoing?
What do you think people willbe talking about on podcasts in
(50:32):
2035?
With regards to Full Arch,that's great.
Dr. David Zelig (50:37):
I definitely think that we're getting to a
point where we got a system thatworks.
The patient-specific implant isgoing to find a way to get
perfected for the, for themultiply revised cases.
Having having had jointreplacements, I can I think I
(50:58):
could also tell you thatorthopedists look at these
things differently.
They don't call failuresfailures.
You need a revision.
And you need a revision becausea car is not going to last
forever unless it's maintainedperfectly.
And even an antique car is notgoing to drive the same as a new
car, even if it'swell-maintained.
So things do change.
(51:19):
It doesn't mean failure as longas new guys with the great new
ideas.
(51:41):
We talked a little bit about theimmediate finals.
I don't know that that's goingto last.
I think that you also talkedabout the lifetime warranties.
I don't think that people canstay in business when they're
advertising pie in the sky kindof things that are not
necessarily going to work.
Um, but it might be the, theflash in the pan.
(52:04):
It might work right now, yeah,I think.
I think the the guys that aredoing it right, responsibly,
will end up if I could use theterm winning, will end up just,
uh, being into the long game.
You'll end up just uh, being infor the long game.
You'll still be doing it bythen.
Yeah, I don't know about medoing it, but I'm saying you
know it's as long as you'redoing the right thing for the
(52:25):
right reasons um, you'll stillbe doing it that's great.
Dr. Soren Paape (52:29):
well, we definitely appreciate having
guys like you that are helpingus in the next generation with
with uh, you know these advancedtechniques and making sure that
you know guys like Tyler and Icoming up have the ability to to
fix these cases when we need to, because without, without
people like you, we wouldn't beable to or we wouldn't know
(52:49):
where we could go, you know.
Dr. David Zelig (52:52):
You honor me by saying that, but I just, you
have no idea the you've given uslife.
I don't know what to say.
Great, great to have that.
It's great to have that, causeI cause I had that.
You know, I had those mentors.
Dr. Tyler Tolbert (53:06):
Yeah, yeah, I mean oh Clark, we lost you.
I'm mute again.
Dr. Clark Damon (53:12):
Yeah, I'm sure Check your.
I think now it's easier to havea tribe Right.
I think now it's easier to havea tribe right and so it's
easier to, you know, collaborate, it's easier to talk about
cases, and so I think that youknow advancement will be quicker
and it will be, you know,better.
(53:34):
I don't know what is around thecorner, I don't know how it can
get any better, you know, Imean I think what Molo, you know
, I don't know, I don't knowwhat is around the corner, I
don't know how it can get anybetter.
You know, I mean I think what,what Molo, you know came out
with, you know really startedoff a lot, and then what you
know, you know things you knowlike Dan you know coming out and
you know.
You know I was doing pterygoidsbefore Dan's book came out, but
(53:55):
you know Dan has really kind ofhelped.
You know, talk about pterygoidsand then bring in the no cant.
You know Dan has really kind ofhelped.
You know, talk about pterygoidsand then bring in the no
cantilevers and and and reallykind of broaden that out to
where I really feel that youknow our implants are better and
our patients are being treatedbetter.
So it'll.
It'll be a fun.
It'll be a fun, you know nextchapter, but I think that the
(54:17):
the clinicians who are coming up, I think they have a better
education experience, betteraccess to education and access
to a community yeah yeah and youcan find that at clark's course
, if you need good education.
Dr. Soren Paape (54:32):
It's a good spot to go, for sure yeah,
that's right, my uh, tyler and Iand caleb, who's our other
partner we talk with this a lotabout, you know, because we
always are trying to stay aheadof the curve when it comes to,
like, the business side of fullarch.
Um, and where we're reallyexcited about is the potential
for a lot of like the ai and theprosthetics.
(54:54):
As far as um know, I'm surewe'll get to a point where a lot
of the design is going to bedone via AI and maybe you can
take a, take a picture of apatient right and then get a
smile design, and that smiledesign will turn into, you know,
a surgical guide right, or orjust like the provisional
prosthetic already designed foryou on those multi unit
(55:17):
positions, and that's what we'rereally excited for, I think
that that is going to be cominghere pretty shortly.
Dr. Tyler Tolbert (55:24):
Yeah, I think a lot of the advancements we'll
see are going to be on theprosthetic side and on the
actual planning side of things,right, I mean, we had Dr Sven
Bone on here not too long agotalking about his programs that
are doing a fine elementanalysis to look at prostheses
and figure out where their weakpoints are, and that's yeah, and
that's some well a break.
Exactly precisely and you knowthat's an AI driven thing.
(55:44):
Ai can be driven to, you know,either generate or analyze an
implant plan.
You know, on an extremelyatrophic case, it can figure out
where the stress points are, ormaybe even a patient specific
implant, like David wasmentioning, finding where those
stress points are going to beand how that's going to work out
prosthetically.
I think it's going to make us alot smarter in terms of you
know what we're putting on topof our implants.
(56:05):
But my hope is that the Yominever catches up to us and we'll
still be the ones executingthese surgeries.
That will always be a humanbeing.
Yeah, that's what I'm hopingfor.
I hope I get David's age andI'm still talking about slinging
arches on the daily.
Dr. David Zelig (56:26):
And that's what I'm still going to participate
in, and this will only getbetter as we go.
But I guess time will tell Ihave a perfect.
Not that I need a closing line,but we opened maybe before we
started recording.
I thanked you for sending methis, what I call the Rush
Limbaugh EIB microphone, sendingme this, what I call the Rush
Limbaugh EIB microphone.
So Rush Limbaugh, it turns out,if I can quote him again,
before he got sick and before hedied he was also a tech expert,
an Apple expert.
(56:46):
He said I'm not afraid of dying, I'm afraid of all the tech I'm
going to miss, and I think thatapplies here, man, we're all
growing up and getting older,but look how this is growing
yeah it is.
Dr. Soren Paape (57:01):
I mean going from just and I think, David,
you might have mentioned thatyou still, a lot of your cases
are analog, but from analog to,and I know yours are too, Clark,
but go ahead.
Dr. David Zelig (57:13):
No, no, no, I said I was analog and trying to
figure out all this tech thatyou sent me to start.
Dr. Tyler Tolbert (57:17):
Okay, no, no, no.
I said I was analog and tryingto figure out all this tech that
you sent me to start.
Dr. David Zelig (57:19):
No, no, no, I'm mostly digital In that world.
I'm mostly digital.
Dr. Tyler Tolbert (57:22):
Yeah, clark is not as over here.
Dr. David Zelig (57:24):
Yeah, just like you.
Dr. Clark Damon (57:28):
Well, I don't have a prosthodontist that I can
just bring in and just say okay, you know, give him the teeth.
You know, Of course, of course,yeah give them the teeth.
Dr. Soren Paape (57:39):
You know, of course, of course, yeah, but the
advancements on the digitalside?
In the last five years havebeen exponential, which is so
cool to to be a part of and, um,you know I'm incredibly excited
to see what's to come in thenext five years in that front.
For sure, for sure uh well,david.
Dr. Tyler Tolbert (57:51):
thank you so much, um, for taking this time
with us to share your knowledge,your wisdom, and you know the
energy you brought forth withthis is just, it's just amazing.
And you know you're obviouslygenuinely interested in this and
appreciative of what we do, andthat's just extremely humbling.
You know, just as a host of theshow, to have that and and
Clark, of course, thank you somuch for sparing your time to
come on and you know Iappreciate, you know the, the
(58:15):
how you've escalated theseconversations, because you're
certainly able to pull more outof david than we are, um, given
your experience.
So I think this has just beenan incredible interview and and
I really appreciate you both forfor coming on thank you for the
opportunity.
Dr. David Zelig (58:26):
I want to learn more from you guys well, you're
too kind.
Dr. Tyler Tolbert (58:31):
Well, maybe we'll have you back on the show
in the future and, uh, sharesome more war stories.
So, uh, thank you guys so muchand thank you all for listening.
We'll see you next time on thefixed podcast.
Thank you, thank you, bye, allright.
My name is Dr Tyler Tolbert and I'm Dr Soren
Poppy, and you're listening tothe Fix Podcast, your source for
all things implant dentistry.
Dr. Clark Damon (00:10):
So what is the talk about the Norris?
Is this like a 375 or a 35?
Dr. David Zelig (00:17):
What's its size ?
On the Norris it's a 375.
It's a 375 with a narrow apex.
To me it's a nicely taperedapex and the rest of it is
threaded to the crest.
Same exact thread the whole way.
It's not aggressively threadedand it has that added benefit of
(00:40):
the bold surface.
Dr. Tyler Tolbert (00:42):
the non-threaded portion, uh,
mid-shaft yeah, do you thinkthat that would have any
indication for use?
Dr. David Zelig (00:53):
uh, with trans sinus as well, yes, yeah, yeah,
definitely, it's um, um, yeah, Imean it's.
It's really.
You don't need thatnon-threaded surface in the
trans sinus, but it doesn't.
You don't need threads in thetrans sinus portion either.
So, yeah, it certainly can be.
Dr. Tyler Tolbert (01:11):
Okay.
Dr. David Zelig (01:12):
Yeah.
Dr. Tyler Tolbert (01:13):
Fair, fair.
So one thing I don't thinkwe've put a lot of attention to
is pterygoid implants as well,right?
So of course we've talked aboutthe full gamut of you know of
remote anchorage and things.
So you know, I'm curious whatkind of you know tips might you
have for applying pterygoids insomeone's practice?
What kind of implant designsare you looking for there?
(01:33):
And are you a drill guy,osteotome guy?
A little bit of both, greatquestion.
Dr. David Zelig (01:40):
It's really funny because I did the same
thing.
By the way, I flew around thecountry watching people do this
too.
It was really no, no definedtechniques around and no real
defined anatomical landmarks touse, and so it's funny that that
I'm.
I'm not going to call myselfone of the mentors here, but
(02:02):
there are a few of us thatstarted teaching this a while
back.
Each one of us is kind ofadopted points of the others and
and we've each one is distilled, their own, their own technique
.
So I generally use I'll startwith an osteotomy I use, I
really use every landmark that Ican.
(02:22):
I use the hamulus.
Hamulus is the medial mostpoint of the, the inferior most
point of the medial pterygoidplate.
That's going to be my end point.
Typically, I'll just imagine apoint 20 millimeters above.
That is going to be my, myaiming point for this and the.
Depending on how much bonethere is under the sinus, I'll
(02:44):
start as far forward as I canunderneath the sinus or in the
posterior maxilla.
So typically, let's say, acentimeter in front of the
hemular notch, which, by the way, you really do need to reduce
the tuberosity to make sureyou're not losing all that
wasted bone.
There's a wasted height, lengthof an implant.
(03:06):
But once you do that you caneven even feel it.
The other trick that I've beendoing most recently is I'll take
the the two millimeter sharposteotome and dissect, well with
a with a periosteal dissect,the posterior to the hamular
notch and a little bit furtherposteriorly to see the fibers of
(03:26):
the musculature.
Then I'll take the point, theosteotome, and put it between
those two plates in the musclejust a few millimeters and use
medial lateral movement toactually I'm hitting the medial
plate, I'm hitting the lateralplate and it really directs me
to that medial plate so thatthat gives me a little bit more.
Every possible clue that I canget out of this patient I'm
(03:51):
going to use to get me in theright direction.
You know we have a very healthyrespect for the pterygoid
region, all the bleeding thingsthat are back there.
So medial is the way to go andI'll use that sharp osteotome
(04:11):
first just to get through themaxilla, hit the pyramidal
process of the palatine bone,stop right there and then go to
the same burrs that I'll use forthe transnasal, the sharp two
millimeter long pilot, and thenfollowed by that implant
specific drill and that's reallyit.
But I use that.
I use that, by the way, in thezygoma handpiece, the, the
straight handpiece that I don'tuse for zygomas it's hard to use
(04:35):
that for posterior zygoma, bythe way, but it should be called
the pterygoid handpiece becauseyou're standing behind the
patient.
Whatever you're doing, the samedirection as the osteotome goes
, the handpiece goes.
And I use that handpiece withboth of those drills, the pilot
drill and the implant-specificdrill, almost as an osteotome.
I'm sounding as I go boom, boom, boom, boom, boom, boom, and
(04:58):
then I'll go to the.
I definitely use theRosen-Smiler driver.
I think that's a clutch.
I like saying I make fun ofmyself, but I was almost
self-defecating, not justself-deprecating.
When you lose an implant there,you'll lose more than an
implant.
(05:19):
You know what I mean.
It's the worst.
So it's a very scary moment.
So that Rosen-Smiler driver hasjust locked the implant in place
.
There's one for for theinternal hex connection is one
for the neodymium connection,which is sin.
I mean you, you don't need togo without it and it's just a
way to stay safe and that's it.
I mean it's from an implantchoice.
(05:40):
I like something moreaggressively threaded and
generally I will leave the flathex or the dot, depending on
what implant company I'm using,facing forward so that, um, ever
so slightly a 17 degreetypically 17 degree or 30 degree
multi-unit will will come everso slightly in an anterior
(06:03):
vector and ever so slightly in afacial vector so that I can get
a driver in there.
If it's right over the lowercusps or lower central groove of
a second molar, it's impossibleto get a driver in there.
Dr. Soren Paape (06:17):
Yeah, I would say too, by doing that a lot of
times we're angling our anteriorimplants forward to get that
proper prosthetic right behindthe iso edge, so it prevents a
divergence.
Yeah, um which luckily now Imean I don't know what, if you
guys are doing photogrammetry atall or anything but something
(06:38):
that's been very helpful in myoffice is our photogrammetry
unit specifically will tell youthe divergence.
So you know that day like, okay,I need to make a quick
adjustment on my multi-unit.
But by having that anteriormulti-unit it matches the
anteriors a little bit better aswell.
And a little tip too forlisteners that I've been doing
(07:01):
is when I have a case of apatient who you know their teeth
are flared forward quite a bitand I'm doing my angled, my
anterior implants angled forwardquite a bit, I will not angle
my posterior ones as much maybea little bit less than 30,
because that will pull thoseforward as well, specifically
(07:23):
when I'm doing pterygoids, sothat everything's in line and I
get much less divergence onthose implants.
A question that I have for youabout your medial angle for your
pterygoid implants is are youcommonly trying to get full bone
in contact, going throughdirectly at the medial plate, or
(07:44):
what are your opinions on, youknow, popping through the that
process into the, the fossathere?
Dr. David Zelig (07:51):
Yeah, sure, okay, let me just say that the
greatest thing, the greatestthing about you know, one of the
things I would suggest toanybody is just don't stay alone
in your office and stay in yourlittle world.
Just, social media is great andthis is a great.
Just to share this passion thatwe all have, it's wonderful.
(08:12):
I believe that the I believethat the real anchorage of a
pterygoid implant is thepyramidal process of the
palatine bone.
If you hit a plate, a medialplate, in most cases you're
going to hit it in an area whereit's a thin plate.
It's really not going to giveyou much.
(08:33):
Maybe it'll give you anothercortex, another little bit of
stability.
But I think most of thestability is really that
pyramidal process, so thatgetting through into the, if you
get into the pterygoid fossabetween the plates, once you're
past that you're gaining nothingexcept maybe causing some
trismus for a while, but you'renot gaining anything.
(08:55):
So extra length once you dothat is not gaining anything.
So I don't see a benefit there.
If you can aim, sure, ideallyaim towards the medial plate and
if you hit it, then you'll getsome more.
But most of the real stabilityis along that path in the
(09:15):
palatine bone.
And if you look at if you lookat, look at an anatomy book and
and the kind that separateseverything out, and look what
that palatine bone is, it's,it's a nice thick, solid bone.
Um, you got to be pretty luckyand this is a blind placement.
I mean, unless you're, unlessyou're doing it guided which you
(09:37):
owe me another discussion, youowe me all fans of that.
It's another discussion.
But unless you're doing a guy,you know it is a blind procedure
.
So you're using the landmarksthat you have and you're gaining
the stability as you go.
So I'm not necessarily tryingto pop through.
If I do pop through, I surehope it's after 18 millimeters.
You know at least I have 18millimeters of implant before I
(09:58):
pop through.
That's my goal.
Dr. Clark Damon (10:01):
That's my goal.
Yeah, I would say that I wouldnever know if I was right into
the pterygoid fossa, right?
So just solid anchorage in thepalatine bone, versus if we
nailed the complete medial wingthere, right, I wouldn't know.
(10:23):
There's really no way toactually tell.
And, and to be honest, if youpop through the medial wing of
this, the pterygoid, you're,you're into the nasal fossa,
right You're, you're in thenasal pharynx.
And so I've seen other people'saxial um slices and I'm like
(10:45):
that tip of that implant is inair.
You know, like if they ever getintubated or whatever.
You know nasally, that implantmay puncture the tube.
Dr. Tyler Tolbert (10:57):
And this is something too.
And I've done this, clark, I'vegone, I mean I'll just, you
know, I'll put myself out there.
I mean I'm always going forthat medial wing and just like
David was describing earlierwith putting his osteotome
between the plates, I did thesame thing with my Lance drill.
Right, I like to get in betweenthere and actually move the
head physically and I'm alwaysshooting for that medial plate
(11:22):
and I've had a few times littlebit more medial and like, yeah,
I mean I've got a few that start, you know, edging into that
nasal cavity and I've beencurious.
I mean they've torqued outwonderfully every time, of
course, but I've been curious ifthere's anything, any negative
sequela that could come fromthat.
I'm not, I'm not entirely sure.
I've never taken anything outjust because of that, yeah.
Dr. David Zelig (11:40):
It's, it's way back there.
I mean, it really isn't nasalpharynx, so there's good thick
mucosa over it, so it shouldn'tdehist through.
But, like what Clark was saying, I wonder what happens in a
nasal intubation or some othertrauma or something like that.
Right, but generally, how farare you going to poke through?
I mean, I would probably saypoking through a millimeter or
(12:00):
two into the nasal floor is alsono consequence.
Dr. Tyler Tolbert (12:03):
Yeah, yeah, I mean generally, if I'm deeper
than I don't know if I'm goingto play something longer than
2022 millimeters I need toreally know where I'm at and
have a good idea why?
Um, most of mine are just 18.
Dr. David Zelig (12:13):
So I mean they're not going to go that far
.
Dr. Tyler Tolbert (12:15):
Um, but, uh.
But something I was curiousabout too is, uh, you know, you
mentioned how, um, your, I guessyour anterior, posterior entry
point with relation to thehamlet or notch, is dependent on
how much bone you have backthere, right?
So I'm curious.
I mean, I have some cases wherethere's really not any runway
at all.
I mean, I got a shell of boneall the way back, does that?
(12:38):
I mean I've done some of thesecases where you know,
essentially what I'm doing is atrans sinus, right?
You know?
I mean I'm curious of yourthoughts on that, if there's a
way to circumvent that, if it'sa non-issue, you know, how do
you view?
Dr. David Zelig (12:51):
it.
So the way to circumvent it I'mnot recommending it, but the
way to circumvent it is the lessbone you have under the sinus,
the more vertical that implantbecomes, more posterior, but
then it becomes prostheticallyuseless.
Yes, so you have to play thegame.
On the other hand, how manycases do we see that your
reduction plane is already inthe sinus, whether you have to
(13:14):
lift or crush the sinus floor,whatever you got to do, even at
the posterior maxilla, at thetuberosity.
So if you're already at sinus,okay, ideally you've lifted the
membrane there and you canactually see the posterior
wallilla at the tuberosity.
So if you're already at sinus,okay, ideally you've lifted the
membrane there and you canactually see the posterior wall
at that point, which is not abad thing, you can see the
posterior wall, you can seewhere your medial plate is and
you're you're already inpyramidal process.
(13:36):
Yeah, that's great if you can doit, but it does, you know.
It leaves a good bit of implanthanging in midair, not not in
the sinus, but in midair.
What that does long-term do weknow.
You know, it's not like azygoma.
You have a lot less stability,it's less of a bony anchorage
(14:00):
Less of a bending motion Right.
There's less of a long arm there, that's true, um, and it is the
posterior it eliminates.
You can't deliver.
So there is a benefit.
Um, I didn't.
I started this business as aall-on-four purist.
You know, clark, you probablydid too, you know you.
(14:20):
You come out of there andsaying any more than four is an
emotional implant.
That fifth implant is an amaze.
You feel better, but it doesn'tdo anything.
Well, we know that it does dosomething.
I mean, at least the territoryis eliminated, and you can't
believe it does have a benefit.
But I came.
I came to it a little later.
You know, I used it as anemergency for years and
(14:42):
eventually it's.
It's not necessarily every case, but it's most of my cases.
Dr. Tyler Tolbert (14:48):
Yeah, I think of the less emergency.
More insurance, yeah.
Dr. Clark Damon (14:52):
Yeah, and I think, go into surgery that
you're only going to do it onceand do it the best you can.
I don't understand otherclinicians who say, well, we
want to save bone, we want tosave this for when we have to
redo it, like if, if that's yourthinking, then why?
Why even do it?
Because when you have to redoit, it's on you and it's even
(15:15):
harder, you know, um, so youknow, in in my practice,
everybody gets a pterygoid.
Uh, I'm, we're doing nocantilevers and I actually
compiled my data for vichy andI've got, over the past five
years, I've got nine hundred andsixty four pterygoid implants
(15:36):
completed, with only four failsso.
So it's interesting, you know, Ireally, it really is Getting
all that data.
But yeah, you know, when you goto Nobel, they told you that
the fifth implant, like you said, emotional implant or it's the
boat payment right.
(15:56):
And you know I've got a lot ofcases where, yeah, they're doing
great at you know eight, tenyears on four, where, yeah,
they're doing great at you knoweight, ten years on four, but
man, if we could have eliminatedsome cantilevers or given
patients extra teeth.
You know, one thing that Ilearned a long time ago is when
you're treating Indian patients,or you know patients from you
(16:20):
know the East, what do theyoften have that many of
caucasian americans don't?
They often have third molars,and so when you give them a
all-on-four on 12 teeth, youknow they, they are upset,
they're like where's my molars?
Oh, you've, we gave you a molarand they're like where's the
(16:44):
other four?
um, so you know, just, youalways have to think of that.
That was, that was a big aha,you know, moment of my, you know
american americanism, uh, sojust think that through and
that's that's you know you wantto make sure that you're doing
teriquids on them.
I have have one.
Dr. Soren Paape (17:03):
I have one patient right now that, uh, I
did.
You know I try to doretroframenol on every one of my
cases as well to get those backmolars and um, it was an Indian
patient and I the didn't gettorque on that, so I just put a
cover screw.
I usually come back at threemonths, especially in that in
the posterior mandibleible.
Um, sometimes I'll get thosewhere you know, I come back at
(17:24):
three months, expose it and thenadd it to my.
My case at that point, and herbiggest complaint over and over
and over again was that rightside, was that she was missing
two molars back there and nowfor the three months that was
the worst thing that I ever didto her.
Uh, luckily went back in and youknow it would torque fine.
Everything looked good, butexact same thing that you were
(17:45):
talking about yeah, it's just,you know the learning curve of
forage, david.
Dr. Clark Damon (17:51):
I wanted to ask you, um you know, often times
you know when we're talkingabout pterygoids and when you
talk about patsy protocol.
All right, posterior, anterior,um you?
Dr. David Zelig (18:03):
know middle.
Dr. Clark Damon (18:04):
I, I kind of like Pam, right?
Um, that's that's what Juan'sbeen saying lately.
If he could rename it, he wouldrename it as Pam posterior,
anterior and middle.
Um, I don't like doing mypterygoids first.
Um, now, if, if I know off thebat, hey, this is going to be a
bilateral zygoma case, then sureI will.
(18:25):
I will roll in and do thepterygoid first, but just on my
run-of-the-mill standard arch.
Let's say it's relatively easyin complexity.
I actually like doing theanterior four implants first
before I do the pterygoid, sothat I can make sure that I get
(18:48):
the platform all on the samelevel right.
Whenever we're talking aboutimplant depth, I prefer to have
my anterior four abutments onbefore I place the pterygoid.
I find that that really helpsme get the correct depth versus
having to go back in and forthand take an abutment off because
(19:11):
you didn't get your pterygoiddeep enough.
That's kind of one of thethings I typically find in the
learning curve is not placingyour pterygoid deep enough.
And then when you have yourabutment on, it's too shallow
and so you kind of get like ayou know your bar, your
prosthesis kind of dips downwhere that pterygoid is because
(19:31):
you didn't get it prostheticallyin the right spot.
Dr. David Zelig (19:35):
So yeah, it makes sense.
That does make sense.
So AMP instead of PAM, Okay.
Dr. Clark Damon (19:40):
That's how I approach some of my cases right
now, the hard ones, you know.
We're doing the posterior,we're doing the posterior, we're
doing the pterygoid first, or Iactually may do the anterior
first on a really hard case.
I'll do the two anterior onesjust to kind of get a good rep
(20:01):
and then I'll do the pterygoidand then finish up with my
zygoma.
Dr. David Zelig (20:02):
The logic of the pterygoid first is to help
you position your tilted orzygoma to have that posterior
implant.
For example, if you don't getthe pterygoid, then your
zygomatic implant needs to be alittle further posterior just to
limit the cantilever.
(20:23):
I mean, I understand that logicbut assuming that you're going
to get them all, your logic isgood.
Your logic is good.
Dr. Tyler Tolbert (20:36):
I'm curious too, david.
So when it comes to so, let'ssay you're in that situation
where you haven't been able toget the pterygoid If you don't
get it, the patient probablyjust doesn't have pterygoids,
they're just an anomaly haven'tbeen able to get the pterygoid
patient.
If you don't get it, thepatient probably doesn't have
pterygoids, they're just ananomaly.
But um, let's say you don'thave that.
Now you're trying to establishthat posterior stop and you're
going to do that with azygomatic implant.
(20:56):
Are you incorporating thehessian zygo, that sort of
infant temporal zygo that goesall the way back to the first
molar?
Are you trying to do that, oris it more just like a
traditional a-frame coming outin the first, second premolar?
How are you going about it?
Dr. David Zelig (21:11):
I generally.
I generally go to an a-frameand go back as far back as I can
, hessian.
I've done them.
I've done them.
Um, it's interesting, I've doneit in a case.
It was a I remember one.
The first time I did was arevision case failed zygomas
from elsewhere and the onlything the only zygoma I can get
was back there.
But I started with thepterygoid first, so that the
(21:34):
zygoma and the pterygoid was soclose they ended up burying the
pterygoid, not even using it atthe end of the day.
So really it really was a wayposterior zygoma.
So there's a lot of leeway upthere there really is is a lot
of freedom once you can get backbehind the infratemporal fossil
like that.
I think it's very useful, um,but generally I'm able to with
(21:55):
an a-frame limit, the cantilever.
The same way are you, tyler Iwould.
Dr. Clark Damon (21:59):
I would say on your characterization there uh,
hessian would be more in thepterygoid spot and a a-frame
would be more in the pterygoidspot and a frame would be more
in the first or even secondmolar spot.
The traditional Braziliantechnique is where they're a
little more parallel.
(22:20):
They're parallel, okay.
And that's more in the premolarposition.
I appreciate that.
Dr. David Zelig (22:26):
And, by the way , that's a great use for a
zygomatic handpiece when you, ifyou're doing parallel or an
anterior zygoma I love thathandpiece yeah, I love that
handpiece, but I love it morefor pterygoids now yeah that
makes sense are you in asituation where you you aren't
getting a pterygoid but you are,you can't you do get the
standard four in the front?
Dr. Soren Paape (22:48):
At what point would you consider putting a
zygomatic implant in, becauseyour tilted implants are too far
forward?
If you're coming out canine,are you putting a zygomatic
implant back there?
If you come out first pre, whatis your logic?
Dr. David Zelig (23:06):
The biggest cantilever I want is going to be
a 10 millimeter cantilever.
So if I can get to secondpremolar, first molar junction,
I'm happy.
Ideally I want to be at thefirst molar exit point.
Um, that's, that's my ideal, um, especially if I don't have a
pterygoid.
If not, if I'm at firstpremolar or something like that,
I'll put as I go in to get backthere, got it.
Dr. Soren Paape (23:29):
And then the second question I had was more
for people who are venturinginto the pterygoid space.
If, let's say, you get a reallybad bleed back there, I would
love to hear how you, how youmanage that, what you know.
Just some tips for doctors ifthey run into that situation.
What are the steps that you'dtake?
Dr. David Zelig (23:50):
So the really bad bleed.
You should never get it backinto meaning the pterygoid
plexus or the internal maxillary.
If you're there, you reallyshouldn't have been there to
begin with.
So you're going the wrong way.
So you really have to followyour, your anatomy, follow your
landmarks.
And assuming that you'refollowing your landmarks, I mean
(24:11):
it's like saying you know whatif you poke in the eyeball, I
mean you just shouldn't havebeen there.
I mean there are ways to dealwith it, of course, but you got
to pack the hell out of it.
You should have some toolsavailable to help you.
Avertine is something thatshould be in your office
microfibrillar collagen to helpthe first stage of clots.
(24:32):
And, by the way, the best wayto use that Avitine is if you
take a TB syringe, a 1cc syringe.
I do the same thing with bone.
You just take a 1cc syringe andcut off the tip, the lower lock
tip or the catheter tip.
Cut that off and you could useit as a bone syringe too.
You take your bone in yourDappen dish and just fill it up
(24:53):
from the bottom, like we used todo with impression material.
Just fill it up that way andthen you can use it.
You can do the same thing withAvertine Make little Avertine
balls, put it in the syringe andthat way you can direct it as
you take your pack away direct,and that way you can direct it
as you take your pack away,direct that syringe into where
it's bleeding and start packingthat.
So packing obviously is the wayto do it.
(25:17):
In the case of the realisticbleed, which is one that you're
going too far, medial, and youget descending palatine artery,
there are two things you can do.
First, you can try it dependson where you hit it.
You can try and get the palate,compress the palate on the
palatal side of the, of theincision, try and get it.
If you, if you got that low, ifit's high, then you have to get
into that, into that foramen.
(25:37):
Today, just let me.
I told you I did a, just helpeda guy out with a zygote case
and patient was complaining ofsome pain, flap was open and he
was trying to get a v2 block andsometimes you can hit it and
sometimes you can't.
I said, well, hey, let's cheat,just dissect that palate a
little bit, you can see wherethe periosteum starts to get
(25:57):
into the, the greater palatineforamen, and just once you know
where that is.
Now you can cheat, put the flapback and you go through there.
So I'm saying, do the samething, get into the foramen and
use some epi there.
And then the next thing is toget into the osteotomy that
you've created that caused thebleeding and pack it.
Pack it there, pack it withavatine, pack it with gauze and
(26:19):
then get an implant in there.
I mean, that's really those arethe only ways.
Um, bovi is not particularlybeneficial at that depth.
You're not going to get there.
It's great, by the way, bovi isa great tool to have.
I think some electrocautery isimportant.
It's most important when youstart punching the mucosa around
(26:40):
your palatal multiunits and youget these little arteriolar
bleeds kind that you can stopfor a moment with epi, but then
it starts bleeding again whenthe patient goes home.
So use a bovie when you seethose, or the posterior superior
alveolar artery intraosseousbranch that you see it across
the lateral maxillary wallbefore you get into it with a
(27:01):
zygoma burr or a sinus lift,just zap it, touch the bone and
it'll burn that too.
But the DPA bleeds are notamenable to bovies.
And then the last thing isdon't just let a patient bleed
out and die.
There is interventionalradiology for these things.
(27:22):
So pack it if you're really introuble.
Before you get to that levelthere is, you know, pack it,
stabilize the patient, get intoa hospital that has IR and that
can be fixed.
But again, the real trouble oneis internal max and you just
shouldn't be there.
There's no reason to be there.
Dr. Clark Damon (27:42):
I mean on the internal max, you're not going
to have time to go to thehospital.
Dr. David Zelig (27:45):
Interesting it depends, I mean, if you really
max, you're not going to havetime to go to the hospital.
Interesting, it depends, I mean, if you really get it, that's
true, if you really get it,that's true.
But I've seen some bad bleeds.
I have seen a human being bleedout from a face by the way,
coincidentally, I was finishingsurgery in the operating room
(28:05):
this was in Memphis and thechief of surgery comes running
up Zellig, we need you in the ER.
And I'm like you'll never needme like that.
But he's no.
This guy got brought in in ahelicopter, ejected from a car.
They intubated him in the field.
He essentially had a split faceand I packed everything that
you could possibly pack.
It turns out there wereinternal carotid bleeds,
(28:30):
ethmoidals.
He literally just unfortunately, watched the guy bleed out.
It was just terrible.
The argument you can't bleedout from your face is just not
true.
Wow.
Dr. Clark Damon (28:41):
Let's get off this topic.
I have a Zygo question for you.
What do you think about for you?
What do you think about Zygo?
And or do you do everythingextra maxillary?
Dr. David Zelig (29:03):
That's a great question.
So let's just take a Zy zero orone.
We have a straight wall becauseeverything else, everything
else, is pretty much going to beextra max light, sure?
So the only one that could beintra max, intra alveolus anyway
, is going to be a zaga zero orone.
And on those cases the bigquestion to me is what am I
(29:27):
gaining from saving that littlemillimeter or two?
You know, I mean I'm not goingto debate Carlos Aparicio on
this, but you know in my ownmind what am I really gaining?
The only thing I gain from thatis preventing some dehiscence
of soft tissue over the shaft ofthe implant, at the crest To me
(29:51):
.
To me, because I'm not using athreaded implant, so I'm not
going to get osteointegration inthat crest, so that's the only
thing I'm saving.
It makes it technically morelikely to me to perforate the
sinus membrane low, I'm talkingat the crest.
(30:14):
So, although I've done it inthese cases, you've got this
really beautiful, thick alveolusand it would be a crime to
grind through it.
I've done that, but at the sametime I've made a window, a long
enough window in the side ofthe membrane to be able to lift
everything.
Not that I'm an impatientsurgeon because I think I got
patients to do it right if ittakes it, but I just I question
(30:36):
the benefit.
I question the benefit.
So, yes, I've done in somecases.
I don't see a lot of those fullalveolus cases, so almost all
of them are ground down.
Use that lateral extra sinusburr.
Dr. Clark Damon (30:50):
So let's just say it's a zaga three.
You know, you have two options,right.
You can either tunnel orchannel, right, so um I channel.
Okay, there you go all rightwell what do you do?
I'm more flexible, I'm a littlemore open-minded, I tend to be
(31:21):
more Zaga versus extra maxillary, but you're a big Norris guy,
right.
Dr. David Zelig (31:25):
So Norris likes to.
That's true too.
Today was a near that case, butum, I don't, I don't, um, I
don't know.
I just I wonder.
I think that the soft tissuemanagement, I just don't see a
lot of the dehiscence.
If I'm gonna see it, you know,I can generally predict it a
(31:46):
smoker or something like that,and I use thick tissue and, by
the way, I started on edentulouscases I really went back to a
vestibular incision, like aLaforte incision, and bring all
that you know, really punch thetissue so that my incision is
far from the crest.
Dr. Clark Damon (32:14):
So you're going .
What 10 millimeters?
Dr. David Zelig (32:15):
beyond, or 10 millimeters apical to the… Into
mucosa, into mucosa, into mucosa, and bring the whole thing over
.
It makes, I mean, in aconventional case, in
conventional not necessarilyzygoma cases, but in
conventional cases it just endsup looking like, wow, this is
healed already.
You know, as soon as you finishyour case, it's just, it's so.
It just makes it so clean andthen you don't worry about your
(32:35):
incision line.
The only thing I worry about indoing it that way with zygomas
is is there going to bedehiscence along the shaft?
And I'm using fat, I'm thickand covered, so I really have
not seen that.
Dr. Clark Damon (32:49):
So now do you pull fat on every zygoma case or
will you do like a scarf graft?
I do both.
Dr. David Zelig (32:59):
I do both.
Not on every case, but I willdo both.
Non-smokers with good thicktissue I don't always do, and if
it's a Zaga 1 or so then Idon't necessarily.
Dr. Clark Damon (33:12):
Yeah, I tend to hold the fat, to reserve the
fat and harvest as muchpedicalized CT when possible
Makes sense.
Dr. David Zelig (33:24):
Makes sense.
Dr. Tyler Tolbert (33:26):
So I'm curious about this vestibular
approach, because that's notsomething I'm super familiar
with.
So does that?
Is that to say that you'reincising into the actual
vestibulum and then Not that,not quite.
Dr. David Zelig (33:36):
It's called the vestibular incision, but it's
not.
It's essentially it's what'sused for a Laforte osteotomy.
You're, you're leaving all theattached gingiva, attached in
this case to the palate, um, andyou know again, normally you do
some little forward osteotomy.
There are teeth that stay there, so the attached gingiva stays
(33:57):
there.
It's not stripped.
In this case it's an edentulousarch.
So um into the free gingiva,okay, at the attached gingiva,
free gingiva junction, almost orfurther apical than that, and
then strip the entire flap overpallet, okay, so you go past the
end of the j and then you comeback over and now, when you
(34:19):
close, it's then I punch through.
I essentially am punchingthrough the crest yeah, wow, wow
.
Dr. Clark Damon (34:25):
One of the drawbacks, though, is that you
can't thin the palate.
But, um, on the edentulous case, it's really just edentulous
cases.
Yeah, it'd have to be a casewhere you don't have to do any
tuberosity reduction or thinningor anything like that.
Dr. David Zelig (34:41):
Good, um, nice question.
So I do.
I do when I, because how areyou going to get your pterygoid
in Same problem?
So I do change that incision.
I'll have to show you one day.
It's towards the crest and thengoes vestibular At the
tuberosity.
It's crestal over thetuberosity and then comes over.
Dr. Clark Damon (35:01):
Yeah.
Dr. Tyler Tolbert (35:02):
I think I can see that yeah.
Dr. Clark Damon (35:03):
Just looks like a denture almost.
It kind of goes up and has aflame.
Yeah, that, yeah, just lookslike a denture almost.
It kind of goes up and has aflame.
Yeah, yeah, yeah, nice, nice,wow, that's great.
Now one other question, um, youknow, you, you brought up in one
(35:24):
of the chat, chat groups thatwe're in about, uh, basically
bracing your zygoma shaft alongthe palatal wall.
And you know, one thing that Iwill often do is because, on a
scenario like what you'retalking about, where you've got
a channel right along thatalveolar wall and like, let's
(35:44):
say, it's a, that case would belike a, like a zaga, maybe one
or two, something like that.
Right, I, uh, chu, I think, ishis name, he's out of hong kong,
he's got a great article.
It's an older article, um, buthe, he lifts the entire membrane
and actually does particulategrafting there.
(36:06):
I don't like particulategrafting with zygos, but
oftentimes what I'll do is,whenever I lift, I'll put in
maybe some collar tape orsomething like that, so that I
actually will wind up gettingsome type of bone formation
several years after this is allsaid and done.
(36:28):
So I'll still kind of prefer torest it along that palatal
channel, but I'll lift mymembrane and then I'll put in a
collar tape so that it stays inplace and hopefully we get some
bone formation later.
Dr. David Zelig (36:48):
Alternative.
Again, these are cases that youhave to do so much bone
reduction that you're past thesinus floor, right?
That's what we're talking about, those kind of cases.
So what I'd like to do is startyour reductions until you start
to see that membrane andthere's still bone over it and
just infracture that floor sothat there is bone on that inner
(37:10):
aspect of your implant still,but it's still it's it's too
palatable.
I mean, it's still palatable tothe ideal, um, but that was the
alternative.
Speaking of using some kind ofmembrane is um, I toyed with
using volumax thick ossexmembrane.
When ossex first came out,their big claim to fame was that
(37:32):
the membrane itself ossifies,so that the thickness of that
membrane.
You go back in there sometimesand you see the texture of the
membrane still now bone.
So Volumax, the argument is yougot this thick membrane that
will ossify in theory.
So I started using that,actually on the facial of some
(37:57):
zygomas as well.
Dr. Clark Damon (37:58):
Let's see what happens.
Well, it's easier than a ramusgraft.
Yes, it sure is.
Dr. David Zelig (38:04):
So that's an alternative is to use something
like that, a good thick membrane.
Certainly it'll help with anyoral-antral communication, but
it might help with someossification too.
Dr. Clark Damon (38:14):
I think that's a really good thought there.
Dr. Soren Paape (38:17):
the ossic exfoliants Just changing topics
a little bit.
I'm curious, david, what yourthoughts are on the best
practices for general dentistsdoing remote anchorage just for,
like, protection from boardcomplaints and being compliant
(38:39):
and making sure and I don't knowif you've seen it happen or
anything but like a generaldentist who perhaps had a board
complaint or something for aremote Anchorage based implant.
Is there anything that you'veseen dentists do to protect
themselves from that, to ensurethat and not not I'm not talking
(38:59):
about cases where they weredoing something that they
shouldn't have been doing orlike in a location they
shouldn't have been, but just toensure that they're staying up
to par with someone, like likean oral surgeon, oral
maxillofacial surgeon.
If they came across the boardand just said, oh, he's a
general dentist, he shouldn't bedoing this, so you know, we, we
had, we have the same issue, ifyou think about it.
Dr. David Zelig (39:20):
You know, when I, when I wanted a well, so I
trained in a training programwhere we did our own hips, we,
we took our own hip bone andmost of us do today I went to
Memphis, a very conservativetown, and they didn't want to
let me do it, and so I spoke tothe chief of surgery.
The chief of surgery was anorthopedist who trained the
Jackson Memorial, where BobMarks was, and they wrote the
(39:43):
book on grafting from the hip,and he knew that and he actually
supported me.
So bottom line is I had thetraining and I had the support
of an orthopedist to suggestthat I'm right and it worked.
So in this case it's the samething A general dentist should
get the training, and we justdiscussed what that is.
(40:04):
It's the same thing thatmedical education letting go of
the hands and slowly taking thetraining wheels off it's a
learning curve.
It clearly is, and probablymore of a learning curve for a
general dentist that didn't havea surgical residency.
So take your time, have thebacking of the people that
trained you and go out and do it.
I don't think that you stay inyour lane, so to speak, do what
(40:30):
you're trained and well-trainedto do, and I think you should
have some backup, somebody tocall.
Well, you know David some of thethings that I see is just in
record keeping.
Dr. Clark Damon (40:48):
That's a good point.
It's very technical, yeah,absolutely well, sure, but, um,
very simple.
You know, everybody who's goingto undergo anesthesia just get
a medical consult.
Right, it's not a medicalclearance, it's just a medical
consult.
So we get that on everybody andwhat you get back from the
physicians is their entiremedical history, right, like
(41:09):
I've seen people get dingedbecause they didn't put an ASA
classification, you know, on oneof their notes.
You know, or something, orsomething crazy.
But if you in your part of yourrecord is the patient's record
from the medical doctor, you aremore than covered.
You know, and I you know.
I think it's also importantthat you know the our medical
(41:31):
colleagues.
They don't give us clearance,right.
We are the ones who aredeciding to work on.
So, and it's just having havinga very, a very nice medical
consultation letter that you arejust asking is this patient
medically optimized and do youhave any objections?
Dr. Soren Paape (41:56):
is.
You know you've been doing full, I mean practicing oral surgery
and then getting into the fullarch dentistry.
I would love to hear kind ofyour tips as far as what you do
to for your own personal health,to ensure that you can, you
know, keep doing these things,because right now, you know me,
I'm like leaned over upside downin the patient and I don't
(42:21):
think that that's the best forlongevity right, our dogs are
okay and I would love to hearyour tips.
I know some guys do it sittingdown like I'm just oh, here's
what?
Dr. David Zelig (42:31):
here's what I started with.
First of all, I think that allof us are all front anterior
chain in physical therapy terms.
We're all anterior deltoids andpecs and everything's in the
front All right.
So our backs are critical.
So I came.
Before I started this, I was apowerlifter First, it was
(42:54):
martial, I was a nut, I waswrestling team in college and
power lifting and all thisnonsense.
So because of that, by now Ihave a total shoulder
replacement, two hips and a kneereplaced.
That's aside, but I'm stilldoing all this.
I'm still lifting.
I'm still doing the rest of ittoo good so I think that staying
, staying fit and stretched andall that stuff is really
(43:15):
critical.
I really think that's veryimportant, which opens up the
other thing balance in life.
Because we can I think I was, Ihad a better balance in life
before I became a full arch guy,but that's another discussion
you start to get down in therabbit hole.
Um, I do sit.
Uh, in the last 10 yearsprobably I started sitting and I
use years probably I startedsitting and I use a sit stand
(43:43):
stool.
I use a sally stool, which islike you're, you're almost
standing, so you can feel like asurgeon.
And, um, no, I'm seriously,because that was the big thing
oral surgeons, here you don'tsit.
What are you a dentist?
You know that kind of thing isridiculous, but but that was it,
was the thing.
So, and everybody in theoperating room stands.
So this thing is you, you'realmost standing, your feet are
almost straight, but you're in astool.
Sally's stool, great for men,has a pudendal groove to let
(44:08):
your prostate be healthy andkeep the boys from being asleep,
so anyhow, so that's, I dorecommend that.
I do recommend sitting andsitting in a stool.
If you're in a horse's saddleyou can't slouch, so you really
are maintaining a good, a goodposture.
So I think that's important, um, but sitting high so that
you're still looking down andable to see what you need to see
(44:31):
.
Headlight, like I said, I don'tuse the loops, um, um, I used to
use it for a lot in surgery,but not in arches.
You really, I feel like you gotto see the whole headlight.
What's that?
What headlight do you like touse?
I have the kls martin, the, theuh med led chrome, okay, um,
(44:53):
but I've tried them all.
I have another one that sits onmy glasses.
Oh, I just recently I'm notwearing them now, but I just got
somebody bought me a giftcertificate, gave me a gift
certificate for the Ray-Ban Metaglasses.
You know the AI glasses.
Yeah, I put the camera in there.
I actually started using it forfilming in surgery.
(45:16):
It's great.
Dr. Tyler Tolbert (45:17):
Someone suggested this to me on
Instagram and I was curious.
Yeah, it's great.
Dr. David Zelig (45:21):
You just.
There's something.
You just.
You can't use your headlightwhen you're doing that, though,
it's too bright, but once youyou take the headlight off, it's
great.
It really is very useful it's ahigh quality video is high
resolution.
They it's a high qualityresolution.
They're limited.
You can do live stream by the.
You can do live stream, by theway.
You can do live stream with it,but the video length is limited
(45:43):
to like three minutes.
Dr. Clark Damon (45:44):
But you know you want to show somebody,
something.
Dr. David Zelig (45:47):
You can take pictures and you can do little
snippets.
Oh, that's cool.
Dr. Soren Paape (45:52):
When you're doing the.
Actually, you know, I was justgoing to ask about the three
minute thing, cause when Tylerand I, previous to our current,
what we're currently doing, wewere doing a lot of a clinical
director like helping peoplewith their first surgery, so we
were taking a lot of video andit's always a pain in the butt
to have this video camera likeabove and it's like focusing in
and out every time you leanforward, you know.
Dr. David Zelig (46:13):
Um, uh, what's that?
There is a camera that is onthe on the overhead light
fujiden, I forget what it'scalled, but there's one that
does well.
But the other one I got that umheadlight camera.
I have that too five thousanddollar, yeah it was.
You know, what else am I goingto do with the money, you know,
(46:34):
but anyway, I it's veryuncomfortable and, um, heavy.
You're like a lot.
Dr. Soren Paape (46:39):
Right, there's a lot of this going on, so, um,
I haven't found the secret sowhen you're doing your um, when
you're on your, your sally stool, and you're, you're, you're
doing it, you're at the 12o'clock position.
Are you doing your mandiblesfrom the 12 o'clock position?
Dr. David Zelig (46:55):
Yeah, mandible, more of the mandible.
So 12 o'clock to 3 o'clock.
I mean I'm to the side of thepatient as well, but I try.
More I can do from behind, thebetter.
Patient is flat, that's.
The other thing is, you know,when I did, when I'm doing my
own sedation, my own deepsedation, the worst position for
a patient when they're in openairway is flat.
(47:17):
So you know, but it's the rightway for us to do surgery.
It's the easiest way for us tosee the maxilla and the mandible
.
So I do fight it.
When I'm doing my own sedation,I often use a nasopharyngeal
airway to help with that.
When I'm elsewhere not my owncenter, I have an
anesthesiologist, the patient'sintubated, that's beautiful.
(47:38):
So I have no airway issues.
Um, and when I'm doing themandible, I'll just sit the
patient up a little bit.
So I'm looking down, but I tryto be from the standpoint of
when I'm doing the osteotomies.
Dr. Soren Paape (47:50):
I'm behind the patient, which just makes
everything symmetrical I havetried doing that so many times
and I keep.
I always come around to thefront of the patient to do mine,
but it's just one of thosethings that you gotta, you gotta
, but as long as I mean, if yourback is straight, that's the
main thing.
Dr. David Zelig (48:08):
Yeah, you just keep your back straight and look
down, keep the patient low andjust look them down and good
well, hey, I appreciate thosetips, that's great yeah, we need
something, something that a lotof people don't think about,
but I'm hoping a long careerahead and get out there and play
pickleball or something.
Dr. Tyler Tolbert (48:28):
Oh man.
But yeah, maybe I'll just startwearing one of the powerlifting
suits, you know, with the thoseare beautiful.
Dr. Soren Paape (48:35):
Just the belt during the surgery.
Dr. Tyler Tolbert (48:37):
Yeah, I have done that actually, but uh, but
no, that that's great, and soyou know I mean that that
question kind of alludes to youknow, you know how long you've
been doing this and your abilityto continue to do it.
I'm curious about you, know,looking forward for yourself
professionally.
Obviously you've been doingarches a long time.
You're practicing at the top ofwhat we can really do.
(48:59):
Um, you know, what are youlooking forward to for the rest
of your career?
I mean, do you see moreadvancement, more growth in your
clinical uh pursuits?
I mean, what do you?
Dr. David Zelig (49:07):
see for yourself.
It's so funny.
You know everybody I havefriends that some have retired,
some are retiring, some areslowing down, some of everybody
else, and I'm like I'm still onfire on this.
I love it.
Um, yeah, it's great.
You know, there was a.
There's an old singer that wasthe other thing I did was I was,
(49:29):
I was in a choir, but anyhow,this guy, we did this opera
together and the old man sang inthe winter of my life.
I feel like it is spring again,is what he's saying.
I'm not in the winter of mylife or anything, but I feel
like this is keeping me going,excited in this every day.
(49:50):
I love what we're able to dofor patients.
It's a privilege, it's a realprivilege and I love it.
So do I want?
Yeah, yeah, I definitely wantto do more.
I want to keep teaching, I wantto help the next generation and
, um, just keep doing the rightthings for patients, you know
yeah, yeah, and looking forward.
Dr. Tyler Tolbert (50:11):
For you know, obviously you you've had the
wisdom and the experience to seehow far full Arch has come, all
the way going back to whenPaula Malone was first talking
about this kind of stuff.
So you have probably as muchauthority as anybody to say what
does it look like for the next10 years?
Where do you think Full Arch isgoing?
What do you think people willbe talking about on podcasts in
(50:32):
2035?
With regards to Full Arch,that's great.
Dr. David Zelig (50:37):
I definitely think that we're getting to a
point where we got a system thatworks.
The patient-specific implant isgoing to find a way to get
perfected for the, for themultiply revised cases.
Having having had jointreplacements, I can I think I
(50:58):
could also tell you thatorthopedists look at these
things differently.
They don't call failuresfailures.
You need a revision.
And you need a revision becausea car is not going to last
forever unless it's maintainedperfectly.
And even an antique car is notgoing to drive the same as a new
car, even if it'swell-maintained.
So things do change.
(51:19):
It doesn't mean failure as longas new guys with the great new
ideas.
(51:41):
We talked a little bit about theimmediate finals.
I don't know that that's goingto last.
I think that you also talkedabout the lifetime warranties.
I don't think that people canstay in business when they're
advertising pie in the sky kindof things that are not
necessarily going to work.
Um, but it might be the, theflash in the pan.
(52:04):
It might work right now, yeah,I think.
I think the the guys that aredoing it right, responsibly,
will end up if I could use theterm winning, will end up just,
uh, being into the long game.
You'll end up just uh, being infor the long game.
You'll still be doing it bythen.
Yeah, I don't know about medoing it, but I'm saying you
know it's as long as you'redoing the right thing for the
(52:25):
right reasons um, you'll stillbe doing it that's great.
Dr. Soren Paape (52:29):
well, we definitely appreciate having
guys like you that are helpingus in the next generation with
with uh, you know these advancedtechniques and making sure that
you know guys like Tyler and Icoming up have the ability to to
fix these cases when we need to, because without, without
people like you, we wouldn't beable to or we wouldn't know
(52:49):
where we could go, you know.
Dr. David Zelig (52:52):
You honor me by saying that, but I just, you
have no idea the you've given uslife.
I don't know what to say.
Great, great to have that.
It's great to have that, causeI cause I had that.
You know, I had those mentors.
Dr. Tyler Tolbert (53:06):
Yeah, yeah, I mean oh Clark, we lost you.
I'm mute again.
Dr. Clark Damon (53:12):
Yeah, I'm sure Check your.
I think now it's easier to havea tribe Right.
I think now it's easier to havea tribe right and so it's
easier to, you know, collaborate, it's easier to talk about
cases, and so I think that youknow advancement will be quicker
and it will be, you know,better.
(53:34):
I don't know what is around thecorner, I don't know how it can
get any better, you know, Imean I think what Molo, you know
, I don't know, I don't knowwhat is around the corner, I
don't know how it can get anybetter.
You know, I mean I think what,what Molo, you know came out
with, you know really startedoff a lot, and then what you
know, you know things you knowlike Dan you know coming out and
you know.
You know I was doing pterygoidsbefore Dan's book came out, but
(53:55):
you know Dan has really kind ofhelped.
You know, talk about pterygoidsand then bring in the no cant.
You know Dan has really kind ofhelped.
You know, talk about pterygoidsand then bring in the no
cantilevers and and and reallykind of broaden that out to
where I really feel that youknow our implants are better and
our patients are being treatedbetter.
So it'll.
It'll be a fun.
It'll be a fun, you know nextchapter, but I think that the
(54:17):
the clinicians who are coming up, I think they have a better
education experience, betteraccess to education and access
to a community yeah yeah and youcan find that at clark's course
, if you need good education.
Dr. Soren Paape (54:32):
It's a good spot to go, for sure yeah,
that's right, my uh, tyler and Iand caleb, who's our other
partner we talk with this a lotabout, you know, because we
always are trying to stay aheadof the curve when it comes to,
like, the business side of fullarch.
Um, and where we're reallyexcited about is the potential
for a lot of like the ai and theprosthetics.
(54:54):
As far as um know, I'm surewe'll get to a point where a lot
of the design is going to bedone via AI and maybe you can
take a, take a picture of apatient right and then get a
smile design, and that smiledesign will turn into, you know,
a surgical guide right, or orjust like the provisional
prosthetic already designed foryou on those multi unit
(55:17):
positions, and that's what we'rereally excited for, I think
that that is going to be cominghere pretty shortly.
Dr. Tyler Tolbert (55:24):
Yeah, I think a lot of the advancements we'll
see are going to be on theprosthetic side and on the
actual planning side of things,right, I mean, we had Dr Sven
Bone on here not too long agotalking about his programs that
are doing a fine elementanalysis to look at prostheses
and figure out where their weakpoints are, and that's yeah, and
that's some well a break.
Exactly precisely and you knowthat's an AI driven thing.
(55:44):
Ai can be driven to, you know,either generate or analyze an
implant plan.
You know, on an extremelyatrophic case, it can figure out
where the stress points are, ormaybe even a patient specific
implant, like David wasmentioning, finding where those
stress points are going to beand how that's going to work out
prosthetically.
I think it's going to make us alot smarter in terms of you
know what we're putting on topof our implants.
(56:05):
But my hope is that the Yominever catches up to us and we'll
still be the ones executingthese surgeries.
That will always be a humanbeing.
Yeah, that's what I'm hopingfor.
I hope I get David's age andI'm still talking about slinging
arches on the daily.
Dr. David Zelig (56:26):
And that's what I'm still going to participate
in, and this will only getbetter as we go.
But I guess time will tell Ihave a perfect.
Not that I need a closing line,but we opened maybe before we
started recording.
I thanked you for sending methis, what I call the Rush
Limbaugh EIB microphone, sendingme this, what I call the Rush
Limbaugh EIB microphone.
So Rush Limbaugh, it turns out,if I can quote him again,
before he got sick and before hedied he was also a tech expert,
an Apple expert.
(56:46):
He said I'm not afraid of dying, I'm afraid of all the tech I'm
going to miss, and I think thatapplies here, man, we're all
growing up and getting older,but look how this is growing
yeah it is.
Dr. Soren Paape (57:01):
I mean going from just and I think, David,
you might have mentioned thatyou still, a lot of your cases
are analog, but from analog to,and I know yours are too, Clark,
but go ahead.
Dr. David Zelig (57:13):
No, no, no, I said I was analog and trying to
figure out all this tech thatyou sent me to start.
Dr. Tyler Tolbert (57:17):
Okay, no, no, no.
I said I was analog and tryingto figure out all this tech that
you sent me to start.
Dr. David Zelig (57:19):
No, no, no, I'm mostly digital In that world.
I'm mostly digital.
Dr. Tyler Tolbert (57:22):
Yeah, clark is not as over here.
Dr. David Zelig (57:24):
Yeah, just like you.
Dr. Clark Damon (57:28):
Well, I don't have a prosthodontist that I can
just bring in and just say okay, you know, give him the teeth.
You know, Of course, of course,yeah give them the teeth.
Dr. Soren Paape (57:39):
You know, of course, of course, yeah, but the
advancements on the digitalside?
In the last five years havebeen exponential, which is so
cool to to be a part of and, um,you know I'm incredibly excited
to see what's to come in thenext five years in that front.
For sure, for sure uh well,david.
Dr. Tyler Tolbert (57:51):
thank you so much, um, for taking this time
with us to share your knowledge,your wisdom, and you know the
energy you brought forth withthis is just, it's just amazing.
And you know you're obviouslygenuinely interested in this and
appreciative of what we do, andthat's just extremely humbling.
You know, just as a host of theshow, to have that and and
Clark, of course, thank you somuch for sparing your time to
come on and you know Iappreciate, you know the, the
(58:15):
how you've escalated theseconversations, because you're
certainly able to pull more outof david than we are, um, given
your experience.
So I think this has just beenan incredible interview and and
I really appreciate you both forfor coming on thank you for the
opportunity.
Dr. David Zelig (58:26):
I want to learn more from you guys well, you're
too kind.
Dr. Tyler Tolbert (58:31):
Well, maybe we'll have you back on the show
in the future and, uh, sharesome more war stories.
So, uh, thank you guys so muchand thank you all for listening.
We'll see you next time on thefixed podcast.
Thank you, thank you, bye, allright.
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