December 30, 2024 • 48 mins
Dr. Simon, an esteemed expert in implant dentistry, particularly Full Arch procedures, joins us to unravel his captivating journey from a conventional dentist to a revolutionary implant surgeon. He shares his experiences in trauma surgery and how a passion for transformative dentistry led to a focus on full arch implants, reviving his career and offering life-changing solutions for orally compromised patients.
Venture with us into the dynamic world of Full Arch dentistry as we explore both the advancements and challenges facing dental professionals today. Dr. Simon highlights the growing importance of mastering complex cases, underscoring the necessity of continuous learning in a field where the potential of AI is becoming increasingly significant. We discuss innovative implant techniques, including zygomatic and pterygoid implants, emphasizing the balance between surgical precision and personal experience in optimizing patient outcomes.
Our conversation takes an insightful turn into the technical aspects of sinus reconstruction and the innovative strategies that are shaping the future of implant dentistry. From creating sinus windows to managing sinus complications, Dr. Simon details his hands-on training experiences that have honed his expertise. We also explore the promising future of materials like Tetranite, which could revolutionize current practices and improve surgical predictability. Join us for an episode that promises to enlighten and inspire dental professionals and enthusiasts alike.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
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.
One thing that we prideourselves on here is having the
clout to bring on the bestimplant surgeons in the world,
and I think that we have notfallen short of that today.
Today, we have on Dr Simon oh,who, if you don't know him then
(00:24):
you're probably pretty new toFull Arch.
So this is somebody that Sorenand I have been following for a
long time.
I've actually interviewed himbefore, and he's graciously
agreed to come back on and talkabout all of his expertise.
We're huge fans of him, of hisInstagram channel, of his work
and also his work with OrcaGlobal, which I'm sure you've
heard of, as well as theirupcoming symposium.
(00:45):
So we're going to be gettinginto all that, but before we do,
welcome back to the show, simon.
Simon Oh (00:49):
Hey, thanks a lot, guys, good to see you again, For
sure, for sure.
Tyler Tolbert (00:53):
So it's been a little bit since we've talked
and certainly things have grownand we want to talk about all
the updates that are going on inyour life and career, of course
.
But for those who don't knowwho you are, would you mind just
kind of giving us a briefintroduction as to how you got
into implants, how you got towhere you are, from dental
school to here?
Simon Oh (01:17):
Yeah, sure, I reside outside of Philadelphia in the
suburbs.
I ended up here.
Because I ended up here,because you know, I grew up in
Maryland.
I actually have only lived intwo states, maryland and
Pennsylvania Went to all thestate schools, so University of
Maryland, college Park, forundergrad, university of
Maryland for dental school, andthen I ended up at Hahnemann
(01:38):
Hospital for oral surgery andbasically I did that until med
school ended up, leaving theprogram but and I was planning
to move back to Maryland, but Imet my wife.
She was a med student atJefferson at the time.
She was doing a residency thereand then like, okay, we're
(01:59):
gonna go back now, and then thatdidn't happen.
We had kids and then then, youknow, they had friends and so
like, of course.
But yeah, I mean, you know, interms of implants, um, we didn't
do too much in when I was inresidency.
It was mostly trauma uh centerof philadelphia, um level one
(02:20):
trauma center, just gunshotwounds non-stop.
You know, like that's basicallylike what we did um.
So you know, after um I left, II picked up a uh position as
like a traveling exodontist,slash implant person, um.
So you know, exodontia isreally cool I, I like it because
(02:40):
, um, just from a lifestyleperspective, like it's very
simple.
You know you meet the patient,they're in pain or they need
their wisdom teeth, whatever,and you get them out, you say
hello, goodbye, and then maybeyou see them for follow up and
that's it, and you know that's,that's pretty convenient.
But, you know, in terms of likeimpact, I'd say like the
implants is really where thingssort of like my focus went into,
(03:04):
because that's that really madepeople happy.
You know, people aren't exactlyhappy to get a tooth pulled,
they're happy to get toothrestored.
So, um, you know, little bylittle I started with singles,
did multiples edentulous ridgesand then, um, you know, at one
point I was actually consideringleaving dentistry because I was
getting pretty tired of it.
A lot of people were notexactly thrilled to see you, but
(03:29):
then I stumbled onto a fullarch.
You know, like I startedlearning about it, reading about
it, you know, following a lotof guys on social and reading
articles, reading the history.
I really enjoy reading that andI just realized, like, realized,
like, wow, like you can,actually, instead of just like a
single tooth or a bridge orsomething, implants like you
(03:50):
could do their whole mouth,change their life in a single
day.
Give them function again, givethem aesthetics again, um, and
like, that just changed thewhole game for me.
So, like ever since, that'spretty much all I've been doing,
I haven't.
I mean, I maybe placed like Idon't know 50 single implants a
year or something, like notreally that much, but like full
(04:14):
arches are just that's that'sall I do.
So, yeah, I mean, in terms ofimpact, I really like it because
, you know, like in anything inhealthcare, you sort of treat a
certain segment of health, so,like you know, veneer people
take somebody that's alreadyhealthy and makes them a little
bit better, right, like they'reat the upper echelon of like
(04:35):
health.
And then you have like yourmiddle segment, which is, like
you know, crown and bridge andjust routine dentistry, and then
you have, like the very bottomsegment, really, the orally
crippled people, and what thatprocedure does is we take those
people and bring them all theway back up to here again, um,
so I I think it's just great.
Um, I, I love the, I love thework, I love the technicality of
(04:56):
it.
Um, I love the sort of umgeometric aspect to it, um, like
geometry, and I don't know ifyou guys remember the PAT from
the DAP.
Tyler Tolbert (05:06):
Oh yeah, we remember.
Simon Oh (05:08):
Yeah, for me it's just so interesting.
So that's really all I reallylove right now, cool.
Soren Paape (05:18):
I really like that analogy.
I might have to steal that oneof the three tiers.
That's really good.
You know it's funny, simon, Ialways say the same thing and
I've probably mentioned it inthe podcast before.
But something that I love aboutfull arch dentistry is the fact
that, instead of your patientscoming in for like a routine
(05:40):
checkup and you telling themthat they have a cavity and it
being like the worst thing oftheir day, you know you're the
people that are coming in to seeyou.
They already know that amajority of them already know
they need their teeth out andyou're there to provide them a
solution.
Um, and instead of beingsomeone's you know worst part of
their day, you can, you canreally make someone's day, uh.
So I really love that aboutfull arch dentistry as well.
Simon Oh (06:05):
Oh, dude, yeah, yeah, I mean, and you know the, the
people that you meet along theway, you know, like, for all the
consultations that we do, likeyou hear their stories and it's
sad you know, a lot of themreally live in the dumps, like
mentally.
Tyler Tolbert (06:16):
You know, yeah, and yeah that's uh, I like sort
of helping those people you know, yeah, totally, and I think
there's I mean, there's just sofew things in dentistry that you
can do that so quickly improveall aspects of someone's health,
you know, physically,emotionally, nutritionally, uh,
everything that goes along withthat and and kind of going along
with what you're saying, islike the kind of dentistry we do
(06:38):
, like these are.
These are treatments thatpatients get to have done.
They don't have to have donealways I mean, have to is kind
of a different term but theyfeel this opportunity, like when
you come in and say, yes, I cando this, they've probably
already been told several timesthat it couldn't be done, they
didn't have enough bone, and Iknow for sure that you're seeing
cases a lot of times that havemaybe already been done and
(06:58):
things are going wrong and it'slooking really bad.
Or maybe a patient that justhas so little bone left that
they couldn't find anybody thatsaid that something could be
done, um, at least in areasonable manner.
Because you know we, ifanyone's familiar with your page
and your cases there's a wholelot of, you know, quad, zygote
cases, terry cases, things thatare, you know, combination of
remote anchorage and stuff, andwe definitely want to get into
that.
But, um, you know, just beingable to make what patients
(07:21):
thought was impossible possibleis the coolest part.
And seeing that surprise intheir face it really never.
It never gets old.
It's very rewarding dude.
Simon Oh (07:28):
Yeah, and you know, I've noticed a uh, an uptick in
uh, people with failing implantstoo.
Of course, one thing to have,you know, a failing dentition or
just completely a dentureless,but then you have the people who
have already been through thatyou know, and then you know.
So, um, yeah, it's, it's sortof getting a little more
(07:49):
complicated.
Just cool for on the technicalside and the sort of interesting
aspect, a little bit sad for,you know, humanity, yeah, I
can't say for sure for sure Iwould say, uh also, I've seen a
lot of an uptick in my office ofI would.
Soren Paape (08:04):
I would consider them prosthetic failures, where
they come in and maybe they wentto a dentist who, um was was
just getting started with withfull arch or who who know, who
knows why.
But you know, they come in andtheir prosthetic is like
basically a denture.
You know it's so thick andthey're just like.
You know, dr Pabby, I've beendealing with this for the last
(08:27):
two, three years and I keepgoing to the same dentist and I
just don't feel comfortable init.
It's been like a nightmare and Ithought it was something that
would be like an easy solution.
So I find that kind of fun, too, being able to take those cases
.
Um, so I I find that kind offun to being able to take those
cases and whether it means, youknow, sometimes replacing
(08:48):
implants, other times justputting on different multi units
and trying to trying to getthem to a point where we can
make them a prosthetic that's alittle bit thinner, that they
can talk with better, that theyfeel more comfortable with it in
their mouth.
Um, I find that really fun andchallenging as well.
Simon Oh (09:03):
Oh, absolutely, man.
And you know that's sort oflike the best case scenario for
call it a revision is smalltweaks to get them comfortable.
Yeah, I mean, dude, if we don'thave to put a scalp on
someone's mouth, that's a goodday.
Tyler Tolbert (09:17):
Yeah, definitely I'm curious.
So you see a decent volume ofrevisions.
So the ones that you're seeing,you know, are these kind of,
from what you can tell, arethese being done 10, 15 years
ago, Like what's kind ofcomprises like the bulk of those
revisions?
Are some of them more recentlybut poorly done?
Or are they just aging at thispoint, Like what are you seeing
(09:38):
most of the time?
Simon Oh (09:51):
Yeah, I mean you know, for I guess I guess for my
practice it's probably differentbecause you know we get a lot
of referrals for rescues andstuff and if someone's having a
hard time with the case.
But yeah, I mean I would sayyou know, I've certainly seen a
lot of old school dentistry,like some of the first
pterygoids that went in, like Isaw a bunch of blades from Link
Out.
Like some of the first terroidsthat went in, like I saw a
bunch of blades from link out,you know, like years ago, and
like cases from like so Tom ball, she used to practice near me.
(10:16):
He was like the first terroids,the first like full arch, sort
of concepts that we're doing allthe time now.
And yeah, I'm seeing a coupleof cases like that come in.
But I've also seen a lot ofcases that are doing stellar of
theirs.
So it's kind of hard to say.
But yeah, I mean I would say alot of the problems that I do
(10:38):
see like on a day-to-day is morerecent.
So that sucks, you know.
That sucks, you know, forhaving to sort of go through
this all the time.
But you know it is what it is,you know, as long as we're all
doing our best and sort ofkeeping the patient's best
interest in mind, you know.
Soren Paape (10:59):
Yeah.
Simon Oh (11:00):
There's no way that we don't have crystal balls to
predict the future and see howcertain patients are going to
turn out the future, but um, andsee how certain patients kind
of turn out, but um, but yeah,it's.
It's sort of a mixed bag, I'dsay, but a lot of them, a lot
more than I would think um, arerecent cases.
Tyler Tolbert (11:15):
Yeah, it's interesting because, you know,
especially when you're seeinghistorical cases from people who
you know, of who you know didsome of those early cases and
things, it's like you're adental anthropologist or
something and you're just, likeyou know, finding fossil
evidence of, like our history,of what we do.
It's really cool.
But yeah, I think it's probably.
You know, you talk about seeinga lot of recent stuff and I
imagine that's sort of amultifactorial thing, right,
(11:37):
because so many more people aredoing full arch now.
You know, even if the rate atwhich those would be complicated
was similar to the how it was20 years ago, you're still going
to see a lot more cases justbecause it's become so much more
commonplace, um, but at thesame time, you may also have a
lot of people who, because sortof the barrier to entry into
this kind of thing has beenlowered, you have people maybe
getting into it a little bitsooner than they need to be
(11:58):
doing it improperly, not quitehaving the right training or
taking on cases they aren'taware of how complex they
actually are prior to gettinginto it, maybe.
Um, so, yeah, that's definitelyinteresting.
I think that, you know, for alot of the people that are, you
know, have been doing full archfor a couple years now, getting
really comfortable with it,starting to identify as full
arch doctors.
What we also have to realize isthat we're not just going to be
like the primary full archpeople.
(12:19):
For someone who's getting fullarch for the first time, you
really have to learn, uh, youknow historically, like what all
these restorations um, or looklike how to take them apart.
You know, if I ran into a blade, I'm not entirely sure exactly.
You know how I rehab that andthe best way to take that out
and what to do with it, um, so,learning that history and how
all those things workprosthetically, the types of
drivers you might need, you knowhow to pick these old cases
(12:41):
apart and how best to revisethem.
You know, conservatively isgoing to be a big part of it
because we're going to be fixingthe new Fuller surgeons work as
well.
So I think that's just kind ofa mantle that you have to take
up as someone who, you know,wants to do this exclusively.
Simon Oh (12:55):
Yeah, no, absolutely.
I mean, you know the what sortof comes to mind is like an
edentional search, like we allget it.
We tilt the posterior implants30 degrees, interiors somewhat
straight, if you can Otherwisetilt 30 degrees, basically to
avoid stuff.
What's going to get interestingis when we start to develop
(13:21):
protocols or techniques for therevision.
I don't think anybody hasreally thought that through in
terms of like okay, this onefails, what do you do next?
Is it okay?
to have a conserved arch upfront with pteroids or something
to avoid a zygomatic.
That's where I sort of I havesome relief thinking about that,
(13:43):
because we're having AI come inand so, like you can, I think
that that complexity would besomething that machine learning
could be pretty useful for.
You know, to sort of analyze,we can upload a DICOM file into
the machine and it spits out analgorithm of like hey, this is
your best chance of long-termsuccess for this patient.
(14:05):
Yeah, yeah.
Tyler Tolbert (14:06):
Yeah.
Soren Paape (14:06):
I really like that.
Tyler Tolbert (14:08):
Yeah, I mean we, we kind of see, you know that
future coming on, uh, fromdifferent directions.
Like we're getting new ways toget data right, like obviously
our data acquisition is gettingbetter.
On the CBCT side of things,we're getting good at um arch
tracing, where we're able to mappeople's bite forces and things
like that.
And then, you know, ai can goin there, kind of consider those
types of factors, maybeparafunctional habits, occlusal
(14:31):
dynamics and things, and then itcan look and find, you know,
you know where, where are zygosgoing to be best suited on on
this bone?
You know where are we going tobe able to fit that?
Is that really going to makesense?
You know it can kind of analyze, based on the arch form, you
know how much tuning fork motionyou're going to have on your
anterior superior zygote if ithas to go way up front or
something like that.
It's really amazing to see orto just think about where this
(14:53):
might be in, you know, five to10 years and how we can really
be assisted through AI machinelearning.
But yeah, that's a great point.
I'm very interested to seewhere that goes.
Simon Oh (15:02):
Yeah, you know, I was listening to Elon Musk on an
interview just what his sort ofpredictions were for machine
learning, and apparently it getsbetter by 10 times every year,
so about I don't know four orfive years, 10,000 times better.
So it compounds.
Tyler Tolbert (15:23):
So yeah, life and practice is going to look much
different very soon, you knowyeah, for sure, yeah, we, we may
soon be dinosaurs and we'lljust have yonis doing everything
, something of that sort um,simon, um, I'm uh, I'm curious.
Soren Paape (15:38):
You know we talked a little bit about your
background, getting into fullarch.
Um, I'd love to hear a littlebit about, you know, your
progression through full archfrom just maybe traditional
all-on-four to what, whatcourses you enjoyed the most,
getting into remote anchorageand um.
For someone who maybe is isdoing like some pterygoids or
(16:02):
like doing all-on you'drecommend for um to to bring get
them into like the remoteAnchorage world.
And I know you you have Orcaand some of these courses.
But I'd love to hear yourhistory and how you kind of
started getting into that styleof dentistry.
Simon Oh (16:18):
Yeah, you know, um, I guess, uh, I first heard about
the possibility and I think Idid what a lot of people who had
been placing conventionalsingle implants for a long time
would say, which is like that'scrazy.
You know you're going to loadit right away, you know you got
to wait, and so that reallypiqued my interest and caught my
(16:42):
attention.
So I just started reading, Iread, I read a lot of articles,
I read a lot of textbooks on theon the subject matter and and
it was very compelling evidencethat this is a very viable and
very good treatment option andprotocol.
But you know it didn't really.
You know like you can takeconcepts and think about it and
(17:04):
learn statistics and everything,but it doesn't really click
clinically.
Like you have a jaw flabbedopen.
You know what do I do right now.
You know like what's what, likewhere I put these things, you
know and, and so I went online,I started placing them the best
way I thought, and I mademistakes along the way.
(17:28):
In hindsight, I wish I did somesort of overseas conventional
only live surgery course,because that would have made it
click very quickly with theright instructions of course.
But yeah, I made some mistakesalong the way, I started getting
better at it.
But I started realizing, hey,some of these upper back
(17:49):
implants aren't talking likewhat do I do right now, you know
, um?
And then I would see otherpatients who just don't have
that bone segment and I'm like Ireally want to help these
people.
So I started looking intozygomatic implants.
Um, that came first for me,before the pterygoid.
I didn't even think about thepterygoid.
I was just like zygos are cool,like look at those x-rays.
(18:12):
But I sort of got obsessed withit at home and started reading
about it, exploring differentbrands, following other guys in
social, and then I was like I'mnot going to do this, I'm not
just going to try to shoot fromthe hip with this thing.
I went down to Brazil, a towncalled Campinas, right next to
(18:35):
Sao Paulo.
There's two really good guys,Abelio Copete and Thiago de Maio
, not very well known, butthey're good guys.
Actually, the Neodent rephooked me up with those guys.
So me and my buddy, um, alexBanner, we went down there.
Um, that's where I met ChavaneGupta.
I don't know if you guys knowhim, he's in Georgia.
He's a good guy, um.
(18:58):
But yeah, we, we sort of jammedout a bunch of Zygos down there
in this really, uh, sort of um,um, kind of a sketchy, or
there's like there's three rooms, there's like a tummy tuck here
, us, and then like some otherbody part procedure, and there
is one anesthesiologist and likeat one point, like the suction
(19:19):
went down or like what the fuckis going on.
It was pretty crazy, man, butlike it was fine, you know, it
was safe, nobody got hurt, um,it was fine, um.
But yeah, we just we werejamming out zygas.
They had.
They had lined up like, uh,like a ton of cases um, for for
the week for us.
So it was muscle memory, youknow, like, and and that's what
(19:41):
I wanted, which was like a veryimmersive course that you can
just go boom, boom, boom, boom,boom and get like really tired
at the end of the day, becausethat's when it really registers.
You know, um, keep doing itover and over and over and over
and over, uh, understanding whatthe zygomatic bone looks like
from the mouth, like I had seenit uh, uh, during like trauma
(20:01):
cases from here and here, butlike never from, like
intraorally, and so like, likeit's very new and just, you know
, extending a long drill inthere, you know, so that that
really made it click.
And so, like, when I got, whenI, when I left there, that's
when things really sort of tookoff, cause I could, I was able
to treat every patient that camein the door and and yeah, that,
(20:23):
that, that sort of that waslike the inflection point for my
full arch career.
Was that course in Brazil.
After that, you know, I startedgetting into pterygoids.
I'm like, oh, it'd be nice toget some back there, started
seeing some guys out there, youknow, like Dan Holtzclaw, ramsey
Amin, like you know the OGs ofthis space, juan Gonzalez too,
(20:45):
and I was seeing pterygoids.
I was like that's really cool,like I could maybe avoid this or
, you know, this helps sort ofstabilize the whole thing
because I guess flex, um, sosort of reading about that,
reading about that, readingabout that, and just and and
started sort of doing it.
I I created my own sort ofalgorithm along the way to make
sure that I get into the rightspots.
(21:06):
It's you sort of pinpoint thehamular notch and the greater
palatine canal.
Just go right between the two.
You start at the level of theGP canal, because that kind of
goes straight up and you juststart at the same inter
posterior line and then you justgo right in between the hamular
notch and the GP canal.
You pinpoint it but but yeah,that that sort of that was like
(21:30):
the next step.
You know like it was startingto go like that and then you
know you've seen like stocks andstuff do that, so that's that's
sort of where it is.
And then you know, along theway start seeing more problems.
I want a solution for thatproblem.
Some are going to fail.
What do I do after that?
You know, or like, is there abetter way?
So I noticed a guy, uh, aVanderlim on Instagram
(21:55):
transnasals was like what thehell is that Like?
how are they going to prove?
Um but it turns out, you know,like I I lecture on this where,
um, it's, it's very clever, it's, it's sort of like a hack of
the nasal cavity because it doesnot obstruct airflow by x-rays
you're like that's going toobstruct airflow.
It does not obstruct airflow.
(22:16):
So if you think evolutionarily,whatever your faith is, but
from a functional standpoint,our olfactory senses are at the
cribriform plate, which is thebase of the skull, which is
right above the nasal cavity.
That's where we smell stuff.
So you know, functionally, allthe air goes up there, you know.
(22:38):
So, if you see, there's atechnique called acoustic
rhinometry my brother-in-law'san auntie, um but there's a
technique where you can measureairflow and actually goes way up
high to the superior turbinearea and the airflow is the
lowest where that implant is.
Tyler Tolbert (22:59):
So it's, it's pretty awesome, yeah okay, it's
great so you're saying that it'skind of like it's like a, a
wind tunnel that goes not in thedirection of the inferior
conscious, so there reallyshouldn't be anything along that
path.
Simon Oh (23:13):
Anything along that path is not really going to
obstruct the airflow, despitewhat intuition would suggest
yeah, no, exactly, and you know,think, think of, like what's
out there in all of mammals,like smell is a big way to
detect a predator.
You know, yeah, and so you knowit would make sense for that
sense or for the airflow to gowhere the uh directly to where
(23:34):
the olfactory receptors aregoing to be.
Yeah, yeah, exactly so it's likeit's.
It's such a smooth, um sort ofsneaky almost way of getting by
getting anchorage up front inthe intermaxilla without
creating any functional harm.
It's pretty cool yeah, that'sinteresting.
Tyler Tolbert (23:50):
So I'm curious about you know, uh, you know you
mentioned juan and uh, we've uhtalked to dr sammy before and
uh, holtzclaw as well, and uh,you know the patsy algorithm
gets thrown a lot and I thinkyou know they've done some
incredible work and reallytrying to, you know, codify that
into something that's easilydigestible and helps us
understand how a, you know,fully remote Anchorage certified
(24:14):
surgeon thinks through an arch.
Would you say that that is, youknow, really part and parcel
how you think about a full arch,or are there kind of some
nuances about the types oftechniques that you will go to
first, what you start withthings like that?
Simon Oh (24:29):
Yeah, no, that's.
That's a great question, youknow, I think I think Patsy's a
really, really smart way toapproach it.
You know, I would say thatthere are, there are definitely
times where I go where I placethe pterigoids first, that way
you know what's going on for therest of the arch.
But you know, I, I'm a creatureof habit, I guess, and I I
(24:52):
always start with the anteriorand if I'm questionable about
the middle, yeah, I'll do thepterygoids second.
But, like for me, I want to getwarmed up, you know, I want to
get my rhythmized, get theturbine spinning.
So I always know I want to getmy right nose, get the the
turbine spinning, um, so Ialways do the first, just out of
habit, I guess.
But I, I don't thinkalgorithmically it really
changes anything if you placethe front first and then the
(25:14):
turquoise, because, like youknow, the front doesn't work.
You know what's your nextoption.
It's basically the samealgorithm.
So I, I don't, yeah to me, youknow I maybe I'm wrong, but like
I don't think it necessarily,at least on a conventional arch,
I don't think it, uh, reallychanges much, um but yeah, I
mean the the reason why I go upfront first is because you know
(25:34):
the, the anterior bone for the,the upper and the lower, is
always going to be better thanthe posterior right, always that
, always.
So I I use the anterior as alitmus test.
So I will.
I will do my normal protocol.
I'll drill.
You know, if it's a 4-2 implant, I'll drill to about 3.2 a lot
of the time and I'll see whatthe torque is if I'm just at 35
(25:58):
newton centimeters I now knowthat I'm not going to do any
better with the same protocol inthe posterior, so I I under
prep it, after that useDensibers, so that's that to me.
It sort of gives me the bestsense and then, you know, once
I've built my confidence, that'swhen I feel good to hit the
(26:20):
territory.
So yeah, maybe there's like anemotional, like an anxiety
protective kind of feature forme to not do the teragrace first
Cause, like if I had missed myteragrace.
Tyler Tolbert (26:33):
I'm like girl like what am I going to do now
Different?
Yeah, I can, actually I cantotally relate to that, cause
there's definitely a pointduring a surgery where you know
you got the critical implantsthat you need and then
everything else is kind of justlike ah, we're good, I got the
case, like it's secure it's likenothing's really going to go
wrong at this point exactly yeahyeah, because yeah, I mean you,
(26:56):
you guys get it it's.
Simon Oh (26:57):
It's a high stakes game, you know, like if we don't
hit our numbers, we're notgoing to be able to deliver the
promise to the patient.
They're going to be reallyupset you know, know, yeah, so
yeah.
I, I think just from like amental point of view, terror
goats first kind of freaks meout a little bit.
I mean, if I have to do it Iwill, but I definitely like to
(27:20):
go up front first.
That makes sense.
Soren Paape (27:22):
Yeah, I do the same thing.
I like to get my security withmy front four.
And once I have my front four, Iknow, okay, I can load this
case regardless, and then for meit's like I can add a little
more support for those tiltedimplants and a little more teeth
for the patient if I get thosepterygoids in.
But if I miss them, thepatient's still going home with
(27:45):
a loaded prosthetic and I don'thave.
I don't have to have aconversation with them about why
, you know, maybe the casewasn't able to get loaded.
So I agree with that.
I mean, I think it is a senseof security where you get your
front four, you get theprosthetic to a point where you
can load it for the patient andthat way, no matter what, the
patient's going to go home happyand then just adding that extra
security of placing thosepterygoids goes a long way.
Tyler Tolbert (28:08):
Yeah, I think the only, the only nuance I can
think of when it comes to beinganterior first, and obviously
your whole mental calculus isdifferent when you know that
you're in a severely atrophiedsituation.
But Juan was talking about in acase that he knows that is
going to be a zygote case, hewill, in the interior, go for a
(28:28):
nasal palatine and try to getthat to reduce how far interior
the anterior superior implantneeds to go so he can use a
shorter implant and reduce thattuning for capability.
So I guess like it doesn'tnecessarily mean that, uh, you
can't go to the interior first,but you kind of already have to
have in mind what's going tohappen after that to determine
whether, um, maybe you're goingto do trans nasals or you're
(28:50):
going to try to do two in thefront, or whatever the case may
be.
Simon Oh (28:55):
Yeah, you know, that's interesting, I never thought of
it that way and I talked toJuan like all the time.
So like I'm surprised that, uh,we haven't talked about that.
But that makes a lot of sensebecause the um, the lever arm on
, uh, say, a lateral incisor umposition on your superior is
pretty far, uh, even though it's, you know, just one tooth
(29:18):
segment of right.
I would have to think that theum it's sort of logarithmic with
the amount of flexure thelonger you go.
So um, so yeah, that makes alot of sense to go for the
nasopalatine um position andthen sort of load it from there.
I, I uh for quads, I have alwaysum done the nasopal or the
(29:40):
midline nasopalatine implantlast for some reason, you know,
because there was a study that Iread that the all-on-four or
the four-implant configurationwith one Zygo on each side, two
conventionals up front, had ahigher rate of failure of the
(30:02):
anterior conventional implants.
And to me my hypothesis is thatthe posterior implants are
flexing, putting a lot of stresson smaller implants.
So I would have to think thatthe fail rate on a nasopalatine
implant with the quad segmentwould be higher, and so I'm just
(30:24):
one.
I don't know what the answer is, but that's interesting though.
Tyler Tolbert (30:28):
Yeah, yeah.
Simon Oh (30:29):
Yeah, so like say it does fail or you have a patient
that is high risk or the torqueis only 30 or something, would I
have rather have less anteriorcantilever with anterior
superior zyggas going moreanteriorly?
I don't know what the answer isto that.
But, that's definitely adiscussion I think we need to
(30:52):
have.
Tyler Tolbert (30:53):
Yeah for sure.
And I think too is like, withkind of pioneering these
algorithms, we don't have reallythe luxury of tons of data with
all these differentconfigurations in mind to really
know like a lot of this is moreintuitive and just kind of
thinking about biomechanics.
It's not necessarily in thenumbers.
We can't really look at theforce vectors over 10, 15, 20
(31:14):
years, and so you know, for themost part we're just kind of
shooting, shooting from the hipand doing the best we possibly
can.
You know so, but of course it'simportant to you know plan for
failure.
And and I thought about thattoo when I heard that, I was
like well, if you lose thenasopalatine and you kind of
scooted back your anteriorsuperior implant, now you've got
this huge anterior cantilever.
You know is, have you kind ofcompromised the case a little
bit in that way?
Simon Oh (31:47):
It's hard to say, you know, when you we it comes down
to is is the, the decrease inflex, the decrease in flex
enough to have increasedsurvivability of the naso pallet
implant?
Yeah, to the point where itreally makes sense to do that,
and that's sort of.
I think we need engineers,probably people better with
numbers than us yeah, materialsinvolved.
(32:09):
Like it's going to be differentfor grade four, titanium versus
23 or five, you know.
So like yeah, uh, yeah, I meanthat that's all um again.
I I hope that freaking chat gptcan help us, maybe that, maybe
it can yeah, chat.
Tyler Tolbert (32:24):
GPT.
Well, based on what Elon said,by next year.
We don't even need to recordthis anymore, we just say it's a
conversation between thesethree guys and it'll use our
digital avatars and make thewhole episode.
It'll be great.
Yeah, that's awesome.
(32:45):
So you actually you recentlyposted a case, and it was.
It was really auspicious becauseSoren, myself and our third
partner, caleb Stott, werehaving a conversation because a
case had come through Soren'sclinic where he had a patient
with a.
It was a younger patient with ahigh smile line and very
severely pneumatized sinuses notjust pneumatized, but those
would look like the Kellysyndrome, where it kind of is
actually coming in sort ofalmost into the plane of
occlusion and there was no waywith reduction to hide the
(33:08):
prosthetic line.
And so we were talking aboutoptions with, you know, a
factory in the sinus floor doinglifts on both sides, coming
back alveoli later.
And then it was, I think,either on that day or the day
after you posted your case, ofdoing literally the exact same
thing.
So I was wondering if you couldjust kind of expound a little
bit on that and just kind oftalk about how you thought
through that case and how youapproached it.
Simon Oh (33:28):
Yeah, you know, I sort of recognize that sort of
complex case conundrum severalyears ago when, yeah, I mean,
because we all look at theDuchesne smile and the big smile
um, when we evaluate like wherea reduction plane is going to
go, and uh, yeah, I mean in interms of solutions, I didn't
(33:52):
really have much.
I mean, there there was.
There's always times where wesort of kiss the sinus floor on
our reduction.
You know, like we always seethat, um, but like, what do you
do when it's like way higherthan that?
Is that going to seriouslyinjure our patients?
Is there a one step option toto sort of fix this problem?
(34:14):
So I started doing like an upfracturing technique, so similar
to what you said.
I used to take a piezo and sortof cut like one in the middle
and then crosses like sort oflike a pack of ice cubes you
know ice tray.
I would do that and then sortof try to tap it up.
(34:35):
Because my thought process wasOK, well, we'll still have
periosteal attachment to thosebone segments, so that'll be
fine, that the segments mightactually create a little bit of
stability of the sinus floor.
And what I did after that was Iwould take something that would
(34:56):
a biomaterial that would hardento an extent.
And so I used Augma for that,which is hydroxy by basic
calcium sulfate.
It becomes hard.
So I did that but I found that,like you know, it had good
success, but the the times whereit didn't work were bad, you
(35:18):
know, like terrible.
We will have sinusitis or anancho fistula, like oh God, what
a nightmare, you know.
So that that to me, you know,made me really sort of careful
with how I approach those cases.
And so you know, just, maybeit's I'm getting older and I'm
(35:39):
like tired, but I don't want todeal with that like
complications, like, um, if Ican avoid it, um, I will.
If somebody's very sort of, ifsomebody twists my arm, yeah, I
mean, I'm not like a robot, youknow I'll think about how
they're they're feeling about it, but, um, ultimately, you know,
(36:00):
my, the way I've sort of beenhandling it these days is serial
sinus lift and then go in, doyour reduction plane.
Even if the sinus bone doesn'tconvert and it's just powder, at
least you have some sort ofbiological barrier between the
sinus and the cavity.
Who cares if it's living boneor not, as long as it doesn't
get infected?
(36:20):
That's me, if you do azygomatic it'll be nested in a
nice little thing, you know.
So that's that's sort of how Iapproach them, I, I, I like
predictability and sort of youknow, getting these people
through smoothly.
Yeah, I mean, if, if you can,um, I guess the the hard one is
(36:44):
the edentulous patient with that, because, like, if somebody has
a few teeth, you can give thema partial for a while while they
heal, you know, and let thesinus lifts heal.
But the full denture patient, Iguess they sort of just have to
.
I guess they've been in adenture for a long time, but
yeah, it's not really an easything.
Um, but yeah, it's not, it'snot really an easy thing.
(37:05):
I, you know, I'm that's uh,that's one of the reasons I'm
really looking forward to, um,this product called tetranite,
which is, uh, rev bio.
So those guys are smart too.
So, like they took, um, theytook a protein from one of the
only creatures that can createadhesion in in water in the
ocean.
They took that protein.
Um, I don't know if I'm allowedto say what it is, I forget if
(37:27):
I signed an nda but um, theytook that protein and, uh, uh
put it in bone grafting material.
I'm sure you guys have heard ofit, so like, I tested that
stuff is crazy.
So like, yeah, it comes like ina old amalgam, or like uh the
cement, uh container, where youlike put in the the shaker, take
(37:48):
it out, you put in that uh thetriturator yeah, yeah, whatever
it's better than it, yeah, yeahso it comes in that thing, you
squirt it in, um, it becomeshard within like five or three,
five minutes or something.
And I tested it where it was anempty hole, I injected the
(38:09):
material, just sat an implantinto it, let it set.
It torqued to 45 Newtoncentimeters when it set.
So that stuff is rock hard,like you can bang on it.
It sounds like.
It sounds like I don't knowplate or something.
So I'm just wondering if, um,that is going to change things.
I don't know what the sort ofblood flow requirements of that
(38:32):
is.
And there's a lot of sort of uhresearch and development of like
what the proper protocols toconvert that into bone are going
to be, but like if that canrepair a sinus floor, um, that'd
be amazing.
Um, or if that could sort oflike uh, wipe it over the, uh,
(38:53):
the the up fracture, if thatcould be a viable option, that
would be sort of revolutionary.
You know, I think a lot ofpeople at least the people that
are careful enough that canthink through these kinds of
patient problems um, that'sgoing to be revolutionary for
for everybody, you know.
Tyler Tolbert (39:06):
Yeah, and if nothing else, if it couldn't um
sustain an implant longterm forI don't know blood flow reasons
or whatever, I'm not even sureif it's that relevant with that
type of material.
But you know, it's still thatinert barrier kind of like what
you were talking about insteadof just counting on the sinus
grafting bone to heal after sixto nine months or whatever you
know, if it just instantlyhardens right there, you've
already got something that'sgoing to support it and might
(39:27):
actually be an instantaneoussolution, because you could just
go ahead, lift the sinus floorwith that material, do your
alveo and just finish the case.
I mean, that would actually bea instant thing.
So that's really cool.
Soren Paape (39:37):
Yeah For my.
I actually called Simon aboutthis case.
Simon Oh (39:41):
Uh.
Soren Paape (39:41):
I think I'd talk with you and I'd talk with Chris
Barrett if you're familiar withChris and because I was like
you know, just I really wantedto help.
It's a young, young patienthe's, I think he's like 30.
And he at least in my benefithe's been.
He's kind of had his teeth atthe gum line for three, four
(40:04):
years now.
So he's never really he hasn'thad teeth in so long and I
wanted a solution for him in aday, right.
I mean, like that's always kindof the goal, but in his case in
particular I had theconversation with him.
Just let him know like, hey,your best bet by far is if we
could do bilateral sinus lifts,let that heal for about five,
(40:26):
six months and then at leastwe'll have when we go in and do
our alveoloplasty, we'll havesomething supporting the sinus
floor.
Otherwise, you know, you couldend up in a situation, like you
said, where if we end up with anoral-antral communication that
we can't repair, you're going tobe in much, much worse shape
(40:48):
than you are now.
So you've been three yearswithout teeth.
It might be another six months,but the chances of survival of
that case are going to be muchhigher than trying to get it
done in one day and as a youngguy right 30 years old, he's got
a long life to live with theseteeth.
Like three, six months is asmall portion to pay for for
(41:10):
something that I think is goingto be much better suited for him
.
One, one complication that I'mhaving with this case and I'm
curious how you treat it, isthat his right sinus is like
completely full.
Um, I think it's because of the, because of the his dentition,
(41:30):
like he just has a bunch ofroots in there that are just
causing infection.
Um, and I think I saw him outlike december 1st and I asked
him to go to an ent to see if hecould do like a fast right to
clear it out.
But is you know, in your let'ssay, that he came into your
clinic and he didn't want to goto an ENT, would you, would you
(41:50):
still do that sinus lift?
Would you?
Would you maybe make a smallhole and clear the sinus out
yourself?
How would you manage that?
Simon Oh (41:57):
no, so if all right.
So the scenario is a 30 yearold or 30 some year old guy with
a portentation, so like rootcarries or like carries into the
pulp sort of situation.
Yeah, so if the sinus iscompletely pacified, yeah, I
would not do a sinus graft.
(42:17):
I mean, the sinus has to behealthy in order for that to
work out.
Be healthy in order for that towork out, what if?
If, like, say, health insuranceis an issue you know, which
sometimes is what I wouldpropose to him to sort of work
with him, would be to remove theteeth that have protrusion or
proximity to the sinus and seewhat happens.
(42:38):
You know who knows, so, like,but yeah, in terms of grafting,
or even zygomatics or um transsinus implants with the opaque
sinus, now, I would get thatcleared up before you do
anything else, you know yeah,I've got, I have to.
Soren Paape (42:54):
I have a call with him tomorrow and and hopefully
he's seen an ent in the in themeantime and maybe, um, he's
gonna have a solution for that.
But if not, my plan was removethe teeth first, see if we can
get some clearance on thesinuses and then go do the large
sinus lifts and then, you know,in some time come back, do my
traditional all on four withwith pterygoids probably, or
(43:18):
however, we'll see how the sinuslifts heal.
In the case you recently didwhat did, do you know how much
graft you used to lift thosesinuses?
Simon Oh (43:28):
um yeah, we, we lost.
I I lost count after um 10 cc'syeah I don't remember, because
I was just like, oh, my god, god, it's not stopping, like I'm
like shoveling the stuff inthere and like run out of bone,
I'm like I need another, I needanother.
(43:49):
So, like there, I would, if Ihad to guess, it would probably
be 12 CCs and, yeah, it wascombined with a sticky bone or,
like you know, prf, lpr.
So so, yeah, that that wasinteresting, yeah.
Tyler Tolbert (44:06):
How do you know when to stop?
Simon Oh (44:09):
It's, it's a very, um, uh, subtle thing.
So the way that I tested, Isort of got a sense of like,
okay, if I poke the window withmy finger, it feels like this
much tension.
Window with my finger, it feelslike this much tension, um, and
that's okay, no one to stop.
I, I can't really explain it toyou.
I, I um, because like, if youpush too hard it's gonna burst,
(44:31):
you know, everywhere.
That's like horrible.
So, um, I, I just I fill it upuntil it gets into the window.
I gently push to see if thereare any pockets where you know
it's not stuck and then keepfilling it.
But yeah, I mean, there's sortof like a tension type feeling
that I sort of got used to.
Very light, not very light.
Tyler Tolbert (44:53):
Yeah, and with regards to the window, what for
a case like that?
You know what's the moststrategic but conservative place
, and what kind of size ofwindow do you really need?
Simon Oh (45:11):
Yeah, you know, for for that case I couldn't afford
any perfs, you know so as of howmuch I wanted to get done.
So I I made a window, basicallyexpanded from anterior to
posterior, except I didn't go asfar back as the tuberosity.
I sort of had enough accessbecause, you know, we see things
from the interior, so I couldsort of peek in there without
sort of getting rid of that bone, yeah.
But yeah, I mean, I wouldprobably guesstimate about a
(45:35):
centimeter in height fromanterior to probably like the
first or second molar area.
Okay, that's significant, yeah,it's very significant.
But I always make sure to leavea shelf of bone it's not at the
floor of the sinus, that way itcan sort of hold it.
(45:55):
And I always try to keep thewindows away from the incision
line, because if you keep bothat the same area you sort of
risk the problems by doing that.
So I always try to offset themsomehow.
Keep it, yeah, but about acentimeter height, enough to get
the entire uh side action sinus, uh curette in there.
Soren Paape (46:18):
You know, okay, okay yeah, that was my plan a
long like a long thin window allthe way across Cause.
Again, I can't perfect either.
Like it's perfect that we're ina really bad spot.
Tyler Tolbert (46:30):
So that was, that was my plan as well.
Soren Paape (46:32):
Um with that case in particular.
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.
One thing that we prideourselves on here is having the
clout to bring on the bestimplant surgeons in the world,
and I think that we have notfallen short of that today.
Today, we have on Dr Simon oh,who, if you don't know him then
(00:24):
you're probably pretty new toFull Arch.
So this is somebody that Sorenand I have been following for a
long time.
I've actually interviewed himbefore, and he's graciously
agreed to come back on and talkabout all of his expertise.
We're huge fans of him, of hisInstagram channel, of his work
and also his work with OrcaGlobal, which I'm sure you've
heard of, as well as theirupcoming symposium.
(00:45):
So we're going to be gettinginto all that, but before we do,
welcome back to the show, simon.
Simon Oh (00:49):
Hey, thanks a lot, guys, good to see you again, For
sure, for sure.
Tyler Tolbert (00:53):
So it's been a little bit since we've talked
and certainly things have grownand we want to talk about all
the updates that are going on inyour life and career, of course
.
But for those who don't knowwho you are, would you mind just
kind of giving us a briefintroduction as to how you got
into implants, how you got towhere you are, from dental
school to here?
Simon Oh (01:17):
Yeah, sure, I reside outside of Philadelphia in the
suburbs.
I ended up here.
Because I ended up here,because you know, I grew up in
Maryland.
I actually have only lived intwo states, maryland and
Pennsylvania Went to all thestate schools, so University of
Maryland, college Park, forundergrad, university of
Maryland for dental school, andthen I ended up at Hahnemann
(01:38):
Hospital for oral surgery andbasically I did that until med
school ended up, leaving theprogram but and I was planning
to move back to Maryland, but Imet my wife.
She was a med student atJefferson at the time.
She was doing a residency thereand then like, okay, we're
(01:59):
gonna go back now, and then thatdidn't happen.
We had kids and then then, youknow, they had friends and so
like, of course.
But yeah, I mean, you know, interms of implants, um, we didn't
do too much in when I was inresidency.
It was mostly trauma uh centerof philadelphia, um level one
(02:20):
trauma center, just gunshotwounds non-stop.
You know, like that's basicallylike what we did um.
So you know, after um I left, II picked up a uh position as
like a traveling exodontist,slash implant person, um.
So you know, exodontia isreally cool I, I like it because
(02:40):
, um, just from a lifestyleperspective, like it's very
simple.
You know you meet the patient,they're in pain or they need
their wisdom teeth, whatever,and you get them out, you say
hello, goodbye, and then maybeyou see them for follow up and
that's it, and you know that's,that's pretty convenient.
But, you know, in terms of likeimpact, I'd say like the
implants is really where thingssort of like my focus went into,
(03:04):
because that's that really madepeople happy.
You know, people aren't exactlyhappy to get a tooth pulled,
they're happy to get toothrestored.
So, um, you know, little bylittle I started with singles,
did multiples edentulous ridgesand then, um, you know, at one
point I was actually consideringleaving dentistry because I was
getting pretty tired of it.
A lot of people were notexactly thrilled to see you, but
(03:29):
then I stumbled onto a fullarch.
You know, like I startedlearning about it, reading about
it, you know, following a lotof guys on social and reading
articles, reading the history.
I really enjoy reading that andI just realized, like, realized,
like, wow, like you can,actually, instead of just like a
single tooth or a bridge orsomething, implants like you
(03:50):
could do their whole mouth,change their life in a single
day.
Give them function again, givethem aesthetics again, um, and
like, that just changed thewhole game for me.
So, like ever since, that'spretty much all I've been doing,
I haven't.
I mean, I maybe placed like Idon't know 50 single implants a
year or something, like notreally that much, but like full
(04:14):
arches are just that's that'sall I do.
So, yeah, I mean, in terms ofimpact, I really like it because
, you know, like in anything inhealthcare, you sort of treat a
certain segment of health, so,like you know, veneer people
take somebody that's alreadyhealthy and makes them a little
bit better, right, like they'reat the upper echelon of like
(04:35):
health.
And then you have like yourmiddle segment, which is, like
you know, crown and bridge andjust routine dentistry, and then
you have, like the very bottomsegment, really, the orally
crippled people, and what thatprocedure does is we take those
people and bring them all theway back up to here again, um,
so I I think it's just great.
Um, I, I love the, I love thework, I love the technicality of
(04:56):
it.
Um, I love the sort of umgeometric aspect to it, um, like
geometry, and I don't know ifyou guys remember the PAT from
the DAP.
Tyler Tolbert (05:06):
Oh yeah, we remember.
Simon Oh (05:08):
Yeah, for me it's just so interesting.
So that's really all I reallylove right now, cool.
Soren Paape (05:18):
I really like that analogy.
I might have to steal that oneof the three tiers.
That's really good.
You know it's funny, simon, Ialways say the same thing and
I've probably mentioned it inthe podcast before.
But something that I love aboutfull arch dentistry is the fact
that, instead of your patientscoming in for like a routine
(05:40):
checkup and you telling themthat they have a cavity and it
being like the worst thing oftheir day, you know you're the
people that are coming in to seeyou.
They already know that amajority of them already know
they need their teeth out andyou're there to provide them a
solution.
Um, and instead of beingsomeone's you know worst part of
their day, you can, you canreally make someone's day, uh.
So I really love that aboutfull arch dentistry as well.
Simon Oh (06:05):
Oh, dude, yeah, yeah, I mean, and you know the, the
people that you meet along theway, you know, like, for all the
consultations that we do, likeyou hear their stories and it's
sad you know, a lot of themreally live in the dumps, like
mentally.
Tyler Tolbert (06:16):
You know, yeah, and yeah that's uh, I like sort
of helping those people you know, yeah, totally, and I think
there's I mean, there's just sofew things in dentistry that you
can do that so quickly improveall aspects of someone's health,
you know, physically,emotionally, nutritionally, uh,
everything that goes along withthat and and kind of going along
with what you're saying, islike the kind of dentistry we do
(06:38):
, like these are.
These are treatments thatpatients get to have done.
They don't have to have donealways I mean, have to is kind
of a different term but theyfeel this opportunity, like when
you come in and say, yes, I cando this, they've probably
already been told several timesthat it couldn't be done, they
didn't have enough bone, and Iknow for sure that you're seeing
cases a lot of times that havemaybe already been done and
(06:58):
things are going wrong and it'slooking really bad.
Or maybe a patient that justhas so little bone left that
they couldn't find anybody thatsaid that something could be
done, um, at least in areasonable manner.
Because you know we, ifanyone's familiar with your page
and your cases there's a wholelot of, you know, quad, zygote
cases, terry cases, things thatare, you know, combination of
remote anchorage and stuff, andwe definitely want to get into
that.
But, um, you know, just beingable to make what patients
(07:21):
thought was impossible possibleis the coolest part.
And seeing that surprise intheir face it really never.
It never gets old.
It's very rewarding dude.
Simon Oh (07:28):
Yeah, and you know, I've noticed a uh, an uptick in
uh, people with failing implantstoo.
Of course, one thing to have,you know, a failing dentition or
just completely a dentureless,but then you have the people who
have already been through thatyou know, and then you know.
So, um, yeah, it's, it's sortof getting a little more
(07:49):
complicated.
Just cool for on the technicalside and the sort of interesting
aspect, a little bit sad for,you know, humanity, yeah, I
can't say for sure for sure Iwould say, uh also, I've seen a
lot of an uptick in my office ofI would.
Soren Paape (08:04):
I would consider them prosthetic failures, where
they come in and maybe they wentto a dentist who, um was was
just getting started with withfull arch or who who know, who
knows why.
But you know, they come in andtheir prosthetic is like
basically a denture.
You know it's so thick andthey're just like.
You know, dr Pabby, I've beendealing with this for the last
(08:27):
two, three years and I keepgoing to the same dentist and I
just don't feel comfortable init.
It's been like a nightmare and Ithought it was something that
would be like an easy solution.
So I find that kind of fun, too, being able to take those cases
.
Um, so I I find that kind offun to being able to take those
cases and whether it means, youknow, sometimes replacing
(08:48):
implants, other times justputting on different multi units
and trying to trying to getthem to a point where we can
make them a prosthetic that's alittle bit thinner, that they
can talk with better, that theyfeel more comfortable with it in
their mouth.
Um, I find that really fun andchallenging as well.
Simon Oh (09:03):
Oh, absolutely, man.
And you know that's sort oflike the best case scenario for
call it a revision is smalltweaks to get them comfortable.
Yeah, I mean, dude, if we don'thave to put a scalp on
someone's mouth, that's a goodday.
Tyler Tolbert (09:17):
Yeah, definitely I'm curious.
So you see a decent volume ofrevisions.
So the ones that you're seeing,you know, are these kind of,
from what you can tell, arethese being done 10, 15 years
ago, Like what's kind ofcomprises like the bulk of those
revisions?
Are some of them more recentlybut poorly done?
Or are they just aging at thispoint, Like what are you seeing
(09:38):
most of the time?
Simon Oh (09:51):
Yeah, I mean you know, for I guess I guess for my
practice it's probably differentbecause you know we get a lot
of referrals for rescues andstuff and if someone's having a
hard time with the case.
But yeah, I mean I would sayyou know, I've certainly seen a
lot of old school dentistry,like some of the first
pterygoids that went in, like Isaw a bunch of blades from Link
Out.
Like some of the first terroidsthat went in, like I saw a
bunch of blades from link out,you know, like years ago, and
like cases from like so Tom ball, she used to practice near me.
(10:16):
He was like the first terroids,the first like full arch, sort
of concepts that we're doing allthe time now.
And yeah, I'm seeing a coupleof cases like that come in.
But I've also seen a lot ofcases that are doing stellar of
theirs.
So it's kind of hard to say.
But yeah, I mean I would say alot of the problems that I do
(10:38):
see like on a day-to-day is morerecent.
So that sucks, you know.
That sucks, you know, forhaving to sort of go through
this all the time.
But you know it is what it is,you know, as long as we're all
doing our best and sort ofkeeping the patient's best
interest in mind, you know.
Soren Paape (10:59):
Yeah.
Simon Oh (11:00):
There's no way that we don't have crystal balls to
predict the future and see howcertain patients are going to
turn out the future, but um, andsee how certain patients kind
of turn out, but um, but yeah,it's.
It's sort of a mixed bag, I'dsay, but a lot of them, a lot
more than I would think um, arerecent cases.
Tyler Tolbert (11:15):
Yeah, it's interesting because, you know,
especially when you're seeinghistorical cases from people who
you know, of who you know didsome of those early cases and
things, it's like you're adental anthropologist or
something and you're just, likeyou know, finding fossil
evidence of, like our history,of what we do.
It's really cool.
But yeah, I think it's probably.
You know, you talk about seeinga lot of recent stuff and I
imagine that's sort of amultifactorial thing, right,
(11:37):
because so many more people aredoing full arch now.
You know, even if the rate atwhich those would be complicated
was similar to the how it was20 years ago, you're still going
to see a lot more cases justbecause it's become so much more
commonplace, um, but at thesame time, you may also have a
lot of people who, because sortof the barrier to entry into
this kind of thing has beenlowered, you have people maybe
getting into it a little bitsooner than they need to be
(11:58):
doing it improperly, not quitehaving the right training or
taking on cases they aren'taware of how complex they
actually are prior to gettinginto it, maybe.
Um, so, yeah, that's definitelyinteresting.
I think that, you know, for alot of the people that are, you
know, have been doing full archfor a couple years now, getting
really comfortable with it,starting to identify as full
arch doctors.
What we also have to realize isthat we're not just going to be
like the primary full archpeople.
(12:19):
For someone who's getting fullarch for the first time, you
really have to learn, uh, youknow historically, like what all
these restorations um, or looklike how to take them apart.
You know, if I ran into a blade, I'm not entirely sure exactly.
You know how I rehab that andthe best way to take that out
and what to do with it, um, so,learning that history and how
all those things workprosthetically, the types of
drivers you might need, you knowhow to pick these old cases
(12:41):
apart and how best to revisethem.
You know, conservatively isgoing to be a big part of it
because we're going to be fixingthe new Fuller surgeons work as
well.
So I think that's just kind ofa mantle that you have to take
up as someone who, you know,wants to do this exclusively.
Simon Oh (12:55):
Yeah, no, absolutely.
I mean, you know the what sortof comes to mind is like an
edentional search, like we allget it.
We tilt the posterior implants30 degrees, interiors somewhat
straight, if you can Otherwisetilt 30 degrees, basically to
avoid stuff.
What's going to get interestingis when we start to develop
(13:21):
protocols or techniques for therevision.
I don't think anybody hasreally thought that through in
terms of like okay, this onefails, what do you do next?
Is it okay?
to have a conserved arch upfront with pteroids or something
to avoid a zygomatic.
That's where I sort of I havesome relief thinking about that,
(13:43):
because we're having AI come inand so, like you can, I think
that that complexity would besomething that machine learning
could be pretty useful for.
You know, to sort of analyze,we can upload a DICOM file into
the machine and it spits out analgorithm of like hey, this is
your best chance of long-termsuccess for this patient.
(14:05):
Yeah, yeah.
Tyler Tolbert (14:06):
Yeah.
Soren Paape (14:06):
I really like that.
Tyler Tolbert (14:08):
Yeah, I mean we, we kind of see, you know that
future coming on, uh, fromdifferent directions.
Like we're getting new ways toget data right, like obviously
our data acquisition is gettingbetter.
On the CBCT side of things,we're getting good at um arch
tracing, where we're able to mappeople's bite forces and things
like that.
And then, you know, ai can goin there, kind of consider those
types of factors, maybeparafunctional habits, occlusal
(14:31):
dynamics and things, and then itcan look and find, you know,
you know where, where are zygosgoing to be best suited on on
this bone?
You know where are we going tobe able to fit that?
Is that really going to makesense?
You know it can kind of analyze, based on the arch form, you
know how much tuning fork motionyou're going to have on your
anterior superior zygote if ithas to go way up front or
something like that.
It's really amazing to see orto just think about where this
(14:53):
might be in, you know, five to10 years and how we can really
be assisted through AI machinelearning.
But yeah, that's a great point.
I'm very interested to seewhere that goes.
Simon Oh (15:02):
Yeah, you know, I was listening to Elon Musk on an
interview just what his sort ofpredictions were for machine
learning, and apparently it getsbetter by 10 times every year,
so about I don't know four orfive years, 10,000 times better.
So it compounds.
Tyler Tolbert (15:23):
So yeah, life and practice is going to look much
different very soon, you knowyeah, for sure, yeah, we, we may
soon be dinosaurs and we'lljust have yonis doing everything
, something of that sort um,simon, um, I'm uh, I'm curious.
Soren Paape (15:38):
You know we talked a little bit about your
background, getting into fullarch.
Um, I'd love to hear a littlebit about, you know, your
progression through full archfrom just maybe traditional
all-on-four to what, whatcourses you enjoyed the most,
getting into remote anchorageand um.
For someone who maybe is isdoing like some pterygoids or
(16:02):
like doing all-on you'drecommend for um to to bring get
them into like the remoteAnchorage world.
And I know you you have Orcaand some of these courses.
But I'd love to hear yourhistory and how you kind of
started getting into that styleof dentistry.
Simon Oh (16:18):
Yeah, you know, um, I guess, uh, I first heard about
the possibility and I think Idid what a lot of people who had
been placing conventionalsingle implants for a long time
would say, which is like that'scrazy.
You know you're going to loadit right away, you know you got
to wait, and so that reallypiqued my interest and caught my
(16:42):
attention.
So I just started reading, Iread, I read a lot of articles,
I read a lot of textbooks on theon the subject matter and and
it was very compelling evidencethat this is a very viable and
very good treatment option andprotocol.
But you know it didn't really.
You know like you can takeconcepts and think about it and
(17:04):
learn statistics and everything,but it doesn't really click
clinically.
Like you have a jaw flabbedopen.
You know what do I do right now.
You know like what's what, likewhere I put these things, you
know and, and so I went online,I started placing them the best
way I thought, and I mademistakes along the way.
(17:28):
In hindsight, I wish I did somesort of overseas conventional
only live surgery course,because that would have made it
click very quickly with theright instructions of course.
But yeah, I made some mistakesalong the way, I started getting
better at it.
But I started realizing, hey,some of these upper back
(17:49):
implants aren't talking likewhat do I do right now, you know
, um?
And then I would see otherpatients who just don't have
that bone segment and I'm like Ireally want to help these
people.
So I started looking intozygomatic implants.
Um, that came first for me,before the pterygoid.
I didn't even think about thepterygoid.
I was just like zygos are cool,like look at those x-rays.
(18:12):
But I sort of got obsessed withit at home and started reading
about it, exploring differentbrands, following other guys in
social, and then I was like I'mnot going to do this, I'm not
just going to try to shoot fromthe hip with this thing.
I went down to Brazil, a towncalled Campinas, right next to
(18:35):
Sao Paulo.
There's two really good guys,Abelio Copete and Thiago de Maio
, not very well known, butthey're good guys.
Actually, the Neodent rephooked me up with those guys.
So me and my buddy, um, alexBanner, we went down there.
Um, that's where I met ChavaneGupta.
I don't know if you guys knowhim, he's in Georgia.
He's a good guy, um.
(18:58):
But yeah, we, we sort of jammedout a bunch of Zygos down there
in this really, uh, sort of um,um, kind of a sketchy, or
there's like there's three rooms, there's like a tummy tuck here
, us, and then like some otherbody part procedure, and there
is one anesthesiologist and likeat one point, like the suction
(19:19):
went down or like what the fuckis going on.
It was pretty crazy, man, butlike it was fine, you know, it
was safe, nobody got hurt, um,it was fine, um.
But yeah, we just we werejamming out zygas.
They had.
They had lined up like, uh,like a ton of cases um, for for
the week for us.
So it was muscle memory, youknow, like, and and that's what
(19:41):
I wanted, which was like a veryimmersive course that you can
just go boom, boom, boom, boom,boom and get like really tired
at the end of the day, becausethat's when it really registers.
You know, um, keep doing itover and over and over and over
and over, uh, understanding whatthe zygomatic bone looks like
from the mouth, like I had seenit uh, uh, during like trauma
(20:01):
cases from here and here, butlike never from, like
intraorally, and so like, likeit's very new and just, you know
, extending a long drill inthere, you know, so that that
really made it click.
And so, like, when I got, whenI, when I left there, that's
when things really sort of tookoff, cause I could, I was able
to treat every patient that camein the door and and yeah, that,
(20:23):
that, that sort of that waslike the inflection point for my
full arch career.
Was that course in Brazil.
After that, you know, I startedgetting into pterygoids.
I'm like, oh, it'd be nice toget some back there, started
seeing some guys out there, youknow, like Dan Holtzclaw, ramsey
Amin, like you know the OGs ofthis space, juan Gonzalez too,
(20:45):
and I was seeing pterygoids.
I was like that's really cool,like I could maybe avoid this or
, you know, this helps sort ofstabilize the whole thing
because I guess flex, um, sosort of reading about that,
reading about that, readingabout that, and just and and
started sort of doing it.
I I created my own sort ofalgorithm along the way to make
sure that I get into the rightspots.
(21:06):
It's you sort of pinpoint thehamular notch and the greater
palatine canal.
Just go right between the two.
You start at the level of theGP canal, because that kind of
goes straight up and you juststart at the same inter
posterior line and then you justgo right in between the hamular
notch and the GP canal.
You pinpoint it but but yeah,that that sort of that was like
(21:30):
the next step.
You know like it was startingto go like that and then you
know you've seen like stocks andstuff do that, so that's that's
sort of where it is.
And then you know, along theway start seeing more problems.
I want a solution for thatproblem.
Some are going to fail.
What do I do after that?
You know, or like, is there abetter way?
So I noticed a guy, uh, aVanderlim on Instagram
(21:55):
transnasals was like what thehell is that Like?
how are they going to prove?
Um but it turns out, you know,like I I lecture on this where,
um, it's, it's very clever, it's, it's sort of like a hack of
the nasal cavity because it doesnot obstruct airflow by x-rays
you're like that's going toobstruct airflow.
It does not obstruct airflow.
(22:16):
So if you think evolutionarily,whatever your faith is, but
from a functional standpoint,our olfactory senses are at the
cribriform plate, which is thebase of the skull, which is
right above the nasal cavity.
That's where we smell stuff.
So you know, functionally, allthe air goes up there, you know.
(22:38):
So, if you see, there's atechnique called acoustic
rhinometry my brother-in-law'san auntie, um but there's a
technique where you can measureairflow and actually goes way up
high to the superior turbinearea and the airflow is the
lowest where that implant is.
Tyler Tolbert (22:59):
So it's, it's pretty awesome, yeah okay, it's
great so you're saying that it'skind of like it's like a, a
wind tunnel that goes not in thedirection of the inferior
conscious, so there reallyshouldn't be anything along that
path.
Simon Oh (23:13):
Anything along that path is not really going to
obstruct the airflow, despitewhat intuition would suggest
yeah, no, exactly, and you know,think, think of, like what's
out there in all of mammals,like smell is a big way to
detect a predator.
You know, yeah, and so you knowit would make sense for that
sense or for the airflow to gowhere the uh directly to where
(23:34):
the olfactory receptors aregoing to be.
Yeah, yeah, exactly so it's likeit's.
It's such a smooth, um sort ofsneaky almost way of getting by
getting anchorage up front inthe intermaxilla without
creating any functional harm.
It's pretty cool yeah, that'sinteresting.
Tyler Tolbert (23:50):
So I'm curious about you know, uh, you know you
mentioned juan and uh, we've uhtalked to dr sammy before and
uh, holtzclaw as well, and uh,you know the patsy algorithm
gets thrown a lot and I thinkyou know they've done some
incredible work and reallytrying to, you know, codify that
into something that's easilydigestible and helps us
understand how a, you know,fully remote Anchorage certified
(24:14):
surgeon thinks through an arch.
Would you say that that is, youknow, really part and parcel
how you think about a full arch,or are there kind of some
nuances about the types oftechniques that you will go to
first, what you start withthings like that?
Simon Oh (24:29):
Yeah, no, that's.
That's a great question, youknow, I think I think Patsy's a
really, really smart way toapproach it.
You know, I would say thatthere are, there are definitely
times where I go where I placethe pterigoids first, that way
you know what's going on for therest of the arch.
But you know, I, I'm a creatureof habit, I guess, and I I
(24:52):
always start with the anteriorand if I'm questionable about
the middle, yeah, I'll do thepterygoids second.
But, like for me, I want to getwarmed up, you know, I want to
get my rhythmized, get theturbine spinning.
So I always know I want to getmy right nose, get the the
turbine spinning, um, so Ialways do the first, just out of
habit, I guess.
But I, I don't thinkalgorithmically it really
changes anything if you placethe front first and then the
(25:14):
turquoise, because, like youknow, the front doesn't work.
You know what's your nextoption.
It's basically the samealgorithm.
So I, I don't, yeah to me, youknow I maybe I'm wrong, but like
I don't think it necessarily,at least on a conventional arch,
I don't think it, uh, reallychanges much, um but yeah, I
mean the the reason why I go upfront first is because you know
(25:34):
the, the anterior bone for the,the upper and the lower, is
always going to be better thanthe posterior right, always that
, always.
So I I use the anterior as alitmus test.
So I will.
I will do my normal protocol.
I'll drill.
You know, if it's a 4-2 implant, I'll drill to about 3.2 a lot
of the time and I'll see whatthe torque is if I'm just at 35
(25:58):
newton centimeters I now knowthat I'm not going to do any
better with the same protocol inthe posterior, so I I under
prep it, after that useDensibers, so that's that to me.
It sort of gives me the bestsense and then, you know, once
I've built my confidence, that'swhen I feel good to hit the
(26:20):
territory.
So yeah, maybe there's like anemotional, like an anxiety
protective kind of feature forme to not do the teragrace first
Cause, like if I had missed myteragrace.
Tyler Tolbert (26:33):
I'm like girl like what am I going to do now
Different?
Yeah, I can, actually I cantotally relate to that, cause
there's definitely a pointduring a surgery where you know
you got the critical implantsthat you need and then
everything else is kind of justlike ah, we're good, I got the
case, like it's secure it's likenothing's really going to go
wrong at this point exactly yeahyeah, because yeah, I mean you,
(26:56):
you guys get it it's.
Simon Oh (26:57):
It's a high stakes game, you know, like if we don't
hit our numbers, we're notgoing to be able to deliver the
promise to the patient.
They're going to be reallyupset you know, know, yeah, so
yeah.
I, I think just from like amental point of view, terror
goats first kind of freaks meout a little bit.
I mean, if I have to do it Iwill, but I definitely like to
(27:20):
go up front first.
That makes sense.
Soren Paape (27:22):
Yeah, I do the same thing.
I like to get my security withmy front four.
And once I have my front four, Iknow, okay, I can load this
case regardless, and then for meit's like I can add a little
more support for those tiltedimplants and a little more teeth
for the patient if I get thosepterygoids in.
But if I miss them, thepatient's still going home with
(27:45):
a loaded prosthetic and I don'thave.
I don't have to have aconversation with them about why
, you know, maybe the casewasn't able to get loaded.
So I agree with that.
I mean, I think it is a senseof security where you get your
front four, you get theprosthetic to a point where you
can load it for the patient andthat way, no matter what, the
patient's going to go home happyand then just adding that extra
security of placing thosepterygoids goes a long way.
Tyler Tolbert (28:08):
Yeah, I think the only, the only nuance I can
think of when it comes to beinganterior first, and obviously
your whole mental calculus isdifferent when you know that
you're in a severely atrophiedsituation.
But Juan was talking about in acase that he knows that is
going to be a zygote case, hewill, in the interior, go for a
(28:28):
nasal palatine and try to getthat to reduce how far interior
the anterior superior implantneeds to go so he can use a
shorter implant and reduce thattuning for capability.
So I guess like it doesn'tnecessarily mean that, uh, you
can't go to the interior first,but you kind of already have to
have in mind what's going tohappen after that to determine
whether, um, maybe you're goingto do trans nasals or you're
(28:50):
going to try to do two in thefront, or whatever the case may
be.
Simon Oh (28:55):
Yeah, you know, that's interesting, I never thought of
it that way and I talked toJuan like all the time.
So like I'm surprised that, uh,we haven't talked about that.
But that makes a lot of sensebecause the um, the lever arm on
, uh, say, a lateral incisor umposition on your superior is
pretty far, uh, even though it's, you know, just one tooth
(29:18):
segment of right.
I would have to think that theum it's sort of logarithmic with
the amount of flexure thelonger you go.
So um, so yeah, that makes alot of sense to go for the
nasopalatine um position andthen sort of load it from there.
I, I uh for quads, I have alwaysum done the nasopal or the
(29:40):
midline nasopalatine implantlast for some reason, you know,
because there was a study that Iread that the all-on-four or
the four-implant configurationwith one Zygo on each side, two
conventionals up front, had ahigher rate of failure of the
(30:02):
anterior conventional implants.
And to me my hypothesis is thatthe posterior implants are
flexing, putting a lot of stresson smaller implants.
So I would have to think thatthe fail rate on a nasopalatine
implant with the quad segmentwould be higher, and so I'm just
(30:24):
one.
I don't know what the answer is, but that's interesting though.
Tyler Tolbert (30:28):
Yeah, yeah.
Simon Oh (30:29):
Yeah, so like say it does fail or you have a patient
that is high risk or the torqueis only 30 or something, would I
have rather have less anteriorcantilever with anterior
superior zyggas going moreanteriorly?
I don't know what the answer isto that.
But, that's definitely adiscussion I think we need to
(30:52):
have.
Tyler Tolbert (30:53):
Yeah for sure.
And I think too is like, withkind of pioneering these
algorithms, we don't have reallythe luxury of tons of data with
all these differentconfigurations in mind to really
know like a lot of this is moreintuitive and just kind of
thinking about biomechanics.
It's not necessarily in thenumbers.
We can't really look at theforce vectors over 10, 15, 20
(31:14):
years, and so you know, for themost part we're just kind of
shooting, shooting from the hipand doing the best we possibly
can.
You know so, but of course it'simportant to you know plan for
failure.
And and I thought about thattoo when I heard that, I was
like well, if you lose thenasopalatine and you kind of
scooted back your anteriorsuperior implant, now you've got
this huge anterior cantilever.
You know is, have you kind ofcompromised the case a little
bit in that way?
Simon Oh (31:47):
It's hard to say, you know, when you we it comes down
to is is the, the decrease inflex, the decrease in flex
enough to have increasedsurvivability of the naso pallet
implant?
Yeah, to the point where itreally makes sense to do that,
and that's sort of.
I think we need engineers,probably people better with
numbers than us yeah, materialsinvolved.
(32:09):
Like it's going to be differentfor grade four, titanium versus
23 or five, you know.
So like yeah, uh, yeah, I meanthat that's all um again.
I I hope that freaking chat gptcan help us, maybe that, maybe
it can yeah, chat.
Tyler Tolbert (32:24):
GPT.
Well, based on what Elon said,by next year.
We don't even need to recordthis anymore, we just say it's a
conversation between thesethree guys and it'll use our
digital avatars and make thewhole episode.
It'll be great.
Yeah, that's awesome.
(32:45):
So you actually you recentlyposted a case, and it was.
It was really auspicious becauseSoren, myself and our third
partner, caleb Stott, werehaving a conversation because a
case had come through Soren'sclinic where he had a patient
with a.
It was a younger patient with ahigh smile line and very
severely pneumatized sinuses notjust pneumatized, but those
would look like the Kellysyndrome, where it kind of is
actually coming in sort ofalmost into the plane of
occlusion and there was no waywith reduction to hide the
(33:08):
prosthetic line.
And so we were talking aboutoptions with, you know, a
factory in the sinus floor doinglifts on both sides, coming
back alveoli later.
And then it was, I think,either on that day or the day
after you posted your case, ofdoing literally the exact same
thing.
So I was wondering if you couldjust kind of expound a little
bit on that and just kind oftalk about how you thought
through that case and how youapproached it.
Simon Oh (33:28):
Yeah, you know, I sort of recognize that sort of
complex case conundrum severalyears ago when, yeah, I mean,
because we all look at theDuchesne smile and the big smile
um, when we evaluate like wherea reduction plane is going to
go, and uh, yeah, I mean in interms of solutions, I didn't
(33:52):
really have much.
I mean, there there was.
There's always times where wesort of kiss the sinus floor on
our reduction.
You know, like we always seethat, um, but like, what do you
do when it's like way higherthan that?
Is that going to seriouslyinjure our patients?
Is there a one step option toto sort of fix this problem?
(34:14):
So I started doing like an upfracturing technique, so similar
to what you said.
I used to take a piezo and sortof cut like one in the middle
and then crosses like sort oflike a pack of ice cubes you
know ice tray.
I would do that and then sortof try to tap it up.
(34:35):
Because my thought process wasOK, well, we'll still have
periosteal attachment to thosebone segments, so that'll be
fine, that the segments mightactually create a little bit of
stability of the sinus floor.
And what I did after that was Iwould take something that would
(34:56):
a biomaterial that would hardento an extent.
And so I used Augma for that,which is hydroxy by basic
calcium sulfate.
It becomes hard.
So I did that but I found that,like you know, it had good
success, but the the times whereit didn't work were bad, you
(35:18):
know, like terrible.
We will have sinusitis or anancho fistula, like oh God, what
a nightmare, you know.
So that that to me, you know,made me really sort of careful
with how I approach those cases.
And so you know, just, maybeit's I'm getting older and I'm
(35:39):
like tired, but I don't want todeal with that like
complications, like, um, if Ican avoid it, um, I will.
If somebody's very sort of, ifsomebody twists my arm, yeah, I
mean, I'm not like a robot, youknow I'll think about how
they're they're feeling about it, but, um, ultimately, you know,
(36:00):
my, the way I've sort of beenhandling it these days is serial
sinus lift and then go in, doyour reduction plane.
Even if the sinus bone doesn'tconvert and it's just powder, at
least you have some sort ofbiological barrier between the
sinus and the cavity.
Who cares if it's living boneor not, as long as it doesn't
get infected?
(36:20):
That's me, if you do azygomatic it'll be nested in a
nice little thing, you know.
So that's that's sort of how Iapproach them, I, I, I like
predictability and sort of youknow, getting these people
through smoothly.
Yeah, I mean, if, if you can,um, I guess the the hard one is
(36:44):
the edentulous patient with that, because, like, if somebody has
a few teeth, you can give thema partial for a while while they
heal, you know, and let thesinus lifts heal.
But the full denture patient, Iguess they sort of just have to
.
I guess they've been in adenture for a long time, but
yeah, it's not really an easything.
Um, but yeah, it's not, it'snot really an easy thing.
(37:05):
I, you know, I'm that's uh,that's one of the reasons I'm
really looking forward to, um,this product called tetranite,
which is, uh, rev bio.
So those guys are smart too.
So, like they took, um, theytook a protein from one of the
only creatures that can createadhesion in in water in the
ocean.
They took that protein.
Um, I don't know if I'm allowedto say what it is, I forget if
(37:27):
I signed an nda but um, theytook that protein and, uh, uh
put it in bone grafting material.
I'm sure you guys have heard ofit, so like, I tested that
stuff is crazy.
So like, yeah, it comes like ina old amalgam, or like uh the
cement, uh container, where youlike put in the the shaker, take
(37:48):
it out, you put in that uh thetriturator yeah, yeah, whatever
it's better than it, yeah, yeahso it comes in that thing, you
squirt it in, um, it becomeshard within like five or three,
five minutes or something.
And I tested it where it was anempty hole, I injected the
(38:09):
material, just sat an implantinto it, let it set.
It torqued to 45 Newtoncentimeters when it set.
So that stuff is rock hard,like you can bang on it.
It sounds like.
It sounds like I don't knowplate or something.
So I'm just wondering if, um,that is going to change things.
I don't know what the sort ofblood flow requirements of that
(38:32):
is.
And there's a lot of sort of uhresearch and development of like
what the proper protocols toconvert that into bone are going
to be, but like if that canrepair a sinus floor, um, that'd
be amazing.
Um, or if that could sort oflike uh, wipe it over the, uh,
(38:53):
the the up fracture, if thatcould be a viable option, that
would be sort of revolutionary.
You know, I think a lot ofpeople at least the people that
are careful enough that canthink through these kinds of
patient problems um, that'sgoing to be revolutionary for
for everybody, you know.
Tyler Tolbert (39:06):
Yeah, and if nothing else, if it couldn't um
sustain an implant longterm forI don't know blood flow reasons
or whatever, I'm not even sureif it's that relevant with that
type of material.
But you know, it's still thatinert barrier kind of like what
you were talking about insteadof just counting on the sinus
grafting bone to heal after sixto nine months or whatever you
know, if it just instantlyhardens right there, you've
already got something that'sgoing to support it and might
(39:27):
actually be an instantaneoussolution, because you could just
go ahead, lift the sinus floorwith that material, do your
alveo and just finish the case.
I mean, that would actually bea instant thing.
So that's really cool.
Soren Paape (39:37):
Yeah For my.
I actually called Simon aboutthis case.
Simon Oh (39:41):
Uh.
Soren Paape (39:41):
I think I'd talk with you and I'd talk with Chris
Barrett if you're familiar withChris and because I was like
you know, just I really wantedto help.
It's a young, young patienthe's, I think he's like 30.
And he at least in my benefithe's been.
He's kind of had his teeth atthe gum line for three, four
(40:04):
years now.
So he's never really he hasn'thad teeth in so long and I
wanted a solution for him in aday, right.
I mean, like that's always kindof the goal, but in his case in
particular I had theconversation with him.
Just let him know like, hey,your best bet by far is if we
could do bilateral sinus lifts,let that heal for about five,
(40:26):
six months and then at leastwe'll have when we go in and do
our alveoloplasty, we'll havesomething supporting the sinus
floor.
Otherwise, you know, you couldend up in a situation, like you
said, where if we end up with anoral-antral communication that
we can't repair, you're going tobe in much, much worse shape
(40:48):
than you are now.
So you've been three yearswithout teeth.
It might be another six months,but the chances of survival of
that case are going to be muchhigher than trying to get it
done in one day and as a youngguy right 30 years old, he's got
a long life to live with theseteeth.
Like three, six months is asmall portion to pay for for
(41:10):
something that I think is goingto be much better suited for him
.
One, one complication that I'mhaving with this case and I'm
curious how you treat it, isthat his right sinus is like
completely full.
Um, I think it's because of the, because of the his dentition,
(41:30):
like he just has a bunch ofroots in there that are just
causing infection.
Um, and I think I saw him outlike december 1st and I asked
him to go to an ent to see if hecould do like a fast right to
clear it out.
But is you know, in your let'ssay, that he came into your
clinic and he didn't want to goto an ENT, would you, would you
(41:50):
still do that sinus lift?
Would you?
Would you maybe make a smallhole and clear the sinus out
yourself?
How would you manage that?
Simon Oh (41:57):
no, so if all right.
So the scenario is a 30 yearold or 30 some year old guy with
a portentation, so like rootcarries or like carries into the
pulp sort of situation.
Yeah, so if the sinus iscompletely pacified, yeah, I
would not do a sinus graft.
(42:17):
I mean, the sinus has to behealthy in order for that to
work out.
Be healthy in order for that towork out, what if?
If, like, say, health insuranceis an issue you know, which
sometimes is what I wouldpropose to him to sort of work
with him, would be to remove theteeth that have protrusion or
proximity to the sinus and seewhat happens.
(42:38):
You know who knows, so, like,but yeah, in terms of grafting,
or even zygomatics or um transsinus implants with the opaque
sinus, now, I would get thatcleared up before you do
anything else, you know yeah,I've got, I have to.
Soren Paape (42:54):
I have a call with him tomorrow and and hopefully
he's seen an ent in the in themeantime and maybe, um, he's
gonna have a solution for that.
But if not, my plan was removethe teeth first, see if we can
get some clearance on thesinuses and then go do the large
sinus lifts and then, you know,in some time come back, do my
traditional all on four withwith pterygoids probably, or
(43:18):
however, we'll see how the sinuslifts heal.
In the case you recently didwhat did, do you know how much
graft you used to lift thosesinuses?
Simon Oh (43:28):
um yeah, we, we lost.
I I lost count after um 10 cc'syeah I don't remember, because
I was just like, oh, my god, god, it's not stopping, like I'm
like shoveling the stuff inthere and like run out of bone,
I'm like I need another, I needanother.
(43:49):
So, like there, I would, if Ihad to guess, it would probably
be 12 CCs and, yeah, it wascombined with a sticky bone or,
like you know, prf, lpr.
So so, yeah, that that wasinteresting, yeah.
Tyler Tolbert (44:06):
How do you know when to stop?
Simon Oh (44:09):
It's, it's a very, um, uh, subtle thing.
So the way that I tested, Isort of got a sense of like,
okay, if I poke the window withmy finger, it feels like this
much tension.
Window with my finger, it feelslike this much tension, um, and
that's okay, no one to stop.
I, I can't really explain it toyou.
I, I um, because like, if youpush too hard it's gonna burst,
(44:31):
you know, everywhere.
That's like horrible.
So, um, I, I just I fill it upuntil it gets into the window.
I gently push to see if thereare any pockets where you know
it's not stuck and then keepfilling it.
But yeah, I mean, there's sortof like a tension type feeling
that I sort of got used to.
Very light, not very light.
Tyler Tolbert (44:53):
Yeah, and with regards to the window, what for
a case like that?
You know what's the moststrategic but conservative place
, and what kind of size ofwindow do you really need?
Simon Oh (45:11):
Yeah, you know, for for that case I couldn't afford
any perfs, you know so as of howmuch I wanted to get done.
So I I made a window, basicallyexpanded from anterior to
posterior, except I didn't go asfar back as the tuberosity.
I sort of had enough accessbecause, you know, we see things
from the interior, so I couldsort of peek in there without
sort of getting rid of that bone, yeah.
But yeah, I mean, I wouldprobably guesstimate about a
(45:35):
centimeter in height fromanterior to probably like the
first or second molar area.
Okay, that's significant, yeah,it's very significant.
But I always make sure to leavea shelf of bone it's not at the
floor of the sinus, that way itcan sort of hold it.
(45:55):
And I always try to keep thewindows away from the incision
line, because if you keep bothat the same area you sort of
risk the problems by doing that.
So I always try to offset themsomehow.
Keep it, yeah, but about acentimeter height, enough to get
the entire uh side action sinus, uh curette in there.
Soren Paape (46:18):
You know, okay, okay yeah, that was my plan a
long like a long thin window allthe way across Cause.
Again, I can't perfect either.
Like it's perfect that we're ina really bad spot.
Tyler Tolbert (46:30):
So that was, that was my plan as well.
Soren Paape (46:32):
Um with that case in particular.
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