The debate of pterygoid and zygomatic implants takes center stage as two masters of implant dentistry present dramatically different philosophies on full arch restoration. Dr. Robert Stanley, a dual-trained PhD engineer and dentist, maintains that 99% of patients can be successfully treated without remote anchorage techniques when proper prosthetic principles are applied. Meanwhile, Dr. Damon reveals he incorporates pterygoid implants in virtually all his cases, citing biomechanical advantages and superior outcomes.
This riveting discussion dives deep into the engineering principles that govern implant success. Dr. Stanley introduces the concept of "truss systems" that explains why tilted implants work in full arch configurations despite contradicting single-tooth biomechanics. He emphasizes how proper prosthetic design—utilizing adequate vertical height, strong zirconia materials, and limited cantilevers—can achieve excellent long-term outcomes without resorting to specialized techniques.
Dr. Damon counters with compelling arguments for pterygoid implants, noting their ability to eliminate cantilevers completely while anchoring into dense cortical bone of the pyramidal process with longer implants. His philosophy that "the best zygoma is the one you never have to do" highlights how pterygoids can often help clinicians avoid more complex procedures.
Both experts share concerns about inexperienced practitioners attempting advanced techniques without proper training, noting an alarming trend of recent graduates jumping directly into complex full arch cases. Their contrasting approaches demonstrate that in implant dentistry, understanding fundamental principles allows for multiple pathways to success based on individual patient needs rather than dogmatic adherence to a single technique.
Whether you're just beginning your implant journey or looking to refine your approach to complex cases, this episode provides invaluable insights from two different yet equally successful perspectives in modern implant dentistry. What will you take from this debate to enhance your own practice?
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Tyler Tolbert (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren
Papi, and you're listening tothe Fix Podcast, your source for
all things implant dentistry.
Variety of opinions here, and Ithink we have so much to learn
from the areas where we agree,but I think we have a lot more
to learn in areas where wedisagree, and we can kind of
help people that are listeningto the show kind of find their
own way in things by learningfrom experienced guys like
(00:24):
yourself speaking on thesetopics and wherever you may
differ, people can kind of findthemselves in different places
and sort of figure out the waythat they want to approach.
You know these full arch casesand that's what we're all about.
So again, thank you guys somuch for coming on and welcome
to the show.
Well, thank you.
So, yeah, for sure, for sure.
And Dr Damon, welcome as well,of course.
(00:45):
Welcome back, yeah, thanks forhaving me again.
Dr. Clark Damon (00:48):
Good to see you all.
Dr. Tyler Tolbert (00:55):
And Soren.
Dr. Robert Stanley (00:55):
I suppose you're welcome too.
Dr. Tyler Tolbert (00:56):
Though you may be the co-host of the show,
I want to make sure you knowyou're welcome too.
So yeah, I'll kind of talk alittle bit about just sort of
the format of the debate andthen I'll kind of lead in with
introductions for you guys aswell, just to give people
context that they don't alreadyknow who you are.
So for this format, for thisdebate, we have a few different
topics here and I'll start byjust giving some context from
the topic where we're comingfrom, what the subject is and
kind of a little bit of theperspectives that I've heard,
(01:19):
watching you guys' videos andgoing to lectures and things
like that.
And then we'll be taking turns,giving Dr Stanley and Dr Damon
the opportunity to speak on thetopic, go ahead and give their
perspective with whateversupporting evidence that they
have today, and then after thatthe other will have a chance to
respond.
And then from there we'll kindof moderate sort of a more
(01:40):
open-ended discussion as well aspresent some questions that we
put together ahead of time forthose topics, and then we'll
just kind of let those live outas they may.
We'll try and find a middleroad if we can, and if not we
move on to the next thing andthen from there we'll see what
our audience has to say about itand maybe in subsequent
episodes we can do somefollow-ups and talk a lot more
about it.
So I'll go ahead and get intoour introduction.
(02:01):
So, dr Damon, I'll start withyou.
So Dr Damon is a dentist andeducator with extensive
experience in full arch, fromadvanced surgeries to prosthetic
fabrication.
He is the owner and operator ofTexas Implant and Dental
Centers in Dallas, fort Worthand Amarillo, texas.
He's completed thousands offixed arches and educates
doctors on everything from basicall four to the most atrophic
cases we encounter, utilizingzygomatic implants, pterygoids
(02:24):
and other accessory techniquesto treat the most difficult
cases.
Dr Robert Stanley is with us.
He is an oral surgeon anddiplomat of the ABOI and the
ICOI.
He is a continued educationinstructor and founder of the
Stanley Institute.
His channel has posted over 400videos on the topics of dental
implants, guided surgery andfull arch dentistry.
He is also an adjunctinstructor at the UNC Chapel
(02:46):
Hill and somehow has found sometime in his day to come on our
humble podcast.
So I really appreciate that.
Thank you so.
Dr. Robert Stanley (02:51):
Dr Tola, real quick I do oral surgery,
but I am not an oral surgeon.
Dr. Tyler Tolbert (02:55):
You're not an oral surgeon.
I could have sworn you were anoral surgeon.
Yeah, no, I do.
Dr. Robert Stanley (03:06):
I do a lot of surgery, so that's it's a
common, it's a common mistake.
Dr. Tyler Tolbert (03:07):
but I, I'm a dual trained PhD in engineering
and dentist.
Okay, very good, very good.
Well, you fooled me.
I could have sworn you were anoral surgeon, but I appreciate
you clarifying, yeah.
Okay, so we'll get into ourfirst topic, and that's going to
be the role of zygomaticpterygoid implants and other
remote anchorage techniques.
One of the most popular topicsin full arch dentistry currently
is the utilization of extramaxillary techniques such as
(03:27):
pterygoids and zygomaticimplants.
Dr Stanley, in your video Idon't need pterygoids or
zygomatics in my practice youstated that 99% of patients can
get by without the use ofpterygoid or zygomatic implants.
With the focus on advancedtechniques that we're seeing in
the full arch landscape, thereis a notable asymmetry between
what you say and also what thegeneral consensus around full
(03:48):
arch seems to be that thesetechniques are indicated a lot
more often in full arch patientsthan they can be usable even on
a daily basis.
Could you elaborate a littlebit on this point, and how are
you able to circumvent some ofthose situations where most
providers are opting for some ofthese more advanced techniques?
Dr. Robert Stanley (04:03):
Sure, I'd be happy to.
So the first thing that we needto make sure we understand is
that doing these remoteanchorage solutions, they're not
contraindicated.
Okay, they're just another toolin our toolbox.
But, as it happens in so manythings not even just dentistry,
but just in life when somethingnew comes along, there's energy
(04:25):
and excitement and people peoplehave tendency to jump in and
and go oh, you know, I'velearned this new technique.
And then on Monday they see acase.
They go.
Well, I could actually do thaton that case, and so what I feel
like what we're having rightnow is just we've got a
deviation from the mean, wherewe have a lot of people that are
learning about these remoteanchorage solutions and yet the
(04:47):
traditional root form implantsare more often than not,
sufficient to suffice for justabout like I said in my video 99
of the cases.
So what does that mean?
Well, it means if you actuallydo a prosthetic protocol where
you start with the teeth andthen you back into the way the
implants and you use some CBCTscans and optical scans to do
(05:09):
that, you can almost find enoughbone, almost always find enough
bone, and so you go.
Well, if I'm finding the bone,then you have to ask yourself if
I've got enough bone to do anall on X, but you know between
the sinuses or between theforamen or something like that,
then why would I want to bringinto my practice this other
solution?
Well, the first answer is is ifyou don't have that bone, then
(05:32):
that would be a good place tostart looking right, so you
would start to look at otherplaces.
So that's the first thing.
The second thing is is that youwould say well, I'm looking for
increase in stability, and as amechanical engineer, you can
imagine that I have a verystrong belief about reducing
mechanical complications throughbasic mechanical principles.
And having a distal cantileverthat's excessive can really
(05:55):
cause a lot of problems.
And so you know, you look tothe literature and you have a
lot of people that are saying,if we don't have a terminal
abutment on our prostheses,there's a lot of complications
associated with it, and that'strue.
But there's a couple otherthings that go into play here,
and that is the type ofmaterials that are being used to
implement these solutions.
So, for instance, let's sayyou're doing an FP1 where you
(06:17):
just have regular crown andbridge height.
You don't have a very tallbridge right, your beam is
rather narrow, and so if youhave a long span cantilever with
a small interocclusal space andyou don't have a strong impact
if you put all those thingstogether, it's like gasoline and
matches right You've just putyourself in a position where
you're going to have a lot ofcomplications.
(06:39):
However, if you take on thephilosophy that I'm only going
to cantilever small amountsenough to get me to first molar
occlusion and I'm going to usezirconia for my final prosthesis
and I'm going to do FP3, so I'mgoing to have a minimum height
of, say, 13 to 14, 15millimeters of arch height from
(07:00):
the incisal edge to the intagliosurface and you use a reputable
implant which is made out oflike a titanium alloy, then all
those problems go away.
So at that moment you say, well, can I get by with first molar
occlusion?
For the vast preponderance ofpeople and it's been my
experience is that most peoplethat need full arch are about 55
years old and they haven'tenjoyed their smile their entire
(07:21):
life.
And what I mean by that isthey've either been plagued by
rampant caries or they've beenplagued by periodontal disease
their entire life.
So at 55, when you tell them,listen, mr Smith, I can wrap you
in a warm blanket, put you tosleep and wake you up in an hour
with a brand new smile, andthat's pretty, pretty powerful,
right?
And that's the kind of spacewe're living in.
(07:43):
Now.
Let's say you don't have all ofthose, all of those things
don't align and you don't haveenough bone.
Well, that's when you wouldwant to look to one of these
railroad anchorage solutions.
And my contention is this unlessyou've set up your practice in
a way where you're doing theseall the time, you don't need to
be doing them.
And what I mean by that is ifyou're not doing something all
(08:05):
the time like I mountain bike onthe side, right If I'm not in
the field, if I'm not out in thewoods mountain biking I get
rusty.
So if I'm not doing theseadvanced techniques, often I'm
going to get rusty, right, andthen that's when you can really
hurt someone.
So my contention is this if youdon't have those conditions in
place, then I would send it tosomeone who does.
I would send it to someonewho's qualified, who does this,
(08:27):
basically the one guy in thecounty or the town or the city
or the state that focuses onthis one solution, because
they're so rare.
I mean, the indications are sorare to need them that when you
need it, send it to somebodywho's qualified.
When you need it, send it tosomebody who's qualified.
Dr. Tyler Tolbert (08:44):
Okay, yeah, no, I think that's an excellent
position.
So before we get into you know,rebuttals and those points I
know we're all kind of takingmental notes about a lot of the
different things you said and Iappreciate your well thought out
response.
Dr Damon, would you like totake a turn to this as well?
Dr. Clark Damon (09:00):
Yeah, I mean I think that there's definitely
some things that I agree with.
You know, talking about doing amaximum of a one-tooth
cantilever, talking about doingFP3.
I'm a big proponent of FP3.
And same with zirconia and youknow, making sure that your
(09:22):
zirconia thickness is adequate,right.
So minimum of you know 13.
So I think there's a lot of youknow, a lot of stuff that I
definitely agree with.
Where I tend to, you know, havea different philosophy is just
(09:45):
well, let me.
Let me ask Stanley this Are youdoing so?
Typically, all of your all on Xcases in the maxilla are
anterior to the sinus.
Dr. Robert Stanley (09:59):
I would say if I had to guess, I'd say about
50%%.
And the reason is is that wehave the new short implants
right and so that allows us toget a short root form implant
typically in that secondpremolar, sometimes even in the
molar position, and it helps toeliminate needing to do a lot of
sinus grafts as well, becauseyou can get that posterior
(10:20):
anchorage you're looking forwith the new short implants.
Dr. Clark Damon (10:28):
And so you're just doing this sub-anchorly A
lot of times.
Dr. Robert Stanley (10:29):
Yeah, what size.
The short implant that I haveavailable to me the shortest one
is 6 millimeters in length andit's 5.2 in diameter.
Dr. Clark Damon (10:45):
So, yeah, I mean I'm not.
There's no biomechanicaladvantage having six implants
anterior to the sinus.
The four is all that you need.
And in fact, if you're going todo six anterior to the sinus
and if this patient ever needs arevision, they're going to be
(11:07):
an automatic quad.
You're going to have so muchiatrogenic bone destruction when
those implants get removed.
I don't advocate for sixanterior to the sinus.
I don't advocate for sixanterior to the sinus.
I mean, I definitely appreciateDr Stanley's desire to want to
(11:28):
be safe and desire to want tohave the best outcome for the
patient.
Right, and you know there'sabsolutely nothing wrong with
referring.
I think.
I think, you know I, I do agreewith Dr Stanley and the fact
that you know we are seeing adeviation from the mean.
(11:48):
I think it's because a lot ofyoung docs I mean I can't tell
you how many docs out of schoolcome in to take my full arch
course.
It's their first, it's theirfirst course and they've already
, they've already done 10 to 20arches and I'm like, okay, wait
a minute, where, where did youguys get your education?
And they're, they're, they'rejust blowing and going.
(12:10):
So you know, I, I don't knowhow to describe it.
You know, maybe, maybe a lot ofyounger docs are just, you know
, very hungry and, you know,willing to take on a lot of risk
.
I think that they don't evenknow the risk that they're
(12:30):
taking on.
So I kind of think thisdeviation from the mean is not
only just with respect to, youknow, treating atrophic maxillas
, but I think it's also guysgetting in and jumping into full
arch way too early.
So I don't know, dr Stanley, doyou think there's something
there?
Dr. Robert Stanley (12:51):
I would have to concur with you.
I did a course recently.
I was invited to teach a coursefor two days and it was like a
DSO, so they procured theirpatients, their doctors, and
about halfway through the firstday you know you get a sense for
the level of understanding inthe room.
And there were only four peoplein that room of 70 that should
have been in there.
(13:12):
The other group of peopleshould have been in the onesie,
twosie implant course.
They shouldn't have been in thefull mouth course.
It was kind of shocking.
Dr. Clark Damon (13:23):
Yeah.
Dr. Soren Paape (13:23):
I would say uh go ahead, Soren.
Yeah, I was just going to say.
You know, I feel like there's somany um whether it's podcasts
or uh just just hype around fullarch dentistry right now, where
these large DSO groups are um,right now, where these large dso
(13:46):
groups are um, they are needingto to fill that void of
patients and and they want to,they also want um to sell these
treatments right, but they don'twant to pay for uh providers
who maybe have uh been doingthis for 10 years.
So their solution is to um tomake full arch dentistry like
the new cool thing to do.
Uh, and I feel like a lot ofthese these groups are sending
(14:09):
doctors right out of schoolbecause those are the people
that jump into their office.
You know they're, they're.
They come to the office to getsurgical experience, to take
teeth out, and then next thing,you know um, they're kind of
like pushed into, let's do fullarch dentistry, and then they
end up in courses like likeyours, clark, and probably the
one that that yours, you wereteaching as well, dr Stanley,
(14:29):
and I agree, I think it's, Ithink it's really scary and you
know, I see a lot of casescoming from those clinics and
Tyler and I being the clinicaldirector for a large group, dso.
We saw the quality of some ofthese treatments being done and
they were very much under par,for sure, yeah.
Dr. Tyler Tolbert (14:51):
Yeah, I mean, I think something that we're
kind of touching on here is that, for one, you have people who
are inexperienced, sure, gettinginto full arch, and you know
there's questions about you knowwho should be doing full arch
and who's really qualified to dothat, and I think that's an
entirely different subjectaltogether as valuable of a
conversation as it may be.
But one thing that I thinkbecomes a little bit contentious
(15:14):
is especially, you know, as itis relevant to the topic too is
you know, when we start talkingabout the advantages of, you
know, let's say, pterygoidsfirst of all, right, I mean we
can talk about zygomatics,because those kind of come into
play with really atrophic caseswhere you have very I mean
little, I mean no subantral bonereally and nothing really in
zone two whatsoever.
But with pterygoids, one of thepurported benefits of it is,
(15:37):
you know, you go from talkingabout what is a tolerable
cantilever to having nocantilever at all, and a lot of
people can purport the benefitsof that and saying, okay, we
have absolutely no cantilever.
That's clearly better thanhaving some right.
And then you start to hearthings about that being, you
know, potentially even astandard of care.
So now someone says, okay.
Well, I'm experienced enough toget into full arch.
(15:58):
I'm starting to do some all infour.
I'm doing that, I'm runninginto some problems.
Here and there I'm having aposterior tilted implant fail,
then I'm having to graft it andI'm having to deal with all this
.
I need something else to kindof supplement, where I'm running
into trouble and then they hearpeople talking about the
biomechanical advantages ofcompletely eliminating the
cantilever, and so they'resaying, well, if I, you know
(16:19):
upper arm and forearms, now Ineed to be doing pterygoids, and
so there's just this sort ofimmediate succession into a
different level of care ifyou're going to be doing some
full arch.
So you know, we've kind ofalready lowered the barrier of
getting into full arch in thefirst place.
There's a lot of advancementsin the past few years that have
made this a lot easier.
There's a sort of this verystepwise trip into doing really
(16:47):
the most advanced level of carethat we do.
I guess the question is whatreally is the indication for it?
Of course we can talk aboutthose benefits.
There's also risks that comeinto play, and so I think really
it comes to question is youknow, how necessary is it to do,
say, a pterygoid.
I mean, yes, we can completelyeliminate the risks that are
associated with I wouldn't saycompletely, but we can really
(17:08):
mitigate the risks that areintroduced with a cantilever but
is it worth it to go that extrastep and start doing that extra
, more advanced and potentiallydangerous technique for the sake
of doing that?
And it's a risk-benefitanalysis.
And so you know, dr Damon, youknow I'll kind of point to you
because you were the person thatdefinitely pushed us, myself
and Soren, to do a lot morepterigoids.
(17:30):
We already had kind of beenintroduced to the technique, but
for us it was more of okay,this is to help us rescue
ourselves when we have a tiltedfail.
You kind of changed ourmentality a little bit as young
doctors into thinking, okay, youknow, if I started doing
pterygoids more often, even oncases where I could get away
with it, I'm going to have moresuccess long-term because I have
(17:53):
less biomechanical stress.
Can you speak to that just alittle bit and maybe kind of
provide some guidance on that?
Dr. Clark Damon (18:00):
Yeah, so you know, I think you know, one of
the reasons why I wanted us tointerview Dr Stanley is because
you know I do pterygoids on 99%of my cases and he says 99% of
his cases don't need them.
Dr. Tyler Tolbert (18:18):
And I was like man, this is, this will be
a perfect discussion you know,but yeah, so you know to.
Dr. Clark Damon (18:26):
you know, darge Stanley, to one of your points,
right about, like you know, ifyou mountain bike, just on
occasion, you know, you kind ofbetter be careful and not go on
a super tough trail, but youknow if you're mountain biking
every day you know you're readyfor the Olympics, so you know
(18:48):
there's a small degree to thatright.
So like you can't be ready totreat the atrophic maxilla if
you don't practice the atrophicmaxilla on a regular basis.
Now that doesn't mean that weput zygos in on people that
don't need them, but I can'tthink of a reason not to give my
(19:14):
patients a pterygoid and soeverybody gets them right.
So we go with the nocantilevers.
Wilkerson has a really goodbiomechanical article talking
about pterygoids and how itreduces the stress when you
compare it to the standard four.
So we're eliminating stress andstrain, increasing our
stability.
And where I challenge DrStanley with doing the
(19:39):
sub-antral shorter implant,while I would prefer to do that
over a sinus graft and then comeback in place, I would first
prefer to do a pterygoid becauseone we can utilize a longer
implant my average pterygoidimplant length is 18.
And we're able to really lockit in into the pyramidal process
(20:05):
, which has a lot of very densecortical bone, and so our
cumulative torque values go up,the stresses come down and I see
less failures, I see lessprosthetic complications.
In fact I don't.
(20:26):
I don't see any prostheticcomplications with the pterygoid
, other than if you have a youknow, an 85 year old patient, on
occasion they can't.
They can't handle thepterygoids.
I think their tongue getspretty big and and and they just
don't like it.
That's the only patient that Ican think of that doesn't need a
pterygoid is an elderly femalepatient.
(20:48):
They just don't get along wellwith stuff in their maxilla.
But that's kind of my rationalefor doing pterygoids on
everybody.
Dr. Soren Paape (20:59):
Yeah, I would say yeah, and I'm curious as
well about Dr Stanley, yourprosthetic.
When I say prosthetic failure,I don't mean, like you know, in
zirconia, but like fractures oftemporary loaded.
Are you typically doing liketwo to three month temporaries
in your office and thentransitioning to zirconia after
those two to three months?
Dr. Robert Stanley (21:19):
Yeah, so we do a.
We do immediateprovisionalization and that
would be a prefabricatedprovisional.
So we just pick it up that daybut it's prefabricated, and then
we let them wear that.
It's a nanoceramic and we letthem wear that for six months.
And the reason we go a littlelonger than most people in the
industry is they really want thepredominant amount of shrinkage
(21:40):
of the soft tissue before we goto the final zirconia.
And that way when we go to thefinal zirconia you don't have
them.
They say, three years down theroad going, I got a whistle, I'm
getting food underneath myzirconia, which you can fix, but
it's a pain, right?
So that's our typical protocolSince we've gone to the
nanoceramics monolithicnanoceramics.
(22:03):
So the back of the day used tobe a titanium bar wrapped with
PMMA.
That was our long-termprovisional and those fractured
a lot.
We got a lot of fracturesduring the healing phase with
that and it makes sense when youhave more components in a
system you have more possibilityfor failure.
But once we've gone to the newnanoceramic we just don't have
fractures in those long-termprovisionals.
And the really cool thing isthat even if we did, we can
(22:26):
print a new one in 23 minutes.
So if we had to, we'd justprint a new one and bring them
in and just unscrew it and put anew one in, so we can manage
that really well.
But I think that it'sinteresting that we should
probably and this is somethingin the industry that we don't
really discuss too much there'stwo kinds of problems that
(22:47):
people talk about.
When we talk aboutcomplications, we talk about
forces and stresses and thesekinds of things a lot, but
there's the risk to themechanicals, the mechanical
operation.
There's a risk to thebiological right, and the
literature is pretty clear now.
Whereas we used to think thatthere was a significant risk to
the biologics of force, that waspredominantly taught by Carl
(23:11):
right, carl Misch, and he wasworried about overstressing the
bone and that would cause boneloss.
But we know that there's noevidence that that happens.
Okay, so you can put a lot ofstress on the bone and, if you
think about it, the purpose ofthe bone is to carry load, right
, that's what nature made thebone for.
It's designed to carry load.
(23:31):
So that kind of concept goesaway.
So when you really talk aboutwhat are the risks when we have
a cantilever to our system, thereal risk you're talking about
is mechanical.
Okay, so we can call itbiomechanical because it's part
of the body.
But what you're looking at isfractures of the prosthesis or,
like you said, it's screwloosening, it's abutment
(23:52):
breakage, it's abutmentdelamination from your
prosthesis, these kinds ofthings.
Those are the predominantproblems and the literature is
pretty clear on that too.
We're seeing three to fourtimes more of those than we are
the biological one.
So what oftentimes happens iswhen you have a case and you
have a failure like an implantthat doesn't integrate properly,
it's so many reasons why itcould not integrate.
(24:12):
Right, I've got 52 that I'velisted it just at the high level
.
You could go even deeper if youwanted to.
So when you have a failure,sometimes it's very difficult to
differentiate between I thinkthis failure was because of
mechanical loading or thisfailure was because of biologics
, right, and what I would argueis that the vast proponents of
failure to integrate arebiological in nature.
(24:35):
Okay, in other words, we didn'tget the implant in the right
location, we didn't get enoughbone around it, there was a
failure to get good woundhealing and then the implant it
partially integrates, it hasstability, but it doesn't
integrate long term, and so youget a failure downstream.
So getting that implant in theright location in the very
beginning is really paramount topreventing these kinds of
(24:59):
problems happening later.
Then the second part is is ifthe implants are in the right
location and your prosthesis isproperly designed, you're going
to minimize your off-axis loads,ie you're gonna minimize your
cantilevers or eliminate them inthe cases of doing the remote
anchorage, and that's a reallygood thing for the system, right
?
So if you do that, that's great.
(25:19):
But if you do everything thatI'm talking about in terms of
the method that I that Idescribed earlier, where the
implants are in the rightlocation, they're actually
loaded.
You've got a tall prosthesis andit's made out of strong
zirconia.
We've never had a.
We've never had a zirconiafracture.
We've never had a zirconiaprosthesis fracture ever in our
(25:40):
in our entire career.
And Tischler you know Tischlertook the payday.
He's gone now, right but whenhe was working he published a
really neat paper.
I think it was 2,500 FP3s thathe did.
He had like a less than 1%complication and of those I
think he had really goodexplanations for why they broke.
(26:01):
So I think that it's prettyclear that if you have enough
height to your zirconia, you'renot going to have a lot of
problems, right, you're notgoing to have a lot of fractures
and such.
So that's really the key.
And when we see a lot of peoplethat are pushing for FP1s right,
traditional crowded heightspace, where your connector
(26:21):
space between an FP1, yourconnector space gets very, very
tiny, and if you have a verytiny connector space and your
implants are spread out like anall-on-four and your beam length
is long, they're going to break.
They're going to break all daylong.
And then you start looking for,well, why are they breaking?
And if you say, well, mayberemote anchorage, so I don't
have this cantilever, well, thatmakes a lot of sense.
But you see, it's more thanjust one variable, isn't it?
(26:47):
It's a combination of variablesthat, if we put together, it's
all about reducing that risk andimproving the outcomes for the
patient.
But you've got to take a lookat it more than just one
parameter that you're doing inorder to have that kind of
success.
Dr. Tyler Tolbert (27:00):
So you bring up an interesting point with
respect to the loading of theimplants.
Now it does sound like you'remaking a few different points
here.
For one, we can compensate abit for the presence of a
cantilever by having implants inthe correct location.
And I assume, since youmentioned axially loaded
(27:22):
implants, that you also meanthat the implants are being
axially placed, which is kind ofimplied that that is what you
consider to be the correctlocation.
So in a lot of patients one ofthe main reasons that we have
tilted implants is all in for inthe Paul Malo technique is
because of the anterior borderof the sinus.
You're tilting an implant inorder to obviously decrease that
(27:42):
cantilever and you're tiltingthat.
And so I guess really thecontrast here is you have, in
one case you might have siximplants anterior to sinus
placed axially.
Perhaps you have a subantralshort implant right and some
mitigated cantilever.
We've managed to get the patientback to first molar, versus
(28:04):
having the you know tiltedconfiguration that's more
typical in the palomelo and thenhaving the pterygoids as well.
So you know, I know we'retalking about biomechanics, I
know we're talking about how theimplants are loaded.
I guess it really is kind of aquestion of you know, is six
implants with no pterygoidsplace axially going to be better
biologically or mechanicallyversus those tilted implants?
(28:27):
How do you kind of you knowwhat are the different things
that you're considering betweenthose two?
You know modalities, becausethey are very different.
Right, you have long implantsthat are tilted versus shorter
implants placed straight.
What is kind of the rationale?
Dr. Robert Stanley (28:40):
That's a great question and this is
something that a lot of doctorsget really confused on,
especially those young ones, doc, when they come out and they're
like, wait a minute, I thoughtyou said you want to actually
load your implants, but how dothe all-in-fours work?
Because you've got a tiltedimplant there and they get
really confused.
So let me clear this up foreveryone.
Really, really simply, ifyou're doing a single implant,
(29:00):
the way an implant is designed,it's designed to be loaded
axially, which means all theforces should be directed down
through the long axis of theimplant.
Okay, anything that you do thatcreates a bending moment on,
that is going to create problems.
So if you get the implant inthe wrong location, let's say
you're doing a first molar andyou put the implant in and you
get a little pucker factor, soyou scoot it a little bit
towards the distal and nowyou've got a cantilever to the
(29:23):
mesial.
So you've got a cantilever.
If you look at thetwo-dimensional radiograph, the
crown that you put on therelooks like a Snoopy, and so I
call it a Snoopy.
When you see it, it's got along nose on one side.
Right, it's short on one side.
That's a cantilever on a firstmolar, they bite and they hit
the medial marginal ridge ofthat prosthesis.
It's going to bend that.
It's going to bend that.
And what you're doing is, everytime you're bending that
(29:45):
prosthesis, you're torquing theentire system.
So you're putting the stressonto the abutment screw.
You're putting the stress ontothe cement that cements the
zirconia crown, to the hybridtie base and the hybrid tie base
to the implant.
So none of the system, none ofit, likes that, likes that.
Okay.
So you want to prevent thatoff-axis load.
You want to load axially.
So that makes a lot of sense.
(30:05):
Would any of you think it wouldbe a good idea to place a
single implant at 30 degrees andload it with a crown?
And I think all of you wouldsay, well, no, I don't think
that's a good idea at all.
Right, so?
And I don't, I don't know thatI've seen anyone actually do
that, where they've placed asingle implant at a 30-degree
angle and then used a 30-degreecorrection to design a single
(30:25):
crown.
However, in Turkey, in Turkey,yeah, yeah.
Dr. Tyler Tolbert (30:33):
We see a lot of cool stuff in Turkey.
Dr. Clark Damon (30:34):
Yeah Well, y'all have all seen the lateral
incisor implant where it'scoming like this, and then I
think they put maybe like a 55degree or like a 60.
Dr. Robert Stanley (30:44):
You're going to have to share some of those
pictures with me.
Dr. Clark Damon (30:49):
And it looks, it looks terrible.
You know the, the, the, thebone regeneration doctors in New
York, they get these things allthe time.
Sure, yeah, I would like to seesome pictures of that.
Dr. Robert Stanley (31:02):
That's good.
So now here's because you'rewaiting, so you want to know
well, how do angled implantswork.
When you do an all-in-X, youchange the complete dynamics.
It's called in engineering,it's called a truss.
Okay, if you're going down theinterstate and you see one of
those signs across, that'sbridged across, it's got the,
(31:22):
you know.
It tells you what interstateyou're on.
It's made out of a series ofbars and those bars kind of go
zigzag like this, right, andthat's called a truss.
And what happens when we putsomething into a truss?
All of the elements that areloaded in the truss are loaded
axially.
Oh right, are you guys gettingthis?
(31:42):
So when you tie, when you tie auh, an axillary implant with an
off-axis implant and you tiethem together with a prosthesis,
and at the base they're tiedtogether with bone, you've just
created a truss, which meansthat implant is not being loaded
off-axis, it's being loadedaxillary, which is something
that that I always wanted totalk to Carl about.
(32:05):
That, because Carl would alwayssay you know, remember that
debate he had with Paul DiMallo?
Right, it was brutal, right,they got on stage and they were
going at each other and he waslike would you build a tree
house for your kids with postslike this.
And he was like no, you wouldn'tright, but what he wasn't
talking about and what he wasfailing to kind of bring to
(32:26):
light was that it's not a singleimplant it's a system or a
system together is a trust, andif you put the trust together
it's incredibly strong, which iswhy which is why, when you put
your prostheses on top, itshould be rigid.
So there was a time where peoplewere thinking maybe I should
(32:46):
put some like a small, like anelastomer type of plastic on the
top that would give right, sothat it would absorb the
occlusal loads and such.
That's a terrible idea, becausenow your implants are going to
be not rigidly coupled, whichmeans they're going to be
allowed to bend and that youlose that trust, you would lose
that trust function and it wouldfail.
So that's why using somethingreally rigid like a nanoceramic
(33:09):
or even more rigid, like like aceramic, like an oxide, like
zirconia, that's why it works.
So that that is a distinctionthat really.
I hope that people arelistening.
They really understand.
There is a huge distinctionbetween loading individual
implants and tying them togetherin a prosthesis.
It's a completely differentanimal.
Dr. Clark Damon (33:29):
Right, I mean that's that's why we see our
implant success in all on X beso much higher than you know,
our our single units Um but, youknow I still, I still would
prefer a longer implant in thepterygoid than a shorter implant
sub-antrally.
(33:50):
And it's not just length orlocation, it's really kind of
more type of bone.
You know, the bone in theposterior maxilla is oftentimes
just garbage.
The posterior maxilla isoftentimes just garbage and it's
not something that I want to.
(34:10):
You know, really sink my teethinto right and you know, going
back to the truss, when you lookat those pterygoids, you know,
then you know, if you look atmany of my cases, you know it's
leaning back into the pterygoid.
You know posterior, superiorly,and then you've got the
posterior ones leaning, you know, anteriorly, in front of the
(34:30):
sinus, and then when I do the,the nasal crest, you know
everything is at an angle and soit's.
It's a huge trust.
So I'd like to encourage you,or Stanley, to, uh, you know,
consider doing some terrordroids.
Dr. Robert Stanley (34:49):
I, I, you know what I, I, um, I would love
to.
I, I love to do everything inthis planet and I'm running out
of time.
My, my days are becominglimited.
I just told a colleague thismorning.
I said I've got to starttelling people no, and he said
what do you mean?
I'm burning the candle at bothends here, I'm trying to get my
(35:10):
book written and, on top of allthe other things I'm doing, I'm
like I got to start tellingpeople no.
He started laughing because heknows I'm never going to do that
.
So, yeah, I'd love to do it,because why not?
I mean learning.
The only way to improveyourself on this planet is to
learn right, and so learning isparamount, right?
You've got to keep expanding,you've got to keep learning.
(35:32):
Yeah, and you know one of thereasons to actually do a
pterygoid is because the bestzygoma is the one you never have
done.
Expand on that.
Dr. Clark Damon (35:47):
We can all agree to that.
So we can, we can, we can use.
You know, I started doingzygomatics first in 2014, 2015.
And then I started branchingout in 2016, 17 into doing
pterygoids, 2016-17 into doingpterygoids.
(36:09):
And you know, interestinglyenough, you know we didn't have
osteotomes, so so, so I I drillmy pterygoids and um, because we
didn't have the instrumentation, and so that's that's how I
learned and developed mytechnique, uh, developed my
(36:31):
technique.
But you know, I would havesaved myself the hassle of doing
lots of other zygos had I beenable just to pop in a pterygoid.
You know literally I've got avideo start to finish with the
abutment on.
I think it is like two minutesand 19 seconds from initial
osteotomy, and so you know theygo really well, they go really
fast.
You know you've got to get yourangles right or you can be in
(36:54):
the three neighborhoods that youdon't want to be in right,
lateral to anterior and, youknow, to superior.
You hit the big red IMAX, but Ido tend to think, or I know, uh
, two, superior you hit the bigred IMAX, but uh, I, I do tend
to think, uh, or I know that the, the risks of pterygoids are, I
think, overstated and, um, Ithink, I think it's, it's it's
(37:15):
wise to have an appreciation for, uh, the risks and the danger,
but I don't really feel that aproperly, you know, trained
individual is, you know, canreally risk the life of a
patient.
Now that being said, I have seena properly trained individual
(37:39):
with a 25 millimeter implant.
You know, way in the back, youknow very close to where I think
the IMAX would be and you knowI don't know what that
individual was thinking whenthey did that.
But even in a trainedindividual you know there are.
You know you can getdisoriented.
(37:59):
Maybe I don't know, I wasn't, Iwasn't there, but the x-ray
looks pretty bad.
But you know, I think thatpterygoids help us avoid zygos.
My name is Dr Tyler Tolbert and I'm Dr Soren
Papi, and you're listening tothe Fix Podcast, your source for
all things implant dentistry.
Variety of opinions here, and Ithink we have so much to learn
from the areas where we agree,but I think we have a lot more
to learn in areas where wedisagree, and we can kind of
help people that are listeningto the show kind of find their
own way in things by learningfrom experienced guys like
(00:24):
yourself speaking on thesetopics and wherever you may
differ, people can kind of findthemselves in different places
and sort of figure out the waythat they want to approach.
You know these full arch casesand that's what we're all about.
So again, thank you guys somuch for coming on and welcome
to the show.
Well, thank you.
So, yeah, for sure, for sure.
And Dr Damon, welcome as well,of course.
(00:45):
Welcome back, yeah, thanks forhaving me again.
Dr. Clark Damon (00:48):
Good to see you all.
Dr. Tyler Tolbert (00:55):
And Soren.
Dr. Robert Stanley (00:55):
I suppose you're welcome too.
Dr. Tyler Tolbert (00:56):
Though you may be the co-host of the show,
I want to make sure you knowyou're welcome too.
So yeah, I'll kind of talk alittle bit about just sort of
the format of the debate andthen I'll kind of lead in with
introductions for you guys aswell, just to give people
context that they don't alreadyknow who you are.
So for this format, for thisdebate, we have a few different
topics here and I'll start byjust giving some context from
the topic where we're comingfrom, what the subject is and
kind of a little bit of theperspectives that I've heard,
(01:19):
watching you guys' videos andgoing to lectures and things
like that.
And then we'll be taking turns,giving Dr Stanley and Dr Damon
the opportunity to speak on thetopic, go ahead and give their
perspective with whateversupporting evidence that they
have today, and then after thatthe other will have a chance to
respond.
And then from there we'll kindof moderate sort of a more
(01:40):
open-ended discussion as well aspresent some questions that we
put together ahead of time forthose topics, and then we'll
just kind of let those live outas they may.
We'll try and find a middleroad if we can, and if not we
move on to the next thing andthen from there we'll see what
our audience has to say about itand maybe in subsequent
episodes we can do somefollow-ups and talk a lot more
about it.
So I'll go ahead and get intoour introduction.
(02:01):
So, dr Damon, I'll start withyou.
So Dr Damon is a dentist andeducator with extensive
experience in full arch, fromadvanced surgeries to prosthetic
fabrication.
He is the owner and operator ofTexas Implant and Dental
Centers in Dallas, fort Worthand Amarillo, texas.
He's completed thousands offixed arches and educates
doctors on everything from basicall four to the most atrophic
cases we encounter, utilizingzygomatic implants, pterygoids
(02:24):
and other accessory techniquesto treat the most difficult
cases.
Dr Robert Stanley is with us.
He is an oral surgeon anddiplomat of the ABOI and the
ICOI.
He is a continued educationinstructor and founder of the
Stanley Institute.
His channel has posted over 400videos on the topics of dental
implants, guided surgery andfull arch dentistry.
He is also an adjunctinstructor at the UNC Chapel
(02:46):
Hill and somehow has found sometime in his day to come on our
humble podcast.
So I really appreciate that.
Thank you so.
Dr. Robert Stanley (02:51):
Dr Tola, real quick I do oral surgery,
but I am not an oral surgeon.
Dr. Tyler Tolbert (02:55):
You're not an oral surgeon.
I could have sworn you were anoral surgeon.
Yeah, no, I do.
Dr. Robert Stanley (03:06):
I do a lot of surgery, so that's it's a
common, it's a common mistake.
Dr. Tyler Tolbert (03:07):
but I, I'm a dual trained PhD in engineering
and dentist.
Okay, very good, very good.
Well, you fooled me.
I could have sworn you were anoral surgeon, but I appreciate
you clarifying, yeah.
Okay, so we'll get into ourfirst topic, and that's going to
be the role of zygomaticpterygoid implants and other
remote anchorage techniques.
One of the most popular topicsin full arch dentistry currently
is the utilization of extramaxillary techniques such as
(03:27):
pterygoids and zygomaticimplants.
Dr Stanley, in your video Idon't need pterygoids or
zygomatics in my practice youstated that 99% of patients can
get by without the use ofpterygoid or zygomatic implants.
With the focus on advancedtechniques that we're seeing in
the full arch landscape, thereis a notable asymmetry between
what you say and also what thegeneral consensus around full
(03:48):
arch seems to be that thesetechniques are indicated a lot
more often in full arch patientsthan they can be usable even on
a daily basis.
Could you elaborate a littlebit on this point, and how are
you able to circumvent some ofthose situations where most
providers are opting for some ofthese more advanced techniques?
Dr. Robert Stanley (04:03):
Sure, I'd be happy to.
So the first thing that we needto make sure we understand is
that doing these remoteanchorage solutions, they're not
contraindicated.
Okay, they're just another toolin our toolbox.
But, as it happens in so manythings not even just dentistry,
but just in life when somethingnew comes along, there's energy
(04:25):
and excitement and people peoplehave tendency to jump in and
and go oh, you know, I'velearned this new technique.
And then on Monday they see acase.
They go.
Well, I could actually do thaton that case, and so what I feel
like what we're having rightnow is just we've got a
deviation from the mean, wherewe have a lot of people that are
learning about these remoteanchorage solutions and yet the
(04:47):
traditional root form implantsare more often than not,
sufficient to suffice for justabout like I said in my video 99
of the cases.
So what does that mean?
Well, it means if you actuallydo a prosthetic protocol where
you start with the teeth andthen you back into the way the
implants and you use some CBCTscans and optical scans to do
(05:09):
that, you can almost find enoughbone, almost always find enough
bone, and so you go.
Well, if I'm finding the bone,then you have to ask yourself if
I've got enough bone to do anall on X, but you know between
the sinuses or between theforamen or something like that,
then why would I want to bringinto my practice this other
solution?
Well, the first answer is is ifyou don't have that bone, then
(05:32):
that would be a good place tostart looking right, so you
would start to look at otherplaces.
So that's the first thing.
The second thing is is that youwould say well, I'm looking for
increase in stability, and as amechanical engineer, you can
imagine that I have a verystrong belief about reducing
mechanical complications throughbasic mechanical principles.
And having a distal cantileverthat's excessive can really
(05:55):
cause a lot of problems.
And so you know, you look tothe literature and you have a
lot of people that are saying,if we don't have a terminal
abutment on our prostheses,there's a lot of complications
associated with it, and that'strue.
But there's a couple otherthings that go into play here,
and that is the type ofmaterials that are being used to
implement these solutions.
So, for instance, let's sayyou're doing an FP1 where you
(06:17):
just have regular crown andbridge height.
You don't have a very tallbridge right, your beam is
rather narrow, and so if youhave a long span cantilever with
a small interocclusal space andyou don't have a strong impact
if you put all those thingstogether, it's like gasoline and
matches right You've just putyourself in a position where
you're going to have a lot ofcomplications.
(06:39):
However, if you take on thephilosophy that I'm only going
to cantilever small amountsenough to get me to first molar
occlusion and I'm going to usezirconia for my final prosthesis
and I'm going to do FP3, so I'mgoing to have a minimum height
of, say, 13 to 14, 15millimeters of arch height from
(07:00):
the incisal edge to the intagliosurface and you use a reputable
implant which is made out oflike a titanium alloy, then all
those problems go away.
So at that moment you say, well, can I get by with first molar
occlusion?
For the vast preponderance ofpeople and it's been my
experience is that most peoplethat need full arch are about 55
years old and they haven'tenjoyed their smile their entire
(07:21):
life.
And what I mean by that isthey've either been plagued by
rampant caries or they've beenplagued by periodontal disease
their entire life.
So at 55, when you tell them,listen, mr Smith, I can wrap you
in a warm blanket, put you tosleep and wake you up in an hour
with a brand new smile, andthat's pretty, pretty powerful,
right?
And that's the kind of spacewe're living in.
(07:43):
Now.
Let's say you don't have all ofthose, all of those things
don't align and you don't haveenough bone.
Well, that's when you wouldwant to look to one of these
railroad anchorage solutions.
And my contention is this unlessyou've set up your practice in
a way where you're doing theseall the time, you don't need to
be doing them.
And what I mean by that is ifyou're not doing something all
(08:05):
the time like I mountain bike onthe side, right If I'm not in
the field, if I'm not out in thewoods mountain biking I get
rusty.
So if I'm not doing theseadvanced techniques, often I'm
going to get rusty, right, andthen that's when you can really
hurt someone.
So my contention is this if youdon't have those conditions in
place, then I would send it tosomeone who does.
I would send it to someonewho's qualified, who does this,
(08:27):
basically the one guy in thecounty or the town or the city
or the state that focuses onthis one solution, because
they're so rare.
I mean, the indications are sorare to need them that when you
need it, send it to somebodywho's qualified.
When you need it, send it tosomebody who's qualified.
Dr. Tyler Tolbert (08:44):
Okay, yeah, no, I think that's an excellent
position.
So before we get into you know,rebuttals and those points I
know we're all kind of takingmental notes about a lot of the
different things you said and Iappreciate your well thought out
response.
Dr Damon, would you like totake a turn to this as well?
Dr. Clark Damon (09:00):
Yeah, I mean I think that there's definitely
some things that I agree with.
You know, talking about doing amaximum of a one-tooth
cantilever, talking about doingFP3.
I'm a big proponent of FP3.
And same with zirconia and youknow, making sure that your
(09:22):
zirconia thickness is adequate,right.
So minimum of you know 13.
So I think there's a lot of youknow, a lot of stuff that I
definitely agree with.
Where I tend to, you know, havea different philosophy is just
(09:45):
well, let me.
Let me ask Stanley this Are youdoing so?
Typically, all of your all on Xcases in the maxilla are
anterior to the sinus.
Dr. Robert Stanley (09:59):
I would say if I had to guess, I'd say about
50%%.
And the reason is is that wehave the new short implants
right and so that allows us toget a short root form implant
typically in that secondpremolar, sometimes even in the
molar position, and it helps toeliminate needing to do a lot of
sinus grafts as well, becauseyou can get that posterior
(10:20):
anchorage you're looking forwith the new short implants.
Dr. Clark Damon (10:28):
And so you're just doing this sub-anchorly A
lot of times.
Dr. Robert Stanley (10:29):
Yeah, what size.
The short implant that I haveavailable to me the shortest one
is 6 millimeters in length andit's 5.2 in diameter.
Dr. Clark Damon (10:45):
So, yeah, I mean I'm not.
There's no biomechanicaladvantage having six implants
anterior to the sinus.
The four is all that you need.
And in fact, if you're going todo six anterior to the sinus
and if this patient ever needs arevision, they're going to be
(11:07):
an automatic quad.
You're going to have so muchiatrogenic bone destruction when
those implants get removed.
I don't advocate for sixanterior to the sinus.
I don't advocate for sixanterior to the sinus.
I mean, I definitely appreciateDr Stanley's desire to want to
(11:28):
be safe and desire to want tohave the best outcome for the
patient.
Right, and you know there'sabsolutely nothing wrong with
referring.
I think.
I think, you know I, I do agreewith Dr Stanley and the fact
that you know we are seeing adeviation from the mean.
(11:48):
I think it's because a lot ofyoung docs I mean I can't tell
you how many docs out of schoolcome in to take my full arch
course.
It's their first, it's theirfirst course and they've already
, they've already done 10 to 20arches and I'm like, okay, wait
a minute, where, where did youguys get your education?
And they're, they're, they'rejust blowing and going.
(12:10):
So you know, I, I don't knowhow to describe it.
You know, maybe, maybe a lot ofyounger docs are just, you know
, very hungry and, you know,willing to take on a lot of risk
.
I think that they don't evenknow the risk that they're
(12:30):
taking on.
So I kind of think thisdeviation from the mean is not
only just with respect to, youknow, treating atrophic maxillas
, but I think it's also guysgetting in and jumping into full
arch way too early.
So I don't know, dr Stanley, doyou think there's something
there?
Dr. Robert Stanley (12:51):
I would have to concur with you.
I did a course recently.
I was invited to teach a coursefor two days and it was like a
DSO, so they procured theirpatients, their doctors, and
about halfway through the firstday you know you get a sense for
the level of understanding inthe room.
And there were only four peoplein that room of 70 that should
have been in there.
(13:12):
The other group of peopleshould have been in the onesie,
twosie implant course.
They shouldn't have been in thefull mouth course.
It was kind of shocking.
Dr. Clark Damon (13:23):
Yeah.
Dr. Soren Paape (13:23):
I would say uh go ahead, Soren.
Yeah, I was just going to say.
You know, I feel like there's somany um whether it's podcasts
or uh just just hype around fullarch dentistry right now, where
these large DSO groups are um,right now, where these large dso
(13:46):
groups are um, they are needingto to fill that void of
patients and and they want to,they also want um to sell these
treatments right, but they don'twant to pay for uh providers
who maybe have uh been doingthis for 10 years.
So their solution is to um tomake full arch dentistry like
the new cool thing to do.
Uh, and I feel like a lot ofthese these groups are sending
(14:09):
doctors right out of schoolbecause those are the people
that jump into their office.
You know they're, they're.
They come to the office to getsurgical experience, to take
teeth out, and then next thing,you know um, they're kind of
like pushed into, let's do fullarch dentistry, and then they
end up in courses like likeyours, clark, and probably the
one that that yours, you wereteaching as well, dr Stanley,
(14:29):
and I agree, I think it's, Ithink it's really scary and you
know, I see a lot of casescoming from those clinics and
Tyler and I being the clinicaldirector for a large group, dso.
We saw the quality of some ofthese treatments being done and
they were very much under par,for sure, yeah.
Dr. Tyler Tolbert (14:51):
Yeah, I mean, I think something that we're
kind of touching on here is that, for one, you have people who
are inexperienced, sure, gettinginto full arch, and you know
there's questions about you knowwho should be doing full arch
and who's really qualified to dothat, and I think that's an
entirely different subjectaltogether as valuable of a
conversation as it may be.
But one thing that I thinkbecomes a little bit contentious
(15:14):
is especially, you know, as itis relevant to the topic too is
you know, when we start talkingabout the advantages of, you
know, let's say, pterygoidsfirst of all, right, I mean we
can talk about zygomatics,because those kind of come into
play with really atrophic caseswhere you have very I mean
little, I mean no subantral bonereally and nothing really in
zone two whatsoever.
But with pterygoids, one of thepurported benefits of it is,
(15:37):
you know, you go from talkingabout what is a tolerable
cantilever to having nocantilever at all, and a lot of
people can purport the benefitsof that and saying, okay, we
have absolutely no cantilever.
That's clearly better thanhaving some right.
And then you start to hearthings about that being, you
know, potentially even astandard of care.
So now someone says, okay.
Well, I'm experienced enough toget into full arch.
(15:58):
I'm starting to do some all infour.
I'm doing that, I'm runninginto some problems.
Here and there I'm having aposterior tilted implant fail,
then I'm having to graft it andI'm having to deal with all this
.
I need something else to kindof supplement, where I'm running
into trouble and then they hearpeople talking about the
biomechanical advantages ofcompletely eliminating the
cantilever, and so they'resaying, well, if I, you know
(16:19):
upper arm and forearms, now Ineed to be doing pterygoids, and
so there's just this sort ofimmediate succession into a
different level of care ifyou're going to be doing some
full arch.
So you know, we've kind ofalready lowered the barrier of
getting into full arch in thefirst place.
There's a lot of advancementsin the past few years that have
made this a lot easier.
There's a sort of this verystepwise trip into doing really
(16:47):
the most advanced level of carethat we do.
I guess the question is whatreally is the indication for it?
Of course we can talk aboutthose benefits.
There's also risks that comeinto play, and so I think really
it comes to question is youknow, how necessary is it to do,
say, a pterygoid.
I mean, yes, we can completelyeliminate the risks that are
associated with I wouldn't saycompletely, but we can really
(17:08):
mitigate the risks that areintroduced with a cantilever but
is it worth it to go that extrastep and start doing that extra
, more advanced and potentiallydangerous technique for the sake
of doing that?
And it's a risk-benefitanalysis.
And so you know, dr Damon, youknow I'll kind of point to you
because you were the person thatdefinitely pushed us, myself
and Soren, to do a lot morepterigoids.
(17:30):
We already had kind of beenintroduced to the technique, but
for us it was more of okay,this is to help us rescue
ourselves when we have a tiltedfail.
You kind of changed ourmentality a little bit as young
doctors into thinking, okay, youknow, if I started doing
pterygoids more often, even oncases where I could get away
with it, I'm going to have moresuccess long-term because I have
(17:53):
less biomechanical stress.
Can you speak to that just alittle bit and maybe kind of
provide some guidance on that?
Dr. Clark Damon (18:00):
Yeah, so you know, I think you know, one of
the reasons why I wanted us tointerview Dr Stanley is because
you know I do pterygoids on 99%of my cases and he says 99% of
his cases don't need them.
Dr. Tyler Tolbert (18:18):
And I was like man, this is, this will be
a perfect discussion you know,but yeah, so you know to.
Dr. Clark Damon (18:26):
you know, darge Stanley, to one of your points,
right about, like you know, ifyou mountain bike, just on
occasion, you know, you kind ofbetter be careful and not go on
a super tough trail, but youknow if you're mountain biking
every day you know you're readyfor the Olympics, so you know
(18:48):
there's a small degree to thatright.
So like you can't be ready totreat the atrophic maxilla if
you don't practice the atrophicmaxilla on a regular basis.
Now that doesn't mean that weput zygos in on people that
don't need them, but I can'tthink of a reason not to give my
(19:14):
patients a pterygoid and soeverybody gets them right.
So we go with the nocantilevers.
Wilkerson has a really goodbiomechanical article talking
about pterygoids and how itreduces the stress when you
compare it to the standard four.
So we're eliminating stress andstrain, increasing our
stability.
And where I challenge DrStanley with doing the
(19:39):
sub-antral shorter implant,while I would prefer to do that
over a sinus graft and then comeback in place, I would first
prefer to do a pterygoid becauseone we can utilize a longer
implant my average pterygoidimplant length is 18.
And we're able to really lockit in into the pyramidal process
(20:05):
, which has a lot of very densecortical bone, and so our
cumulative torque values go up,the stresses come down and I see
less failures, I see lessprosthetic complications.
In fact I don't.
(20:26):
I don't see any prostheticcomplications with the pterygoid
, other than if you have a youknow, an 85 year old patient, on
occasion they can't.
They can't handle thepterygoids.
I think their tongue getspretty big and and and they just
don't like it.
That's the only patient that Ican think of that doesn't need a
pterygoid is an elderly femalepatient.
(20:48):
They just don't get along wellwith stuff in their maxilla.
But that's kind of my rationalefor doing pterygoids on
everybody.
Dr. Soren Paape (20:59):
Yeah, I would say yeah, and I'm curious as
well about Dr Stanley, yourprosthetic.
When I say prosthetic failure,I don't mean, like you know, in
zirconia, but like fractures oftemporary loaded.
Are you typically doing liketwo to three month temporaries
in your office and thentransitioning to zirconia after
those two to three months?
Dr. Robert Stanley (21:19):
Yeah, so we do a.
We do immediateprovisionalization and that
would be a prefabricatedprovisional.
So we just pick it up that daybut it's prefabricated, and then
we let them wear that.
It's a nanoceramic and we letthem wear that for six months.
And the reason we go a littlelonger than most people in the
industry is they really want thepredominant amount of shrinkage
(21:40):
of the soft tissue before we goto the final zirconia.
And that way when we go to thefinal zirconia you don't have
them.
They say, three years down theroad going, I got a whistle, I'm
getting food underneath myzirconia, which you can fix, but
it's a pain, right?
So that's our typical protocolSince we've gone to the
nanoceramics monolithicnanoceramics.
(22:03):
So the back of the day used tobe a titanium bar wrapped with
PMMA.
That was our long-termprovisional and those fractured
a lot.
We got a lot of fracturesduring the healing phase with
that and it makes sense when youhave more components in a
system you have more possibilityfor failure.
But once we've gone to the newnanoceramic we just don't have
fractures in those long-termprovisionals.
And the really cool thing isthat even if we did, we can
(22:26):
print a new one in 23 minutes.
So if we had to, we'd justprint a new one and bring them
in and just unscrew it and put anew one in, so we can manage
that really well.
But I think that it'sinteresting that we should
probably and this is somethingin the industry that we don't
really discuss too much there'stwo kinds of problems that
(22:47):
people talk about.
When we talk aboutcomplications, we talk about
forces and stresses and thesekinds of things a lot, but
there's the risk to themechanicals, the mechanical
operation.
There's a risk to thebiological right, and the
literature is pretty clear now.
Whereas we used to think thatthere was a significant risk to
the biologics of force, that waspredominantly taught by Carl
(23:11):
right, carl Misch, and he wasworried about overstressing the
bone and that would cause boneloss.
But we know that there's noevidence that that happens.
Okay, so you can put a lot ofstress on the bone and, if you
think about it, the purpose ofthe bone is to carry load, right
, that's what nature made thebone for.
It's designed to carry load.
(23:31):
So that kind of concept goesaway.
So when you really talk aboutwhat are the risks when we have
a cantilever to our system, thereal risk you're talking about
is mechanical.
Okay, so we can call itbiomechanical because it's part
of the body.
But what you're looking at isfractures of the prosthesis or,
like you said, it's screwloosening, it's abutment
(23:52):
breakage, it's abutmentdelamination from your
prosthesis, these kinds ofthings.
Those are the predominantproblems and the literature is
pretty clear on that too.
We're seeing three to fourtimes more of those than we are
the biological one.
So what oftentimes happens iswhen you have a case and you
have a failure like an implantthat doesn't integrate properly,
it's so many reasons why itcould not integrate.
(24:12):
Right, I've got 52 that I'velisted it just at the high level
.
You could go even deeper if youwanted to.
So when you have a failure,sometimes it's very difficult to
differentiate between I thinkthis failure was because of
mechanical loading or thisfailure was because of biologics
, right, and what I would argueis that the vast proponents of
failure to integrate arebiological in nature.
(24:35):
Okay, in other words, we didn'tget the implant in the right
location, we didn't get enoughbone around it, there was a
failure to get good woundhealing and then the implant it
partially integrates, it hasstability, but it doesn't
integrate long term, and so youget a failure downstream.
So getting that implant in theright location in the very
beginning is really paramount topreventing these kinds of
(24:59):
problems happening later.
Then the second part is is ifthe implants are in the right
location and your prosthesis isproperly designed, you're going
to minimize your off-axis loads,ie you're gonna minimize your
cantilevers or eliminate them inthe cases of doing the remote
anchorage, and that's a reallygood thing for the system, right
?
So if you do that, that's great.
(25:19):
But if you do everything thatI'm talking about in terms of
the method that I that Idescribed earlier, where the
implants are in the rightlocation, they're actually
loaded.
You've got a tall prosthesis andit's made out of strong
zirconia.
We've never had a.
We've never had a zirconiafracture.
We've never had a zirconiaprosthesis fracture ever in our
(25:40):
in our entire career.
And Tischler you know Tischlertook the payday.
He's gone now, right but whenhe was working he published a
really neat paper.
I think it was 2,500 FP3s thathe did.
He had like a less than 1%complication and of those I
think he had really goodexplanations for why they broke.
(26:01):
So I think that it's prettyclear that if you have enough
height to your zirconia, you'renot going to have a lot of
problems, right, you're notgoing to have a lot of fractures
and such.
So that's really the key.
And when we see a lot of peoplethat are pushing for FP1s right,
traditional crowded heightspace, where your connector
(26:21):
space between an FP1, yourconnector space gets very, very
tiny, and if you have a verytiny connector space and your
implants are spread out like anall-on-four and your beam length
is long, they're going to break.
They're going to break all daylong.
And then you start looking for,well, why are they breaking?
And if you say, well, mayberemote anchorage, so I don't
have this cantilever, well, thatmakes a lot of sense.
But you see, it's more thanjust one variable, isn't it?
(26:47):
It's a combination of variablesthat, if we put together, it's
all about reducing that risk andimproving the outcomes for the
patient.
But you've got to take a lookat it more than just one
parameter that you're doing inorder to have that kind of
success.
Dr. Tyler Tolbert (27:00):
So you bring up an interesting point with
respect to the loading of theimplants.
Now it does sound like you'remaking a few different points
here.
For one, we can compensate abit for the presence of a
cantilever by having implants inthe correct location.
And I assume, since youmentioned axially loaded
(27:22):
implants, that you also meanthat the implants are being
axially placed, which is kind ofimplied that that is what you
consider to be the correctlocation.
So in a lot of patients one ofthe main reasons that we have
tilted implants is all in for inthe Paul Malo technique is
because of the anterior borderof the sinus.
You're tilting an implant inorder to obviously decrease that
(27:42):
cantilever and you're tiltingthat.
And so I guess really thecontrast here is you have, in
one case you might have siximplants anterior to sinus
placed axially.
Perhaps you have a subantralshort implant right and some
mitigated cantilever.
We've managed to get the patientback to first molar, versus
(28:04):
having the you know tiltedconfiguration that's more
typical in the palomelo and thenhaving the pterygoids as well.
So you know, I know we'retalking about biomechanics, I
know we're talking about how theimplants are loaded.
I guess it really is kind of aquestion of you know, is six
implants with no pterygoidsplace axially going to be better
biologically or mechanicallyversus those tilted implants?
(28:27):
How do you kind of you knowwhat are the different things
that you're considering betweenthose two?
You know modalities, becausethey are very different.
Right, you have long implantsthat are tilted versus shorter
implants placed straight.
What is kind of the rationale?
Dr. Robert Stanley (28:40):
That's a great question and this is
something that a lot of doctorsget really confused on,
especially those young ones, doc, when they come out and they're
like, wait a minute, I thoughtyou said you want to actually
load your implants, but how dothe all-in-fours work?
Because you've got a tiltedimplant there and they get
really confused.
So let me clear this up foreveryone.
Really, really simply, ifyou're doing a single implant,
(29:00):
the way an implant is designed,it's designed to be loaded
axially, which means all theforces should be directed down
through the long axis of theimplant.
Okay, anything that you do thatcreates a bending moment on,
that is going to create problems.
So if you get the implant inthe wrong location, let's say
you're doing a first molar andyou put the implant in and you
get a little pucker factor, soyou scoot it a little bit
towards the distal and nowyou've got a cantilever to the
(29:23):
mesial.
So you've got a cantilever.
If you look at thetwo-dimensional radiograph, the
crown that you put on therelooks like a Snoopy, and so I
call it a Snoopy.
When you see it, it's got along nose on one side.
Right, it's short on one side.
That's a cantilever on a firstmolar, they bite and they hit
the medial marginal ridge ofthat prosthesis.
It's going to bend that.
It's going to bend that.
And what you're doing is, everytime you're bending that
(29:45):
prosthesis, you're torquing theentire system.
So you're putting the stressonto the abutment screw.
You're putting the stress ontothe cement that cements the
zirconia crown, to the hybridtie base and the hybrid tie base
to the implant.
So none of the system, none ofit, likes that, likes that.
Okay.
So you want to prevent thatoff-axis load.
You want to load axially.
So that makes a lot of sense.
(30:05):
Would any of you think it wouldbe a good idea to place a
single implant at 30 degrees andload it with a crown?
And I think all of you wouldsay, well, no, I don't think
that's a good idea at all.
Right, so?
And I don't, I don't know thatI've seen anyone actually do
that, where they've placed asingle implant at a 30-degree
angle and then used a 30-degreecorrection to design a single
(30:25):
crown.
However, in Turkey, in Turkey,yeah, yeah.
Dr. Tyler Tolbert (30:33):
We see a lot of cool stuff in Turkey.
Dr. Clark Damon (30:34):
Yeah Well, y'all have all seen the lateral
incisor implant where it'scoming like this, and then I
think they put maybe like a 55degree or like a 60.
Dr. Robert Stanley (30:44):
You're going to have to share some of those
pictures with me.
Dr. Clark Damon (30:49):
And it looks, it looks terrible.
You know the, the, the, thebone regeneration doctors in New
York, they get these things allthe time.
Sure, yeah, I would like to seesome pictures of that.
Dr. Robert Stanley (31:02):
That's good.
So now here's because you'rewaiting, so you want to know
well, how do angled implantswork.
When you do an all-in-X, youchange the complete dynamics.
It's called in engineering,it's called a truss.
Okay, if you're going down theinterstate and you see one of
those signs across, that'sbridged across, it's got the,
(31:22):
you know.
It tells you what interstateyou're on.
It's made out of a series ofbars and those bars kind of go
zigzag like this, right, andthat's called a truss.
And what happens when we putsomething into a truss?
All of the elements that areloaded in the truss are loaded
axially.
Oh right, are you guys gettingthis?
(31:42):
So when you tie, when you tie auh, an axillary implant with an
off-axis implant and you tiethem together with a prosthesis,
and at the base they're tiedtogether with bone, you've just
created a truss, which meansthat implant is not being loaded
off-axis, it's being loadedaxillary, which is something
that that I always wanted totalk to Carl about.
(32:05):
That, because Carl would alwayssay you know, remember that
debate he had with Paul DiMallo?
Right, it was brutal, right,they got on stage and they were
going at each other and he waslike would you build a tree
house for your kids with postslike this.
And he was like no, you wouldn'tright, but what he wasn't
talking about and what he wasfailing to kind of bring to
(32:26):
light was that it's not a singleimplant it's a system or a
system together is a trust, andif you put the trust together
it's incredibly strong, which iswhy which is why, when you put
your prostheses on top, itshould be rigid.
So there was a time where peoplewere thinking maybe I should
(32:46):
put some like a small, like anelastomer type of plastic on the
top that would give right, sothat it would absorb the
occlusal loads and such.
That's a terrible idea, becausenow your implants are going to
be not rigidly coupled, whichmeans they're going to be
allowed to bend and that youlose that trust, you would lose
that trust function and it wouldfail.
So that's why using somethingreally rigid like a nanoceramic
(33:09):
or even more rigid, like like aceramic, like an oxide, like
zirconia, that's why it works.
So that that is a distinctionthat really.
I hope that people arelistening.
They really understand.
There is a huge distinctionbetween loading individual
implants and tying them togetherin a prosthesis.
It's a completely differentanimal.
Dr. Clark Damon (33:29):
Right, I mean that's that's why we see our
implant success in all on X beso much higher than you know,
our our single units Um but, youknow I still, I still would
prefer a longer implant in thepterygoid than a shorter implant
sub-antrally.
(33:50):
And it's not just length orlocation, it's really kind of
more type of bone.
You know, the bone in theposterior maxilla is oftentimes
just garbage.
The posterior maxilla isoftentimes just garbage and it's
not something that I want to.
(34:10):
You know, really sink my teethinto right and you know, going
back to the truss, when you lookat those pterygoids, you know,
then you know, if you look atmany of my cases, you know it's
leaning back into the pterygoid.
You know posterior, superiorly,and then you've got the
posterior ones leaning, you know, anteriorly, in front of the
(34:30):
sinus, and then when I do the,the nasal crest, you know
everything is at an angle and soit's.
It's a huge trust.
So I'd like to encourage you,or Stanley, to, uh, you know,
consider doing some terrordroids.
Dr. Robert Stanley (34:49):
I, I, you know what I, I, um, I would love
to.
I, I love to do everything inthis planet and I'm running out
of time.
My, my days are becominglimited.
I just told a colleague thismorning.
I said I've got to starttelling people no, and he said
what do you mean?
I'm burning the candle at bothends here, I'm trying to get my
(35:10):
book written and, on top of allthe other things I'm doing, I'm
like I got to start tellingpeople no.
He started laughing because heknows I'm never going to do that
.
So, yeah, I'd love to do it,because why not?
I mean learning.
The only way to improveyourself on this planet is to
learn right, and so learning isparamount, right?
You've got to keep expanding,you've got to keep learning.
(35:32):
Yeah, and you know one of thereasons to actually do a
pterygoid is because the bestzygoma is the one you never have
done.
Expand on that.
Dr. Clark Damon (35:47):
We can all agree to that.
So we can, we can, we can use.
You know, I started doingzygomatics first in 2014, 2015.
And then I started branchingout in 2016, 17 into doing
pterygoids, 2016-17 into doingpterygoids.
(36:09):
And you know, interestinglyenough, you know we didn't have
osteotomes, so so, so I I drillmy pterygoids and um, because we
didn't have the instrumentation, and so that's that's how I
learned and developed mytechnique, uh, developed my
(36:31):
technique.
But you know, I would havesaved myself the hassle of doing
lots of other zygos had I beenable just to pop in a pterygoid.
You know literally I've got avideo start to finish with the
abutment on.
I think it is like two minutesand 19 seconds from initial
osteotomy, and so you know theygo really well, they go really
fast.
You know you've got to get yourangles right or you can be in
(36:54):
the three neighborhoods that youdon't want to be in right,
lateral to anterior and, youknow, to superior.
You hit the big red IMAX, but Ido tend to think, or I know, uh
, two, superior you hit the bigred IMAX, but uh, I, I do tend
to think, uh, or I know that the, the risks of pterygoids are, I
think, overstated and, um, Ithink, I think it's, it's it's
(37:15):
wise to have an appreciation for, uh, the risks and the danger,
but I don't really feel that aproperly, you know, trained
individual is, you know, canreally risk the life of a
patient.
Now that being said, I have seena properly trained individual
(37:39):
with a 25 millimeter implant.
You know, way in the back, youknow very close to where I think
the IMAX would be and you knowI don't know what that
individual was thinking whenthey did that.
But even in a trainedindividual you know there are.
You know you can getdisoriented.
(37:59):
Maybe I don't know, I wasn't, Iwasn't there, but the x-ray
looks pretty bad.
But you know, I think thatpterygoids help us avoid zygos.
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