Shaping the Debate: Opinions in Full Arch Implant Dentistry with Dr. Damon vs Dr. Stanley: Part 2

Does successful implant dentistry depend more on the tools you use or the brain behind them? This riveting debate between two masters of full arch implant restoration showcases fundamentally different approaches to achieving predictable success.

Dr. Damon champions freehand surgery with unwavering confidence, arguing that true mastery comes from maintaining complete anatomical awareness and adaptability. "Your brain is the guide," he asserts, explaining how this approach allows surgeons to pivot instantly when encountering unexpected challenges during surgery. His patients thank him for removing the burden of guided surgery, appreciating both the clinical flexibility and reduced costs.

Meanwhile, Dr. Stanley applies engineering optimization principles to implant dentistry, challenging conventional wisdom about stability, torque, and surgical planning. "The idea of undersizing an osteotomy meaning that you made the hole smaller means that when you put the thread in, it's going to compress the bone more," he explains, unveiling how guided surgery creates predictable stability even in challenging bone quality. His revolutionary perspective on torque—demonstrating how a zero-torque implant can have 100% stability—forces listeners to question fundamental assumptions about implant success.

Both doctors present compelling evidence for their methods, sharing illuminating clinical examples and practice management insights. Whether discussing pterygoid implants, stackable guides, or the globalization of digital dentistry, this conversation transcends mere technique to explore the philosophy behind predictable outcomes. For practitioners weighing efficiency against flexibility, or considering the true definition of implant stability, this episode delivers paradigm-shifting perspectives.

What's your approach to full arch implants? Have you found your perfect balance between planning and adaptability? Share your experiences and continue the conversation!

Episode Transcript

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.
Yeah, so that, actually, I thinkthat transitions us pretty well
into my next topic.
So we talk about the dangersthat come along with placing
pterygoid implants that's whatyou mentioned, dr Damon.

(00:22):
So we can get disoriented right, and even when we're doing
freehand surgery and we've doneit a million times it's very
possible to get your eyes tired,maybe you're a little bit off
angle, maybe you thought youwere, you had everything locked
in, but you got deviated, or youjust got a whole lot deeper
than you expected to, and so onething that a lot of doctors are
proponents of is guided surgeryeven guided pterygoids as well

(00:43):
and so one thing I did want totalk about is the role of guided
surgery specific to full arch.
So it's one of the most hotlydebated and polarizing topics in
all of full arch dentistry isshould we be doing this guided
or should we be doing thisfree-handed?
So advocates of guided surgeryare going to be touting the
predictability that comes fromit, the precision, being able to
get implants in the correctlocation and being able to

(01:06):
reduce the risk of complicationsthat can arise from the sort of
human error that you justmentioned about your data.
So, conversely, though,advocates for freehand surgery
would argue that working withoutguides allows for a lot more
flexibility and the ability toreact to complications,
anatomical variations.
We have all seen where you'vegot a CBCT ahead of time.
You thought you knew what youwere getting into, and then you

(01:27):
open it up and something wastotally different, right?
So, dr Stanley, you were a hugeadvocate for guided surgery and
in your video I placed guidedimplants in even the toughest
cases.
You stated that guided surgerycan be done anywhere in the
mouth on any patient and thatimplants placed guided are more
predictable, have decreasedrates of infection and will
undergo less mechanical stresses.
Conversely, as for Dr Damon,you have stated in the past that

(01:50):
freehand surgery, completedwith proper training, allows for
the most flexibility in trophiccases and the ability to pivot
to the use of zygomatics orother remote anchorage
techniques when things don't goas planned.
So, dr Damon, I'll have youexpound on this one first, from
the freehand side of things.

Dr. Clark Damon (02:06):
Sure.
So you know all of my cases areguided and you know they're
brain and anatomy guided andthat allows an open mindset.
I can react to whatever type ofsituation occurs.
And we've all seen it, we'veall had it, we have evaluated a

(02:30):
CBCT beforehand and we've, youknow.
Let's just say it's a simpleinfection.
I have watched these apicalinfections grow to much larger
than what the CBCT shows and Imean I have taken infections out

(02:51):
that have traveled.
You know three teeth.
You know anterior or posteriorto that you know.
We can all say that we reduceand or sorry, that we extract
teeth atrophically.
But on occasion you can, youcan definitely.
You know, fracture a buckleplate and you have to be able to
pivot, so I, I, I advocate forfree hand in all cases.

(03:19):
Some of my most stressful caseswere the ones that I did guided
and you know, maybe I didn'tset up the cases how Dr Stanley
may.
However, you know this was using, you know, the Nobel Guide.
This is back in 2014, 15.

(03:40):
And you know really long drillsbecause I always want to
maximize my AP spread.
And so how can I maximize my APspread if I can't even get the
drill back there for yourposterior angle?
In addition, whenever, wheneveryou do a guided case or at least

(04:00):
my experience and what I hearfrom other individuals is that
you leave your brain in youroffice and your brain did not
come to the surgery room becauseyou have given it up.
The second you've walked in thedoor, you've said the guide is
going to be my guide and I'mgoing to do everything that this

(04:22):
guide tells me to do.
So we don't have an open mindwhen going in to do everything
that this guide tells me to do.
Uh, so we don't have an openmind when, uh, going in to do
guided cases.
Um, and you know, I, I, I wouldchallenge you guys have seen my
cases.
I think if you look at myx-rays, my x-rays will look
better free-handed than theywould look guided, even with the

(04:46):
Yomi.
I look at other Yomi doctors, Ilook at their x-rays and I'm
just like, okay, there's lack ofsymmetry, these implants aren't
at the same depth and I havenot been impressed with looking
at Yomi x-rays.

(05:08):
You know, I know that's dynamicguided, but so my position is
open mind, free hand and I thinkit's in my hands is safer and
more predictable.
And I'll tell you this, theguys that come, and guys and
gals that come take my courses,they seem like they have a

(05:29):
weight taken off their shoulders.
When I tell them that they cando the cases freehand, they are
like oh my gosh, dr Damon, thankyou, you know, and I I think it
saves them money.
You know, I don't know, I don'tknow, I don't know what current
guide prices are.
You know, but I mean, Iremember the days where guides

(05:49):
were several thousand dollarsapiece and I'm a huge proponent
of just save money and give itto your kids, you know.
So so to me, things that we, wecan do, that lower cost is a
win for everybody.
So those are my thoughts.

Dr. Tyler Tolbert (06:12):
All right, Dr Stanley.

Dr. Robert Stanley (06:15):
So you know , I often hear the statement I
want to be able to adjust duringsurgery, I want to be able to
pivot or whatever the term youwant to use.
And I'm always shocked whenpeople say that and because when
I approach a surgery, Iapproach it a little bit

(06:36):
different.
Let me explain.
In engineering, we do somethingcalled an optimization problem.
So if we're going to designsomething, let's say we're going
to design something, okay, wedon't want to make it bigger
than it needs to be, but wedon't want to make it too small,
we want to make it just right,okay.
So if you make a screw too big,it costs more and it carries

(06:56):
too much weight.
So if you're trying to launchsomething into space, you don't
want big screws, right.
But if your screw's not bigenough, then your spaceship
falls apart.
So there's somewhere in themiddle where the screw is the
exact best size for thatsolution.
In engineering we do it all thetime.
We typically do it throughmathematics.
Okay, we say through math, wesay what's the optimal solution?

(07:17):
When it comes to dentalimplants, I optimize my implant
location prior to the surgery.
So we do a virtual surgery.
So we're going to do thesurgery on the computer before
we ever do the real surgeryright.
And what do I mean by that?
Well, we're going to virtuallyplace implants.
Those implants are going to beoptimally placed, they're going

(07:40):
to be the optimal length.
So, as we were talking earlier,we want to stay.
What was it?
18 millimeters is the idealrange for the pterygoids, not 25
.
So there's a reason for thatright.
So when you're designing yourcase, you're saying what is the
optimal length, what is theoptimal diameter of my implant?
Where would be the absoluteperfect location for the

(08:03):
multi-unit to stick out of thegums so that it would be in the
perfect location for my screwaccess hole, for my zirconia
prostheses?
You see what I'm talking about.
So we're going to start withthe teeth, then we're going to
back into where the exactperfect implants are the number
of implants, the size of theimplants, the locations and all
of that.
And now we have the perfectplan.
There is no deviation from thatplan that is going to do

(08:28):
anything for you, but make thesystem worse.
So when you go in so this is,this is a concept if you've been
practicing for a while peoplewill say well, the the concept
of the rescue implant.
You guys recall the term therescue implant.
So this guys recall the termthe rescue implant.
So this comes from the old dayswhen, when the when the metric
for success was did the implantstick in the bone?

(08:51):
So we used to say we did asurgery and we walk out of the
surgery and go the implants inthe bone, that was success,
right, that's how we used tomeasure success, really
literally.
And so the way that worked isthat I tried to put an implant
in and I got a spinner.
So you turn to your assistantand go get the next bigger
implant, and so you put a biggerimplant in the hole and you and

(09:12):
you get.
You get primary stability andyou and you're done.
Okay, okay, great.
But but the problem with thatconcept is is that if you could
have placed the bigger implant,you you would have start with,
started with that in the firstplace.
Okay, the reason you didn'tstart with that in the first
place, okay, the reason youdidn't start with it in the
first place, is because,theoretically, the implant you
pushed in that spot in the firstplace was the optimal implant.

(09:33):
So if you could only get a 4.2millimeter implant and a
premolar and you say, well, okay, I don't have stability, so get
me a bigger implant.
So you say, well, give me a 5.2.
Now, right, what happens?
You blow out the buccal bone.
Now you get stability, you getit to integrate and then you get
a dehiscence and the facial,and then you don't get
integration long-term, you gettemporary integration and then

(09:54):
you get a soft tissue dehiscenceand then you're calling up your
periodontist friend and sayingI need a connective tissue graft
and a bone graft or whatever totry to solve this problem.
Which the problem was?
The implant was the wrong sizeIn this case.
If it was the wrong size, justby going to a bigger implant,
well, it's the same thing withthese surgeries.
At what point in my surgerywould I want to pivot?
It's shocking to me to thinkthat while I've got someone

(10:16):
under sedation, that I wouldchange my plan.
You see, my plan was optimizedin the comfort of my office,
drinking a cup of coffee with noone bothering me, where I was
focusing on that patient andoptimizing the solution for them
, such that when I go to thesurgery there is no pivot.
So the concept of I'm going toleave my brain in the other room

(10:38):
, that makes a lot of sense,because when you go in, at the
time that you go in, it's timeto execute.
It's time to execute the saidplan.
It's time to execute the saidplan.
It's not time to change theplant, it's time to execute the
same plan.
And I don't know when people say, well, there could be things
could change.
I, I, the landscape's not goingto change.
You're going to.
You're the the the volume ofbone is not going to change.

(11:00):
All of your planning is notgoing to change.
Even if you have more infectionthan you thought, your plan
doesn't change.
You just had more infectionthan you thought.
But if you're using goodstandard practices for primary
stability, you're going to beable to predict your primary
stability and you're going tohave a success.
You're going to have a win.
So that's kind of how I look atit and I look at the surgical

(11:23):
guide as a tool.
So some people get really upsetabout this.
As you started with theintroduction here, you said this
is a hot topic, right, so yougot.
People are like, hey, no,freehand is the way to go and
that kind of thing religiousabout this.

(11:46):
All I'm saying is it's a tool.
And if you have a tool that canhelp you accomplish your goal,
which is laid out, then why notuse it?
I like to make the analogy uh,you're building a house and
while you're building a house,your hammer breaks.
Okay, it's 11 am, your hammerbreaks.
You have a choice you can pickup a stone and you can keep
driving nails with a stone, oryou could go to home depot and
get a new hammer, okay.
And I think most of us wouldsay, okay, hey, joe, hold on, I

(12:09):
gotta go get a new hammer.
We pause for a minute, we goget a new hammer, right?
So that's the concept of hey,uh, you know, uh, if it breaks,
I gotta go back to freehand.
You know, if I, if my, if myguy doesn't break, if it doesn't
work, I gotta go back tofreehand.
Well, that's never happened inmy career.
Now I've had plastic break andit predicted, you know, most of
the prac.
Uh, the guides that are brokenwere were early on in the

(12:31):
practice, like early on in theyears, back when the guides used
to cost a lot and thoseplastics were weak.
So, you know, you can print.
You can print the guide in youroffice now in minutes, with a,
with a Sprintrate printer, andyour print cost is about $2.
And then you put a mastercylinder in there, and the
master cylinder is about $12 to$15, depending on the company
you're using.
So you're looking at a totalhard cost for you as a surgeon

(12:55):
of around $15.
And then you've got to pay, ofcourse, your overhead for your
labor and such.
But the old days of guidescosting $500, $600 and such,
those days are gone.
Now, for full mouth cases, theguides are still a little more
expensive because typicallyyou're using a company to help
you plan those cases, and sothen you get on a go-to meeting,
you review the case with themand you verify that the

(13:16):
positions meet your design, yoursurgical goals and your
prosthetic goals.
So those can cost a little bitmore, but the benefits are.
Is that I did a case on Mondayupper arch in 34 minutes from
beginning to end, so from layingthe flap, placing the implants,
closing the flap and placingthe prosthesis in 34 minutes.

(13:38):
That's pretty powerful.
And the reason why we were ableto do that isn't because of me,
it's not that I have any sortof God gift or anything like
that.
It's just that if you followthe method it becomes very, very
predictable.
And I have just the opposite,doc.
I have people calling me afterthey've been placed at implants
freehand for 10 years and theythey literally are like holy

(13:58):
shit, I can't believe that itwas this easy.
I'm sorry I cursed on yourproject.

Dr. Tyler Tolbert (14:01):
No, please, we do it all the time.

Dr. Robert Stanley (14:03):
They're like I can't believe it was this
easy.
I remember back I'm old enoughto have done freehand back in
the day.
I remember placing implants andthen going okay, take the
radiograph.
And I'd walk out in the halland I'd lean up against the wall
and I'd be like counting theseconds, wondering if I hit the
adjacent tooth, and I'd walkaround.
I always made sure that theradiograph was up on the back

(14:25):
screen, not in front of thepatient.
I needed to see that radiographfirst and I would look and I
would like, oh, oh, mrs smith,it looks great, you know.
And then all the stress would goaway and the minute you go to
guide it and you know you canget a guide accuracy of about
200 microns, 200, 200 microns isyour positional accuracy.
With a guide, all that stressgoes away.

(14:46):
Now you do have to plan itright.
It doesn't the brain part stillneeds.
You still got to have the brainpart.
It's just the brain part has togo into the planning part, not
during the execution.
You still have to have a.
You still have to be smartduring the execution.
But that's, that's my take onthe, on the, on the guides.

Dr. Clark Damon (15:02):
Yeah, I think, I think you know I, we're able
to optimize our implant positionclinically and you know I can.
I can tell you my implants I, Iam typically able to get
greater AP spread during surgerythan I thought that I was able

(15:24):
to uh when I was reviewing my uhx-ray and plan uh before.
And so, uh, you know, I don't,you know we're, we're, we're
very open, um, I mean, there's,there's a number of times, even
when you follow key principlesright, like perforating the nose
with your posterior implantlift, lifting uh the nasal

(15:46):
mucosa, being able to uh reachin there and have total control
and total feel and have a, youknow, a bear hug and a grip on
this entire patient anatomy, uhto where you know, on on, on
some cases, you've, you'vechosen the correct implant, you
just didn't have the correctpatient and that patient, just,

(16:09):
you know, systemically uh has alot of challenges, especially
with with their bone.
You know postmenopausal females, uh, you know whether they,
whether they have teeth or not.
I mean, I look back at over thepast year I have had I can
think of three patients rightnow off the top of my head that

(16:31):
had teeth.
We extracted, we did.
You know just our standard, allon X procedure and you know,
even placing the smallest drilland and compressing that bone,
going to the floor of the nose,uh, going to cortices, using all
of the principles, uh, that Iteach, I I had, I had no torque

(16:54):
on three implants.
I've, I've had three patientsthat have wound up with with a
quad, uh day of surgery that hadteeth due to, uh, just just you
know, uh, uh, their, their bone, and so uh, did they have
stability?

Dr. Robert Stanley (17:11):
though they had zero torque, did they have
stability?

Dr. Clark Damon (17:16):
Well, if they don't have any torque, I mean
that's, we're not, we're.

Dr. Soren Paape (17:19):
I'm not.

Dr. Clark Damon (17:19):
I don't load, I don't know.
I mean, you know if, if I don'tget again.
I practice predictability and soif we can't get 35 Newton
centimeters of torque withstability, I'm not going to load
it, and so we are going todeviate.
We're going to deviate everytime and we're going to go to
Zygos and because, because weare going to predictably load,

(17:43):
and so deviation in, in, in, in,my perspective is hugely
beneficial for that patient, um,and you know, hugely beneficial
for the, for the case success.
And you know, now they movealong, they get one surgery, one
procedure.
Yeah, it was, it was biggerthan what they intended, but
because we can, because we canshift on the fly, we're able to

(18:07):
treat that patient better andwe're able to optimize that
case's outcome by, by pivotinginteresting, so let me dr
stanley just I have a quickquestion off what you said, um,
do you load?

Dr. Soren Paape (18:24):
are you saying that you load your cases?
If they are, it doesn't matterthe torque necessarily, as long
as the implant is stable.
Is that what you were referringto there?

Dr. Robert Stanley (18:32):
Yeah, that's what I was going to go
into that right now, okay.

Dr. Soren Paape (18:36):
I'm curious yeah.

Dr. Robert Stanley (18:38):
The idea of a cutoff at 30, 32, or 35
newton centimeters for yourinsertion torque.
It's an interesting concept,okay so.
And then you put it togetherfor full arches.
A lot of times people talkabout the cumulative torque
value, right?
So you hear, if I don't have120 across the arch, I'm not
loading.
So let me just start off bysaying this I have loaded every

(19:00):
single upper and lower case I'veever done in my entire career.
I've never had a case where andthey're all guided and I've
never had a case where I didn'tload it.
And that includes all the bonequality.
And we're working on the samepatients, guys, right?
We're working on the same55-year-old patient with poor
quality, right, they're taking aminimum of three meds.
Some of them are, you know,pushing eight meds, right?

(19:22):
Those are the people we'reworking on.
They're not healthy.
The bone quality, bone volumes,it's not there, right?
So you say, well, how is thatpossible?
Well, it comes down to a coupleof different things.
Number one when you freehandand you are hitting two
different types of bone, you'rehitting spongy bone and you're
hitting compact bone.
When you're freehanding, youcan't hold trajectory.

(19:43):
No one can.
I don't care if you're ArnoldSchwarzenegger, you can't hold
trajectory, okay, so you can try, but you can't.
If you're placing a smallimplant and you go in and as
you're doing your osteotomy,it's wiggling in.
One time you're going this wayand the next time you're going a
little bit different, theosteotomy that you made is not
the right size, and so you getan implant that has no stability

(20:04):
, it's just floating.
It's a, it's a spinner or it'sfloating, okay.
So that's the first thing thatyou can have.
When you do guided and you'rein crappy bone, you're in the
same crappy bone.
The guide is going to constrainyour drill and it's going to
hold you on target for everysingle drill.
So the small drill, the mediumdrill, the bigger drill, then
the implant goes through theguide.
So the implant is beingconstrained too.
So if any of those things hithard compact bone up against

(20:27):
spongy bone they don't getknocked out of position.
Okay, they stay on target.
So that's the first thingyou're going to get.
You're going to get an increasein primary stability by using a
guide, because you're going toactually stay on target through
the entire osteotomy and dropeand the implant placement.
The second thing is that we'vebeen kind of misled with the

(20:47):
concept of torque.
Okay, so most dentists havetaught that torque equals
stability and torque does notequal stability.
And I'm going to prove it toyou in the next 30 seconds and
you're going to be shocked.
Okay, here we go, ready.
You're going into a patient onthe lower anterior.
They're 60 years old.
They've been wearing a denturesince they're 19.
You know that lower anteriorbone is going to be rock hard.

(21:09):
There's no spongy bone, it'sall D1 bone, really really hard
bone.
It's all compact.
You drill your osteotomy right.
You drill your entire osteotomyprotocol and because it's D1,
you're going to do somethingcalled tapping the bone.
You guys remember the taps.
They used to have taps in thekits in the old days.
So you're going to get your tapand what your tap is going to

(21:31):
do is it's going to cut a groovein that D1 bone.
You're going to cut the helicalspirals where the threads are
going to go.
So you go in and you tap it andthen you take the tap out, you
grab your implant and you putyour implant in the hole.
What would you think yourimplant torque would be in that
case?

Dr. Tyler Tolbert (21:47):
Zero.

Dr. Robert Stanley (21:48):
Yeah, Maybe three Newton centimeters.
What do you think yourstability is?
Your entire implant, 10.5millimeters long surrounded by
two millimeters of bone, compactbone all the way around it.

Dr. Tyler Tolbert (22:02):
Yeah, you had zero, so it's not going to move
.

Dr. Robert Stanley (22:06):
Exactly and you've got 100 stability.
You couldn't wiggle that thingout.
If you tried, if you got on itwith a, with an ash force effort
, you tried to pull it out, youcouldn't pull it out.
The only way you're going toget that out is put a reverse
torque on it and back it outalong the path of the threads.
So now you're now you'restarting to think wait a minute,
now maybe we've been misledwith this concept of torque,

(22:26):
because people are so fixated ontorque that they're changing
their protocol and they say,well, I'm not going to load this
case or I'm going to pivot inreal time and add extra implants
in other locations because mytorque was low.
Now I've I'm going to tell youright now, I have loaded every
single case and I don't.
I record the torque for for thetreatment notes, because it's

(22:46):
because people still think it'sthe standard of care to record
the torque right.
So we record it.
But I record 16 newtoncentimeters, 12 newton
centimeters occasionally onimplants around the horn.
I don't care, as long as I canscrew the multiunit on there
without it moving and I canattach it to the rigid long-term
provisional.
That implant will integrate andyou will have success.

(23:07):
So it's a complete paradigmshift and that's why I keep
saying cumulative torque valuewas a man-made construct.
It was made by us.
Where do you think 30 newtoncentimeters came from?
Why 30?
Isn't it coincidental that theBrandenburg implant, which was
made out of a soft grade one,titanium, had a limit out of it
at 30 newton centimeters becausethis the abutment screw

(23:27):
stripped.
So imagine you're an earlyimplantologist, the guys that
are actually now the old guysteaching at the universities,
and they kept saying be carefulabout torque, be careful about
torque, be careful about torque.
And what they were reallyworried about is stripping the
abutment in the implant.
They weren't talking about theimplant to bone, but over time
it's very easy to see how peoplewould mistake that and think

(23:48):
we're talking about torque tobone.

Dr. Clark Damon (23:51):
So the fact that we're using 30 for that is
arbitrary.
Yeah, but a lot of yourthoughts there, I think, apply
to mandible but it doesn't applyto the maxilla.
So for example Mollo's initialstudy, 245 patients mandible.
They had 98% success and youknow, obviously these were the

(24:16):
older implant styles.
When they went to the maxillathey had 30% failures.
They did not have a stabilityor a torque requirement and so
once they raised that to load it, then their success rates went
to 97%.
So yeah, I mean the maxilla isjust different bone.

Dr. Tyler Tolbert (24:44):
So I'm curious, dr Stanley, about
loading um, loading everythingright.
So even if you get less than,say, 20 newton centimeters of
torque, um, is that to say thatyou just maybe like hand tighten
a multi-unit onto?

Dr. Robert Stanley (24:57):
the implant .
All of my multi-units are handtightened.
There's no, there's no wrenchat the time of placement okay,
and then are you using?

Dr. Tyler Tolbert (25:06):
so you use the tap analogy, which that's
super interesting.
The torque versus stabilityargument is very interesting to
me.
So are you actually tapping thebone when you use a guide or
are you just using a traditionaldrill that's just going to make
that hole Like?
Is it tap prior to the implantgoing in to give you stability
in those D4, D3, D4 situations?

Dr. Robert Stanley (25:24):
No, no, I haven't used the tap at a long
time.
The tap analogy is just to tryto get you to think differently
about the concept of torque, theconcept of torque being torque
is stability, which it's not, soyou just have to keep that in
your mind.
Now, clearly, if you havehigher torque, what you're doing
is there's more compression ofthe bone from the implant going

(25:47):
in.
So the idea of undersizing anosteotomy meaning that you made
the hole smaller means that whenyou put the thread in, it's
going to compress the bone more.
The bone is going to throughNewton's laws, it's going to
push back onto the threads.
You're going to record that astorque, but really all it is is
the compression of thesurrounding bone.
But really all it is is thecompression of the surrounding

(26:08):
bone.
But the funny thing is is thatyou could go into a.
You could go into a socket andengage compact bone at the
apical aspect of the socket andengage just two threads and have
100 newton centimeters oftorque and the rest of the.
Say it's a 12 millimeter longimplant.
You could have 10 millimetersof that implant floating in the
socket with nothing around itand the bottom two threads could

(26:29):
be engaged in compact bone.
And I've done this and you willmeasure 800 newton centimeters
of torque.
Okay now do you think that thathas good stability?
And the answer is no, becauseany sort of lobe, even putting
the abutment screw on there, ifyou just wiggle it just a little
bit it's going to evulse itright out of that hole because
there's only two threadsengaging.
But if I go into D4, bone Anylateral movement.

(26:52):
Pardon.

Dr. Clark Damon (26:53):
Yeah, any lateral movement in that
scenario would.

Dr. Robert Stanley (26:57):
But imagine this I go into D4 bone
sub-antral, and I've got 10millimeters of D4 bone and I put
a 10-millimeter implant inthere and I get 15 centimeters
of torque.
And I put a 10 millimeterimplant in there and I get 15
centimeters of torque.
Do you think an off-axis loadwith my screwdriver, with my 050
driver, is going to evulse thatimplant?
And the answer is no.
But even though the bone islike styrofoam, even though the
bone is very soft, the fact thatyou have all 10 threads

(27:20):
engaging the bone is going to bemore stable at 15 centimeters
with 10 threads engaging thantwo threads giving you 100
newton centimeters of torque, doyou see?
So this is a this is a paradigmshift that is really important
for people to understand becauseit changes the way you think
about how you do implants.
So even if I'm going into ahealed site and it's d4 bone and

(27:41):
I have low, I have low torque,which is what you would expect I
don't care.
I don't care because I havestability.
It's not going to go anywhere.
And remember what we said theprostheses that we tie to the
top of this acts like bracing.
It holds everything elsetogether.
So the common term is crossarch stabilization right, that's

(28:04):
what people like to call itright.
Cross arch stabilization termis cross arch stabilization
right, that's what people liketo call it right.
Cross arch stabilization Aprosthesis is not a prosthesis
in engineering, it's aprosthesis in dentistry.
In engineering, it's bracing.
So if you put a post in theground with cement, you would
put some triangular two by foursaround it, called bracing, to
hold it while it sets up.
Okay, In the mouth when weplace the implants, we're going

(28:24):
to brace the implants with theprostheses.
We're going to hold all ofthose implants in place with the
teeth.
Dentistry.
We call it the prostheses.
Engineering, we call it bracing.
But they're doing two differentthings, aren't they?
So by tying it together, youget that cross arch
stabilization and you're goingto get great outcomes.
You're going to have justwonderful outcomes.
And I don't ever calculatecumulative torque value.

Dr. Clark Damon (28:48):
So I do agree, I don't calculate cumulative
torque value and you know itdoesn't apply in my hands
because we're getting 360 pluscumulative torque value for all
of our arches, of our arches.

(29:17):
But you know, while yourimplant, sub-anchorly at 15
newtons may be quote-unquotestable, and while I do agree
that we do have a bone splintwith all of the abutments and
everything glued together, justfrom a predictability sake, I do
think that that would work onoccasion, but it's just not
predictable.
And so, you know, in my officesI can't.

(29:39):
You know, we're doing 25, atleast for me, I'm doing 25 to 30
arches a month plus myassociate.
I don't have time to basicallyhave failures, and so that's
where I opt for a morepredictable approach.

Dr. Robert Stanley (30:00):
I'm going to have to reiterate something I
have never had a full arch casenot loaded, and I've only had
two cases where I've hadcatastrophic failures, where
they were both on smokers in mycareer.
So it's either I'm lying or I'mgifted by God, or the third
option is the method works.

(30:21):
So I would hope you guys wouldtake the first two as kind of
funny, but the last one is thetruth, and that is if you follow
the method, you get greatoutcomes.
I tell people, listen, if youturn the Toll House cookie bag
over and you follow theinstructions in the back, you're
going to get good cookies right.
And so if you're not followingthe instructions, you don't get

(30:42):
good cookies.
And so, with respect toimplants, if you follow the
method, you'll get greatoutcomes.
I don't have time for me.
I despise failures.
I'm a winner, and when I have afailure I lament it for days.
I mean, it drives me crazy anddrives my wife even more crazy.

Dr. Tyler Tolbert (31:01):
So so if I were to, if I were to paint a
portrait of the two opinionshere that are opposing, that
claim to be reaching the exactsame result, right?
So, on one hand, we have lessimplants, high cumulative torque
value even though, dr Damien, Iknow that you're not
necessarily saying that's whatit's all about but less implants
, high torque value is creatingstability with rigid fixation.
Alternatively, dr Stanley,fairly irrespective of the

(31:25):
torque, you have more implantsthat are rigidly fixated and
you're getting the same successrate.
Is that idea that, because youhave more implants are being
fixated to each other rigidly bythe, by the material itself, be
it the nanoceramic or thezirconia?
That's why the torque doesn'tmatter and that's why you're
able to sort of get away um withdoing the, the short implants

(31:45):
being placed actually because ofthat fixation, regardless of
the individual torque on theimplants.
I just want to make sure thatI'm characterizing your argument
correctly.

Dr. Robert Stanley (31:53):
So, first of all, I don't think that we
have much of a difference in thenumber of implants, because I
believe that the vast proponentsof your cases are going to have
six implants, and so am I.

Dr. Tyler Tolbert (32:03):
The number of implants are about the same Per
square area, right?
Okay, so the AP spread, sothere's a bigger AP spread.

Dr. Robert Stanley (32:13):
The advantage to the AP spread is to
have a terminal abutment andreduce your cantilevers, which
is a good mechanical principle,right?
It's one that we drive to.
If you do use a cantilever,just keep it short, right?
And then, if you do have acantilever, your beam has to be
thick enough, it has to be madeout of a strong material and the
implants that you're using haveto be strong.
So there's a lot of implantsout there that are grade four

(32:35):
implants.
They're 36% weaker thantitanium alloy.
So, if you see, you'refollowing the recipe now, right?
So I just gave you the TollHouse recipe here for success,
if right.
So I just gave you the, thetoll house recipe here for
success.
If you have a cantilever, itshould be short.
If you have a cantilever, yourprosthesis should be made out of
a strong material zirconia.
It should be tall 13 or moremillimeters in height, so FP3,

(32:58):
and then your implant can't be,it can't be a weak implant.
You have to use a strongimplant.
And then, and then the lastthing is your implants have to
be in the right location, sothey can't be just haphazardly
placed.
They have to be in the rightlocation to support the loads.
Okay.
If you put all that together,you have a recipe for success,
irrespective of cumulativetorque value, irrespective of
individual torque value.

(33:18):
And I believe the reason thatthey integrate is because
they're not moving.
So it's not about your initialtorque, that gives you stability
, that gives you a win.
It's about lack of movement,right?
If we have movement during thehealing, if the implant moves,
it won't integrate.
You'll get fibrous ingrowth,right?
We all agree on that.
I don't think there's anybodythat would argue go ahead and

(33:38):
wiggle it and see what happens.
It just doesn't heal.
But when you have implants andthey're in bone and they have
stability and you tie themtogether, they don't move.
There's no movement.
We don't let them chew on theseteeth right away, okay.
So just to be clear, myprotocol is they're on a liquid
diet for two months.
Okay, and that's rather extreme.

(33:59):
People will say two months,that seems like a long time.
Can't you go shorter?
Guys, if you've been practicingfor a while, you know that when
you ask someone not to chew onteeth for two months, you'd be
lucky if you get a month right.
You know how that.
You know we're going for twomonths of liquid diet.
But that's the goal and if Ican get to two months and if and
I've had three, three or fourpatients that actually did it
and we know how we know whenthey come back at two months

(34:22):
they've lost 15 pounds.
We don't have to ask them 15pounds, we don't have to ask
them, they just go.
God doc, I look great, I lost15 pounds.
Thanks a lot for the benefit.
You know, but that's how youknow that.
But most people, most people,are probably eating on it.
But the fact is is you'redriving for that initial
stability being no movement.
No movement is the key.
That's that's key.
So it's not torque, it's notcompression of the bone.

(34:43):
That's that necessary.
If you had the idea that youwere going to let them go out
and chew on those teeth rightaway, you would have problems
right, because now you're goingto need to have higher stability
based on engaging more compactbone rather than just bone in
general.
So then you're going to go tobicortical stabilization and

(35:04):
those kinds of things.

Dr. Soren Paape (35:06):
So for your guided cases.
Just I'm curious, are you doingstackable guides typically so
yeah, or are you doing yeah?

Dr. Robert Stanley (35:16):
So I worked really closely with NDX back in
the day, with the initial guysthat created NDX and created
those patents, so it was reallyinstrumental in giving them
feedback which helped to improvethe stackable solutions over
the years.
Then some of the guys from NDXspun off and started their own

(35:37):
businesses and what they did isthey made an approach that is
not stackable.
So S3, simple Smile Solutions,is one of the companies I work
with closely now.
It's not stackable, it's fullyguided but it's not stackable.
And one of the advantages ofthat with the new system is that
they looked at, they inventedthe original system.

(35:58):
So then they said, okay, whatcan we do better?
They can take a guided case andthey can actually provide it to
you as a clinician with likethree or four parts total, like
you could do the whole case withthree, three printed parts.
It's amazing how they havereally streamlined it.
So stackable solutions workgreat.
There's a lot of them out there.
There's a lot of copycats now Idon't know how they're getting

(36:18):
around the patents, becausethere are patents out there, but
they're getting around it.
Um, I think that probablybecause there's so many people
doing it, it's hard to just goafter them all but stackable
solutions work really well, buta lot of the copycats are
starting off with stackablesolutions that are about seven
years behind the technology.
In other words, the originalstackable solutions are being

(36:41):
copied versus the evolution ofthe stackable solutions that
have occurred over the last 10years, and the evolutions are
subtle.
Right, there are very littlesubtle details in terms of how
you actually implement astackable solution to improve
the workflow so you can do it inan hour, right, and the new
guys.
You've got to be careful whatI'm just saying to the people

(37:02):
that are listening.
If you're going to use astackable solution, I would
really encourage you to go andlook at somebody who's been
doing it for a while and not tosay that the new guys can't do
it, but I would encourage you tolook at the way the guys have
been doing it for a while.
They're doing it because theyhave had the feedback and
they've improved their systems.
So that's my suggestion on that.

(37:23):
Did you have a question aboutthe stackables?

Dr. Soren Paape (37:26):
that's my suggestion on that.
Did you have a question aboutthe stackables?
Yeah, and I it was more of likea you know, predictability
thing too.
Um, just a couple points that,um, I think are important to
address.
And I'm curious, like what, howyou manage it in your clinic?
Um, one of those things is, ifyou're doing, uh, I guess I
guess the the better point is Isee people that have issues with

(37:48):
guides, right, when we have asituation where maybe they plan
the case as a stackable case andthen they go in and they, you
know, let's say, the patient haslike 10 to 12 teeth and those
teeth are severely decayed butreally good root structure, and
they go in and they're takingthe teeth out and all of a
sudden they have a fracture,buckled plate on one of the, on

(38:09):
one of the, uh, the roots, um,and then, and that's a location
that your implant is planned andguided, and they, they have
this stackable case in theiroffice that they paid X amount
of dollars for and that's a keyposition for one of those
implants and, um, you know, itprobably wasn't, you know, could
have been the provider's fault,right, but maybe it was just a
really difficult tooth to comeout and that buckle plate

(38:31):
fractured off and it was in oneof those key positions of their
implant.
And it doesn't matter what thetorque value is or the stability
is of that implant, but it's ina very critical position that
now they can't use anymore.
It's no longer usable, what youknow.
What is your solution in thatsituation?
How do you manage that for anew guide?

(38:52):
Do you go replan the case,print another guide in your
office?
What does it look like in thatsituation?
Do you then go freehand in thatsituation?
And if you do go freehand inthat situation, if the guide is
stackable, you have the teethprefabricated.
I'm just curious how you'dmanage that in that particular
situation, and I feel likethat's a pretty common thing

(39:13):
that might happen.

Dr. Robert Stanley (39:14):
Yeah, that that is so.
So first of all, I'll say in mycourse I offer a one hour
lecture on how to take out teethwithout that happening.
Okay, so, so used to drive mecrazy.
You know, in in in school, theoral surgeons would come in and
said the best, the best, uh, thebest way to prevent, you know,
the best solution to thesecomplications is prevention.
Right, they used to say thatall the time.

(39:34):
You know, case selection andprevention is so important.
So, first, learning how to takeout teeth atraumatically so
you'll never have that happen,if you take my class or you
watch my video online on myYouTube channel, you will never
break a buccal bone ever againin the aesthetic zone, ever.
It just won't happen.
Okay, so it's just that simple.
People are shocked.
I got compliments this week andI was at Affordable's annual

(39:57):
meeting and I had people comingup that recognized me and they
were thanking me for theextraction video on how to take
out teeth atraumatically.

Dr. Clark Damon (40:04):
So if you haven't watched that, check it
out I on how to take out teethatraumatically.
So if you haven't watched that,check it out.

Dr. Robert Stanley (40:06):
I think you'll get a kick out of it, or
come to the class and you'll geteven more details.
But in the aesthetic zone youwill never fracture another
buckle plate ever In theposterior.
If you're taking out a molarand you're using some 88s and
you've got an old person andit's brittle, it's possible that
you could fracture some of that.
Okay.
So you do have this happen.
Okay, for the sake of theargument, because let's say, you
just did all right.

(40:27):
Well, we're doing an FP3.
So typically with FP3, we'regoing to do longevity leveling.
So longevity leveling is afteryou take out the teeth.
You're going to take off, thebone is going to be jagged,
right.
And we want a nice level bone.
And the reason we want a nicelevel bone is that when we build
the prosthesis, it's nice andsmooth, it's not concave and the

(40:47):
patient can keep it clean.
And you've got longevity rightBecause they can keep it clean
real easy.
So when we level that bone,what do we do with the bone?
Well, we don't throw it away.
We have autogenous bone, whichis the gold standard for
grafting, right.
So what am I going to do withit?
I'm going to put it in my bonemill, I'm going to grind it up
and I'm going to have it ready.
So at the time I'm done with theimplant placement.
I have a four wall defect, so Ihave the apical, the lingual,

(41:12):
the mesial and the distal areall intact, but the buckle's
missing.
I got stability on the implantso I'm going to graft around it.
I'm going to graft with what?
Autogenous bone?
You want to talk about havingan amazing outcome.
Graft with autogenous bone?
There's not.
You can't buy bottle boneanywhere.
That's as good as the humanbone.
It has all the growth factors,osseoinductive, osseoconductive

(41:33):
it's all in there.
You heard Craig Misch talksabout it all the time.
It's the gold standard forgrafting.
So I'm going to graft, I'mgoing to put a little, I'm going
to put a collagenF over thatand we get primary closure and
I'm going to close it up and I'mgoing to tie it with the rest
of the teeth, with the rest ofthe implant to the prosthesis
and I'm going to proceed.
It's a simple solution.
Now, how do I know I'm going toget, even without the buckle

(41:54):
bone, with a buckle bone blowout?
Did I need that for stability?
And the answer is no.
We rarely engage the bucklebone with an implant.

Dr. Soren Paape (42:02):
Really, yeah, I wasn't saying you need it for
stability.

Dr. Robert Stanley (42:04):
I was mainly concerned with Just so
that anyone was getting confused.
We don't need that buckle bone.
We're not trying to engage thatbuckle bone for stability and
that's how we would manage it.

Dr. Soren Paape (42:15):
On the subject of, and that makes sense, I do
the same thing Every single casethat I do.
When I'm removing my bone.
I typically use a ronger andthen use a bone mill, grind it
up and then use that for mygraft and all my sockets, and I
think it's a really greatoutcome and I was just curious
how you manage that.
The second question I have isin an office right, let's say

(42:39):
like an office, like Clark'soffice, where, and maybe your
office too I'm not sure how manyarches you're doing in your
office, but some of theseclinics that are doing 20 plus
arches a month do you think it'spredictable for those offices
to be paying for guides for alltheir cases and then also
managing the production,ensuring that whoever you're

(43:01):
hiring to make those guides isdoing it well and going through
all these cases with them?
Is that like a huge timeconstraint for you?
Have you found it to be prettyefficient at this point?
Where are you at?

Dr. Robert Stanley (43:12):
Yeah, so all the data acquisition is done
by my team members.
So I have a patient who agreesthat they're interested in doing
full arch or full mouth.
All the data acquisition isdone by my team members.
Then we sit down.
Once the data is sent to theplanning company, the planning
company plans it.
Then we do a go-to meeting andthat go-to meeting takes me
about five minutes now and mostof that is just chatting with my

(43:34):
friends on the other side.
But we're going to step througheach implant and we're going to
verify position and it meetsall of our guidelines for
placement right, and so thenwe're done.
Okay, and then the guide showsup in the mail a couple of weeks
later, whatever, depending onthe timeframe, and we schedule
the patient for surgery.
We go through the normalmedical clearance and we get

(43:58):
them in.
We do surgery and we do.
All of our cases are sedatedand we do it.
So I'm in and out for on averageI'm doing an arch in an hour,
on average a little, sometimes alittle bit more, sometimes a
little bit less, but on averageis about one hour per arch.
So imagine you're doing a highvolume clinic, so you start at
eight.
At 10 o'clock you're done withthe first case from 10 to 12,

(44:18):
you take a donut break at 12,you start your second case at
two, you're done.
You just did.
If it's $70,000, $60,000,$70,000 for full mouth, you just
did $120,000, $140,000 ofproduction in four hours.
If I'm a DSO or I'm ahigh-volume practice, you got my

(44:40):
attention.
That's a business model that Ican spend a few hundred dollars
on making a piece of plastic tohave this kind of production.
Now here's where people don'tunderstand.
I saw a patient today who drovedown from Virginia, so that's
about a three-hour drive fromwhere I live.
They drove down to see mebecause they had an all-on
six-placed screw retain thatthey never were comfortable with

(45:04):
and the doctor took theprostheses out, went to a
locator solution they weren'tcomfortable with that took out a
couple of the implants and hecame to me with three implants
and a denture.
He said can you help me?
Okay, so this is what we see inour practice all the time with
freehand, and it's not that justto be clear.
It's not that you can't dofreehand and be successful.

(45:25):
You can.
But if you really really wantto be predictable on each case,
each case, each and every case,and putting it into the hands of
, say, somebody who's not quiteas gifted, right.
So some people are gifted indentistry.
They have the hands ofMichelangelo, right, and others
aren't.
So implants are a great placeto live.

(45:47):
If you're doing guided, if youdon't have hands, if you have a
hard time doing crown preps,then implants are where you
should be, because you don'thave to have that kind of
dexterity.
My hand doesn't get in the wayof the video and so you go.
Well, isn't that dangerous?
No, yeah, I'm in a guide.
The guide's constrained in theposition of the of the drill and

(46:08):
the implant, so there's no riskto the patient.
But I do that so you guys cansee that in the clinical videos
how to do it.
So if I'm running a businessand you tell me not only can you
do it faster, but I'm going tohave less downstream
complications, less bad Googlereviews.
I never got my teeth, this guy'ssaying.
I never got my teeth to work, Ipaid for full arch and now I'm

(46:30):
down to a locator denture.
The guy was even talking abouttaking out their three remaining
implants and doing a denture.
He's going the wrong way.
Usually people start withdentures and work their way into
locators and then to full mouthto a screw retain.
So the poor guy was going thewrong way.
So I can build a business model.
That's just the opposite ofwhat most people tell you that
if you really want to beprofitable in full arch, then

(46:51):
you want to do fully guided andyou can bring these services in
house.
If you're big enough and you'redoing this, you just bring that
design service in house and nowyou're really driving your
costs down and you can get aprinter.
You can even have a designservice done in Egypt and have
the guide printed in your officethe next morning I was going to
ask you that, pardon, do you do?

Dr. Soren Paape (47:12):
are any of your guides?
I was going to ask you aboutthat.
Next, are any of your guidesprinted?
Are you?
Typically, it sounds like youwould get yours shipped in, but
have you tried?
It sounds like you haveprinters in your office.
Have you tried printing them inoffice?
Oh, yeah, have printers in youroffice.
Have you tried?

Dr. Robert Stanley (47:24):
printing them in office.
Does that work well for you?
Yeah, most of our full mouth,no, but we have done that before
.
But because full mouth isn'tnormally I need full mouth
tomorrow, right?
There's never really when theycome to you it's not like, oh,
I've got to do full mouthtomorrow, right?
There can be time pressure,like I'd like to be done by May,
you know, in a couple of monthsfor my family reunion.
That can happen.
But typically you don't havethat time pressure that you have

(47:46):
with a onesie-twosie implant,right.
So the onesie-twosie implant,somebody has an acute affection
and you want to do it immediate,or something like that.
Then you want to print it inthe office right away.
That makes a lot of sense.
But for full arch, typicallyyou can wait.
You can wait.
But if you really are pressedfor time and sometimes that
happens you just talk to thedesign service company and you
have them send you the print jobstraight to your printer and

(48:07):
print in your office.
And that's really anothersubject you guys can talk about
in the future on your podcast isthe globalization of dentistry.
And you can have listen, egyptis sleeping right now.
Right, and in a couple of hours, when we're off this podcast.
They're going to be waking upso they could be planning your

(48:29):
case while you're sleeping.
If you wake up, the case isplanned, so talk about
efficiencies.
You know like and it doesn'thave to be Egypt, I'm just
saying somewhere else on theplanet you can have a design
service and so what we're goingto see, in my opinion, is that
you're going to start to seedigital laboratories, a
consolidation of the digitaltechnology into some big

(48:49):
laboratories that do theplanning for everybody, and
they're going to be superefficient.
They're going to know exactlywhere the implants need to go.
Each doctor could have theirown set of preferences.
This is exactly where I'd likeall of my implants to go.
If they're a pterygoid, this iswhere it needs to go for
optimal solution, and they do itdigitally, and then you just

(49:10):
get on the computer and youverify it, you give it a thumbs
up or thumbs down and you'redone.

Dr. Tyler Tolbert (49:17):
Dr Stanley, one point that I did want to
kind of clarify.

Dr. Soren Paape (49:21):
I appreciate it .
Thank you, by the way.
I appreciate the insights.
Yeah, go ahead, Todd.

Dr. Tyler Tolbert (49:30):
Yeah, yeah, no problem.
A point that I did want toclarify in terms of the
stability of the implants, evenin softer bone right and I'm
trying not to conflate this withtorque, though it's hard, no,
it is hard, isn't it?
It is, it is.
So is the idea that, becauseyou're placing an implant along
a constrained path, that theimplant is inherently more
stable, irrespective of torque,because it's constrained?

(49:51):
You talk about and you have avideo on this too.
You know, when you're trying toplace it freehand, you're going
through heterogeneous boneright.
There's areas of D2, d3, d4.
Your drill is glancing around alittle bit and you're actually
widening the osteotomy a littlebit in different places.
Is your idea that, because it'sguided and it's constrained,
the implant is being tapped inand you have better bone implant

(50:13):
contact, that that is givingyou some stability as well?
Is that part of the argumenttoo?
That's correct.

Dr. Robert Stanley (50:20):
That's absolutely correct.
So what happens is that ifyou're freehanding it, you're
feeling the bone.
So freehand dentists will sayI'd like to feel the bone, I'd
like to feel that tactile feel.
And that makes sense becauseyou can feel it right, you can
feel I'm hitting hard bone here.
Oh, I know what that is.
You're visualizing the anatomyin your head as you're drilling.
You go oh, I know what I'm, Iknow what I'm touching up,
that's what.

(50:40):
So they're feeling it.
The problem is is that as thatdrill goes in, if it comes out a
little, if it goes in this wayand it comes out a little bit
like this, it now made a hole,that's it's wider than the pen,
right, it's wider than yourdrill.
So now you go in, yourosteotomy hole is bigger than
you wanted it to be.
It's not.
It's not as tight as you want.
So remember, the idea behindundersizing an osteotomy is to

(51:01):
make it smaller so that you havemore compression of the bones,
so you have better stability,okay, well, if you're going in
there freehand and every timeyou go in you go in a slightly
different angle, the final holeyou get is not going to be
designed.
What in engineering it's calledthe pitch diameter.
Okay, the engineers havedesigned that, the final, the
final drill to match yourimplant specifically.

(51:22):
And if you, if you waller thathole out that's what we say in
the South, here we say waller itout If you waller out that hole
, the hole is going to be bigger.
So you've done the opposite ofosteodensification right.
You've made the implant moreloose in the hole and that's
more inclined to give yousomething that has zero
stability, basically a spinneror zero stability.

Dr. Tyler Tolbert (51:44):
Right.
So the antithesis of that is,of course and, Damon, I'll let
you finish there, Sorry theantithesis of that idea is, you
know, the idea that we cananchor extra long implants and
only just a few millimetersabove right and that's really
the whole concept of a remoteanchorage implant is we're able
to still get stability just offof just a few millimeters of
density.

(52:04):
But sorry, Dr Damon, I didn'tmean to interject.

Dr. Clark Damon (52:07):
Well, I was going to say that you know
Waller, waller.
I don't even know how you saythat, waller.

Dr. Robert Stanley (52:12):
Waller.

Dr. Tyler Tolbert (52:13):
It's not spelled, it's only said.

Dr. Robert Stanley (52:16):
There's no spelling for it.

Dr. Clark Damon (52:20):
You know that is obviously not the goal of
freehand, right?
So saying that that happens infreehand is like well, that that
could happen into a moreinexperienced provider, but not
that doesn't happen, that's.
That's not a applicablestatement to all free hands so I

(52:43):
will argue.

Dr. Robert Stanley (52:44):
I will argue the contrary to that in
the following way compact boneis 10 times stiffer than spongy
bone.
So the modulus of elasticity ofcompact bone is 10 times
stiffer than spongy bone.
That's why we call it spongybone, right?
I don't like to use corticalbone or trabecular bone because
it modifies the water.
We're going to call it spongybone because it's soft like

(53:05):
sponge.
Okay, so now it's almost likethis little foam foam on my
microphone here.
It's spongy and compact bone isten times harder.
So the problem is is thatwhenever you hit compact bone
anywhere in the mouth, that thatdrill is going to kick off that
compact bone and slide intothat, into that soft spongy bone
, every single time, with orwithout experience.

(53:28):
Now, with experience, you canlearn to try to compensate for
that, right, you learn with time.
I'm feeling it.
So I have to push this way orthat way to try to get my
implant on the right location.
But it is a mechanicalconstraint, not a clinician,
it's not a hand skill.
You see, it's a physics issue.
You are going to.

(53:49):
If I asked you to place animplant and I wanted you to
drill, I wanted you to drillright on the edge of the bone.
So the bone is compact and onthe other side is air.
Well, pretty much anybody can'tdo that, right?
But I can do that with a guide.
Do you see?
One side's air.
So as you try to drill down,this side over here is bone and
this side over here is air.
As I try to drill down righthalfway on bone and halfway on

(54:13):
air, it's going to kick out intothe air every time, right?
Unless I have a guide on theside of the hard bone.
So that's the difference.
And so the difference is isthat instead of using air, so I
use air as an analogy, so peoplecan kind of understand.
But if one side is spongy andit's 10 times weaker than the
other side, it does the samething it gets knocked off that

(54:35):
hard bone.
Now you say, well, where's thehard bone?
Well, the obvious location forhard bone is where we all know
it to be, and that's on yourcortical plates, right?
Your buccal plate, your lingualplate.
We all know that.
But vast preponderance of thesepeople are not coming at us
with healthy teeth, right?
So a lot of times you havefocal sclerosis, don't you?
You have idiopathic sclerosisapical to your extraction socket
.
So I call those littlelandmines.

(54:56):
So you're going in, you'rethinking everything's great, you
get towards the bottom and allof a sudden you hit some of
these hard bones, the hard,dense, bony islands, and at the
very bottom there your implantgets out of position a little
bit and for onesies, twosies,the free-handed dentists go oh,
that's not exactly where Iwanted it, but I guess it's good
enough.
And then they leave it.
And then what happens?
It integrates, because thefirst rule of implantology is if

(55:18):
the implant's placed in thewrong position, it integrates we
all know that.
So then what happens is they puta Snoopy on there and then the
Snoopy is on there for about twoand a half years and then the
screw, the screw loosens, andwhen the screw loosens, the
abutment loosens and theabutment breaks the implant and
they go.
What happened?
Well, it's two and a half yearsand the most most dentists say
what, mrs Smith, what did youeat last night?

(55:41):
Cause, clearly it the blame onthe patient.
And this was a problem thatstarted the day the implant was
placed.
And we see it all the time, andwe have the benefit of the time
because these failures theyfail through a mechanical
mechanism called cyclic fatigue,right, fatigue failure.
Fatigue failure is if I have acoat hanger and I bend that coat

(56:01):
hanger back and forth reallyfast, it gets hot and then the
coat hanger breaks.
So if I have an implant and Ibend it back and forth enough
times, it will break, okay.
And so in our case, thattypically takes about two and a
half to three years before itstarts to break, Depending on
the implant you use.
If you use a weaker implant,it's going to break readily.
So the time difference is oursaving grace, because if these

(56:25):
things broke within the firstweek, we would all be changing
our methods.
They're not breaking in thefirst week.
So we have this time betweenthe placement and the failure
and we have what we callplausible deniability.
We go Mrs Smith, what did youhave for dinner, like what she
had for dinner the night before,caused the failure.
Right, that's not what causedthe failure.

(56:46):
It all goes back to the implantwas placed in the wrong
position and it was a weakimplant.

Dr. Clark Damon (56:52):
Well, I mean, I , I, I think that guides have a
place for single implants.
Uh, just not, not in, not infull arch, and so um, which
brings up a really good point.
You know, as, as you weretalking, I haven't done a single

(57:13):
implant in probably three years.
All I've been doing is is, is,is is fixed arches, which is
really, really nice.
You know, we, we have ways tonavigate, you know, kind of
around those.
You know, for me, I really lockmy wrist and you know, there
isn't, there is no wrist bending.
But you know, I, I don'tnecessarily think that
complications are due to lack ofguide versus freehand.

(57:36):
I just think that complicationsare due to a lack of ability to
execute, and so that's, that'sright.

Dr. Robert Stanley (57:45):
I wouldn.
I wouldn't disagree with you atall.
I would say 100%.
You're right.
It's all about the execution.
I have an analogy I sayeverybody goes to the Super Bowl
or the World Cup with the planto win.
Both teams plan to go to winright and we all know if we
watch sports at all we all knowthat typically the team that
executes their game plan winsthe game right.

(58:07):
It's usually the team thatdoesn't turn the ball over, that
executes their game planappropriately, that ends up
winning, and they don't have themistakes.
I look at the guide as simply atool to help me execute my game
plan.
That's how I look at it.

Dr. Tyler Tolbert (58:24):
Fair enough.
Fair enough, would you say.
Dr Stanley, you did kind oftalk about you know the role of
DSOs and the potential, you knowupsides, of using a guided
workflow.
It seemed that you wereinferring though you didn't say
explicitly that a lessexperienced clinician you know
it can at least take teeth outatraumatically would have more

(58:46):
success using this guidedworkflow because it's not as
technique sensitive.
Is that something that youwould agree with?

Dr. Robert Stanley (58:52):
A hundred percent.
The planning still has to bedone properly because, remember,
if you plan wrong, the guidewill give you the wrong answer.
The guide doesn't fix wrongplanning, so you do have to be
educated on the planning.
So let's say the planning isdone properly.
We'll make that an assumption.
The planning was done properly,then I I routinely have people

(59:13):
do over the shoulder for theirfirst implant cases, for their
first implant cases, full archcases over the shoulder, and
it's world-class outcomes.
And it's the first case I everdid and they and they have no,
no, no experience whatsoeverbecause it's just a tool.
I have another analogy here's.
Here's an analogy if you do anywoodworking and you and you
have to make repetitive cuts inthe in the garage, you make a

(59:34):
jig, right.
If you, if you do any, if youdo, uh, any clothing, you do any
fabric work like sewing orsomething, you make a pattern
and then from the pattern youmake the right.
So the guide in dentistry isjust like those two analogies.
The guide just simply helps youget the implant on the right
location.
That's why I don't get realfanatical about it.

(59:55):
It's just the tool.
And if you can accomplish itwithout the tool, great.
I just can't do it repetitively.
I could do it occasionally, Ijust can't do it on every case.
Then you ask the questionrepetitively I could do it
occasionally, I just can't do iton every case.
Then you ask the question whichpatient deserves your less than
best performance?
Is it going to be your mom?
Maybe your sister, yourdaughter?

(01:00:15):
Who in your practice are yougoing to do dentistry on and say
I just wasn't on my game thatday?
So I would prefer to say mygame is always A plus, and it's
always A plus because I usethese guides and the guides get
me in the position that weplanned to go, that's all.

Dr. Tyler Tolbert (01:00:31):
I understand, yeah Well.

Dr. Clark Damon (01:00:33):
Hey, uh, I got a question.
Um, you know, you know there'sbeen a lot of talk.
Uh, you know, stanley, I don'tknow how big into the full arch
game your practice is, but youknow what are you seeing on, you
know the East Coast, what areyou seeing kind of in your

(01:00:54):
market?
And I'll just kind of tell youwhat I am seeing.
What has been very interestingfor me is every year I've been
able to charge more for myarches and uh, you know, and
every year I'm doing more andmore arches, uh, even even being

(01:01:15):
in Dallas, and as, as, as asyou're well aware, you know,
dallas led the nation in fixedarches from probably about 2012
to uh, uh, 2018, 2019.
And then it went elsewhere intoChicago and DC and, uh, vegas,
um, but so, so, so, even incompetition, I've been able to

(01:01:36):
ramp up.
I hear and I see other fullarch, uh, heavy practices that
are really struggling, um, andyou know, I don't know, are you,
do you have any thoughts onthat?
Are you seeing somethingsimilar?
What?
What are your thoughts in themarket?

Dr. Robert Stanley (01:01:56):
So my my practice, I practice with my
wife, we and we have been a feefor service practice since the
early nineties and so we westill are fee for service.
So our fees are set based onmarket value.
And I do a lot of work with theDSOs and I do a lot of work

(01:02:17):
with recoveries of people thathave had full mouth attempted.
So I see them come to me, so wehave somewhat of a pulse on the
industry.
What I see is I see that thereare people that are trying to

(01:02:38):
acquire volume by reducing priceand in doing so, they don't
have the margins.
And since they don't have themargins, they have to figure out
a way to make it work.
And the way that they do thatis they cut out tools, right,
like a guide.
Like you're going to cut theguide out and they're going to
cut.
They're not going to do siximplants, they're going to do
four implants, right, they'regoing to.
They're going to cut, cut, cut.
They're going to.
They're going to use a cheaperimplant, and I don't mean an
inexpensive implant, I mean acheap implant, one that's made

(01:03:00):
poorly, because that's wherethey're going to.
They're going to save theirmoney.
You put all those thingstogether and they can charge
less, but they have a lot ofcomplications and failures in
the industry.
And so I see, in my, in my area,I see a lot of problems coming
to me from these big boxes.
You know the big box companiesthat do lots of full arches and
stuff.
I get a lot of them coming tome after it goes to Cass I got

(01:03:22):
this, got this doc, I got thisdone.
Can you, can you help me?
And it's after the fact and youguys know how hard it is because
you really want to help thesepeople and you go oh my gosh,
you know that the implants theyintegrated because they're in
the wrong spot or they're notdeep enough for and you're
trying to help them and they,they basically have an FP one
with a high smile line and thetransition showing and you're
going yeah, guys, I mean, howdid how did this even?

(01:03:45):
How did this even happen fromthe beginning?
You know, out the gate.
It's.
It's frustrating for those ofus who are that really care
about the patients and we'rereally trying to make a
difference and you want to helpthem when they come and the only
way to help them is kind ofhave to start the whole process
over again Many times.
It's really frustrating.