April 21, 2025 • 39 mins
Two masters of full-arch implant dentistry face off in a thought-provoking debate that challenges conventional wisdom about photogrammetry and implant placement strategies. What begins as a discussion about digital scanning accuracy evolves into a fascinating exploration of biomechanical principles that could fundamentally change how you approach your next full-arch case.
Dr. Stanley boldly asserts that photogrammetry isn't always necessary, revealing how his team consistently achieves impeccable results using only intraoral scanning. His engineer's mind breaks down the physics of prosthesis flexure, explaining why adding an extra implant can reduce mechanical stress by 300% when maintaining the same anterior-posterior spread. When he states, "After a couple of years of doing dual scans, my assistant stopped because they were always accurate every single time," you'll understand why his confidence in this approach is unwavering.
Dr. Damon counters with equally compelling arguments for a different philosophy. "When we really treat a titanium deficiency with a lot of titanium, we now incorporate lack of blood flow into those areas," he explains, advocating for strategic implant placement rather than simply adding more titanium. His preference for pterygoid implants creates wider support without crowding the anterior region, potentially providing better contingency options when complications arise.
Both experts share insider tips on achieving predictable outcomes, whether through guided surgery and perfect parallelism or mastery of freehand techniques with anatomical considerations. Their respectful debate reveals that successful implant dentistry isn't about dogmatically following a single approach but understanding the biomechanical and biological principles that govern long-term success.
Whether you're just beginning your implant journey or have placed thousands of implants, this exchange between two leading clinicians will give you valuable perspectives to enhance your practice. Listen now to determine which philosophy aligns with your clinical style and patient needs.
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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.
So we talk about current trendsin full arch and things that are
sort of emergent, and theybecome very popular and often
talked about, and one of thesesubjects is that of
(00:21):
photogrammetry.
So this is something that cameout, I mean, I think for me.
I mean I really haven't been inthe game that long, but
photogrammetry came after I gotout of school.
That's how recent it is, and Iwon't give away my age here, but
so I'm going to lead into ournext topic with photogrammetry.
So in today's world ofimmediate load surgery, the
(00:43):
surgical and restorativechallenges that are associated
with flourish practice havereally blended together, right,
and there's, of course, thishuge incentive to do things
faster and less appointments,and one of these modalities
that's come about is the adventof photogrammetry, so even the
most advanced intraoral scanners.
The issue that's being broughtup is that there's a difficulty
that comes from the inaccuracythat comes from when we're
(01:06):
trying to scan a cross arch,because there's a lot of
stitching.
You're taking a lot of photosacross the arch digitally, the
software is trying to stitchthese things together and you're
incorporating inaccuracy uponinaccuracy, right.
And so photogrammetry comesinto the landscape and it says,
okay, here's a separateperipheral You're going to
essentially.
You know this is a veryrudimentary version of it, but
(01:27):
we're going to take a picture ofwhere all the multi-units are
in space, in orientation inrelation to one another.
It's much truer than cross-archstitching right, and this has
become very popular and hasbecome a compulsory aspect of
what is now the full digitalworkflow.
So, dr Stanley, in your videowhy I Don't Need Photogrammetry
in my Practice, you stated thatyou were able to circumvent the
(01:47):
need for photogrammetry with twoprinciples that you talk about.
One is the intraoral scanningis more accurate when the
implants, or multis, areparallel, and full arch scans
are more accurate when theimplants are closer together.
In other words, by placing moreimplants with an axial
configuration and using guidedsurgery, you were able to
capture accurate records usingonly intraoral scanning, and I
(02:09):
do hope that I've characterizedthat accurately.
So, dr Stanley, could youplease expand on that topic and
talka little bit more about it?
I appreciate it.
Dr. Robert Stanley (02:17):
Yeah, I think you captured that really
well, Tyler.
So for a number of years we'vebeen doing digital workflow
right and so we're scanningtheir full arch cases and we're
having great success.
And I was shocked becausephotogrammetry came on pretty
strong.
People were like we're going tophotogrammetry, we're going to
photogrammetry, and you wouldhear these people say I can't
(02:40):
scan across the arch accuratelyand you would see the reports
that would confirm this.
They would have reports.
People would put studies up onthis on the podium and say
here's the study.
It doesn't work.
And I'm like this is reallyweird.
I don't understand, because inmy office it's working and and
and I was talking to my teammembers and we we just couldn't
figure it out Two summers ago,not this.
(03:01):
Yeah, it was two summers ago,not this last summer.
It was the summer before I wasat the COIS Symposium in Seattle
and Dr COIS has a digitalspecialist and she was on stage
and she was stepping through herannual update on digital
technology, digital workflow,and she had a series of
different presentations that shewas doing.
Each one it was like a 10 to 15minute presentation, but she
(03:23):
was working her way through itand one of the things she said
was it was really.
I was like, wow, that'sinteresting.
She says if your scan bodiesare parallel, if your scan
bodies are parallel, the scannerdoes a better job of picking
them up.
And I'm in the audience and I'mlike, well, that, as an
engineer, that doesn't make anysense whatsoever.
The scan body should be givingyou a coordinate system in space
(03:46):
and it should be telling youwhere that implant is.
That doesn't make any sense.
But okay, she said that.
And then a little bit later on,she said if the scan bodies are
closer together, so instead oftwo scan bodies further apart,
but if the scan bodies arecloser together, the scanner
does a better job.
Well, that one makes sense toeverybody, right?
Because when the scanner takesa picture, if the two implants
(04:10):
are in the picturesimultaneously, they are
referenced to each other, right?
That's why a lot of these scanbodies now they look like the
letter T, they screw on and theyhave like an arm to them.
Well, the idea is that if thatarm comes close to the next arm,
then you're you're bridging thegap, right?
So that makes a lot of sense.
So I'm sitting there going thisis interesting.
(04:30):
And I said I think I figured outwhy our system works.
So the first thing is myimplants are almost they're.
They're within a couple ofdegrees of each other in terms
of parallel after themulti-units are placed, because
it clearly, if we do it anangled implant, we use an angled
multi-unit, but because theywere guided that the the
(04:50):
parallelism of the of the scanbodies is very parallel.
So that was the first thing.
And then the second thing is,as an engineer, I I over
engineer systems, I don't underengineer systems.
So if they needed four implants, they get five.
If they needed five, they get,they get five.
If they needed five, they getsix.
That's how it goes.
We always add like one implant.
It's a simple method of doingit.
And so if you have, say, siximplants in the maxilla and
(05:17):
you've got a decent AP spread,the implants are close enough to
gather in their parallel.
You can scan it with a regularscanner.
You do not need photogrammetry.
And I I have had so many peoplehate on me on social media, on
youtube, like you can't do it,you can't do it.
I'm doing it every single day.
Every single day.
Every one of my arches foryears has been done this way.
They're like it can't work.
(05:37):
I'm like stop telling me itcan't work.
I'm doing it every single day.
So, once again, if you followthe recipe, you get great
results.
People, if you're not followingthis recipe, if you're doing a
different recipe, you're notgoing to get the same results.
So, if you think about it, ifyou're freehanding implants
because this is wherephotogrammetry really has its
advantage right, you'refreehanding implants you don't
(05:58):
really know where the implantsare going to go.
You're going to do ananatomical approach, you're
going to flap the ridge, you'regoing to look for the bone,
you're going to look for yourlandmarks, you're going to place
the implants at the time.
You're done with that.
If they're not, if they're notreally well parallel and and you
and you just do it all on four,because that's what you're just
doing they're not close enoughtogether, you can't scan it.
So that's where photogrammetrymakes a lot of sense.
(06:21):
You put some photogrammetry onthere and you can scan it and
then do an immediate provisional, either print it that day or
the next day.
Some people do it the next dayand that's a workflow that works
for a lot of people, right?
But the answer is is that ifyou do it the way that we're
talking about.
You can actually get a.
You can do digital scanningwith a regular scanner, with a
(06:43):
regular scan body, and you cando it all day long and I will
prove to you that it's accurate.
And you know how you prove toyou it's accurate.
People are like how do you know?
How do you know it's passive?
So it's real simple.
You just scan the arch twice.
Okay, scan it once, then tellthe computer I'm going to scan
it again.
You now have two identicalscans.
It's like taking twoimpressions.
(07:08):
In school we did two, two GUIimpressions, right, but in this
case we can superimpose thosetwo data sets inside the
software and then we can lookfor error and if the error is
less than 40 microns across theentire arch, you have a.
You have two perfectly accuratescans and there's no way you're
going to do that.
And and and just luck, get lucky.
You know they're to do that andjust get lucky.
They're the same.
And we used to do that on everysingle case.
And then one day I asked myassistant.
(07:33):
I said Sarah, can I see thedual scan today?
And she goes well, I stoppeddoing that.
And I said Sarah, why did youstop doing that?
And she says well, doc, I'lltell you they were always
accurate every single time.
So after a couple of years ofdoing just, it was a waste of my
time, so she just stopped doingit.
So that's our position onphotogrammetry.
If you are placing implants andthey're not close together,
you're going to need it.
If your implants are all wonky,you're going to need it.
(07:55):
Uh, but if you get enoughimplants close enough together
and they're rather relativelyparallel, it appears that you
don't need it.
Dr. Clark Damon (08:06):
Dr Damon, your rebuttal, I would just say that
placing your implants closetogether to avoid photogrammetry
would not be an indication.
So you know photogrammetry.
Dr. Robert Stanley (08:44):
So I would say this if you can get more
space between your implants,more AP spread limit for
implants anterior to the sinus.
Doing that recipe and thatprinciple, you're going to need
photogrammetry.
So just to be clear, we're notadding implants so that we can
avoid photogrammetry.
We're adding implants to reducerisk and so it's a risk
reduction protocol.
And the main reason is, if youjust do a simple comparison of
an all-on-four to an all-on-fivewith the same AP spread, you
(09:13):
reduce your flexure of yourprosthesis 300%.
You want to say it again?
I'm going to compare anall-on-four to an all-on-five
with the same AP spread.
Okay, so the same AP spread.
One has five implants and onehas four and the prostheses are
identical.
They have the same material,everything's identical.
The flexure of your prosthesesis 300 times higher with an
(09:35):
all-on-four than an all-on-five.
If you want to talk aboutlong-term stability, if you do
an all-on-four you are going tohave more fractures long-term
than you do with an all-on-five.
And if you go from all-on-fiveto all-on-six, you reduce it by
like 700%.
So we don't add implants toavoid photogrammetry.
(09:58):
That would be silly.
Everybody would know that wouldbe silly.
That's how you think.
You think about what's in thebest interest of the patient and
when people, when people say,doc, you did, you did six
implants and you did longevityleveling.
What are you going to do ifthey fail?
Well, I told you I had twocases that failed, right, and
they, they were smokers, theysmoked and they failed.
(10:18):
And they they had, they hadstopped smoking after they
failed, they had stopped smokingafter they failed.
Okay, they didn't stop whenthey were supposed to, but they
stopped afterwards, of course.
So we did it again.
Right Now you say, well, howcould you have done it again?
Well, if you look to first molarocclusion, you've got from
first molar to first molar, fromsix to six.
(10:41):
You have 12 teeth.
Could each and every one of usplace an implant in each one of
those locations?
Today, if you said, I'm goingto take out each tooth and place
an implant in each tooth, andthe answer is yes, we've seen
them on the internet.
We've seen the pictures of animplant in every tooth.
We've seen those pans circulateon the internet, so we know
that we can do that.
So if I place six implants,what's between those six
implants, bone?
(11:01):
So I could have six implantsfail and I could place six
implants the next day in thein-between space, because
there's in-between space.
Now you have to do it guidedbecause you can't fall into
those holes, but you could do itthat way.
So I have a differentperspective on crowding
so-called crowding the anteriorby adding these risk reduction
(11:22):
protocols.
I don't look at them as a riskfor a contingency plan in case
those implants fail, because Iknow there's plenty of bone
between it and if it's anall-in-five I have even more
space right.
So I'm not looking to create alot of space because that
creates mechanical complications.
As I said at the beginning ofthe podcast, we have three to
(11:42):
four times more complicationsmechanically than we do
biologically.
So I'm not worried about thatand I'm also trying to keep my
patients from smoking.
Dr. Clark Damon (11:52):
Yes, uh.
However, like if you have a,when you have a biologic uh
complication and you have filledthe anterior maxilla with six
implants, you now have a majoruh, a major uh problem on your
hand to fix.
I have never, I have not seen acase where if you have six
(12:16):
implants anterior to the sinus,that you have any bone to go
back in and place implants inbetween, have any bone to go
back in and place implants inbetween.
It's typically on those casesit's titanium heavy and you know
(12:38):
, often, oftentimes, there'sthere's reasons why we're
redoing these cases, as, as youmentioned, you know you, you see
a lack of executed cases.
I see them as well and thechallenge is you then
iatrogenically create them to bea quad or at least have two
zygomas.
Maybe you can get lucky and getthem into the lateral nasal
(12:59):
crest.
But that is a significantconcern that I see very often
and I am a very big proponent ofeliminating that approach of
having six implants entered tothe sinus for that reason in a
lack of execution or abiological failure.
(13:22):
So also, you know, we know thistoo, from you know, years ago,
when we would do, you know,eight implants, you know
oftentimes, you know, multipleimplants would wind up failing.
So when we really treat atitanium deficiency with a lot
of titanium, we now incorporatelack of blood flow into those
(13:46):
areas.
So by sticking with fourimplants anterior to the sinus,
we are going to have fallbackareas if we need them and we are
going to increase our bloodflow.
And where I will you know,encourage if you want to avoid,
(14:07):
or the way that I eliminatemechanical issues, is by doing
pterygoids on everybody.
So now we are moving thoseimplants away, we are building a
strong bridge on six implants.
We are just moving thesupporting structures to the
(14:30):
further edges of the mouth.
Dr. Tyler Tolbert (14:34):
So I have a few notes on this, dr Stanley.
So for one, do you have any?
So you talked about and it wasvery interesting, you talked
about all-in-four versusall-in-five versus all-in-six,
controlling for the AP spread,everything being the same there,
reducing the mechanical stress.
(14:55):
Is there a study thatcorrelates to that that I could
look up?
Dr. Robert Stanley (15:00):
It's actually I just calculated.
I did the beam analysis myself.
I haven't published it, but I'dbe happy to send the content
over to you so you can see it.
Dr. Tyler Tolbert (15:09):
Please, yeah, no, I'd like to look into that
as well, Because there aresimilar studies, like Dr Damon
mentioned, the Wilkerson studythat talks about reduction in
biomechanical stresses with theuse of pterigoids.
So it's interesting to see botharguments being supported, or
both Very different modalitiesreaching a similar conclusion
Well and then you know, tyler,also, you've got this DUYEC
(15:30):
study in 2000.
Dr. Clark Damon (15:33):
And you know they used in vivo stress and
strain gauge abutments and itwas 13 patients.
They found that there was nostatistical difference in stress
or strain in four, five or siximplant scenarios when it was in
(15:55):
an anterior approach, when theywere anterior to the sinus.
Dr. Tyler Tolbert (16:01):
Anterior to the sinus.
Okay.
Dr. Robert Stanley (16:04):
What stress were they measuring?
Stress delivered to the bone.
Dr. Clark Damon (16:14):
They were looking at tension moments.
Dr. Robert Stanley (16:18):
Tension moments.
I don't know what that term is.
So what happens is that if youapply an occlusal force to an
all-on-four or you apply thesame occlusal force to an
all-on-six, the force deliveredto the bone is the same.
So if their study was to set upto see if that wouldn't change,
(16:40):
the stress would change becauseyou'd have more area with six
implants than you would withfour.
So you'd have less stress tothe bone with the six.
But the flexure of the beam canbe done.
You don't.
You don't need to do this inthe mouth.
It gets complicated when you doit in the mouth.
You just do it on a piece ofpaper.
So if I have, if I have, twocolumns that are this far apart
and I have a beam running acrossit, you guys know, you guys
(17:04):
know just inherently that if Imove these columns in closer,
the beam will flex.
In between it will bend less.
Okay, correct.
So if you're trying to cross acreek and there's a narrow creek
or a wide creek, if you try tocross the narrow creek with a
2x12, you can walk across it.
But if the creek is really wideand you cross it with a 2x12
when you're in the middle, thatboard is sagging.
(17:25):
Okay.
So that's the idea behind yourimplants.
If your implants are closetogether, your zirconia
prosthesis will flex less.
If your implants are furtherapart, your zirconia will flex
more.
That's mechanical, you don't.
You don't really want to dothis as an in vivo study,
because all that does is thismuddy the water.
So that's some master's studenttrying to get their master's
(17:47):
degree in Perio or something, orPras.
It just muddies the waterbecause it's basically it's
basic engineering, right.
So we don't need to make itmore complicated than if the
beams.
If the beam length is longer,it flexes more.
You can just look it up onGoogle tonight and you'll just
see the beam length is how muchit flexes.
So if you do an all-in-four oryou do pterygoids and you spread
(18:08):
that beam out, you better makesure you're going with a tall
beam, because if you do thiswith an FP1, you guys that are
listening if you do this with acrown high space that's narrow
and you spread your implants outreally far, you're going to
have more failures.
You're going to have moremechanical failures mechanical
complications.
Dr. Clark Damon (18:30):
I mean, I'm not , I'm not advocating for that in
the FP1.
In fact I don't.
Dr. Robert Stanley (18:34):
I don't advocate for FP1s at all, but I
you know.
Dr. Clark Damon (18:38):
Elon.
Elon Musk, you know he talksabout engineers wind up
over-engineering things, right,things that don't even need to
be optimized or engineered.
And so I think, going afterbeam length, you know well, sure
, if you're in between, you knowyour zirconia is 20 millimeters
or more, then you needsomething there.
(18:59):
But I don't believe thatover-engineering a titanium
deficiency to reduce beam lengthis a wise thing to do, in my
opinion.
I don't think it's.
It doesn't need to be there.
Dr. Robert Stanley (19:17):
Because you're concerned that if there's
a failure, there's no recovery.
Dr. Clark Damon (19:20):
It's either.
It's either yeah, in a failure,or lack of execution.
You know, on on down the road,it's it's just.
I want to leave more bone, Iwant to leave more blood flow.
You just and, and and.
I want to be simpler, and if if.
I want to then optimize.
(19:42):
Right, you know so so.
So where do I optimize?
I optimize in, in, in theposterior, because I do think
when you have a implant bridgethat has six implants, I think
it is phenomenal.
I think we agree on that.
I think it's just kind of morewhere they need to be.
Dr. Soren Paape (20:22):
Dr Stanley, do you think that it's predictable
for most clinicians to getaccurate scans for these?
Let's say you have a bunch ofclinicians and they all are
doing guided cases right, sothey're getting that parallel
above and it sounds like that'show you're know you're getting a
lot of that parallelism is, thecases are guided, you're able
to.
You know exactly where themulti unit position is.
You know that they're going tobe parallel, so you get that
scan and it looks great, itlooks accurate.
Is that something that you knowyour team has just has a lot of
(20:44):
experience with?
Because I find a lot ofproviders, even if, let's say,
the scans are I mean the scanbodies, healing caps, whatever
you're scanning right areparallel In a bloody field.
I just see a lot of cliniciansjust struggling with that.
Is there anything that you doin particular that would be like
a good gold nugget forclinicians to make that scanning
(21:08):
easier for them to prevent,like these bloody fields or how
are?
How is your team doing it toget that 40 microns accuracy
over and over and over again?
Dr. Robert Stanley (21:18):
So most of the time we're doing, we're
doing this scan, so we're notdoing.
It's very rare for us to do thescan the day of the surgery,
you see, because I already havea prosthesis made, so I'm not
doing any sort of day of.
Very rarely do I do a day ofsurgery scan and then make the
(21:40):
prosthesis immediately.
I've done that a couple oftimes for the sole purposes of
measuring throughput, how fast Icould do it, so I can do a full
arch in an hour, like we'vesaid a couple of times tonight.
But when I did it where Ididn't have a prefabricated
provisional, I wanted to see howfast I could do it.
So what I did is I placed siximplants and then I scanned them
(22:02):
before I sutured.
I placed six implants and thenI scanned them before I sutured
the bone, and the reason I didthat is that I had the substance
right.
So we blotted it when wescanned it and everything, and
then we delivered it.
The whole process took threehours, so still rather quick
(22:22):
compared to some people'sconversions that are taking four
to six hours.
Rather quick compared to somepeople's conversions that are
taken four to six hours.
Rather quick compared to somepeople's conversions that are
taken four to six hours.
They take the implants, theyscan and then they build their
provisional.
Dr. Soren Paape (22:33):
And that makes a lot of sense.
Dr. Robert Stanley (22:38):
But that took me three hours and I can do
it routinely with one hour witha prefabricated provisional.
So I don't do it very oftenwith one hour with a
prefabricated provisional.
Dr. Soren Paape (22:48):
So I don't do it very often yeah, I understand
that yeah, I wanted to clarifythat, just to make sure, because
, um, doing no photogrammetry inan office I feel like might not
be very predictable if you'redesigning same day and doing
same day fabrication.
I could see that being maybesomething that people are
(23:12):
misconstrued and maybe whyyou're getting some of that hate
.
Dr. Robert Stanley (23:22):
You're absolutely right.
That's a great sorry.
That's a great clarification,because we just don't do.
I think we've only done ittwice.
I think we're going to doanother one coming up in the
near future because I'm alwaysexperimenting, as we said.
I'm always trying differentthings.
So I think I'm going to doanother one coming up again.
But it was successful.
It's just that you know, if youdo these cases, everybody will
agree Sometimes you havebleeders right and sometimes you
(23:43):
don't.
And sometimes you don't evenyou don't even know why.
You can't even really predictit.
You're like, is this person onaspirin?
And they go no, they're notaspirin, they're not on any.
They're not any any Plavix.
You're trying to figure out whythey're bleeding like a stuck
pig Right.
And uh, on those cases, it'sgoing to be hard to get a scan
right.
It will be hard, so that'swhere photogrammetry would make
a lot of sense.
Dr. Tyler Tolbert (24:05):
So I have a couple of things.
Um for one.
Would you say then that, um,because it all matters, you know
how close the scan bodies areto one another.
It doesn't necessarily meanthat the implants themselves
have to be close to one another,right?
So now what we're seeing arescan bodies you mentioned, like
the T-shaped scan bodies.
Now we have a Shining EliteTrue Abutment has one where, no
(24:27):
matter where the implants are,they've got these arms that all
point concentrically and bringall these implants together and
you can sort of now remotelyrelate the implants together
using just a scan body.
And that's a big thing that'sgoing on right now, and people
are trying to pivot away fromphotogrammetry or at least
provide a product that's just ina box, everything's there in a
box.
So that's just.
That's less of a question, moreof just a note, really.
(24:49):
And then, second, the onlything I would challenge just
slightly is when it comes to theparallelism of the multi-unit
trajectory, right, like howparallel all of our multi-units
are.
I would only say that I don'tknow that that's always ideal,
especially in the maxilla,namely in the atrophic maxilla,
(25:12):
and also in a case where we arehoping to do, potentially, class
correction.
So a lot of times, you know,between myself and Soren and
Caleb, we had a little bit of acontest on who could get who
could freehand the most parallelmulti-units on the mandible, to
get down to single digitdeviation.
This cool thing the micromapperdoes you, take a picture of it,
it tells you what yourdeviation is, and we all got
(25:33):
there eventually.
But on the maxilla that that'snot something that I I'm ever
really shooting for.
Right On the, in the uhanterior, I'm almost invariably
tilting, uh my implantsanteriorly to buck out a little
bit to compensate for theresorption of a maxilla,
especially one that's adentureless right.
So then, how you know, if, if Iwere to try and get everything
(25:53):
perfectly parallel and stillhave access holes that are in
the cingulum, the cinguli of theanterior teeth and the, you
know, within the clusal table ofthe posterior teeth, I don't
think I could actually do thatin a parallel way.
I actually want all of mymulti-use to be flaring out
slightly buckly.
So if I tried everything Icould to get everything parallel
(26:14):
, I think it would actually havevery palatable access holes
across the maxilla.
Dr. Robert Stanley (26:20):
I think that's a really good point.
Tyler, I would say that I dothe exact same thing.
So all of my screw holes arecoming out the cingulum and I'm
always driving my digitalplanners to make sure that
they're in the cingulum.
They want to place them 3, four, five millimeters lingual to
the singular and if you've evergotten one of those provisionals
back, you know that's justawful for the patient.
(26:41):
They have this massive wad ofplastic on the roof of the mouth
and they can't talk and they'relistening.
It's terrible.
So I'm always driving them todo these cases the same way.
They would do a single implant.
So that access hole has to beout the cingulum.
So that's where they're at.
So there is going to bedivergence, but they are still
more parallel than they're not,if that makes sense.
(27:04):
Okay, the divergence betweenthis one and this one might be
quite a bit, but this one tothis one, this one.
Dr. Tyler Tolbert (27:12):
Oh, the adjacents are something.
Yeah, as you're stepping around.
Dr. Robert Stanley (27:14):
they're not diverging too much around the
horn, right, I see the nuance.
Okay, yeah.
Dr. Tyler Tolbert (27:19):
Okay yeah, that's fair.
Okay yeah, very good.
Dr. Soren Paape (27:27):
I was just going to say, you know, before
we start wrapping things up,this did go a lot longer than we
had expected.
And I loved the points for bothof you guys.
They were.
They were excellent and I think.
I think it really comes down tolike every provider has their
own set of skills that they wantto be proficient in, right,
like some, some providers.
(27:48):
They're not going to want tohave to get a guide for every
single case and in thatsituation, like free hands,
wonderful.
But if you want another tool tohelp you know, make the like
you were saying, some of theseproviders that you have seen do
arches for the first time rightare having excellent outcomes.
You know guides can be, can beexcellent, but I, either way, I
(28:11):
would like you guys both to geta chance to talk about you know,
your courses that you have and,if they want to go down that
Avenue, I'd love for you guys tohave an opportunity to to let
our audience know where theymight get some more information
from you.
Sure.
Dr. Clark Damon (28:28):
Awesome.
Well, I would say thisphotogrammetry is Achilles heel.
Is the fact that it has to berelated to an intraoral scanner
right?
So, like you know, when yourelate your PIC to white healing
caps or ICAM scan bodies, youknow, or Micron mapper, that's
(28:50):
kind of the Achilles heel, andwe've all seen cases where when
you go to align your implantposition to your jaw scan,
there's there's some variabilitythere.
So that's that's.
That is definitely the Achillesheel Now granted it is, it is
going to fit perfectly.
(29:10):
But that is when you're going toget these occlusal issues, and
you know, then you kind of godown this whole occlusal rabbit
hole of dealing with realigningjaw data and jaw scans.
So we are, we don't have theperfect, we don't have the
perfect restorative material, wedon't have the perfect
(29:33):
photogrammetry and we don't havethe perfect scanner.
So you know, I assumeeventually we will, but we'll
just have to stay tuned.
But right now it's, you know,using all of these different
things that are dealing with thelimitations that the technology
(29:53):
that we have is able to provideus.
So, so, with that, let's see,I've I've got the Texas Implant
Institute.
We do basically two courses.
We do all on X standard andit's hands-on models, and day
two we go into cadavers and sowe skyrocket your surgical
(30:20):
experience.
I mean, I've even had doctorsthat have done a thousand arches
.
Come take my course and they'relike man, I learned so much and
I was like, really, they'relike, yeah, you taught me to
hold the retractor the right way.
You taught me to, you know, dothis with the periosteal
elevator.
So it's just, you know,everybody has like different
(30:48):
little bitty pearls that theyjust kind of pick up and we go
over.
You know how to sell the cases,how to talk to the patients and
you know the whole history,treatment, planning, all of that
, and then we have our All on Xadvanced course for atrophic
maxillas, which is zygomas,pterygoids, nasal crest, and
it's really the same formatdidactic lecture, hands-on
(31:11):
models, and then day two, weroll into cadavers.
Dr. Soren Paape (31:17):
I'll advocate as well.
We I think tyler and I bothprobably had done over 500
arches.
We went to your first courseand I and I took away a lot of
takeaways that were great thatwere very, very helpful.
Awesome, awesome yeah so we'vebeen.
Dr. Clark Damon (31:29):
We've been doing it since 2018 and uh,
we're, I guess, in seventh yearit's.
It's a little odd this year, um, you know, my, my co-director,
rick klein, passed away, uh,right after one of our courses,
and so we're we're still tryingto figure out you know who, who
we're going to do the courseswith.
Right now I'm a little solo,but uh, still still get just
(31:53):
great education.
I, I, I primarily did all thelecturing, um, so that that
really uh doesn't change at all.
Um, so we are uh located indallas and you know we always
have a good, a good happy hourand a good program.
And we like to, you know, eat,drink and be merry after good
state too, yeah, yeah, yeah,come texas, but, but, but, but,
but, but really, you know we eat, drink and be merry after Good
(32:14):
state too.
Yeah, yeah, come to Texas, but,but, but, but, but.
But, really, you know, we alsooffer the mentoring program and
you know you guys are in our uh,uh, what is that?
The WhatsApp group, and uh, youknow it's, it's uh, you guys
get access to me, which is whichis a good or a bad thing,
because I'm going to call youout.
(32:36):
I can vouch for that.
I'm going to hold you guysaccountable because, at the end
of the day, I want excellentresults for your patients.
This is a lifelong learningthing.
There is no one course you needto take.
Maybe after this, I'll startsending people that need some
help over to take Um, you know,maybe after this I'll I'll start
(32:56):
sending you know people thatthat need some help over to Dr
Stanley's course.
Dr. Tyler Tolbert (33:03):
That's good.
Dr. Clark Damon (33:05):
Say, say.
Hey, you know what I, I think,uh, I think freehand is not for
you.
Dr. Tyler Tolbert (33:11):
That's a good segue into a Dr Stanley, if you
wouldn't mind talking aboutyour courses.
Dr. Robert Stanley (33:16):
Thanks guys, I really appreciate the time.
As you guys probably note, I'ma bit of a talker.
But I'm not very good at sellingmyself.
I can talk about implants allday long, but I usually turn
that over to my team, mydirector of the Institute,
stanley Institute.
We're based just outside ofRaleigh, north Carolina, about
eight minutes from the airport,so if you fly in it's real
(33:37):
convenient.
We have basically StanleyInstitute, for Comprehensive
Dentistry is.
The two primary educators aremyself and my wife.
My wife teaches the business ofdentistry.
So if you want to learn, so Ilike to say there's offense and
there's defense in a business.
Right, offense is how manycases can I do, how much money
do I make?
Defense is how much money do Ikeep?
(33:59):
Okay, what my wife teaches youis the defense, which almost no
one talks about.
Right, we're always like well,if I add this skill set to my
practice, I can generate morerevenue for my team and for my
family and get closer to mygoals.
What we don't talk about is howcan we reduce our tax burden,
how can we set up ourcorporations in a way that are
beneficial for us in the longrun?
(34:20):
That's what she talks about.
So she talks about the businessindustry.
I talk about pretty muchimplants.
So we have a onesie-twosiecourse.
It's three courses, but thefirst course is online, so the
first is called Essentials 1.
1 and that's the planningcourse.
That's where you learn how toplan.
So that's all online.
And then Essentials 2 and 3 arealso online.
(34:42):
So if you're a remote watcher,you can have a lot of people
that follow me overseas so theycan take the course remotely.
So Essentials 2 and 3 aretaught together now as a
three-day weekend.
Okay, it's a three-day weekend.
Okay, it's a three-day weekend,and I encourage people to come
to the real course versus thevirtual one, because you get to
(35:03):
do the hands-on parts.
Okay, so we have all thesehands-on experiments and there's
live surgery as well.
So that's how we do the onesie,twosies For the full arch
course.
It's a three-day course thatyou're all on X course and it
covers everything.
It's a three-day course thatyou're all on X course and it
covers everything.
It covers from planning, itcovers the surgery, it covers
the digital workflow all the waythrough the prosthetics.
And the main goal with ourinstitute is rather simple Our
(35:26):
goal is to reduce risk andimprove outcomes for patients,
and we do that predominantlythrough a pragmatic approach to
implantology.
So we look at some basic thingsthat people really don't
consider very often and we'vetalked about many of those
tonight and hopefully that willgive you guys some food for
thought in terms of ways toreduce risk through mechanical,
basic mechanical principles.
And we eliminate things liketorque.
(35:47):
We talk about torque in a waywhere you start to understand
the limitations of that metricversus what most dentists do,
because we've been trained acertain way is we kind of stick
to these old things and that canlead you down a path that it
can lead you down a path whereyou're doing things that aren't
in the best interest of thepatient.
So that's kind of it.
(36:09):
And we have a failure to ananti-failure to launch program,
which was rather negative, sothen we called it a success
program.
So the anti-failure to launchprogram, which was rather
negative, so then we called it asuccess program.
So the anti-failure to launchprogram is that we were told
that a lot of doctors come tocourses and after they take a
course they get really excited,but on Monday they're they're
back at the, they're back at thegrind, right, and they don't
have time to actually implementeverything that they, that they
learned.
So we have a success program tokind of walk you through your
(36:31):
first few cases and we mentoryou and hold your hand through
that whole process.
So people really like that andit really helps them get going,
because once you get going, it'spretty powerful.
Dr. Tyler Tolbert (36:42):
Cool, cool.
Well, listen, guys, I, you know, there was definitely a world
where I saw, you know, bringingon the two of you guys who are
very intelligent, veryexperienced and have a lot of
success in your own practice,albeit with almost polar
opposite modalities, and, youknow, we railed off a few
questions and you guys went backand forth and you both just
stormed off and said, screw this, this is dumb.
(37:03):
So I really appreciate that wedidn't let the egos take over
here at all and we actually hada really lively and educational
debate.
I mean, there were a lot oftopics that I think are going to
be, you know, talked about byour audience that listens to
this, and I think there were alot of challenges, you know, for
both camps and looking acrossthe aisle and saying, well,
maybe there are some merits atthis point, and vice versa.
(37:26):
So I really just want to thankyou both for coming on, bringing
on your expertise, bringing onyour experience and, you know,
just be mature about this and,you know, living out the
Socratic debate and just talkingabout things in a way that you
know is really just meant tobenefit those that are trying to
(37:46):
do more full arch and trying tobenefit patients and trying to
do better for people.
And you know, personally, Ilearned a lot here.
I know Dr Soren did as well andI just, you know, can't thank
you guys enough for your time.
We're running into about twoand a half hours.
There's actually a record forour podcast.
We never recorded that long.
Well, maybe we have with DrDamon, but we did it in parts.
So thank you guys so much forsparing your time and coming on.
(38:08):
I really can't thank you enough.
Dr. Robert Stanley (38:10):
Awesome, that's my pleasure thanks guys,
I really appreciated it awesomeyou guys take care okay, bye.
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.
So we talk about current trendsin full arch and things that are
sort of emergent, and theybecome very popular and often
talked about, and one of thesesubjects is that of
(00:21):
photogrammetry.
So this is something that cameout, I mean, I think for me.
I mean I really haven't been inthe game that long, but
photogrammetry came after I gotout of school.
That's how recent it is, and Iwon't give away my age here, but
so I'm going to lead into ournext topic with photogrammetry.
So in today's world ofimmediate load surgery, the
(00:43):
surgical and restorativechallenges that are associated
with flourish practice havereally blended together, right,
and there's, of course, thishuge incentive to do things
faster and less appointments,and one of these modalities
that's come about is the adventof photogrammetry, so even the
most advanced intraoral scanners.
The issue that's being broughtup is that there's a difficulty
that comes from the inaccuracythat comes from when we're
(01:06):
trying to scan a cross arch,because there's a lot of
stitching.
You're taking a lot of photosacross the arch digitally, the
software is trying to stitchthese things together and you're
incorporating inaccuracy uponinaccuracy, right.
And so photogrammetry comesinto the landscape and it says,
okay, here's a separateperipheral You're going to
essentially.
You know this is a veryrudimentary version of it, but
(01:27):
we're going to take a picture ofwhere all the multi-units are
in space, in orientation inrelation to one another.
It's much truer than cross-archstitching right, and this has
become very popular and hasbecome a compulsory aspect of
what is now the full digitalworkflow.
So, dr Stanley, in your videowhy I Don't Need Photogrammetry
in my Practice, you stated thatyou were able to circumvent the
(01:47):
need for photogrammetry with twoprinciples that you talk about.
One is the intraoral scanningis more accurate when the
implants, or multis, areparallel, and full arch scans
are more accurate when theimplants are closer together.
In other words, by placing moreimplants with an axial
configuration and using guidedsurgery, you were able to
capture accurate records usingonly intraoral scanning, and I
(02:09):
do hope that I've characterizedthat accurately.
So, dr Stanley, could youplease expand on that topic and
talka little bit more about it?
I appreciate it.
Dr. Robert Stanley (02:17):
Yeah, I think you captured that really
well, Tyler.
So for a number of years we'vebeen doing digital workflow
right and so we're scanningtheir full arch cases and we're
having great success.
And I was shocked becausephotogrammetry came on pretty
strong.
People were like we're going tophotogrammetry, we're going to
photogrammetry, and you wouldhear these people say I can't
(02:40):
scan across the arch accuratelyand you would see the reports
that would confirm this.
They would have reports.
People would put studies up onthis on the podium and say
here's the study.
It doesn't work.
And I'm like this is reallyweird.
I don't understand, because inmy office it's working and and
and I was talking to my teammembers and we we just couldn't
figure it out Two summers ago,not this.
(03:01):
Yeah, it was two summers ago,not this last summer.
It was the summer before I wasat the COIS Symposium in Seattle
and Dr COIS has a digitalspecialist and she was on stage
and she was stepping through herannual update on digital
technology, digital workflow,and she had a series of
different presentations that shewas doing.
Each one it was like a 10 to 15minute presentation, but she
(03:23):
was working her way through itand one of the things she said
was it was really.
I was like, wow, that'sinteresting.
She says if your scan bodiesare parallel, if your scan
bodies are parallel, the scannerdoes a better job of picking
them up.
And I'm in the audience and I'mlike, well, that, as an
engineer, that doesn't make anysense whatsoever.
The scan body should be givingyou a coordinate system in space
(03:46):
and it should be telling youwhere that implant is.
That doesn't make any sense.
But okay, she said that.
And then a little bit later on,she said if the scan bodies are
closer together, so instead oftwo scan bodies further apart,
but if the scan bodies arecloser together, the scanner
does a better job.
Well, that one makes sense toeverybody, right?
Because when the scanner takesa picture, if the two implants
(04:10):
are in the picturesimultaneously, they are
referenced to each other, right?
That's why a lot of these scanbodies now they look like the
letter T, they screw on and theyhave like an arm to them.
Well, the idea is that if thatarm comes close to the next arm,
then you're you're bridging thegap, right?
So that makes a lot of sense.
So I'm sitting there going thisis interesting.
(04:30):
And I said I think I figured outwhy our system works.
So the first thing is myimplants are almost they're.
They're within a couple ofdegrees of each other in terms
of parallel after themulti-units are placed, because
it clearly, if we do it anangled implant, we use an angled
multi-unit, but because theywere guided that the the
(04:50):
parallelism of the of the scanbodies is very parallel.
So that was the first thing.
And then the second thing is,as an engineer, I I over
engineer systems, I don't underengineer systems.
So if they needed four implants, they get five.
If they needed five, they get,they get five.
If they needed five, they getsix.
That's how it goes.
We always add like one implant.
It's a simple method of doingit.
And so if you have, say, siximplants in the maxilla and
(05:17):
you've got a decent AP spread,the implants are close enough to
gather in their parallel.
You can scan it with a regularscanner.
You do not need photogrammetry.
And I I have had so many peoplehate on me on social media, on
youtube, like you can't do it,you can't do it.
I'm doing it every single day.
Every single day.
Every one of my arches foryears has been done this way.
They're like it can't work.
(05:37):
I'm like stop telling me itcan't work.
I'm doing it every single day.
So, once again, if you followthe recipe, you get great
results.
People, if you're not followingthis recipe, if you're doing a
different recipe, you're notgoing to get the same results.
So, if you think about it, ifyou're freehanding implants
because this is wherephotogrammetry really has its
advantage right, you'refreehanding implants you don't
(05:58):
really know where the implantsare going to go.
You're going to do ananatomical approach, you're
going to flap the ridge, you'regoing to look for the bone,
you're going to look for yourlandmarks, you're going to place
the implants at the time.
You're done with that.
If they're not, if they're notreally well parallel and and you
and you just do it all on four,because that's what you're just
doing they're not close enoughtogether, you can't scan it.
So that's where photogrammetrymakes a lot of sense.
(06:21):
You put some photogrammetry onthere and you can scan it and
then do an immediate provisional, either print it that day or
the next day.
Some people do it the next dayand that's a workflow that works
for a lot of people, right?
But the answer is is that ifyou do it the way that we're
talking about.
You can actually get a.
You can do digital scanningwith a regular scanner, with a
(06:43):
regular scan body, and you cando it all day long and I will
prove to you that it's accurate.
And you know how you prove toyou it's accurate.
People are like how do you know?
How do you know it's passive?
So it's real simple.
You just scan the arch twice.
Okay, scan it once, then tellthe computer I'm going to scan
it again.
You now have two identicalscans.
It's like taking twoimpressions.
(07:08):
In school we did two, two GUIimpressions, right, but in this
case we can superimpose thosetwo data sets inside the
software and then we can lookfor error and if the error is
less than 40 microns across theentire arch, you have a.
You have two perfectly accuratescans and there's no way you're
going to do that.
And and and just luck, get lucky.
You know they're to do that andjust get lucky.
They're the same.
And we used to do that on everysingle case.
And then one day I asked myassistant.
(07:33):
I said Sarah, can I see thedual scan today?
And she goes well, I stoppeddoing that.
And I said Sarah, why did youstop doing that?
And she says well, doc, I'lltell you they were always
accurate every single time.
So after a couple of years ofdoing just, it was a waste of my
time, so she just stopped doingit.
So that's our position onphotogrammetry.
If you are placing implants andthey're not close together,
you're going to need it.
If your implants are all wonky,you're going to need it.
(07:55):
Uh, but if you get enoughimplants close enough together
and they're rather relativelyparallel, it appears that you
don't need it.
Dr. Clark Damon (08:06):
Dr Damon, your rebuttal, I would just say that
placing your implants closetogether to avoid photogrammetry
would not be an indication.
So you know photogrammetry.
Dr. Robert Stanley (08:44):
So I would say this if you can get more
space between your implants,more AP spread limit for
implants anterior to the sinus.
Doing that recipe and thatprinciple, you're going to need
photogrammetry.
So just to be clear, we're notadding implants so that we can
avoid photogrammetry.
We're adding implants to reducerisk and so it's a risk
reduction protocol.
And the main reason is, if youjust do a simple comparison of
an all-on-four to an all-on-fivewith the same AP spread, you
(09:13):
reduce your flexure of yourprosthesis 300%.
You want to say it again?
I'm going to compare anall-on-four to an all-on-five
with the same AP spread.
Okay, so the same AP spread.
One has five implants and onehas four and the prostheses are
identical.
They have the same material,everything's identical.
The flexure of your prosthesesis 300 times higher with an
(09:35):
all-on-four than an all-on-five.
If you want to talk aboutlong-term stability, if you do
an all-on-four you are going tohave more fractures long-term
than you do with an all-on-five.
And if you go from all-on-fiveto all-on-six, you reduce it by
like 700%.
So we don't add implants toavoid photogrammetry.
(09:58):
That would be silly.
Everybody would know that wouldbe silly.
That's how you think.
You think about what's in thebest interest of the patient and
when people, when people say,doc, you did, you did six
implants and you did longevityleveling.
What are you going to do ifthey fail?
Well, I told you I had twocases that failed, right, and
they, they were smokers, theysmoked and they failed.
(10:18):
And they they had, they hadstopped smoking after they
failed, they had stopped smokingafter they failed.
Okay, they didn't stop whenthey were supposed to, but they
stopped afterwards, of course.
So we did it again.
Right Now you say, well, howcould you have done it again?
Well, if you look to first molarocclusion, you've got from
first molar to first molar, fromsix to six.
(10:41):
You have 12 teeth.
Could each and every one of usplace an implant in each one of
those locations?
Today, if you said, I'm goingto take out each tooth and place
an implant in each tooth, andthe answer is yes, we've seen
them on the internet.
We've seen the pictures of animplant in every tooth.
We've seen those pans circulateon the internet, so we know
that we can do that.
So if I place six implants,what's between those six
implants, bone?
(11:01):
So I could have six implantsfail and I could place six
implants the next day in thein-between space, because
there's in-between space.
Now you have to do it guidedbecause you can't fall into
those holes, but you could do itthat way.
So I have a differentperspective on crowding
so-called crowding the anteriorby adding these risk reduction
(11:22):
protocols.
I don't look at them as a riskfor a contingency plan in case
those implants fail, because Iknow there's plenty of bone
between it and if it's anall-in-five I have even more
space right.
So I'm not looking to create alot of space because that
creates mechanical complications.
As I said at the beginning ofthe podcast, we have three to
(11:42):
four times more complicationsmechanically than we do
biologically.
So I'm not worried about thatand I'm also trying to keep my
patients from smoking.
Dr. Clark Damon (11:52):
Yes, uh.
However, like if you have a,when you have a biologic uh
complication and you have filledthe anterior maxilla with six
implants, you now have a majoruh, a major uh problem on your
hand to fix.
I have never, I have not seen acase where if you have six
(12:16):
implants anterior to the sinus,that you have any bone to go
back in and place implants inbetween, have any bone to go
back in and place implants inbetween.
It's typically on those casesit's titanium heavy and you know
(12:38):
, often, oftentimes, there'sthere's reasons why we're
redoing these cases, as, as youmentioned, you know you, you see
a lack of executed cases.
I see them as well and thechallenge is you then
iatrogenically create them to bea quad or at least have two
zygomas.
Maybe you can get lucky and getthem into the lateral nasal
(12:59):
crest.
But that is a significantconcern that I see very often
and I am a very big proponent ofeliminating that approach of
having six implants entered tothe sinus for that reason in a
lack of execution or abiological failure.
(13:22):
So also, you know, we know thistoo, from you know, years ago,
when we would do, you know,eight implants, you know
oftentimes, you know, multipleimplants would wind up failing.
So when we really treat atitanium deficiency with a lot
of titanium, we now incorporatelack of blood flow into those
(13:46):
areas.
So by sticking with fourimplants anterior to the sinus,
we are going to have fallbackareas if we need them and we are
going to increase our bloodflow.
And where I will you know,encourage if you want to avoid,
(14:07):
or the way that I eliminatemechanical issues, is by doing
pterygoids on everybody.
So now we are moving thoseimplants away, we are building a
strong bridge on six implants.
We are just moving thesupporting structures to the
(14:30):
further edges of the mouth.
Dr. Tyler Tolbert (14:34):
So I have a few notes on this, dr Stanley.
So for one, do you have any?
So you talked about and it wasvery interesting, you talked
about all-in-four versusall-in-five versus all-in-six,
controlling for the AP spread,everything being the same there,
reducing the mechanical stress.
(14:55):
Is there a study thatcorrelates to that that I could
look up?
Dr. Robert Stanley (15:00):
It's actually I just calculated.
I did the beam analysis myself.
I haven't published it, but I'dbe happy to send the content
over to you so you can see it.
Dr. Tyler Tolbert (15:09):
Please, yeah, no, I'd like to look into that
as well, Because there aresimilar studies, like Dr Damon
mentioned, the Wilkerson studythat talks about reduction in
biomechanical stresses with theuse of pterigoids.
So it's interesting to see botharguments being supported, or
both Very different modalitiesreaching a similar conclusion
Well and then you know, tyler,also, you've got this DUYEC
(15:30):
study in 2000.
Dr. Clark Damon (15:33):
And you know they used in vivo stress and
strain gauge abutments and itwas 13 patients.
They found that there was nostatistical difference in stress
or strain in four, five or siximplant scenarios when it was in
(15:55):
an anterior approach, when theywere anterior to the sinus.
Dr. Tyler Tolbert (16:01):
Anterior to the sinus.
Okay.
Dr. Robert Stanley (16:04):
What stress were they measuring?
Stress delivered to the bone.
Dr. Clark Damon (16:14):
They were looking at tension moments.
Dr. Robert Stanley (16:18):
Tension moments.
I don't know what that term is.
So what happens is that if youapply an occlusal force to an
all-on-four or you apply thesame occlusal force to an
all-on-six, the force deliveredto the bone is the same.
So if their study was to set upto see if that wouldn't change,
(16:40):
the stress would change becauseyou'd have more area with six
implants than you would withfour.
So you'd have less stress tothe bone with the six.
But the flexure of the beam canbe done.
You don't.
You don't need to do this inthe mouth.
It gets complicated when you doit in the mouth.
You just do it on a piece ofpaper.
So if I have, if I have, twocolumns that are this far apart
and I have a beam running acrossit, you guys know, you guys
(17:04):
know just inherently that if Imove these columns in closer,
the beam will flex.
In between it will bend less.
Okay, correct.
So if you're trying to cross acreek and there's a narrow creek
or a wide creek, if you try tocross the narrow creek with a
2x12, you can walk across it.
But if the creek is really wideand you cross it with a 2x12
when you're in the middle, thatboard is sagging.
(17:25):
Okay.
So that's the idea behind yourimplants.
If your implants are closetogether, your zirconia
prosthesis will flex less.
If your implants are furtherapart, your zirconia will flex
more.
That's mechanical, you don't.
You don't really want to dothis as an in vivo study,
because all that does is thismuddy the water.
So that's some master's studenttrying to get their master's
(17:47):
degree in Perio or something, orPras.
It just muddies the waterbecause it's basically it's
basic engineering, right.
So we don't need to make itmore complicated than if the
beams.
If the beam length is longer,it flexes more.
You can just look it up onGoogle tonight and you'll just
see the beam length is how muchit flexes.
So if you do an all-in-four oryou do pterygoids and you spread
(18:08):
that beam out, you better makesure you're going with a tall
beam, because if you do thiswith an FP1, you guys that are
listening if you do this with acrown high space that's narrow
and you spread your implants outreally far, you're going to
have more failures.
You're going to have moremechanical failures mechanical
complications.
Dr. Clark Damon (18:30):
I mean, I'm not , I'm not advocating for that in
the FP1.
In fact I don't.
Dr. Robert Stanley (18:34):
I don't advocate for FP1s at all, but I
you know.
Dr. Clark Damon (18:38):
Elon.
Elon Musk, you know he talksabout engineers wind up
over-engineering things, right,things that don't even need to
be optimized or engineered.
And so I think, going afterbeam length, you know well, sure
, if you're in between, you knowyour zirconia is 20 millimeters
or more, then you needsomething there.
(18:59):
But I don't believe thatover-engineering a titanium
deficiency to reduce beam lengthis a wise thing to do, in my
opinion.
I don't think it's.
It doesn't need to be there.
Dr. Robert Stanley (19:17):
Because you're concerned that if there's
a failure, there's no recovery.
Dr. Clark Damon (19:20):
It's either.
It's either yeah, in a failure,or lack of execution.
You know, on on down the road,it's it's just.
I want to leave more bone, Iwant to leave more blood flow.
You just and, and and.
I want to be simpler, and if if.
I want to then optimize.
(19:42):
Right, you know so so.
So where do I optimize?
I optimize in, in, in theposterior, because I do think
when you have a implant bridgethat has six implants, I think
it is phenomenal.
I think we agree on that.
I think it's just kind of morewhere they need to be.
Dr. Soren Paape (20:22):
Dr Stanley, do you think that it's predictable
for most clinicians to getaccurate scans for these?
Let's say you have a bunch ofclinicians and they all are
doing guided cases right, sothey're getting that parallel
above and it sounds like that'show you're know you're getting a
lot of that parallelism is, thecases are guided, you're able
to.
You know exactly where themulti unit position is.
You know that they're going tobe parallel, so you get that
scan and it looks great, itlooks accurate.
Is that something that you knowyour team has just has a lot of
(20:44):
experience with?
Because I find a lot ofproviders, even if, let's say,
the scans are I mean the scanbodies, healing caps, whatever
you're scanning right areparallel In a bloody field.
I just see a lot of cliniciansjust struggling with that.
Is there anything that you doin particular that would be like
a good gold nugget forclinicians to make that scanning
(21:08):
easier for them to prevent,like these bloody fields or how
are?
How is your team doing it toget that 40 microns accuracy
over and over and over again?
Dr. Robert Stanley (21:18):
So most of the time we're doing, we're
doing this scan, so we're notdoing.
It's very rare for us to do thescan the day of the surgery,
you see, because I already havea prosthesis made, so I'm not
doing any sort of day of.
Very rarely do I do a day ofsurgery scan and then make the
(21:40):
prosthesis immediately.
I've done that a couple oftimes for the sole purposes of
measuring throughput, how fast Icould do it, so I can do a full
arch in an hour, like we'vesaid a couple of times tonight.
But when I did it where Ididn't have a prefabricated
provisional, I wanted to see howfast I could do it.
So what I did is I placed siximplants and then I scanned them
(22:02):
before I sutured.
I placed six implants and thenI scanned them before I sutured
the bone, and the reason I didthat is that I had the substance
right.
So we blotted it when wescanned it and everything, and
then we delivered it.
The whole process took threehours, so still rather quick
(22:22):
compared to some people'sconversions that are taking four
to six hours.
Rather quick compared to somepeople's conversions that are
taken four to six hours.
Rather quick compared to somepeople's conversions that are
taken four to six hours.
They take the implants, theyscan and then they build their
provisional.
Dr. Soren Paape (22:33):
And that makes a lot of sense.
Dr. Robert Stanley (22:38):
But that took me three hours and I can do
it routinely with one hour witha prefabricated provisional.
So I don't do it very oftenwith one hour with a
prefabricated provisional.
Dr. Soren Paape (22:48):
So I don't do it very often yeah, I understand
that yeah, I wanted to clarifythat, just to make sure, because
, um, doing no photogrammetry inan office I feel like might not
be very predictable if you'redesigning same day and doing
same day fabrication.
I could see that being maybesomething that people are
(23:12):
misconstrued and maybe whyyou're getting some of that hate
.
Dr. Robert Stanley (23:22):
You're absolutely right.
That's a great sorry.
That's a great clarification,because we just don't do.
I think we've only done ittwice.
I think we're going to doanother one coming up in the
near future because I'm alwaysexperimenting, as we said.
I'm always trying differentthings.
So I think I'm going to doanother one coming up again.
But it was successful.
It's just that you know, if youdo these cases, everybody will
agree Sometimes you havebleeders right and sometimes you
(23:43):
don't.
And sometimes you don't evenyou don't even know why.
You can't even really predictit.
You're like, is this person onaspirin?
And they go no, they're notaspirin, they're not on any.
They're not any any Plavix.
You're trying to figure out whythey're bleeding like a stuck
pig Right.
And uh, on those cases, it'sgoing to be hard to get a scan
right.
It will be hard, so that'swhere photogrammetry would make
a lot of sense.
Dr. Tyler Tolbert (24:05):
So I have a couple of things.
Um for one.
Would you say then that, um,because it all matters, you know
how close the scan bodies areto one another.
It doesn't necessarily meanthat the implants themselves
have to be close to one another,right?
So now what we're seeing arescan bodies you mentioned, like
the T-shaped scan bodies.
Now we have a Shining EliteTrue Abutment has one where, no
(24:27):
matter where the implants are,they've got these arms that all
point concentrically and bringall these implants together and
you can sort of now remotelyrelate the implants together
using just a scan body.
And that's a big thing that'sgoing on right now, and people
are trying to pivot away fromphotogrammetry or at least
provide a product that's just ina box, everything's there in a
box.
So that's just.
That's less of a question, moreof just a note, really.
(24:49):
And then, second, the onlything I would challenge just
slightly is when it comes to theparallelism of the multi-unit
trajectory, right, like howparallel all of our multi-units
are.
I would only say that I don'tknow that that's always ideal,
especially in the maxilla,namely in the atrophic maxilla,
(25:12):
and also in a case where we arehoping to do, potentially, class
correction.
So a lot of times, you know,between myself and Soren and
Caleb, we had a little bit of acontest on who could get who
could freehand the most parallelmulti-units on the mandible, to
get down to single digitdeviation.
This cool thing the micromapperdoes you, take a picture of it,
it tells you what yourdeviation is, and we all got
(25:33):
there eventually.
But on the maxilla that that'snot something that I I'm ever
really shooting for.
Right On the, in the uhanterior, I'm almost invariably
tilting, uh my implantsanteriorly to buck out a little
bit to compensate for theresorption of a maxilla,
especially one that's adentureless right.
So then, how you know, if, if Iwere to try and get everything
(25:53):
perfectly parallel and stillhave access holes that are in
the cingulum, the cinguli of theanterior teeth and the, you
know, within the clusal table ofthe posterior teeth, I don't
think I could actually do thatin a parallel way.
I actually want all of mymulti-use to be flaring out
slightly buckly.
So if I tried everything Icould to get everything parallel
(26:14):
, I think it would actually havevery palatable access holes
across the maxilla.
Dr. Robert Stanley (26:20):
I think that's a really good point.
Tyler, I would say that I dothe exact same thing.
So all of my screw holes arecoming out the cingulum and I'm
always driving my digitalplanners to make sure that
they're in the cingulum.
They want to place them 3, four, five millimeters lingual to
the singular and if you've evergotten one of those provisionals
back, you know that's justawful for the patient.
(26:41):
They have this massive wad ofplastic on the roof of the mouth
and they can't talk and they'relistening.
It's terrible.
So I'm always driving them todo these cases the same way.
They would do a single implant.
So that access hole has to beout the cingulum.
So that's where they're at.
So there is going to bedivergence, but they are still
more parallel than they're not,if that makes sense.
(27:04):
Okay, the divergence betweenthis one and this one might be
quite a bit, but this one tothis one, this one.
Dr. Tyler Tolbert (27:12):
Oh, the adjacents are something.
Yeah, as you're stepping around.
Dr. Robert Stanley (27:14):
they're not diverging too much around the
horn, right, I see the nuance.
Okay, yeah.
Dr. Tyler Tolbert (27:19):
Okay yeah, that's fair.
Okay yeah, very good.
Dr. Soren Paape (27:27):
I was just going to say, you know, before
we start wrapping things up,this did go a lot longer than we
had expected.
And I loved the points for bothof you guys.
They were.
They were excellent and I think.
I think it really comes down tolike every provider has their
own set of skills that they wantto be proficient in, right,
like some, some providers.
(27:48):
They're not going to want tohave to get a guide for every
single case and in thatsituation, like free hands,
wonderful.
But if you want another tool tohelp you know, make the like
you were saying, some of theseproviders that you have seen do
arches for the first time rightare having excellent outcomes.
You know guides can be, can beexcellent, but I, either way, I
(28:11):
would like you guys both to geta chance to talk about you know,
your courses that you have and,if they want to go down that
Avenue, I'd love for you guys tohave an opportunity to to let
our audience know where theymight get some more information
from you.
Sure.
Dr. Clark Damon (28:28):
Awesome.
Well, I would say thisphotogrammetry is Achilles heel.
Is the fact that it has to berelated to an intraoral scanner
right?
So, like you know, when yourelate your PIC to white healing
caps or ICAM scan bodies, youknow, or Micron mapper, that's
(28:50):
kind of the Achilles heel, andwe've all seen cases where when
you go to align your implantposition to your jaw scan,
there's there's some variabilitythere.
So that's that's.
That is definitely the Achillesheel Now granted it is, it is
going to fit perfectly.
(29:10):
But that is when you're going toget these occlusal issues, and
you know, then you kind of godown this whole occlusal rabbit
hole of dealing with realigningjaw data and jaw scans.
So we are, we don't have theperfect, we don't have the
perfect restorative material, wedon't have the perfect
(29:33):
photogrammetry and we don't havethe perfect scanner.
So you know, I assumeeventually we will, but we'll
just have to stay tuned.
But right now it's, you know,using all of these different
things that are dealing with thelimitations that the technology
(29:53):
that we have is able to provideus.
So, so, with that, let's see,I've I've got the Texas Implant
Institute.
We do basically two courses.
We do all on X standard andit's hands-on models, and day
two we go into cadavers and sowe skyrocket your surgical
(30:20):
experience.
I mean, I've even had doctorsthat have done a thousand arches
.
Come take my course and they'relike man, I learned so much and
I was like, really, they'relike, yeah, you taught me to
hold the retractor the right way.
You taught me to, you know, dothis with the periosteal
elevator.
So it's just, you know,everybody has like different
(30:48):
little bitty pearls that theyjust kind of pick up and we go
over.
You know how to sell the cases,how to talk to the patients and
you know the whole history,treatment, planning, all of that
, and then we have our All on Xadvanced course for atrophic
maxillas, which is zygomas,pterygoids, nasal crest, and
it's really the same formatdidactic lecture, hands-on
(31:11):
models, and then day two, weroll into cadavers.
Dr. Soren Paape (31:17):
I'll advocate as well.
We I think tyler and I bothprobably had done over 500
arches.
We went to your first courseand I and I took away a lot of
takeaways that were great thatwere very, very helpful.
Awesome, awesome yeah so we'vebeen.
Dr. Clark Damon (31:29):
We've been doing it since 2018 and uh,
we're, I guess, in seventh yearit's.
It's a little odd this year, um, you know, my, my co-director,
rick klein, passed away, uh,right after one of our courses,
and so we're we're still tryingto figure out you know who, who
we're going to do the courseswith.
Right now I'm a little solo,but uh, still still get just
(31:53):
great education.
I, I, I primarily did all thelecturing, um, so that that
really uh doesn't change at all.
Um, so we are uh located indallas and you know we always
have a good, a good happy hourand a good program.
And we like to, you know, eat,drink and be merry after good
state too, yeah, yeah, yeah,come texas, but, but, but, but,
but, but really, you know we eat, drink and be merry after Good
(32:14):
state too.
Yeah, yeah, come to Texas, but,but, but, but, but.
But, really, you know, we alsooffer the mentoring program and
you know you guys are in our uh,uh, what is that?
The WhatsApp group, and uh, youknow it's, it's uh, you guys
get access to me, which is whichis a good or a bad thing,
because I'm going to call youout.
(32:36):
I can vouch for that.
I'm going to hold you guysaccountable because, at the end
of the day, I want excellentresults for your patients.
This is a lifelong learningthing.
There is no one course you needto take.
Maybe after this, I'll startsending people that need some
help over to take Um, you know,maybe after this I'll I'll start
(32:56):
sending you know people thatthat need some help over to Dr
Stanley's course.
Dr. Tyler Tolbert (33:03):
That's good.
Dr. Clark Damon (33:05):
Say, say.
Hey, you know what I, I think,uh, I think freehand is not for
you.
Dr. Tyler Tolbert (33:11):
That's a good segue into a Dr Stanley, if you
wouldn't mind talking aboutyour courses.
Dr. Robert Stanley (33:16):
Thanks guys, I really appreciate the time.
As you guys probably note, I'ma bit of a talker.
But I'm not very good at sellingmyself.
I can talk about implants allday long, but I usually turn
that over to my team, mydirector of the Institute,
stanley Institute.
We're based just outside ofRaleigh, north Carolina, about
eight minutes from the airport,so if you fly in it's real
(33:37):
convenient.
We have basically StanleyInstitute, for Comprehensive
Dentistry is.
The two primary educators aremyself and my wife.
My wife teaches the business ofdentistry.
So if you want to learn, so Ilike to say there's offense and
there's defense in a business.
Right, offense is how manycases can I do, how much money
do I make?
Defense is how much money do Ikeep?
(33:59):
Okay, what my wife teaches youis the defense, which almost no
one talks about.
Right, we're always like well,if I add this skill set to my
practice, I can generate morerevenue for my team and for my
family and get closer to mygoals.
What we don't talk about is howcan we reduce our tax burden,
how can we set up ourcorporations in a way that are
beneficial for us in the longrun?
(34:20):
That's what she talks about.
So she talks about the businessindustry.
I talk about pretty muchimplants.
So we have a onesie-twosiecourse.
It's three courses, but thefirst course is online, so the
first is called Essentials 1.
1 and that's the planningcourse.
That's where you learn how toplan.
So that's all online.
And then Essentials 2 and 3 arealso online.
(34:42):
So if you're a remote watcher,you can have a lot of people
that follow me overseas so theycan take the course remotely.
So Essentials 2 and 3 aretaught together now as a
three-day weekend.
Okay, it's a three-day weekend.
Okay, it's a three-day weekend,and I encourage people to come
to the real course versus thevirtual one, because you get to
(35:03):
do the hands-on parts.
Okay, so we have all thesehands-on experiments and there's
live surgery as well.
So that's how we do the onesie,twosies For the full arch
course.
It's a three-day course thatyou're all on X course and it
covers everything.
It's a three-day course thatyou're all on X course and it
covers everything.
It covers from planning, itcovers the surgery, it covers
the digital workflow all the waythrough the prosthetics.
And the main goal with ourinstitute is rather simple Our
(35:26):
goal is to reduce risk andimprove outcomes for patients,
and we do that predominantlythrough a pragmatic approach to
implantology.
So we look at some basic thingsthat people really don't
consider very often and we'vetalked about many of those
tonight and hopefully that willgive you guys some food for
thought in terms of ways toreduce risk through mechanical,
basic mechanical principles.
And we eliminate things liketorque.
(35:47):
We talk about torque in a waywhere you start to understand
the limitations of that metricversus what most dentists do,
because we've been trained acertain way is we kind of stick
to these old things and that canlead you down a path that it
can lead you down a path whereyou're doing things that aren't
in the best interest of thepatient.
So that's kind of it.
(36:09):
And we have a failure to ananti-failure to launch program,
which was rather negative, sothen we called it a success
program.
So the anti-failure to launchprogram, which was rather
negative, so then we called it asuccess program.
So the anti-failure to launchprogram is that we were told
that a lot of doctors come tocourses and after they take a
course they get really excited,but on Monday they're they're
back at the, they're back at thegrind, right, and they don't
have time to actually implementeverything that they, that they
learned.
So we have a success program tokind of walk you through your
(36:31):
first few cases and we mentoryou and hold your hand through
that whole process.
So people really like that andit really helps them get going,
because once you get going, it'spretty powerful.
Dr. Tyler Tolbert (36:42):
Cool, cool.
Well, listen, guys, I, you know, there was definitely a world
where I saw, you know, bringingon the two of you guys who are
very intelligent, veryexperienced and have a lot of
success in your own practice,albeit with almost polar
opposite modalities, and, youknow, we railed off a few
questions and you guys went backand forth and you both just
stormed off and said, screw this, this is dumb.
(37:03):
So I really appreciate that wedidn't let the egos take over
here at all and we actually hada really lively and educational
debate.
I mean, there were a lot oftopics that I think are going to
be, you know, talked about byour audience that listens to
this, and I think there were alot of challenges, you know, for
both camps and looking acrossthe aisle and saying, well,
maybe there are some merits atthis point, and vice versa.
(37:26):
So I really just want to thankyou both for coming on, bringing
on your expertise, bringing onyour experience and, you know,
just be mature about this and,you know, living out the
Socratic debate and just talkingabout things in a way that you
know is really just meant tobenefit those that are trying to
(37:46):
do more full arch and trying tobenefit patients and trying to
do better for people.
And you know, personally, Ilearned a lot here.
I know Dr Soren did as well andI just, you know, can't thank
you guys enough for your time.
We're running into about twoand a half hours.
There's actually a record forour podcast.
We never recorded that long.
Well, maybe we have with DrDamon, but we did it in parts.
So thank you guys so much forsparing your time and coming on.
(38:08):
I really can't thank you enough.
Dr. Robert Stanley (38:10):
Awesome, that's my pleasure thanks guys,
I really appreciated it awesomeyou guys take care okay, bye.
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