October 1, 2024 • 49 mins
What does it take to excel in the field of implant dentistry? Join us on the Fixed Podcast as we host Dr. Chris Barrett, a leading expert known for his skills in placing Zygo implants and remote anchorage cases. Dr. Barrett shares his journey from the University of Iowa to a renowned restorative-only practice in Denver, highlighting how mentorships and collaborations shaped his approach to full arch and implant dentistry. You’ll gain insights into his comprehensive methodology, shaped by influential figures.
Get ready to uncover the latest advancements in digital dentistry! This episode explores the fascinating world of remote anchorage and milling technology, spotlighting the shift towards same-day zirconia deliveries. We tackle the essential balance between immediate finals and proper healing time, along with innovative techniques like socket shielding and root banking. Our discussion goes deep into the nuances of FP1 versus FP3 prosthetics, emphasizing the critical aspects of precise diagnosis and case selection in modern dental practice.
The episode culminates in a thorough examination of the evolution of dental implants. Dr. Barrett recounts historical methods and their limitations, providing context for the advanced techniques available today. From custom implants and mandibular subs to the enduring challenges of zygomatic implants, we cover it all. Discover how modern innovations like extra maxillary methods and pterygoid fixation are setting new standards in implant stability, avoiding the pitfalls of the past. Don't miss this episode packed with expert insights, practical advice, and a forward-thinking perspective on implant dentistry.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Soren (00:00):
My name is Dr Tyler Tolbert and I'm Dr Soren Papi
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Hello and welcome to the FixPodcast.
Today we have Dr Chris Barrettwith us.
We are super excited to haveChris here.
I actually met Chris for thefirst time in Denver about three
(00:21):
months ago probably, and we'vehad a lot of conversations.
Yeah, yeah, we've had a lot ofconversations, probably, and
we've had a lot of conversations.
Yeah, yeah, we've had a lot ofconversations since and we've
been sharing a lot of casestogether and we're very honored
to have him on the podcast today.
He is one of the front runnersfor Zygo implants for GPs
placing quad Zygos doing remoteanchorage cases and we're super
(00:44):
excited to have him on thepodcast here today.
Chris (00:46):
Yeah, excited to be here.
Thanks for having me on andyeah, we have had some great
conversations ever since Denver.
So, yeah, what conference was?
Soren (00:54):
that at.
I think it was a Dykema DSOconference.
Might have been that one, yeah,I came over to the what was the
big conference center.
Chris (01:04):
That hotel out by the airport.
That's massive.
Soren (01:08):
Yeah, I can't remember either Tip of the tongue.
Yeah came out there, had adrink, we discussed both of our
backgrounds and we had a bunchof similarities in our
backgrounds and getting intoimplant dentistry and, yeah, I'm
sure the audience here wouldlove to also hear about your
background.
So if you could fill us in alittle bit your background in
Full Arch, maybe a little bitabout the work history, how you
(01:29):
got into remote Anchorage, Ithink that would be a great
start.
Chris (01:35):
Yeah, I graduated from University of Iowa in 2011 and
wasn't sure exactly what Iwanted to do.
Everyone that I talked to thathad done a GPR was like I would
never trade another year ofprivate practice for my GPR year
.
So I thought, okay, I'll take ayear and do that.
At the time, I really lovedsurgery and I really liked endo
(01:55):
and I think that was justbecause we had what I felt was
just the best adjunct faculty inthe oral surgery and endo
department.
So at Iowa, if you finished withyour requirements early, you
could spend as much time as youwanted to in whatever department
.
So I ended up spending amajority of my oral surgery and
we had these OS guys from allover the state that were at the
(02:18):
later part of the years and theyjust loved coming in and
showing you all their littletips and tricks on exodontia.
And they're just telling youall their little tips and tricks
on exodontia and they're justtelling y'all their little war
stories and this and that, and Imean it was just awesome.
So I took to that and then didthe gpr year.
Honestly, watching the perioand dental school and os faculty
(02:39):
or guys or whatever placeimplants, I was like man that
looks so boring.
I mean they'd take forever toplace one implant and it was
based off of like a dentalstudent guide that never fit and
they're like we're just goingto do this ourselves.
I was like this is whatimplants are.
I was like I'll just go dosomething else, I don't know.
So I ended up practicing Iowafor a year and then all my
(03:02):
siblings actually live in Denverand my parents have siblings
that are out there too and,looking to make a move, went out
West from Iowa and there's alot of Iowa grads out in Denver
and so they'd been out there anumber of years before me.
I had gotten a job that allthese guys were saying, hey,
this is like one of the nicestoffices and so if you get
selected for that job, youshould take it.
The caveat was that it was arestorative only practice.
(03:26):
So, even though I was good atsurgery and I liked different
procedures, they're like hey, weare a fee for service office.
We work with other fee forservice offices here in South
Denver and this is what you'regoing to do.
And so I was like, okay, signedup for that.
They taught three differentlevels of occlusion out of that
office, and the guy who startedthat office I'd say you and
(03:48):
Tyler are younger than me, soren, but let's say around the same
age, and let's say some of thebig names in whatever we're into
, have some sort of study clubor go out and teach or whatever,
and they're looking for guys tohelp teach.
The guy who started this, thatoffice, his mentor, was a
relatively famous prosthodontistnamed Niles Goucher and he
(04:09):
ended up inventing the Dehnerarticulating system.
He also developed somethingthat was like a digital or a
analog jaw tracer for thatsystem, and so they were all
about the study of nathology andbasically joint-based treatment
that as long as the joint wascomfortable and the muscles were
(04:29):
comfortable, you could restoresomeone and you can do it very
predictably.
So they did a lot of TMDtreatment and they worked with a
lot of really greatorthodontists, and so most of
that time was the cases I was apart of was maybe phase one and
phase two, and then phase two issome ortho, maybe some minor
restorative and a little bit ofequilibration.
Every once in a while there'dbe some surgery involved, but
(04:51):
that was like a little residencythat I didn't know anything
about it, and this is two orthree years out of school.
Looking back at it.
Now I'm like, okay, I can seewhere there were some pitfalls
or maybe some different thingsthat maybe I would do
differently, but that's where Ilearned how to restore it the
(05:16):
different analog restorativesteps.
They had labs that would comein.
That's where I learned how torestore it the different analog
restorative steps.
They had labs that would comein.
Well, it's a guy, arnie Hoffman, and I don't know if you know
him.
Soren (05:28):
Yeah, I know.
Chris (05:28):
Arnie.
So I met him at that when I wasat that practice because he
worked at one of the local labs.
He's a German prosthodontist.
Kind of looks like ArnoldSchwarzenegger.
Tyler (05:35):
He looks like him.
Chris (05:39):
Yep, super on restoring those.
Doing it all analog.
I end up going through adivorce while I'm at that office
and I transitioned to adifferent office and start
placing my own implants andgetting back into doing some
surgery I end up living withfirst.
I end up living with my youngersister and I was like, hey, I
(06:02):
got to get out of my youngersister and her husband's house.
Get out of there and thebiohorizon rep does.
Soren (06:08):
matt is matt I actually I was talking to him yesterday
yeah, he's woven into this story.
Chris (06:19):
The, his roommate had gotten his girlfriend pregnant
and so he had to move.
So Matt sent out a group textto like all the guys that are
around the same age that wouldhang out every once in a while
in the Denver area and say, hey,I got a room open.
If anybody's looking for it,that sounds good.
So I ended up living with Mattfor probably a year or so.
And I'm listening to the AAIDpodcast and Mike Freimuth is
(06:42):
co-hosting with Danny Domainbecause Justin Moody was like
out of town or something orwhatever.
And I see and I hear that he'sa diplomat and does a bunch
about implants and he's in WheatRidge, colorado and I'm like,
wow, that's like right here andI look up the ABY and diplomats
and there's like two in thestate and he's one of them.
And I asked him.
I'm like, hey, matt, do youknow?
This guy seems to know a lotabout implant dentistry.
(07:04):
He's like, yeah, he's like mybiggest client.
Guy's like he's just a machine.
I'm having dinner with him nextweek.
So I'm like, is there anychance that I could go to that
dinner with you guys?
Do you think he would mind?
He's all ask him, but I thinkit'd probably be good.
So go over there, have dinnerwith him.
He's actually looking for anassociate and at the time I was
(07:26):
planning on going back to Iowato be closer to my kids that
were back there.
I don't end up working with orwith him or for him, but I ended
up spending every single dayoff I can over his office and he
really expanded my mind as faras what was possible as a
general dentist he had.
He was doing really nice FP1cases in operatory one at the
(07:47):
same time, then he was preppinglike a veneer case in operatory
two and then he had four hygienechairs and then he had already
built out his own in-house lab.
I had two or 3 million machines, two or three lab techs and
this is probably like 2013.
And so when guys are like, ohwow, I just built out a lab or
whatever, I'm like dude.
You guys are no, you think thisis probably like 2013.
And so when guys are like, ohwow, I just built out a lab or
whatever, I'm like dude, youguys are no, you think this is
(08:08):
like a new thing, that's justhappening.
But there's like these guys thatwere like a generation before
you, that were like it's crazy,and they're done and yeah, he's
just, he's always tip of thespear huge on education.
That's how why I started takingKois stuff because he was like,
hey, you got to go take Kois.
He did all the MISH and Koisstuff with.
It was him and Moody way backin the day when he was our age,
(08:28):
and those guys ended up startingPathway and through that
relationship I ended uppracticing with Justin Moody for
a couple of years and takingover his implant practice and
then so I went from placing afew implants a month to that's
all I did and fortunately, I hada really strong comprehensive
dentistry and prosthodonticmindset and I had previous good
(08:50):
surgical skills from Universityof Iowa and the OS department
there in the GPR.
That was just like veryfundamental, basic things that I
feel like you can use foreverand all walks of whatever
surgery you're doing.
So I'm super grateful for that.
And then I ended up moving downto Arizona in 2019 and started a
group called brightly with someprivate equity guys and help
(09:12):
grow that to different officesaround the country, which is
basically just like guys that Iknew or y'all said I knew that,
hey, that looks good, I want todo that too.
And then left that in 2013 orin 2023, excuse me.
And then I've just beentraveling around the Phoenix
Valley for the last year and ahalf or so just doing all on X
from basic law and force toadvanced zygosurgery and then
(09:35):
periodically flying around thecountry mentoring or helping
other docs, just trying tofigure out what I'm going to do
next.
Soren (09:41):
Nice, yeah.
Yeah, it's funny, matt, matt Go, matt goff he.
So I've been working with himwith biohorizons.
We use all of their biologicsin our offices and I think you
made that connection actually atthe which.
So thank you for that, chris.
And yeah, and it was funnybecause I was.
I reached out to him yesterdayjust because I was looking for a
sinus lift kit and I justreached out to him.
(10:02):
I was like, hey, do you guyssell these at all?
I don't think they do, but Iended up going with a Selvin kit
.
So if you have anyrecommendations?
Chris (10:08):
I would have recommended Tatum, but that's fine.
Soren (10:10):
Okay, all right.
Yeah, I should have reached outto you first.
Tyler (10:13):
Now your time.
Soren (10:15):
It's all right, I'm sure the Selvin kits.
He's like, hey, by the way.
Yesterday he said this hey, bythe way, dr jen mansky is my
wife and I was like, oh, no way,because two weeks ago I've got
this patient who comes in and heneeds a.
He's hey, doc, can you?
What exactly do I need here?
And he had one of the mostresorbed maxillons I've ever
(10:38):
seen, like no bone.
He had canine to canine bridgeand then from the canine to
canine.
There was absolutely nothing,like no bone whatsoever.
And I was like this have youhad this for a while?
And he's like, yeah, when I wasa kid I got into a traumatic
accident and lost my front teethand I was like, all right, well
, all on four is going to be outof the question unless we like
(10:58):
have some really extensivegrafting and that's not what you
want to go through at thispoint.
And I don't think he needed iteither.
But his lower bridge wasdefinitely failing and I was
like we can do a lowerimplant-supported bridge.
And I'm like you should go backto your general dentist to see
what they can do with that upperbridge and maybe they can
repair it, because it hadfractured and his dentist
(11:18):
happened to be Jen Manske, so Iwas on the phone with her like
two weeks ago, just like we weretalking about how we were going
to like plan this case out.
And then it just happened thatmatt they were married and I was
like, oh wow, it's such athere's a small world.
Yeah, I feel like the dentalworld's small enough and then,
once you get into the implantdentistry, it gets even smaller,
which is pretty crazy.
Chris (11:36):
Yeah, I there is.
Uh, I went out to californiaabout two months ago and did a
case for a young woman and she'stelling me that her best friend
practices in Arizona.
And sure enough, the one like I.
I, there's only three or fouroffices that I really go to and
(11:56):
my girlfriend, who's a dentalassistant she does some temp
assisting out of.
She literally has not done anysort of temp assisting for years
and then all of a sudden, likeher second gig is this girl's
best friend.
I was like okay that's just tooweird right
Soren (12:14):
yeah, that stuff happens all the time yeah, it's funny
you were saying earlier separatetopic, but you were saying
earlier.
I just wanted to mention thisbefore I forgot that when you
first started, like seeingimplants, you're like man, that
looks super boring, Like I'm notinterested in that too much.
And I remember when I was likesecond or third year of school I
saw these guys that were likeimplantologists, right, and they
(12:36):
were like promoting themselvesas implantologists and I'm like
man, that just sounds so I don'tthink I don't want to just do
one thing, like just play singleimplants every day.
that sounds like the worst thingever and it's so funny, just
and it goes into what you weretalking about earlier about
milling and making your own labthere's just so much that you
don't know until you get intothat avenue, right.
(12:58):
So like you start to learn alittle bit about implants and
then you're like, wait, what'sthis full arch thing?
And all of a sudden you're like, oh my gosh, like it's so cool
that all of a sudden, uh, youcan have a patient that comes in
who needed a denture, that canhave, you know, a new set of
teeth in a day.
So then you get into the fullarch stuff.
And then, once you're in thefull arch stuff, the next kind
of step is like maybe dabblinginto remote anchorage.
(13:20):
I feel like sometimes, prior toremote Anchorage, most people
and especially now, like in thelast year or two will start
getting into like the digitaldentistry stuff, and then that
opens up a whole nother can ofworms there.
So you're, you got all theremote Anchorage stuff and then
all of the dental stuff, andthen you find out like, like for
me, even if, like setting up amill in my office and stuff, I
(13:42):
feel like I'm way ahead of thecurve.
But then in reality there'speople a decade ago that were
like oh yeah, I was doing that.
I was doing that 10 years agoand it's just amazing to see all
of the different avenues andthe things that you can get into
and how many, how there'salways someone out there that's
like one step ahead of you,right, doing these things.
It's just interesting.
(14:05):
I wonder what, like the next bigthing in dentistry is going to
be.
I think right now, in like fullarch probably, that would be
like I've seen guys now that aredoing they'll do digital
designs and they'll have all theteeth designed already but they
won't place the implantpositions.
And then, as soon as theimplant positions are placed,
they'll then and they'll millthe first half of the zirconia.
Then they'll mill like theaccess holes of the zirconia, is
(14:25):
my understanding, and you cando same day zirconia deliveries.
Have you seen that at all yet?
Chris (14:31):
I haven't.
But I'm trying to think of whatthe I'm not a huge fan of doing
same day finals.
I've done a couple of them andif I were going to say, hey, I
think that this was my mom ordad or whatever, I'd probably
make them another one fourmonths later.
Yeah, so that's one of thosethings where it's but, to be
(14:52):
honest, but that's cool, yeah,that's cool that the technology
is like getting to the point ofyou can do that.
So, let's say, it's almost likea healed ridge through a
dentalist.
You're like I just gotta dropsome screws.
And then you're like, oh, itcan make you your final because
I know if the soft tissue is,it's flapless or something
that's cool.
Soren (15:08):
Yeah, no, definitely, and I'm definitely with you there.
I tell all my patients that Iprefer that they wait two, three
months for all the bone tohealing to occur, all the tissue
healing, before we go to yourfinal prosthetic.
But I do think for certainstyles of practice if people are
traveling or something likethat and they don't have a ton
of time in your clinic it can bea really good option for
(15:32):
patients to get same dayzirconia and then at the four
month mark then remill them inthere with the changes that
they've had to their bone andtissue.
But I agree, as far as there'sa lot of healing that occurs and
I don't think even one week,finals and stuff are the best
possible outcome for patients.
But I think there's a lot ofheadway coming into that
direction where some of theseguys I've seen they'll design
(15:55):
the prosthetic in a way thatthey're planning it a certain
distance from that bone levelright, so that way when the
tissue heals they're planningfor that and maybe they end up
having to remill two or threeout of 10 arches, but at least
those seven arches that they did.
The patients are stillrelatively happy with those
cases still relatively happywith those cases?
Chris (16:14):
Yeah, I think, as there's more and more socket shield and
root banking and remoteanchorage and I shouldn't say
that in the same sentence.
For example, I think, for theFP1 cases that I've done, a lot
of times you run into issues inthe molars.
Let's say there's just not alot of bone there for a really
solid molar, so you end upputting in a zygote or terry.
(16:36):
But you can do almost like rootbanking and socket shields in
the front.
When you have something likethat's like a point of
measurement, when you're keepingsomething, then I do.
I do think it makes sense thatthat you could potentially go
closer to final versus, versus.
In my mind, an FP3 is adefensive modality versus, uh,
(16:59):
let's say, an FP1, which is moreyou're playing offense, and
what I mean by that is you doyour FP3, you do your surgery
and then you wait for everythingto heal for three months and
then you're like I'm going towait to see how the body
responds and then I will now goback and I'll do the next part.
Versus something like an FP1,you've got to play more offense
(17:20):
and you have to do moreconnective tissue grafting.
You might have to root bank,you might have to do something
else to get the body to do whatyou want it to do, versus hey,
let's just have this heal andthen see what happens.
Soren (17:33):
Yeah, no, I agree Definitely.
What are your thoughts on?
Have you done a lot of socketshielding, root banking?
I personally haven't done anyof it.
Our colleague Caleb, he, hasdone a couple of cases that have
turned out pretty well, but I'mcurious what your thoughts are
on that.
Chris (17:47):
Yeah, I've done two single socket shields.
I've done some root banking andthat P1 cases that I've done
it's been more uh, a couple ofyears ago, like a xenograft and
connective tissue grafting.
I think if I were going to dothem today, I'd change some of
that stuff.
As far as root banking and andsome socket shields, I just saw
(18:07):
an unbelievable lecture by a guynamed David Atiyah.
He was out of Australia and hejust the amount of detail that
it goes into as far as diagnosisand making sure you get a
quality outcome with, with, withpet or soccer shield or
whatever.
I think you have to select thecases right.
The diagnosis has to bedifferent and it's not, as I
(18:29):
would say, easy, asstraightforward as doing an FP3,
where it's you're basicallyjust giving yourself a blank
canvas to create whatever youwant.
So, yeah, it's very interesting.
That's something that I'mexcited to see how that develops
as far as some more kind ofinnovation or techniques or
things that just give reallypredictable results, because
(18:50):
I'll say, from just doing a lotof FP3s, there's a couple
patients that come to my mind.
Whereas if I could redo that, Iwould do them as an FP1.
Doing a lot of FP3s, there's acouple patients that come to my
mind, whereas if I could redothat, I would do them as an FP1.
And a lot of it was tonguespace and phonetics and almost
nothing to do with aesthetics.
Or these are older patients.
It's not like it was a youngpatient that I'm like hey, I
(19:12):
just artificially aged them byreducing a lot of their bone or
something like that.
This was just more like hey,where are our eights?
Trying and I know you're fromNew York and I know you speak
Italian to your friends over inItaly and they can't understand
that one word, that you say yeah, like they used to say with
your natural taste.
I don't know what else to do,but if I could thin this out
more, I think it would be betterfor you.
(19:34):
And just the style of howeverything was, I just couldn't
make it any thinner.
I learned my lesson just on acouple of those and I could see
them coming.
Now where it's a whether or notthe transition, these are low
lips.
I'm not going for unbelievablyaesthetic FP1 cases.
These are just thinner, smallerrestorations where it's like
hey, the phonetics I think are alittle bit easier and I think
(19:57):
there's a lot more tongue space,definitely yeah.
Tyler (20:00):
No, I agree 100%.
Yeah, chris, I think that's aninteresting point because
whenever I hear aboutindications for FP1, a lot of
times it's what you just alludedto a really young patient, a
high lip line where reduction tohigh the transition line is
going to be pretty absurd for agiven patient, and we're doing
the FB1 to preserve that bonyarchitecture, so on and so forth
(20:20):
, but you're bringing up thephonetic point.
So I'm curious, on the frontend, prior to doing the case.
So all those other thingsnotwithstanding, how do you
diagnose that phonetic issues?
Chris (20:39):
Yeah, the phonetic issues on those cases the way that I
would see them coming is they'remore like wear cases, so they
have very thin tongues will justannex territory as they are
given more space.
So these patients have worn outthin teeth.
They may or may not have anysort of TMD or joint disease,
which may or may not besymptomatic, but their tongues
(21:01):
are big, their teeth are wornout and they have.
I'd say a couple of thepatients had accents already and
I will say that at least outhere in the Phoenix Valley,
patients that have had EasternEuropean or Russian accents or
New York or Northeast accentshave had a more difficult time
(21:22):
getting back to like theirnatural cadence and what they
sound like or their accent witha thicker prosthetic than, I'd
say, midwest patients orsomething like that.
For whatever reason.
I don't know if it's like whenyour tongue is sitting there and
it's just laying naturally withyour mouth closed, it wants to
sit up against eight and nineright behind that area.
(21:43):
And if you have, if you'veplaced your implants seven and
10, and they're even in idealpositions you still have this
bump there.
And that tongue wants to go.
It's like interfering withwhere the tongue wants to lay
and a majority of time peopleget used to it, but for whatever
reason, so I don't know that.
(22:03):
Those would be like the tipoffs for me.
For these older patients,thicker accents, maybe not
really philosophical patients,where it's like hey, I know that
they're going to be verydemanding, they don't even
really want, they're notaesthetically driven.
They're's like hey, I know thatthey're going to be very
demanding, they don't evenreally want a set.
They're not aestheticallydriven, they're just like hey,
my teeth are worn out and Idon't, I need to do something.
And I'm at the last part of this.
(22:24):
Those are things where I'd belike okay, I'm going to do maybe
something a little bitdifferent for you.
They don't understand thedifference between FP1 and FP3.
Even if you show them the modelthere's so much it's like you
go into all of this stuff andit's too much detail, and it's
you just think you spend 20 or30 minutes with someone talking
about what implants are and howthey're going to work and at the
very end they're like so isthat the same thing as a root
(22:46):
canal?
And you're just like okay, wegot to start all over again.
So you're trying to talk aboutnuanced stuff with phonetics,
with different prosthetics, andit's good luck, yeah.
So that's where I think some ofthe experience just comes in,
where it's like I'm not going tocharge you any different, I'm.
I just know I'm going to try toavoid eight try-ins with you
and we're going to do the case.
I'm going to do it this way andI'm going to do this other
(23:07):
style, and so it's hey, this isthe best option for you.
This is our normal cost,whatever.
This is what I.
What?
Soren (23:13):
I think For sure.
Another thing that I think couldbe helpful like after we see
some longer term, some justlength and studies about root
banking and how it works overtime would be I always see those
cases, too, where I see theteeth, and a lot of times as a
patient that probably is agrinder they've worn down their
initial teeth.
(23:34):
The teeth are in, they're in aposition that can't be restored
anymore, but they still havereally good bone and you could
tell that bone is like supercortical and which is going to
be a nightmare to get thoseteeth out.
And in those patients I feellike those are the ones that I
get that you're taking out acanine or something and the
buckle plate just comes andthere's nothing you can do.
That tooth is a vols in thereor ankylosed and like it is just
(23:56):
stuck in there.
And those patients I know, hey,if I just keep that canine, I
have such a better chance ofgetting these teeth out without
causing any major issues withthe bone.
And those cases that too, Ithink would be really are really
beneficial ones to do groupbanking on, and that's one of
the main reasons that I'veconsidered just like learning up
, learning more about groupbanking and what it can do for
(24:17):
these cases, because I think itcould have a better, more
predictable surgical outcomewithout having to worry about
trying to get some canine out.
That, you know, is just goingto be a nightmare.
You know what I mean For sure.
Chris (24:30):
Can you imagine how much faster that surgery would go to
if you just lop that crown off,versus like back and forth and
struggling back?
But yeah, it adds like an extra10 minutes just to try to
address the freaking.
Soren (24:41):
Yes, yeah, yep and then if you do break a buckle plate,
then you're like all right, nowI need to find bone.
We got a graft get a membrane,like it just adds so much time
on to the case, when it couldhave just been avoided by just
cutting the crown off.
So I agree what's?
Chris (24:55):
interesting is keeping those.
So let's say, depending on,like, the arch form and on your
surgical plan, sometimes the tipof your implant is going like
for your posterior maxilla, it'sgoing right towards that canine
.
So now you've got to figure outhey, what's my posterior?
Are you gonna play steroids ornot?
They're just all these littlenuances that as you get deeper
(25:18):
into it, just like you weresaying earlier.
So what's god?
Would you just want to dosingle implants all day, like,
how easy is that?
it's just a monkey, could yeah,now we're talking about the
nuanced difference between archform and the tip of your
posterior maxillary implant andangles and all that stuff which
I don't know.
For whatever reason it makes itinteresting?
Soren (25:35):
it does, yeah, and there's even there's cases out
there, too, where people areputting their implants through
teeth right.
Tyler (25:41):
Yeah, chris, I think you actually presented something
like that at the SIN symposium acouple of years ago, where you
put a pterygoid through aimpacted dermal or something
like that.
Chris (25:49):
I think I had the first documented case and.
Abel put it in his book on Ican't remember which one it was
as a case study, but guy wasyounger, didn't have the steroid
didn't want to do zygos, and heit's.
As soon as you learn how to dopterygoids.
Now, all these patients haveimpacted Maxler once in the
beginning.
So yeah, so I did that.
(26:10):
I did a one-year follow-up onit and everything was fine.
Tyler (26:13):
But, yeah, in be done.
Yeah, yeah, your follow-up onit and everything was fine.
But, yeah, you can be done.
Yeah, yeah, so now you can putthat posterior implant through
the canine and it's just morestability.
Soren (26:19):
That's great, exactly right, yeah, yeah I have a case
actually next wednesday, and thepatient has just a massive
canine from the floor of hismandible all the way up and it's
like taking out a huge chunkand I'm like he's older I think
he's 80, something like that andI'm like I really don't want to
take that out.
It's going to cause so muchmore damage than then like what
(26:40):
it would help by keeping it.
So I think in this particularcase I'm pretty sure I can work
around it.
I think I'm going to use like a10 millimeter implant and I
should be able to go right aboveit and I in my other implant
I'll be on the other side.
My problem is I I'm like thebiggest, I'm super OCD about
symmetry and I love symmetry.
So in my head I'm like just oh,like it's going to drive me
(27:02):
nuts Not taking that canine out.
Chris (27:04):
We just need to treat points on that for sure.
Tyler (27:05):
Yeah, definitely, and I you know what's asymmetrical is
when you break a jaw.
Soren (27:09):
Yes, exactly, so that's what like in my head.
I'm like, all right, like Iwould love to take this canine
out, put the implants in aperfect position, so I have that
nice pretty pano after the fact.
However, this one is not theone, so we're either going to
have to work around it or I justhave to use that canine for
extra stability with my implant.
Chris (27:26):
Before I did that case I went through and I tried to find
other documented cases ofimplants in teeth and a majority
of them are impacted canines, amajority of them are in the
maxilla and there's.
There was maybe like 10 or 15really good documented cases
over a period of at least fiveyears.
They all tried to avoid goinginto where the nerve, like where
(27:49):
the, the vascular canal of thetooth of the nerve was.
So I also tried the implantthat I put through that
pterygoid, the positioning ofthe tooth.
I was able to avoid it becauseI cut a hole through part of the
root but a majority of thecrown, so I didn't know if there
was any sort of nerve bundlegoing into the tooth.
(28:10):
So I, depending on what yourcase looks like now, if you just
go in, the cases that are aredocumented they were just going
into the cementum of the side ofthe route, they weren't like
blasting through the middle ofthe route.
Yeah, I don't know if that'shelpful in your case or not.
80 years old, they've got a lotof tertiary debt going on in
there, may or may not.
Soren (28:27):
Yeah, I think I'm probably just going to work
around it in this situation.
No-transcript of implants.
(29:07):
They want to get into full arch.
What are your recommendationsfor first getting into full arch
Like how many reps should youhave?
What do you recommend there?
And then, after you get intofull arch, what are your
recommendations for, like,getting into pterygoid implants
and then getting into zygoteimplants, and what courses do
you specifically recommend forpeople who are looking into
(29:28):
getting into that style ofdentistry?
Chris (29:30):
My remote Anchorage journey was when I started doing
full arch, up in my very firstone, like restoratively.
It was in Colorado, and then Idid one surgically while I was
there, which, if I look back atnow and got, what the hell was I
thinking?
And then, um, and then amajority of them, when I got
started, was up in South Dakotaand I had tried all sorts of
(29:52):
different techniques.
I'd done freehand.
I started, I did probably everystackable guide system.
I was like, oh, maybe this isthe answer.
Or there's at the time, justnot knowing what I, you just
don't know, what you don't know,and a lot of.
There's so much marketingbehind Full Arch and, as a young
practitioner trying to figureout what exactly you should be
(30:14):
doing, you get sold some stuffthat once you figure out what
exactly you should be doing, youget sold some stuff that once
you figure out maybe this isn'tthe best way to go about it.
So I felt like I was relativelywell versed in what was out
there for full arch.
And then, um, I remember I hada case that my posterior
maxillary implant just it failed, came back grafted.
It failed, came back grafted,it failed again, came back,
(30:38):
luckily worked that third time,but it took the treatment plan
from six months to 18 months.
I'm like man this is.
I didn't know anything aboutremote anchorage at the time.
I'd moved down to Arizona andthere's quite a bit more
competition down here and sothere's probably three or four
guys on my street that offerteeth in a day type of services
and I could not tell patients.
If I don't get adequatestability with your implants,
(31:00):
unfortunately you're going tohave to heal with a denture for
four months.
That just wasn't going to fly,so it forces you into.
Okay, what are the other things?
My first course was out atRamsey Amin.
He'd offered like this privatecadaver course on zygomatic and
pterygoid implants.
Thought that was interestingand then, but I wasn't really
(31:24):
sure what I was going to do withit.
But it started to give me somevocabulary that my mind could
use a little bit, or kind offollow along with what other
people were doing.
And then went down and did DanHoltzclaw's, I think, very first
course, which was in Dallas.
You had guys like Mike Picosthere.
It was like cutting edge stuffhe's learning at the same time
I'm learning.
I was like, oh, that's cool.
And then ended up doing acouple live surgery courses one
(31:51):
down in Brazil with Smiler andRosen and then did Vichy
Brumann's course here inScottsdale.
In between the cadaver courseand live surgery courses I would
line up patients to do in myoffice.
Soren (32:03):
That's smart.
Chris (32:04):
So it wasn't ever okay Spend a bunch of money and take
this time out and then sixmonths later hadn't haven't used
anything, um.
So that's how I got into it andat the time I was just I was
doing enough arches where Icould find arches to practice on
or do these things that I feltlike needed them.
And I think one of the biggestthings, or the reasons why to
(32:27):
get into it, is, if you're doingfull arch, the ability to
revise your own cases, which Ithink is a really big deal.
One from just a practitionerstandpoint of wanting to be able
to provide that, and two, fromthe patient standpoint, to
quickly and efficiently movethem from point A to point B
without this huge either stop intheir treatment or detour where
(32:48):
it's.
We're not exactly sure what'sgoing on.
I can't fix this.
I know I told you I'm the guythat you should trust with your
treatment and now you got to gosee someone else, something
along those lines.
Yeah, the ability to move casesalong and revise your own cases
and treat more cases, I thinkis a really big deal.
The other thing is um, I wastold, or I will, I will say that
(33:09):
there is like some philosophyout there that you should be
doing a hundred all in fourarches before you even get into
remote Anchorage.
And those same guys are likewell, every case should have
pterygoids.
Okay, do you want me to do ahundred cases without pterygoids
first and then do pterygoidsand then have the process before
(33:32):
getting even further into othersensitive techniques or
difficult techniques?
And that's 100% understandable.
(33:54):
One of the one of the issues ispreviously teaching courses or
helping teach courses on some ofthis stuff is that if you teach
someone an all on four, they'reyou've given them a hammer and
when they get back to theiroffice, all of the arches look
like all-in-four arches and whathappens is sure enough.
You get a call or you hey, Idid the reduction like I was
(34:15):
supposed to, I put my implantsin and I don't have enough AP
spread.
And the reason why they getinto that is they have not gone
through other remote anchorageor treatment planning courses
where it's like, hey, that casejust wasn't treatment planning
correctly, because you also needall of these other tools and I
don't know.
I would suggest that people getinto remote anchorage training
(34:38):
early if they want to do it.
Do all in four and arches,specifically to learn the value
of the treatment plans so thatyou can stay out of basically
the deep end for cases that youdon't need to all of a sudden
find yourself in.
I think one of the biggestadvantages of me learning a lot
of PROS stuff and joint stuffwas not that I wanted to treat
(35:00):
all of those cases, but it wasto avoid the cases that were
going to be a huge headache forme and my team and the patients.
I would say go to the livesurgery courses, go to the
cadaver courses sprinkling somepatients, whether or not you're
going to start doing those casesright away.
But once you have thatknowledge, you can't unsee it
and when you start lookingthrough your CBCTs you're going
(35:23):
to be like this is probably ateri-zygo patient.
I shouldn't try to sneak in anall-in-four on this one,
something like that.
The other thing I would say istake some sinus courses because
you need to get comfortablebeing in the sinus.
If you're going to be doingteris and zygos, I'm not saying
(35:46):
you need to do additionalgrafting with these, but if the
first time you're getting intothe sinus is that you're cutting
a slot for your zygote, you'renot going to have the same
feeling of hey, I've been herebefore.
I'm not worried about this, I'mworried about the orbit.
As if you've done a bunch ofsinus work and you're like, hey,
this is no big deal.
Soren (36:09):
If there's an issue, I can repair it this is not a
factor.
I'm focusing on what I should befocusing on, which is the
treatment that I'm trying toprovide.
Yeah, definitely, I agree ahundred percent, especially with
the learning like what remoteanchors can do for you and what
remote anchors can do as far astreatment planning goes.
There's so many doctors outthere who are so excited to get
into full arch.
They go to their first course,maybe they get four or five
arches under their belt andthey're just looking for that
next patient to do a case on,and that maybe that next patient
(36:31):
happens to be someone who justhas like super pneumatized
sinuses and they're, like yousaid, trying to sneak it all on
four on a patient that's goingto have canine access holes.
And then you're stuck in thesituation where the only option
you have is you either do onepre one molar, or you just have
(36:52):
this really big cantilever andthe patient just isn't in the
best prosthetic that they couldbe, or you're just going to be
dealing with this patient forthe next year and like those 15
appointments that you have wherea patient's just frustrated
with you they're frustrated thatthey decided to do the
treatment at this clinic it'snot worth that 20 grand or
(37:14):
whatever you got for thepatient's initial surgery.
So being able to avoid thosepatients and avoid those
problems for you and your teamis going to allow you to do
these cases for a much longerperiod of time.
Tyler and I have trained a lotof these doctors for quite a
while and saw their progressionup, and there's so many doctors
(37:37):
that get into this and then theyquickly realize, because of
problems that they've had withthese cases, wow, I do not want
to do this anymore.
I thought this was what Iwanted to do.
Maybe they had two or threecases that just didn't go the
right way and they had patientsreally frustrated with them, and
then they just decide, okay,this is not the style of
dentistry for me and in reality,if they would have been able to
(38:00):
see those cases up front andavoided them, they probably
would have been able to do somany more arches, got so much
more experience and that way,when one of these problems came
up, they're like, okay, let'shandle this, we can do this, and
it would have just elongatedtheir career in the style of
dentistry 100%.
Chris (38:18):
I think almost every course that either I'm helping
with or that I've attended.
Someone will say, hey, what'sthe next course, what should I
be doing next?
And I would say it's notnecessary.
There's no one single coursethat you're going to learn all
this stuff.
You've got to take them all andyou're going to.
You're going to look dependingon what like evolution you're at
(38:39):
in your career, you'll learndifferent things from those same
courses.
I think the biggest thing isjust finding a mentor, and so
those mentors will help youtreatment plan those cases that
you're not sure of, becauseyou're 100% right.
If you get burned by your firsttwo or three cases, I mean
you've just been scarred andyou're not going to do those.
Soren (38:59):
Yeah, I agree Absolutely.
I want to get into as well.
And oh, funny thing I wanted tomention too you were mentioning
that Mike Picos was at thecourse you're at when I was,
when we went to.
Oh Tyler wasn't with me thistime, but I was in Portugal for
a palatal approach course.
Tyler (39:15):
Yeah.
Soren (39:16):
Bernardo and Mike Picos came to that one, so it was
really cool.
I have this picture of Bernardoand Picos both like on both
sides of me, while I'm like inthere doing like a case, and I
was like, oh, this is, it wasjust like a cool moment for me.
Tyler (39:30):
More specifically, picos is assisting you while doing the
case.
Now, I hate that photo so much,yeah I love I loved it.
I was like oh, this is yeah,he's holding suction for you
while you do it.
Soren (39:43):
That's awesome yeah, but it was just cool to be there,
because it was reassurance thatI was like on the right path, of
kind of the forefront of newtechniques, right.
So I'm like, okay, pico's ishere, obviously some, I'm in the
right course for sure, becausehe's trying to learn this as
well.
And it was also cool because hedid a whole uh over in europe.
(40:07):
Right now, I think subs are likea big thing, like the new sub,
right, so he went custom yeah,yeah the custom implants and he
went over all of these likemandibular sub cases that he has
done over the last 50 years andhe showed like follow-ups maybe
not 50, I don't know exactlyhow long he's been practicing,
but he's showed follow-ups over30 years time of all these
(40:29):
mandibular sub cases that haveworked really well for him.
And was just reassuring thegroup of these custom implants
they work.
You just, if you plan the casecorrectly, you do your flap
correctly, they can be anotherpowerful tool for patients in
this journey.
Because, I feel like a lot ofpatients.
They're in this cycle where thefirst thing is a traditional
(40:52):
all-in-four and then if anythinghappens with that, then what's
the next step?
You either have to decide.
Right now the biggest thing isZygos, right, but if there could
be a solution in between thosetwo where it's maybe we do a
custom implant and then if thatcustom implant doesn't work,
then we can get into quad zygoteterritory.
I don't think we've mentionedon this podcast but I know that
(41:13):
you've mentioned it to mepreviously where the number one
thing to avoid as long as youcan are quad zygos.
Chris (41:22):
That's what my mentors have told me, so I just try to
do what they tell me.
Yeah, you reiterate.
Soren (41:27):
So it'd be cool if there was predictable option that we
could go to prior to going tothat quad.
And I don't know for sure ifthe custom implant is that
option.
It sounds like it is.
I have seen a couple of thecases being done and there is a
decent amount of reduction stillin a decent amount of slots.
But I think that it's going tobe a powerful thing in the next
(41:49):
10 years in implant dentistry.
It's not approved, obviously,in the US yet, but what are your
?
Thoughts on that.
Chris (41:56):
Yeah, my thoughts are.
There's a gentleman named SamJurek over in Genesee and he's
seen a lot more dentistry than Ihave and he's like hey, we've
already been here and we've seena lot of maxillary subs fail.
Mandibular subs are somethingdifferent, and I think I've met
Bernardo a couple of times andI've had nothing but positive
(42:18):
interactions with him, and Ithink he's a great educator.
He speaks well, he carrieshimself well.
I don't agree with everythingthat he says, though.
I had a case yesterday in anoffice where, first I did a
palatal approach, didn't get theprosthetic timing where I
wanted it.
I thought it was going to betoo palatal.
I thought it might cringe onthe tongue space.
(42:40):
Then I tried a tree and sinusand couldn't get the torque that
I needed as well as the archform, with the two anterior
implants even angled so I canget my poster one to slide in.
It just wasn't going to be asideal as what I thought the
patient needed, so Itransitioned and put his eye go
in, and is that a case for aunilateral custom implant sub on
(43:04):
that side?
I don't know, but that doesn'tmake a lot of sense to me.
I think the other thing too isI don't know how much they cost
over in Europe, but over herethey're very expensive, very,
yes.
And so imagine if you're likezygomatic implants are $5,000 a
piece.
Yeah, it'd just be like thatdoesn't make a lot of sense, and
(43:27):
it's just the ration.
I understand a little bit ofthe rationale Now.
Here is my take on why he and Ihaven't had this conversation
with Bernardo, but this is mytake on it.
He was at the Molo Clinic for anumber of years and that's
where he got a lot of histreatment.
He saw a lot of a number ofyears and that's where he got a
lot of his training.
He saw a lot of a lot of arches, a lot of patients.
(43:47):
My understanding is that theyused Nobel's idiomatic implants,
nobel's and I don't know theexact approach that those
clinics were using.
If they're using the originalBrandenburg approach, if they're
doing a Stella and Warner slottechnique, if they were doing
extra maxillary approach, ifthey were doing some Zaga
concept or a combination of allof those, I'm not sure.
(44:08):
But the way that Nobelzygomatic implants are, you are
going to have a higher rate ofcomplication, 100% from the
design and the technique andtheir instrumentation and how
you place them versus some ofthe newer techniques and
instrumentations and implants onthe market.
I'm curious.
Tyler (44:27):
When we talk about newer, obviously we're talking slot
techniques, extra maxillarytechniques.
I think a lot of the zygos thatBernardo would have seen and I
don't want to speak for him, butduring that time when he was at
the model clinic were probablyintrasinus.
And I think you're right aboutthe zygomatic, the Nobel
zygomatic implant.
What were some of the featuresof the implant itself and also
the technique that?
Chris (44:48):
may have led to some negative bias towards that.
So the original one thatBrandenburg had fabricated,
which was at the same timefabricated with the other
implants, so it's been aroundjust as long.
It's not like a newer thing.
Those implants were originallymade for cancer resection and
trauma patients.
If I were to show you some pano.
So there's a book called theOsseointegration Book.
(45:08):
It's right here.
Put up on the screen forYouTube guys, this is one of my
favorite books.
Soren (45:19):
Okay.
Chris (45:25):
And it documents.
Tyler (45:27):
That logo is very interesting actually yeah, it's
a.
Chris (45:31):
This logo is like severe atrophy restored.
Have you seen?
Soren (45:34):
our.
Have you seen the fixed podcastlogo?
Tyler (45:37):
yeah it's, our it's missing.
Chris (45:40):
It's missing terror quotes.
Yep, that's all Ours, isn't?
It's one of those things.
If I were to show you some ofthe original cases what he?
does is he goes through and hesays this is patient number one
and he follows them.
So this is like wow, casenumber one, john, number one by
(46:03):
Brandon Mark.
And then he shows his followupup and this is what he does.
And here's the original.
And guess what?
The poster implant fails andguess what he does?
He puts in a zygomatic implant,like some of these panels look
like today's remote anchoragepanels.
Tyler (46:17):
It's pretty wild Out of time, so it's crazy.
Chris (46:21):
The original implants were machined and they're
basically just like long boltsand it's mainly an intrasinus
technique.
They didn't have angledmulti-units at the time.
So some of those original umocclusal shots where it's like
god, why would someone have theimplant coming right like out
mid palate or whatever?
It was a zero degree abutment.
(46:42):
There was no like hey, swing itover 60 degrees yeah, so some of
that was just what they had,and then the other part of it
was they didn't have greattorque with some of that stuff
as well, as the end of theimplant had a little nipple on
it and so they would have thistechnique where his intrasinus
and then they would feel thedrill come out and then they
(47:04):
would feel the edge of theimplant to make sure that they
knew that it was in far enough.
So you potentially had pressureunderneath the tissue that could
cause some sort of fistula orsomething like that.
Yeah, so at the time of a hey,if you want to get more, if you
want to get better integrationbecause we've had some failures
with these let's coat thesurface with something and now
(47:24):
let's stick it in the sinus,which the surface coating might
make sense for integration, butas far as sinusitis and issues
with the sinus wasn't probablythe right thing to do.
Yeah, so I think if you combinethose things and you do a high
volume of those and you look atsome of that stuff, you're like,
hey, I think there's a betteroption and maybe a custom
(47:45):
implant would be a better optionbecause you can avoid all these
things.
But I do think that over time,with extra maxillary technique
and pterygoid fixation behind itto give those implants
stabilization, I think you caneliminate a lot of those
problems you.
My name is Dr Tyler Tolbert and I'm Dr Soren Papi
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Hello and welcome to the FixPodcast.
Today we have Dr Chris Barrettwith us.
We are super excited to haveChris here.
I actually met Chris for thefirst time in Denver about three
(00:21):
months ago probably, and we'vehad a lot of conversations.
Yeah, yeah, we've had a lot ofconversations, probably, and
we've had a lot of conversations.
Yeah, yeah, we've had a lot ofconversations since and we've
been sharing a lot of casestogether and we're very honored
to have him on the podcast today.
He is one of the front runnersfor Zygo implants for GPs
placing quad Zygos doing remoteanchorage cases and we're super
(00:44):
excited to have him on thepodcast here today.
Chris (00:46):
Yeah, excited to be here.
Thanks for having me on andyeah, we have had some great
conversations ever since Denver.
So, yeah, what conference was?
Soren (00:54):
that at.
I think it was a Dykema DSOconference.
Might have been that one, yeah,I came over to the what was the
big conference center.
Chris (01:04):
That hotel out by the airport.
That's massive.
Soren (01:08):
Yeah, I can't remember either Tip of the tongue.
Yeah came out there, had adrink, we discussed both of our
backgrounds and we had a bunchof similarities in our
backgrounds and getting intoimplant dentistry and, yeah, I'm
sure the audience here wouldlove to also hear about your
background.
So if you could fill us in alittle bit your background in
Full Arch, maybe a little bitabout the work history, how you
(01:29):
got into remote Anchorage, Ithink that would be a great
start.
Chris (01:35):
Yeah, I graduated from University of Iowa in 2011 and
wasn't sure exactly what Iwanted to do.
Everyone that I talked to thathad done a GPR was like I would
never trade another year ofprivate practice for my GPR year
.
So I thought, okay, I'll take ayear and do that.
At the time, I really lovedsurgery and I really liked endo
(01:55):
and I think that was justbecause we had what I felt was
just the best adjunct faculty inthe oral surgery and endo
department.
So at Iowa, if you finished withyour requirements early, you
could spend as much time as youwanted to in whatever department
.
So I ended up spending amajority of my oral surgery and
we had these OS guys from allover the state that were at the
(02:18):
later part of the years and theyjust loved coming in and
showing you all their littletips and tricks on exodontia.
And they're just telling youall their little tips and tricks
on exodontia and they're justtelling y'all their little war
stories and this and that, and Imean it was just awesome.
So I took to that and then didthe gpr year.
Honestly, watching the perioand dental school and os faculty
(02:39):
or guys or whatever placeimplants, I was like man that
looks so boring.
I mean they'd take forever toplace one implant and it was
based off of like a dentalstudent guide that never fit and
they're like we're just goingto do this ourselves.
I was like this is whatimplants are.
I was like I'll just go dosomething else, I don't know.
So I ended up practicing Iowafor a year and then all my
(03:02):
siblings actually live in Denverand my parents have siblings
that are out there too and,looking to make a move, went out
West from Iowa and there's alot of Iowa grads out in Denver
and so they'd been out there anumber of years before me.
I had gotten a job that allthese guys were saying, hey,
this is like one of the nicestoffices and so if you get
selected for that job, youshould take it.
The caveat was that it was arestorative only practice.
(03:26):
So, even though I was good atsurgery and I liked different
procedures, they're like hey, weare a fee for service office.
We work with other fee forservice offices here in South
Denver and this is what you'regoing to do.
And so I was like, okay, signedup for that.
They taught three differentlevels of occlusion out of that
office, and the guy who startedthat office I'd say you and
(03:48):
Tyler are younger than me, soren, but let's say around the same
age, and let's say some of thebig names in whatever we're into
, have some sort of study clubor go out and teach or whatever,
and they're looking for guys tohelp teach.
The guy who started this, thatoffice, his mentor, was a
relatively famous prosthodontistnamed Niles Goucher and he
(04:09):
ended up inventing the Dehnerarticulating system.
He also developed somethingthat was like a digital or a
analog jaw tracer for thatsystem, and so they were all
about the study of nathology andbasically joint-based treatment
that as long as the joint wascomfortable and the muscles were
(04:29):
comfortable, you could restoresomeone and you can do it very
predictably.
So they did a lot of TMDtreatment and they worked with a
lot of really greatorthodontists, and so most of
that time was the cases I was apart of was maybe phase one and
phase two, and then phase two issome ortho, maybe some minor
restorative and a little bit ofequilibration.
Every once in a while there'dbe some surgery involved, but
(04:51):
that was like a little residencythat I didn't know anything
about it, and this is two orthree years out of school.
Looking back at it.
Now I'm like, okay, I can seewhere there were some pitfalls
or maybe some different thingsthat maybe I would do
differently, but that's where Ilearned how to restore it the
(05:16):
different analog restorativesteps.
They had labs that would comein.
That's where I learned how torestore it the different analog
restorative steps.
They had labs that would comein.
Well, it's a guy, arnie Hoffman, and I don't know if you know
him.
Soren (05:28):
Yeah, I know.
Chris (05:28):
Arnie.
So I met him at that when I wasat that practice because he
worked at one of the local labs.
He's a German prosthodontist.
Kind of looks like ArnoldSchwarzenegger.
Tyler (05:35):
He looks like him.
Chris (05:39):
Yep, super on restoring those.
Doing it all analog.
I end up going through adivorce while I'm at that office
and I transitioned to adifferent office and start
placing my own implants andgetting back into doing some
surgery I end up living withfirst.
I end up living with my youngersister and I was like, hey, I
(06:02):
got to get out of my youngersister and her husband's house.
Get out of there and thebiohorizon rep does.
Soren (06:08):
matt is matt I actually I was talking to him yesterday
yeah, he's woven into this story.
Chris (06:19):
The, his roommate had gotten his girlfriend pregnant
and so he had to move.
So Matt sent out a group textto like all the guys that are
around the same age that wouldhang out every once in a while
in the Denver area and say, hey,I got a room open.
If anybody's looking for it,that sounds good.
So I ended up living with Mattfor probably a year or so.
And I'm listening to the AAIDpodcast and Mike Freimuth is
(06:42):
co-hosting with Danny Domainbecause Justin Moody was like
out of town or something orwhatever.
And I see and I hear that he'sa diplomat and does a bunch
about implants and he's in WheatRidge, colorado and I'm like,
wow, that's like right here andI look up the ABY and diplomats
and there's like two in thestate and he's one of them.
And I asked him.
I'm like, hey, matt, do youknow?
This guy seems to know a lotabout implant dentistry.
(07:04):
He's like, yeah, he's like mybiggest client.
Guy's like he's just a machine.
I'm having dinner with him nextweek.
So I'm like, is there anychance that I could go to that
dinner with you guys?
Do you think he would mind?
He's all ask him, but I thinkit'd probably be good.
So go over there, have dinnerwith him.
He's actually looking for anassociate and at the time I was
(07:26):
planning on going back to Iowato be closer to my kids that
were back there.
I don't end up working with orwith him or for him, but I ended
up spending every single dayoff I can over his office and he
really expanded my mind as faras what was possible as a
general dentist he had.
He was doing really nice FP1cases in operatory one at the
(07:47):
same time, then he was preppinglike a veneer case in operatory
two and then he had four hygienechairs and then he had already
built out his own in-house lab.
I had two or 3 million machines, two or three lab techs and
this is probably like 2013.
And so when guys are like, ohwow, I just built out a lab or
whatever, I'm like dude.
You guys are no, you think thisis probably like 2013.
And so when guys are like, ohwow, I just built out a lab or
whatever, I'm like dude, youguys are no, you think this is
(08:08):
like a new thing, that's justhappening.
But there's like these guys thatwere like a generation before
you, that were like it's crazy,and they're done and yeah, he's
just, he's always tip of thespear huge on education.
That's how why I started takingKois stuff because he was like,
hey, you got to go take Kois.
He did all the MISH and Koisstuff with.
It was him and Moody way backin the day when he was our age,
(08:28):
and those guys ended up startingPathway and through that
relationship I ended uppracticing with Justin Moody for
a couple of years and takingover his implant practice and
then so I went from placing afew implants a month to that's
all I did and fortunately, I hada really strong comprehensive
dentistry and prosthodonticmindset and I had previous good
(08:50):
surgical skills from Universityof Iowa and the OS department
there in the GPR.
That was just like veryfundamental, basic things that I
feel like you can use foreverand all walks of whatever
surgery you're doing.
So I'm super grateful for that.
And then I ended up moving downto Arizona in 2019 and started a
group called brightly with someprivate equity guys and help
(09:12):
grow that to different officesaround the country, which is
basically just like guys that Iknew or y'all said I knew that,
hey, that looks good, I want todo that too.
And then left that in 2013 orin 2023, excuse me.
And then I've just beentraveling around the Phoenix
Valley for the last year and ahalf or so just doing all on X
from basic law and force toadvanced zygosurgery and then
(09:35):
periodically flying around thecountry mentoring or helping
other docs, just trying tofigure out what I'm going to do
next.
Soren (09:41):
Nice, yeah.
Yeah, it's funny, matt, matt Go, matt goff he.
So I've been working with himwith biohorizons.
We use all of their biologicsin our offices and I think you
made that connection actually atthe which.
So thank you for that, chris.
And yeah, and it was funnybecause I was.
I reached out to him yesterdayjust because I was looking for a
sinus lift kit and I justreached out to him.
(10:02):
I was like, hey, do you guyssell these at all?
I don't think they do, but Iended up going with a Selvin kit
.
So if you have anyrecommendations?
Chris (10:08):
I would have recommended Tatum, but that's fine.
Soren (10:10):
Okay, all right.
Yeah, I should have reached outto you first.
Tyler (10:13):
Now your time.
Soren (10:15):
It's all right, I'm sure the Selvin kits.
He's like, hey, by the way.
Yesterday he said this hey, bythe way, dr jen mansky is my
wife and I was like, oh, no way,because two weeks ago I've got
this patient who comes in and heneeds a.
He's hey, doc, can you?
What exactly do I need here?
And he had one of the mostresorbed maxillons I've ever
(10:38):
seen, like no bone.
He had canine to canine bridgeand then from the canine to
canine.
There was absolutely nothing,like no bone whatsoever.
And I was like this have youhad this for a while?
And he's like, yeah, when I wasa kid I got into a traumatic
accident and lost my front teethand I was like, all right, well
, all on four is going to be outof the question unless we like
(10:58):
have some really extensivegrafting and that's not what you
want to go through at thispoint.
And I don't think he needed iteither.
But his lower bridge wasdefinitely failing and I was
like we can do a lowerimplant-supported bridge.
And I'm like you should go backto your general dentist to see
what they can do with that upperbridge and maybe they can
repair it, because it hadfractured and his dentist
(11:18):
happened to be Jen Manske, so Iwas on the phone with her like
two weeks ago, just like we weretalking about how we were going
to like plan this case out.
And then it just happened thatmatt they were married and I was
like, oh wow, it's such athere's a small world.
Yeah, I feel like the dentalworld's small enough and then,
once you get into the implantdentistry, it gets even smaller,
which is pretty crazy.
Chris (11:36):
Yeah, I there is.
Uh, I went out to californiaabout two months ago and did a
case for a young woman and she'stelling me that her best friend
practices in Arizona.
And sure enough, the one like I.
I, there's only three or fouroffices that I really go to and
(11:56):
my girlfriend, who's a dentalassistant she does some temp
assisting out of.
She literally has not done anysort of temp assisting for years
and then all of a sudden, likeher second gig is this girl's
best friend.
I was like okay that's just tooweird right
Soren (12:14):
yeah, that stuff happens all the time yeah, it's funny
you were saying earlier separatetopic, but you were saying
earlier.
I just wanted to mention thisbefore I forgot that when you
first started, like seeingimplants, you're like man, that
looks super boring, Like I'm notinterested in that too much.
And I remember when I was likesecond or third year of school I
saw these guys that were likeimplantologists, right, and they
(12:36):
were like promoting themselvesas implantologists and I'm like
man, that just sounds so I don'tthink I don't want to just do
one thing, like just play singleimplants every day.
that sounds like the worst thingever and it's so funny, just
and it goes into what you weretalking about earlier about
milling and making your own labthere's just so much that you
don't know until you get intothat avenue, right.
(12:58):
So like you start to learn alittle bit about implants and
then you're like, wait, what'sthis full arch thing?
And all of a sudden you're like, oh my gosh, like it's so cool
that all of a sudden, uh, youcan have a patient that comes in
who needed a denture, that canhave, you know, a new set of
teeth in a day.
So then you get into the fullarch stuff.
And then, once you're in thefull arch stuff, the next kind
of step is like maybe dabblinginto remote anchorage.
(13:20):
I feel like sometimes, prior toremote Anchorage, most people
and especially now, like in thelast year or two will start
getting into like the digitaldentistry stuff, and then that
opens up a whole nother can ofworms there.
So you're, you got all theremote Anchorage stuff and then
all of the dental stuff, andthen you find out like, like for
me, even if, like setting up amill in my office and stuff, I
(13:42):
feel like I'm way ahead of thecurve.
But then in reality there'speople a decade ago that were
like oh yeah, I was doing that.
I was doing that 10 years agoand it's just amazing to see all
of the different avenues andthe things that you can get into
and how many, how there'salways someone out there that's
like one step ahead of you,right, doing these things.
It's just interesting.
(14:05):
I wonder what, like the next bigthing in dentistry is going to
be.
I think right now, in like fullarch probably, that would be
like I've seen guys now that aredoing they'll do digital
designs and they'll have all theteeth designed already but they
won't place the implantpositions.
And then, as soon as theimplant positions are placed,
they'll then and they'll millthe first half of the zirconia.
Then they'll mill like theaccess holes of the zirconia, is
(14:25):
my understanding, and you cando same day zirconia deliveries.
Have you seen that at all yet?
Chris (14:31):
I haven't.
But I'm trying to think of whatthe I'm not a huge fan of doing
same day finals.
I've done a couple of them andif I were going to say, hey, I
think that this was my mom ordad or whatever, I'd probably
make them another one fourmonths later.
Yeah, so that's one of thosethings where it's but, to be
(14:52):
honest, but that's cool, yeah,that's cool that the technology
is like getting to the point ofyou can do that.
So, let's say, it's almost likea healed ridge through a
dentalist.
You're like I just gotta dropsome screws.
And then you're like, oh, itcan make you your final because
I know if the soft tissue is,it's flapless or something
that's cool.
Soren (15:08):
Yeah, no, definitely, and I'm definitely with you there.
I tell all my patients that Iprefer that they wait two, three
months for all the bone tohealing to occur, all the tissue
healing, before we go to yourfinal prosthetic.
But I do think for certainstyles of practice if people are
traveling or something likethat and they don't have a ton
of time in your clinic it can bea really good option for
(15:32):
patients to get same dayzirconia and then at the four
month mark then remill them inthere with the changes that
they've had to their bone andtissue.
But I agree, as far as there'sa lot of healing that occurs and
I don't think even one week,finals and stuff are the best
possible outcome for patients.
But I think there's a lot ofheadway coming into that
direction where some of theseguys I've seen they'll design
(15:55):
the prosthetic in a way thatthey're planning it a certain
distance from that bone levelright, so that way when the
tissue heals they're planningfor that and maybe they end up
having to remill two or threeout of 10 arches, but at least
those seven arches that they did.
The patients are stillrelatively happy with those
cases still relatively happywith those cases?
Chris (16:14):
Yeah, I think, as there's more and more socket shield and
root banking and remoteanchorage and I shouldn't say
that in the same sentence.
For example, I think, for theFP1 cases that I've done, a lot
of times you run into issues inthe molars.
Let's say there's just not alot of bone there for a really
solid molar, so you end upputting in a zygote or terry.
(16:36):
But you can do almost like rootbanking and socket shields in
the front.
When you have something likethat's like a point of
measurement, when you're keepingsomething, then I do.
I do think it makes sense thatthat you could potentially go
closer to final versus, versus.
In my mind, an FP3 is adefensive modality versus, uh,
(16:59):
let's say, an FP1, which is moreyou're playing offense, and
what I mean by that is you doyour FP3, you do your surgery
and then you wait for everythingto heal for three months and
then you're like I'm going towait to see how the body
responds and then I will now goback and I'll do the next part.
Versus something like an FP1,you've got to play more offense
(17:20):
and you have to do moreconnective tissue grafting.
You might have to root bank,you might have to do something
else to get the body to do whatyou want it to do, versus hey,
let's just have this heal andthen see what happens.
Soren (17:33):
Yeah, no, I agree Definitely.
What are your thoughts on?
Have you done a lot of socketshielding, root banking?
I personally haven't done anyof it.
Our colleague Caleb, he, hasdone a couple of cases that have
turned out pretty well, but I'mcurious what your thoughts are
on that.
Chris (17:47):
Yeah, I've done two single socket shields.
I've done some root banking andthat P1 cases that I've done
it's been more uh, a couple ofyears ago, like a xenograft and
connective tissue grafting.
I think if I were going to dothem today, I'd change some of
that stuff.
As far as root banking and andsome socket shields, I just saw
(18:07):
an unbelievable lecture by a guynamed David Atiyah.
He was out of Australia and hejust the amount of detail that
it goes into as far as diagnosisand making sure you get a
quality outcome with, with, withpet or soccer shield or
whatever.
I think you have to select thecases right.
The diagnosis has to bedifferent and it's not, as I
(18:29):
would say, easy, asstraightforward as doing an FP3,
where it's you're basicallyjust giving yourself a blank
canvas to create whatever youwant.
So, yeah, it's very interesting.
That's something that I'mexcited to see how that develops
as far as some more kind ofinnovation or techniques or
things that just give reallypredictable results, because
(18:50):
I'll say, from just doing a lotof FP3s, there's a couple
patients that come to my mind.
Whereas if I could redo that, Iwould do them as an FP1.
Doing a lot of FP3s, there's acouple patients that come to my
mind, whereas if I could redothat, I would do them as an FP1.
And a lot of it was tonguespace and phonetics and almost
nothing to do with aesthetics.
Or these are older patients.
It's not like it was a youngpatient that I'm like hey, I
(19:12):
just artificially aged them byreducing a lot of their bone or
something like that.
This was just more like hey,where are our eights?
Trying and I know you're fromNew York and I know you speak
Italian to your friends over inItaly and they can't understand
that one word, that you say yeah, like they used to say with
your natural taste.
I don't know what else to do,but if I could thin this out
more, I think it would be betterfor you.
(19:34):
And just the style of howeverything was, I just couldn't
make it any thinner.
I learned my lesson just on acouple of those and I could see
them coming.
Now where it's a whether or notthe transition, these are low
lips.
I'm not going for unbelievablyaesthetic FP1 cases.
These are just thinner, smallerrestorations where it's like
hey, the phonetics I think are alittle bit easier and I think
(19:57):
there's a lot more tongue space,definitely yeah.
Tyler (20:00):
No, I agree 100%.
Yeah, chris, I think that's aninteresting point because
whenever I hear aboutindications for FP1, a lot of
times it's what you just alludedto a really young patient, a
high lip line where reduction tohigh the transition line is
going to be pretty absurd for agiven patient, and we're doing
the FB1 to preserve that bonyarchitecture, so on and so forth
(20:20):
, but you're bringing up thephonetic point.
So I'm curious, on the frontend, prior to doing the case.
So all those other thingsnotwithstanding, how do you
diagnose that phonetic issues?
Chris (20:39):
Yeah, the phonetic issues on those cases the way that I
would see them coming is they'remore like wear cases, so they
have very thin tongues will justannex territory as they are
given more space.
So these patients have worn outthin teeth.
They may or may not have anysort of TMD or joint disease,
which may or may not besymptomatic, but their tongues
(21:01):
are big, their teeth are wornout and they have.
I'd say a couple of thepatients had accents already and
I will say that at least outhere in the Phoenix Valley,
patients that have had EasternEuropean or Russian accents or
New York or Northeast accentshave had a more difficult time
(21:22):
getting back to like theirnatural cadence and what they
sound like or their accent witha thicker prosthetic than, I'd
say, midwest patients orsomething like that.
For whatever reason.
I don't know if it's like whenyour tongue is sitting there and
it's just laying naturally withyour mouth closed, it wants to
sit up against eight and nineright behind that area.
(21:43):
And if you have, if you'veplaced your implants seven and
10, and they're even in idealpositions you still have this
bump there.
And that tongue wants to go.
It's like interfering withwhere the tongue wants to lay
and a majority of time peopleget used to it, but for whatever
reason, so I don't know that.
(22:03):
Those would be like the tipoffs for me.
For these older patients,thicker accents, maybe not
really philosophical patients,where it's like hey, I know that
they're going to be verydemanding, they don't even
really want, they're notaesthetically driven.
They're's like hey, I know thatthey're going to be very
demanding, they don't evenreally want a set.
They're not aestheticallydriven, they're just like hey,
my teeth are worn out and Idon't, I need to do something.
And I'm at the last part of this.
(22:24):
Those are things where I'd belike okay, I'm going to do maybe
something a little bitdifferent for you.
They don't understand thedifference between FP1 and FP3.
Even if you show them the modelthere's so much it's like you
go into all of this stuff andit's too much detail, and it's
you just think you spend 20 or30 minutes with someone talking
about what implants are and howthey're going to work and at the
very end they're like so isthat the same thing as a root
(22:46):
canal?
And you're just like okay, wegot to start all over again.
So you're trying to talk aboutnuanced stuff with phonetics,
with different prosthetics, andit's good luck, yeah.
So that's where I think some ofthe experience just comes in,
where it's like I'm not going tocharge you any different, I'm.
I just know I'm going to try toavoid eight try-ins with you
and we're going to do the case.
I'm going to do it this way andI'm going to do this other
(23:07):
style, and so it's hey, this isthe best option for you.
This is our normal cost,whatever.
This is what I.
What?
Soren (23:13):
I think For sure.
Another thing that I think couldbe helpful like after we see
some longer term, some justlength and studies about root
banking and how it works overtime would be I always see those
cases, too, where I see theteeth, and a lot of times as a
patient that probably is agrinder they've worn down their
initial teeth.
(23:34):
The teeth are in, they're in aposition that can't be restored
anymore, but they still havereally good bone and you could
tell that bone is like supercortical and which is going to
be a nightmare to get thoseteeth out.
And in those patients I feellike those are the ones that I
get that you're taking out acanine or something and the
buckle plate just comes andthere's nothing you can do.
That tooth is a vols in thereor ankylosed and like it is just
(23:56):
stuck in there.
And those patients I know, hey,if I just keep that canine, I
have such a better chance ofgetting these teeth out without
causing any major issues withthe bone.
And those cases that too, Ithink would be really are really
beneficial ones to do groupbanking on, and that's one of
the main reasons that I'veconsidered just like learning up
, learning more about groupbanking and what it can do for
(24:17):
these cases, because I think itcould have a better, more
predictable surgical outcomewithout having to worry about
trying to get some canine out.
That, you know, is just goingto be a nightmare.
You know what I mean For sure.
Chris (24:30):
Can you imagine how much faster that surgery would go to
if you just lop that crown off,versus like back and forth and
struggling back?
But yeah, it adds like an extra10 minutes just to try to
address the freaking.
Soren (24:41):
Yes, yeah, yep and then if you do break a buckle plate,
then you're like all right, nowI need to find bone.
We got a graft get a membrane,like it just adds so much time
on to the case, when it couldhave just been avoided by just
cutting the crown off.
So I agree what's?
Chris (24:55):
interesting is keeping those.
So let's say, depending on,like, the arch form and on your
surgical plan, sometimes the tipof your implant is going like
for your posterior maxilla, it'sgoing right towards that canine
.
So now you've got to figure outhey, what's my posterior?
Are you gonna play steroids ornot?
They're just all these littlenuances that as you get deeper
(25:18):
into it, just like you weresaying earlier.
So what's god?
Would you just want to dosingle implants all day, like,
how easy is that?
it's just a monkey, could yeah,now we're talking about the
nuanced difference between archform and the tip of your
posterior maxillary implant andangles and all that stuff which
I don't know.
For whatever reason it makes itinteresting?
Soren (25:35):
it does, yeah, and there's even there's cases out
there, too, where people areputting their implants through
teeth right.
Tyler (25:41):
Yeah, chris, I think you actually presented something
like that at the SIN symposium acouple of years ago, where you
put a pterygoid through aimpacted dermal or something
like that.
Chris (25:49):
I think I had the first documented case and.
Abel put it in his book on Ican't remember which one it was
as a case study, but guy wasyounger, didn't have the steroid
didn't want to do zygos, and heit's.
As soon as you learn how to dopterygoids.
Now, all these patients haveimpacted Maxler once in the
beginning.
So yeah, so I did that.
(26:10):
I did a one-year follow-up onit and everything was fine.
Tyler (26:13):
But, yeah, in be done.
Yeah, yeah, your follow-up onit and everything was fine.
But, yeah, you can be done.
Yeah, yeah, so now you can putthat posterior implant through
the canine and it's just morestability.
Soren (26:19):
That's great, exactly right, yeah, yeah I have a case
actually next wednesday, and thepatient has just a massive
canine from the floor of hismandible all the way up and it's
like taking out a huge chunkand I'm like he's older I think
he's 80, something like that andI'm like I really don't want to
take that out.
It's going to cause so muchmore damage than then like what
(26:40):
it would help by keeping it.
So I think in this particularcase I'm pretty sure I can work
around it.
I think I'm going to use like a10 millimeter implant and I
should be able to go right aboveit and I in my other implant
I'll be on the other side.
My problem is I I'm like thebiggest, I'm super OCD about
symmetry and I love symmetry.
So in my head I'm like just oh,like it's going to drive me
(27:02):
nuts Not taking that canine out.
Chris (27:04):
We just need to treat points on that for sure.
Tyler (27:05):
Yeah, definitely, and I you know what's asymmetrical is
when you break a jaw.
Soren (27:09):
Yes, exactly, so that's what like in my head.
I'm like, all right, like Iwould love to take this canine
out, put the implants in aperfect position, so I have that
nice pretty pano after the fact.
However, this one is not theone, so we're either going to
have to work around it or I justhave to use that canine for
extra stability with my implant.
Chris (27:26):
Before I did that case I went through and I tried to find
other documented cases ofimplants in teeth and a majority
of them are impacted canines, amajority of them are in the
maxilla and there's.
There was maybe like 10 or 15really good documented cases
over a period of at least fiveyears.
They all tried to avoid goinginto where the nerve, like where
(27:49):
the, the vascular canal of thetooth of the nerve was.
So I also tried the implantthat I put through that
pterygoid, the positioning ofthe tooth.
I was able to avoid it becauseI cut a hole through part of the
root but a majority of thecrown, so I didn't know if there
was any sort of nerve bundlegoing into the tooth.
(28:10):
So I, depending on what yourcase looks like now, if you just
go in, the cases that are aredocumented they were just going
into the cementum of the side ofthe route, they weren't like
blasting through the middle ofthe route.
Yeah, I don't know if that'shelpful in your case or not.
80 years old, they've got a lotof tertiary debt going on in
there, may or may not.
Soren (28:27):
Yeah, I think I'm probably just going to work
around it in this situation.
No-transcript of implants.
(29:07):
They want to get into full arch.
What are your recommendationsfor first getting into full arch
Like how many reps should youhave?
What do you recommend there?
And then, after you get intofull arch, what are your
recommendations for, like,getting into pterygoid implants
and then getting into zygoteimplants, and what courses do
you specifically recommend forpeople who are looking into
(29:28):
getting into that style ofdentistry?
Chris (29:30):
My remote Anchorage journey was when I started doing
full arch, up in my very firstone, like restoratively.
It was in Colorado, and then Idid one surgically while I was
there, which, if I look back atnow and got, what the hell was I
thinking?
And then, um, and then amajority of them, when I got
started, was up in South Dakotaand I had tried all sorts of
(29:52):
different techniques.
I'd done freehand.
I started, I did probably everystackable guide system.
I was like, oh, maybe this isthe answer.
Or there's at the time, justnot knowing what I, you just
don't know, what you don't know,and a lot of.
There's so much marketingbehind Full Arch and, as a young
practitioner trying to figureout what exactly you should be
(30:14):
doing, you get sold some stuffthat once you figure out what
exactly you should be doing, youget sold some stuff that once
you figure out maybe this isn'tthe best way to go about it.
So I felt like I was relativelywell versed in what was out
there for full arch.
And then, um, I remember I hada case that my posterior
maxillary implant just it failed, came back grafted.
It failed, came back grafted,it failed again, came back,
(30:38):
luckily worked that third time,but it took the treatment plan
from six months to 18 months.
I'm like man this is.
I didn't know anything aboutremote anchorage at the time.
I'd moved down to Arizona andthere's quite a bit more
competition down here and sothere's probably three or four
guys on my street that offerteeth in a day type of services
and I could not tell patients.
If I don't get adequatestability with your implants,
(31:00):
unfortunately you're going tohave to heal with a denture for
four months.
That just wasn't going to fly,so it forces you into.
Okay, what are the other things?
My first course was out atRamsey Amin.
He'd offered like this privatecadaver course on zygomatic and
pterygoid implants.
Thought that was interestingand then, but I wasn't really
(31:24):
sure what I was going to do withit.
But it started to give me somevocabulary that my mind could
use a little bit, or kind offollow along with what other
people were doing.
And then went down and did DanHoltzclaw's, I think, very first
course, which was in Dallas.
You had guys like Mike Picosthere.
It was like cutting edge stuffhe's learning at the same time
I'm learning.
I was like, oh, that's cool.
And then ended up doing acouple live surgery courses one
(31:51):
down in Brazil with Smiler andRosen and then did Vichy
Brumann's course here inScottsdale.
In between the cadaver courseand live surgery courses I would
line up patients to do in myoffice.
Soren (32:03):
That's smart.
Chris (32:04):
So it wasn't ever okay Spend a bunch of money and take
this time out and then sixmonths later hadn't haven't used
anything, um.
So that's how I got into it andat the time I was just I was
doing enough arches where Icould find arches to practice on
or do these things that I feltlike needed them.
And I think one of the biggestthings, or the reasons why to
(32:27):
get into it, is, if you're doingfull arch, the ability to
revise your own cases, which Ithink is a really big deal.
One from just a practitionerstandpoint of wanting to be able
to provide that, and two, fromthe patient standpoint, to
quickly and efficiently movethem from point A to point B
without this huge either stop intheir treatment or detour where
(32:48):
it's.
We're not exactly sure what'sgoing on.
I can't fix this.
I know I told you I'm the guythat you should trust with your
treatment and now you got to gosee someone else, something
along those lines.
Yeah, the ability to move casesalong and revise your own cases
and treat more cases, I thinkis a really big deal.
The other thing is um, I wastold, or I will, I will say that
(33:09):
there is like some philosophyout there that you should be
doing a hundred all in fourarches before you even get into
remote Anchorage.
And those same guys are likewell, every case should have
pterygoids.
Okay, do you want me to do ahundred cases without pterygoids
first and then do pterygoidsand then have the process before
(33:32):
getting even further into othersensitive techniques or
difficult techniques?
And that's 100% understandable.
(33:54):
One of the one of the issues ispreviously teaching courses or
helping teach courses on some ofthis stuff is that if you teach
someone an all on four, they'reyou've given them a hammer and
when they get back to theiroffice, all of the arches look
like all-in-four arches and whathappens is sure enough.
You get a call or you hey, Idid the reduction like I was
(34:15):
supposed to, I put my implantsin and I don't have enough AP
spread.
And the reason why they getinto that is they have not gone
through other remote anchorageor treatment planning courses
where it's like, hey, that casejust wasn't treatment planning
correctly, because you also needall of these other tools and I
don't know.
I would suggest that people getinto remote anchorage training
(34:38):
early if they want to do it.
Do all in four and arches,specifically to learn the value
of the treatment plans so thatyou can stay out of basically
the deep end for cases that youdon't need to all of a sudden
find yourself in.
I think one of the biggestadvantages of me learning a lot
of PROS stuff and joint stuffwas not that I wanted to treat
(35:00):
all of those cases, but it wasto avoid the cases that were
going to be a huge headache forme and my team and the patients.
I would say go to the livesurgery courses, go to the
cadaver courses sprinkling somepatients, whether or not you're
going to start doing those casesright away.
But once you have thatknowledge, you can't unsee it
and when you start lookingthrough your CBCTs you're going
(35:23):
to be like this is probably ateri-zygo patient.
I shouldn't try to sneak in anall-in-four on this one,
something like that.
The other thing I would say istake some sinus courses because
you need to get comfortablebeing in the sinus.
If you're going to be doingteris and zygos, I'm not saying
(35:46):
you need to do additionalgrafting with these, but if the
first time you're getting intothe sinus is that you're cutting
a slot for your zygote, you'renot going to have the same
feeling of hey, I've been herebefore.
I'm not worried about this, I'mworried about the orbit.
As if you've done a bunch ofsinus work and you're like, hey,
this is no big deal.
Soren (36:09):
If there's an issue, I can repair it this is not a
factor.
I'm focusing on what I should befocusing on, which is the
treatment that I'm trying toprovide.
Yeah, definitely, I agree ahundred percent, especially with
the learning like what remoteanchors can do for you and what
remote anchors can do as far astreatment planning goes.
There's so many doctors outthere who are so excited to get
into full arch.
They go to their first course,maybe they get four or five
arches under their belt andthey're just looking for that
next patient to do a case on,and that maybe that next patient
(36:31):
happens to be someone who justhas like super pneumatized
sinuses and they're, like yousaid, trying to sneak it all on
four on a patient that's goingto have canine access holes.
And then you're stuck in thesituation where the only option
you have is you either do onepre one molar, or you just have
(36:52):
this really big cantilever andthe patient just isn't in the
best prosthetic that they couldbe, or you're just going to be
dealing with this patient forthe next year and like those 15
appointments that you have wherea patient's just frustrated
with you they're frustrated thatthey decided to do the
treatment at this clinic it'snot worth that 20 grand or
(37:14):
whatever you got for thepatient's initial surgery.
So being able to avoid thosepatients and avoid those
problems for you and your teamis going to allow you to do
these cases for a much longerperiod of time.
Tyler and I have trained a lotof these doctors for quite a
while and saw their progressionup, and there's so many doctors
(37:37):
that get into this and then theyquickly realize, because of
problems that they've had withthese cases, wow, I do not want
to do this anymore.
I thought this was what Iwanted to do.
Maybe they had two or threecases that just didn't go the
right way and they had patientsreally frustrated with them, and
then they just decide, okay,this is not the style of
dentistry for me and in reality,if they would have been able to
(38:00):
see those cases up front andavoided them, they probably
would have been able to do somany more arches, got so much
more experience and that way,when one of these problems came
up, they're like, okay, let'shandle this, we can do this, and
it would have just elongatedtheir career in the style of
dentistry 100%.
Chris (38:18):
I think almost every course that either I'm helping
with or that I've attended.
Someone will say, hey, what'sthe next course, what should I
be doing next?
And I would say it's notnecessary.
There's no one single coursethat you're going to learn all
this stuff.
You've got to take them all andyou're going to.
You're going to look dependingon what like evolution you're at
(38:39):
in your career, you'll learndifferent things from those same
courses.
I think the biggest thing isjust finding a mentor, and so
those mentors will help youtreatment plan those cases that
you're not sure of, becauseyou're 100% right.
If you get burned by your firsttwo or three cases, I mean
you've just been scarred andyou're not going to do those.
Soren (38:59):
Yeah, I agree Absolutely.
I want to get into as well.
And oh, funny thing I wanted tomention too you were mentioning
that Mike Picos was at thecourse you're at when I was,
when we went to.
Oh Tyler wasn't with me thistime, but I was in Portugal for
a palatal approach course.
Tyler (39:15):
Yeah.
Soren (39:16):
Bernardo and Mike Picos came to that one, so it was
really cool.
I have this picture of Bernardoand Picos both like on both
sides of me, while I'm like inthere doing like a case, and I
was like, oh, this is, it wasjust like a cool moment for me.
Tyler (39:30):
More specifically, picos is assisting you while doing the
case.
Now, I hate that photo so much,yeah I love I loved it.
I was like oh, this is yeah,he's holding suction for you
while you do it.
Soren (39:43):
That's awesome yeah, but it was just cool to be there,
because it was reassurance thatI was like on the right path, of
kind of the forefront of newtechniques, right.
So I'm like, okay, pico's ishere, obviously some, I'm in the
right course for sure, becausehe's trying to learn this as
well.
And it was also cool because hedid a whole uh over in europe.
(40:07):
Right now, I think subs are likea big thing, like the new sub,
right, so he went custom yeah,yeah the custom implants and he
went over all of these likemandibular sub cases that he has
done over the last 50 years andhe showed like follow-ups maybe
not 50, I don't know exactlyhow long he's been practicing,
but he's showed follow-ups over30 years time of all these
(40:29):
mandibular sub cases that haveworked really well for him.
And was just reassuring thegroup of these custom implants
they work.
You just, if you plan the casecorrectly, you do your flap
correctly, they can be anotherpowerful tool for patients in
this journey.
Because, I feel like a lot ofpatients.
They're in this cycle where thefirst thing is a traditional
(40:52):
all-in-four and then if anythinghappens with that, then what's
the next step?
You either have to decide.
Right now the biggest thing isZygos, right, but if there could
be a solution in between thosetwo where it's maybe we do a
custom implant and then if thatcustom implant doesn't work,
then we can get into quad zygoteterritory.
I don't think we've mentionedon this podcast but I know that
(41:13):
you've mentioned it to mepreviously where the number one
thing to avoid as long as youcan are quad zygos.
Chris (41:22):
That's what my mentors have told me, so I just try to
do what they tell me.
Yeah, you reiterate.
Soren (41:27):
So it'd be cool if there was predictable option that we
could go to prior to going tothat quad.
And I don't know for sure ifthe custom implant is that
option.
It sounds like it is.
I have seen a couple of thecases being done and there is a
decent amount of reduction stillin a decent amount of slots.
But I think that it's going tobe a powerful thing in the next
(41:49):
10 years in implant dentistry.
It's not approved, obviously,in the US yet, but what are your
?
Thoughts on that.
Chris (41:56):
Yeah, my thoughts are.
There's a gentleman named SamJurek over in Genesee and he's
seen a lot more dentistry than Ihave and he's like hey, we've
already been here and we've seena lot of maxillary subs fail.
Mandibular subs are somethingdifferent, and I think I've met
Bernardo a couple of times andI've had nothing but positive
(42:18):
interactions with him, and Ithink he's a great educator.
He speaks well, he carrieshimself well.
I don't agree with everythingthat he says, though.
I had a case yesterday in anoffice where, first I did a
palatal approach, didn't get theprosthetic timing where I
wanted it.
I thought it was going to betoo palatal.
I thought it might cringe onthe tongue space.
(42:40):
Then I tried a tree and sinusand couldn't get the torque that
I needed as well as the archform, with the two anterior
implants even angled so I canget my poster one to slide in.
It just wasn't going to be asideal as what I thought the
patient needed, so Itransitioned and put his eye go
in, and is that a case for aunilateral custom implant sub on
(43:04):
that side?
I don't know, but that doesn'tmake a lot of sense to me.
I think the other thing too isI don't know how much they cost
over in Europe, but over herethey're very expensive, very,
yes.
And so imagine if you're likezygomatic implants are $5,000 a
piece.
Yeah, it'd just be like thatdoesn't make a lot of sense, and
(43:27):
it's just the ration.
I understand a little bit ofthe rationale Now.
Here is my take on why he and Ihaven't had this conversation
with Bernardo, but this is mytake on it.
He was at the Molo Clinic for anumber of years and that's
where he got a lot of histreatment.
He saw a lot of a number ofyears and that's where he got a
lot of his training.
He saw a lot of a lot of arches, a lot of patients.
(43:47):
My understanding is that theyused Nobel's idiomatic implants,
nobel's and I don't know theexact approach that those
clinics were using.
If they're using the originalBrandenburg approach, if they're
doing a Stella and Warner slottechnique, if they were doing
extra maxillary approach, ifthey were doing some Zaga
concept or a combination of allof those, I'm not sure.
(44:08):
But the way that Nobelzygomatic implants are, you are
going to have a higher rate ofcomplication, 100% from the
design and the technique andtheir instrumentation and how
you place them versus some ofthe newer techniques and
instrumentations and implants onthe market.
I'm curious.
Tyler (44:27):
When we talk about newer, obviously we're talking slot
techniques, extra maxillarytechniques.
I think a lot of the zygos thatBernardo would have seen and I
don't want to speak for him, butduring that time when he was at
the model clinic were probablyintrasinus.
And I think you're right aboutthe zygomatic, the Nobel
zygomatic implant.
What were some of the featuresof the implant itself and also
the technique that?
Chris (44:48):
may have led to some negative bias towards that.
So the original one thatBrandenburg had fabricated,
which was at the same timefabricated with the other
implants, so it's been aroundjust as long.
It's not like a newer thing.
Those implants were originallymade for cancer resection and
trauma patients.
If I were to show you some pano.
So there's a book called theOsseointegration Book.
(45:08):
It's right here.
Put up on the screen forYouTube guys, this is one of my
favorite books.
Soren (45:19):
Okay.
Chris (45:25):
And it documents.
Tyler (45:27):
That logo is very interesting actually yeah, it's
a.
Chris (45:31):
This logo is like severe atrophy restored.
Have you seen?
Soren (45:34):
our.
Have you seen the fixed podcastlogo?
Tyler (45:37):
yeah it's, our it's missing.
Chris (45:40):
It's missing terror quotes.
Yep, that's all Ours, isn't?
It's one of those things.
If I were to show you some ofthe original cases what he?
does is he goes through and hesays this is patient number one
and he follows them.
So this is like wow, casenumber one, john, number one by
(46:03):
Brandon Mark.
And then he shows his followupup and this is what he does.
And here's the original.
And guess what?
The poster implant fails andguess what he does?
He puts in a zygomatic implant,like some of these panels look
like today's remote anchoragepanels.
Tyler (46:17):
It's pretty wild Out of time, so it's crazy.
Chris (46:21):
The original implants were machined and they're
basically just like long boltsand it's mainly an intrasinus
technique.
They didn't have angledmulti-units at the time.
So some of those original umocclusal shots where it's like
god, why would someone have theimplant coming right like out
mid palate or whatever?
It was a zero degree abutment.
(46:42):
There was no like hey, swing itover 60 degrees yeah, so some of
that was just what they had,and then the other part of it
was they didn't have greattorque with some of that stuff
as well, as the end of theimplant had a little nipple on
it and so they would have thistechnique where his intrasinus
and then they would feel thedrill come out and then they
(47:04):
would feel the edge of theimplant to make sure that they
knew that it was in far enough.
So you potentially had pressureunderneath the tissue that could
cause some sort of fistula orsomething like that.
Yeah, so at the time of a hey,if you want to get more, if you
want to get better integrationbecause we've had some failures
with these let's coat thesurface with something and now
(47:24):
let's stick it in the sinus,which the surface coating might
make sense for integration, butas far as sinusitis and issues
with the sinus wasn't probablythe right thing to do.
Yeah, so I think if you combinethose things and you do a high
volume of those and you look atsome of that stuff, you're like,
hey, I think there's a betteroption and maybe a custom
(47:45):
implant would be a better optionbecause you can avoid all these
things.
But I do think that over time,with extra maxillary technique
and pterygoid fixation behind itto give those implants
stabilization, I think you caneliminate a lot of those
problems you.
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