The Fixed Podcast

The Evolution of Implant Dentistry with Dr. Chris Barrett: Part 1

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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.

Soren:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi and you're listening to the Fix Podcast, your source for all things implant dentistry. Hello and welcome to the Fix Podcast. Today we have Dr Chris Barrett with us. We are super excited to have Chris here. I actually met Chris for the first time in Denver about three months ago probably, and we've had a lot of conversations. Yeah, yeah, we've had a lot of conversations, probably, and we've had a lot of conversations. Yeah, yeah, we've had a lot of conversations since and we've been sharing a lot of cases together and we're very honored to have him on the podcast today. He is one of the front runners for Zygo implants for GPs placing quad Zygos doing remote anchorage cases and we're super excited to have him on the podcast here today.

Chris:

Yeah, excited to be here. Thanks for having me on and yeah, we have had some great conversations ever since Denver. So, yeah, what conference was?

Soren:

that at. I think it was a Dykema DSO conference. Might have been that one, yeah, I came over to the what was the big conference center.

Chris:

That hotel out by the airport. That's massive.

Soren:

Yeah, I can't remember either Tip of the tongue. Yeah came out there, had a drink, we discussed both of our backgrounds and we had a bunch of similarities in our backgrounds and getting into implant dentistry and, yeah, I'm sure the audience here would love to also hear about your background. So if you could fill us in a little bit your background in Full Arch, maybe a little bit about the work history, how you got into remote Anchorage, I think that would be a great start.

Chris:

Yeah, I graduated from University of Iowa in 2011 and wasn't sure exactly what I wanted to do. Everyone that I talked to that had done a GPR was like I would never trade another year of private practice for my GPR year. So I thought, okay, I'll take a year and do that. At the time, I really loved surgery and I really liked endo and I think that was just because we had what I felt was just the best adjunct faculty in the oral surgery and endo department.

Chris:

So at Iowa, if you finished with your requirements early, you could spend as much time as you wanted to in whatever department. So I ended up spending a majority of my oral surgery and we had these OS guys from all over the state that were at the later part of the years and they just loved coming in and showing you all their little tips and tricks on exodontia. And they're just telling you all their little tips and tricks on exodontia and they're just telling y'all their little war stories and this and that, and I mean it was just awesome. So I took to that and then did the gpr year. Honestly, watching the perio and dental school and os faculty or guys or whatever place implants, I was like man that looks so boring.

Chris:

I mean they'd take forever to place one implant and it was based off of like a dental student guide that never fit and they're like we're just going to do this ourselves. I was like this is what implants are. I was like I'll just go do something else, I don't know. So I ended up practicing Iowa for a year and then all my siblings actually live in Denver and my parents have siblings that are out there too and, looking to make a move, went out West from Iowa and there's a lot of Iowa grads out in Denver and so they'd been out there a number of years before me. I had gotten a job that all these guys were saying, hey, this is like one of the nicest offices and so if you get selected for that job, you should take it. The caveat was that it was a restorative only practice. So, even though I was good at surgery and I liked different procedures, they're like hey, we are a fee for service office. We work with other fee for service offices here in South Denver and this is what you're going to do. And so I was like, okay, signed up for that. They taught three different levels of occlusion out of that office, and the guy who started that office I'd say you and Tyler are younger than me, soren, but let's say around the same age, and let's say some of the big names in whatever we're into, have some sort of study club or go out and teach or whatever, and they're looking for guys to help teach.

Chris:

The guy who started this, that office, his mentor, was a relatively famous prosthodontist named Niles Goucher and he ended up inventing the Dehner articulating system. He also developed something that was like a digital or a analog jaw tracer for that system, and so they were all about the study of nathology and basically joint-based treatment that as long as the joint was comfortable and the muscles were comfortable, you could restore someone and you can do it very predictably. So they did a lot of TMD treatment and they worked with a lot of really great orthodontists, and so most of that time was the cases I was a part of was maybe phase one and phase two, and then phase two is some ortho, maybe some minor restorative and a little bit of equilibration. Every once in a while there'd be some surgery involved, but that was like a little residency that I didn't know anything about it, and this is two or three years out of school. Looking back at it.

Chris:

Now I'm like, okay, I can see where there were some pitfalls or maybe some different things that maybe I would do differently, but that's where I learned how to restore it the different analog restorative steps. They had labs that would come in. That's where I learned how to restore it the different analog restorative steps. They had labs that would come in. Well, it's a guy, arnie Hoffman, and I don't know if you know him.

Soren:

Yeah, I know.

Chris:

Arnie. So I met him at that when I was at that practice because he worked at one of the local labs. He's a German prosthodontist. Kind of looks like Arnold Schwarzenegger.

Tyler:

He looks like him.

Chris:

Yep, super on restoring those. Doing it all analog. I end up going through a divorce while I'm at that office and I transitioned to a different office and start placing my own implants and getting back into doing some surgery I end up living with first. I end up living with my younger sister and I was like, hey, I got to get out of my younger sister and her husband's house. Get out of there and the biohorizon rep does.

Soren:

matt is matt I actually I was talking to him yesterday yeah, he's woven into this story.

Chris:

The, his roommate had gotten his girlfriend pregnant and so he had to move. So Matt sent out a group text to like all the guys that are around the same age that would hang out every once in a while in the Denver area and say, hey, I got a room open.

Chris:

If anybody's looking for it, that sounds good. So I ended up living with Matt for probably a year or so. And I'm listening to the AAID podcast and Mike Freimuth is co-hosting with Danny Domain because Justin Moody was like out of town or something or whatever. And I see and I hear that he's a diplomat and does a bunch about implants and he's in Wheat Ridge, colorado and I'm like, wow, that's like right here and I look up the ABY and diplomats and there's like two in the state and he's one of them. And I asked him. I'm like, hey, matt, do you know? This guy seems to know a lot about implant dentistry. He's like, yeah, he's like my biggest client. Guy's like he's just a machine. I'm having dinner with him next week. So I'm like, is there any chance that I could go to that dinner with you guys? Do you think he would mind? He's all ask him, but I think it'd probably be good. So go over there, have dinner with him.

Chris:

He's actually looking for an associate and at the time I was planning on going back to Iowa to be closer to my kids that were back there. I don't end up working with or with him or for him, but I ended up spending every single day off I can over his office and he really expanded my mind as far as what was possible as a general dentist he had. He was doing really nice FP1 cases in operatory one at the same time, then he was prepping like a veneer case in operatory two and then he had four hygiene chairs 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, oh wow, I just built out a lab or whatever, I'm like dude. You guys are no, you think this is probably like 2013. And so when guys are like, oh wow, I just built out a lab or whatever, I'm like dude, you guys are no, you think this is like a new thing, that's just happening.

Chris:

But there's like these guys that were 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 the spear huge on education.

Chris:

That's how why I started taking Kois stuff because he was like, hey, you got to go take Kois. He did all the MISH and Kois stuff with. It was him and Moody way back in the day when he was our age, and those guys ended up starting Pathway and through that relationship I ended up practicing with Justin Moody for a couple of years and taking over his implant practice and then so I went from placing a few implants a month to that's all I did and fortunately, I had a really strong comprehensive dentistry and prosthodontic mindset and I had previous good surgical skills from University of Iowa and the OS department there in the GPR. That was just like very fundamental, basic things that I feel like you can use forever and all walks of whatever surgery you're doing. So I'm super grateful for that.

Chris:

And then I ended up moving down to Arizona in 2019 and started a group called brightly with some private equity guys and help grow that to different offices around the country, which is basically just like guys that I knew or y'all said I knew that, hey, that looks good, I want to do that too. And then left that in 2013 or in 2023, excuse me. And then I've just been traveling around the Phoenix Valley for the last year and a half or so just doing all on X from basic law and force to advanced zygosurgery and then periodically flying around the country mentoring or helping other docs, just trying to figure out what I'm going to do next.

Soren:

Nice, yeah. Yeah, it's funny, matt, matt Go, matt goff he. So I've been working with him with biohorizons. We use all of their biologics in our offices and I think you made that connection actually at the which. So thank you for that, chris. And yeah, and it was funny because I was. I reached out to him yesterday just because I was looking for a sinus lift kit and I just reached out to him. I was like, hey, do you guys sell these at all? I don't think they do, but I ended up going with a Selvin kit. So if you have any recommendations?

Chris:

I would have recommended Tatum, but that's fine.

Soren:

Okay, all right. Yeah, I should have reached out to you first.

Tyler:

Now your time.

Soren:

It's all right, I'm sure the Selvin kits. He's like, hey, by the way. Yesterday he said this hey, by the 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 he needs a. He's hey, doc, can you? What exactly do I need here?

Soren:

And he had one of the most resorbed maxillons I've ever seen, like no bone. He had canine to canine bridge and then from the canine to canine. There was absolutely nothing, like no bone whatsoever. And I was like this have you had this for a while? And he's like, yeah, when I was a kid I got into a traumatic accident and lost my front teeth and I was like, all right, well, all on four is going to be out of the question unless we like have some really extensive grafting and that's not what you want to go through at this point. And I don't think he needed it either. But his lower bridge was definitely failing and I was like we can do a lower implant-supported bridge. And I'm like you should go back to your general dentist to see what they can do with that upper bridge and maybe they can repair it, because it had fractured and his dentist happened to be Jen Manske, so I was on the phone with her like two weeks ago, just like we were talking about how we were going to like plan this case out.

Soren:

And then it just happened that matt they were married and I was like, oh wow, it's such a there's a small world. Yeah, I feel like the dental world's small enough and then, once you get into the implant dentistry, it gets even smaller, which is pretty crazy.

Chris:

Yeah, I there is. Uh, I went out to california about two months ago and did a case for a young woman and she's telling me that her best friend practices in Arizona. And sure enough, the one like I. I, there's only three or four offices that I really go to and my girlfriend, who's a dental assistant she does some temp assisting out of. She literally has not done any sort of temp assisting for years and then all of a sudden, like her second gig is this girl's best friend. I was like okay that's just too weird right

Soren:

yeah, that stuff happens all the time yeah, it's funny you were saying earlier separate topic, but you were saying earlier. I just wanted to mention this before I forgot that when you first started, like seeing implants, you're like man, that looks super boring, Like I'm not interested in that too much. And I remember when I was like second or third year of school I saw these guys that were like implantologists, right, and they were like promoting themselves as implantologists and I'm like man, that just sounds so I don't think I don't want to just do one thing, like just play single implants every day.

Soren:

that sounds like the worst thing ever and it's so funny, just and it goes into what you were talking about earlier about milling and making your own lab there's just so much that you don't know until you get into that avenue, right. So like you start to learn a little bit about implants and then you're like, wait, what's this 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, you can have a patient that comes in who needed a denture, that can have, you know, a new set of teeth in a day. So then you get into the full arch stuff. And then, once you're in the full arch stuff, the next kind of step is like maybe dabbling into remote anchorage.

Soren:

I feel like sometimes, prior to remote Anchorage, most people and especially now, like in the last year or two will start getting into like the digital dentistry stuff, and then that opens up a whole nother can of worms there. So you're, you got all the remote Anchorage stuff and then all of the dental stuff, and then you find out like, like for me, even if, like setting up a mill in my office and stuff, I feel like I'm way ahead of the curve. But then in reality there's people a decade ago that were like oh yeah, I was doing that. I was doing that 10 years ago and it's just amazing to see all of the different avenues and the things that you can get into and how many, how there's always someone out there that's like one step ahead of you, right, doing these things. It's just interesting.

Soren:

I wonder what, like the next big thing in dentistry is going to be. I think right now, in like full arch probably, that would be like I've seen guys now that are doing they'll do digital designs and they'll have all the teeth designed already but they won't place the implant positions. And then, as soon as the implant positions are placed, they'll then and they'll mill the first half of the zirconia. Then they'll mill like the access holes of the zirconia, is my understanding, and you can do same day zirconia deliveries. Have you seen that at all yet?

Chris:

I haven't. But I'm trying to think of what the I'm not a huge fan of doing same day finals. I've done a couple of them and if I were going to say, hey, I think that this was my mom or dad or whatever, I'd probably make them another one four months later. Yeah, so that's one of those things where it's but, to be honest, but that's cool, yeah, that's cool that the technology is like getting to the point of you can do that. So, let's say, it's almost like a healed ridge through a dentalist. You're like I just gotta drop some screws. And then you're like, oh, it can make you your final because I know if the soft tissue is, it's flapless or something that's cool.

Soren:

Yeah, no, definitely, and I'm definitely with you there.

Soren:

I tell all my patients that I prefer that they wait two, three months for all the bone to healing to occur, all the tissue healing, before we go to your final prosthetic.

Soren:

But I do think for certain styles of practice if people are traveling or something like that and they don't have a ton of time in your clinic it can be a really good option for patients to get same day zirconia and then at the four month mark then remill them in there with the changes that they've had to their bone and tissue. But I agree, as far as there's a 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 of headway coming into that direction where some of these guys I've seen they'll design the prosthetic in a way that they're planning it a certain distance from that bone level right, so that way when the tissue heals they're planning for that and maybe they end up having to remill two or three out of 10 arches, but at least those seven arches that they did. The patients are still relatively happy with those cases still relatively happy with those cases?

Chris:

Yeah, I think, as there's more and more socket shield and root banking and remote anchorage and I shouldn't say that in the same sentence. For example, I think, for the FP1 cases that I've done, a lot of times you run into issues in the molars. Let's say there's just not a lot of bone there for a really solid molar, so you end up putting in a zygote or terry. But you can do almost like root banking and socket shields in the front. When you have something like that's like a point of measurement, when you're keeping something, then I do.

Chris:

I do think it makes sense that that you could potentially go closer to final versus, versus. In my mind, an FP3 is a defensive modality versus, uh, let's say, an FP1, which is more you're playing offense, and what I mean by that is you do your FP3, you do your surgery and then you wait for everything to heal for three months and then you're like I'm going to wait to see how the body responds and then I will now go back and I'll do the next part. Versus something like an FP1, you've got to play more offense and you have to do more connective tissue grafting. You might have to root bank, you might have to do something else to get the body to do what you want it to do, versus hey, let's just have this heal and then see what happens.

Soren:

Yeah, no, I agree Definitely. What are your thoughts on? Have you done a lot of socket shielding, root banking? I personally haven't done any of it. Our colleague Caleb, he, has done a couple of cases that have turned out pretty well, but I'm curious what your thoughts are on that.

Chris:

Yeah, I've done two single socket shields. I've done some root banking and that P1 cases that I've done it's been more uh, a couple of years ago, like a xenograft and connective tissue grafting. I think if I were going to do them today, I'd change some of that stuff. As far as root banking and and some socket shields, I just saw an unbelievable lecture by a guy named David Atiyah. He was out of Australia and he just the amount of detail that it goes into as far as diagnosis and making sure you get a quality outcome with, with, with pet or soccer shield or whatever.

Chris:

I think you have to select the cases right. The diagnosis has to be different and it's not, as I would say, easy, as straightforward as doing an FP3, where it's you're basically just giving yourself a blank canvas to create whatever you want. So, yeah, it's very interesting. That's something that I'm excited to see how that develops as far as some more kind of innovation or techniques or things that just give really predictable results, because I'll say, from just doing a lot of FP3s, there's a couple patients that come to my mind. Whereas if I could redo that, I would do them as an FP1. Doing a lot of FP3s, there's a couple patients that come to my mind, whereas if I could redo that, I would do them as an FP1. And a lot of it was tongue space and phonetics and almost nothing to do with aesthetics. Or these are older patients. It's not like it was a young patient that I'm like hey, I just artificially aged them by reducing a lot of their bone or something like that.

Chris:

This was just more like hey, where are our eights? Trying and I know you're from New York and I know you speak Italian to your friends over in Italy 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 better for you. And just the style of how everything was, I just couldn't make it any thinner. I learned my lesson just on a couple of those and I could see them coming. Now where it's a whether or not the transition, these are low lips. I'm not going for unbelievably aesthetic FP1 cases. These are just thinner, smaller restorations where it's like hey, the phonetics I think are a little bit easier and I think there's a lot more tongue space, definitely yeah.

Tyler:

No, I agree 100%. Yeah, chris, I think that's an interesting point because whenever I hear about indications for FP1, a lot of times it's what you just alluded to a really young patient, a high lip line where reduction to high the transition line is going to be pretty absurd for a given patient, and we're doing the FB1 to preserve that bony architecture, so on and so forth, but you're bringing up the phonetic point. So I'm curious, on the front end, prior to doing the case. So all those other things notwithstanding, how do you diagnose that phonetic issues?

Chris:

Yeah, the phonetic issues on those cases the way that I would see them coming is they're more like wear cases, so they have very thin tongues will just annex territory as they are given more space.

Chris:

So these patients have worn out thin teeth. They may or may not have any sort of TMD or joint disease, which may or may not be symptomatic, but their tongues are big, their teeth are worn out and they have. I'd say a couple of the patients had accents already and I will say that at least out here in the Phoenix Valley, patients that have had Eastern European or Russian accents or New York or Northeast accents have had a more difficult time getting back to like their natural cadence and what they sound like or their accent with a thicker prosthetic than, I'd say, midwest patients or something like that. For whatever reason. I don't know if it's like when your tongue is sitting there and it's just laying naturally with your mouth closed, it wants to sit up against eight and nine right behind that area. And if you have, if you've placed your implants seven and 10, and they're even in ideal positions you still have this bump there.

Chris:

And that tongue wants to go. It's like interfering with where the tongue wants to lay and a majority of time people get used to it, but for whatever reason, so I don't know that. Those would be like the tip offs 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 very demanding, they don't even really want, they're not aesthetically driven. They're's like hey, I know that they're going to be very demanding, they don't even really want a set. They're not aesthetically driven, they're just like hey, my teeth are worn out and I don't, I need to do something.

Chris:

And I'm at the last part of this. Those are things where I'd be like okay, I'm going to do maybe something a little bit different for you. They don't understand the difference between FP1 and FP3. Even if you show them the model there's so much it's like you go into all of this stuff and it's too much detail, and it's you just think you spend 20 or 30 minutes with someone talking about what implants are and how they're going to work and at the very end they're like so is that the same thing as a root canal? And you're just like okay, we got to start all over again.

Chris:

So you're trying to talk about nuanced stuff with phonetics, with different prosthetics, and it's good luck, yeah. So that's where I think some of the experience just comes in, where it's like I'm not going to charge you any different, I'm. I just know I'm going to try to avoid eight try-ins with you and we're going to do the case. I'm going to do it this way and I'm going to do this other style, and so it's hey, this is the best option for you. This is our normal cost, whatever. This is what I. What?

Soren:

I think For sure.

Soren:

Another thing that I think could be helpful like after we see some longer term, some just length and studies about root banking and how it works over time would be I always see those cases, too, where I see the teeth, and a lot of times as a patient that probably is a grinder they've worn down their initial teeth.

Soren:

The teeth are in, they're in a position that can't be restored anymore, but they still have really good bone and you could tell that bone is like super cortical and which is going to be a nightmare to get those teeth out.

Soren:

And in those patients I feel like those are the ones that I get that you're taking out a canine or something and the buckle plate just comes and there's nothing you can do. That tooth is a vols in there or ankylosed and like it is just stuck in there. And those patients I know, hey, if I just keep that canine, I have such a better chance of getting these teeth out without causing any major issues with the bone. And those cases that too, I think would be really are really beneficial ones to do group banking on, and that's one of the main reasons that I've considered just like learning up, learning more about group banking and what it can do for these cases, because I think it could have a better, more predictable surgical outcome without having to worry about trying to get some canine out. That, you know, is just going to be a nightmare.

Soren:

You know what I mean For sure.

Chris:

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 extra 10 minutes just to try to address the freaking.

Soren:

Yes, yeah, yep and then if you do break a buckle plate, then you're like all right, now I need to find bone. We got a graft get a membrane, like it just adds so much time on to the case, when it could have just been avoided by just cutting the crown off. So I agree what's?

Chris:

interesting is keeping those. So let's say, depending on, like, the arch form and on your surgical plan, sometimes the tip of your implant is going like for your posterior maxilla, it's going right towards that canine. So now you've got to figure out hey, what's my posterior? Are you gonna play steroids or not? They're just all these little nuances that as you get deeper into it, just like you were saying earlier. So what's god? Would you just want to do single implants all day, like, how easy is that?

Chris:

it's just a monkey, could yeah, now we're talking about the nuanced difference between arch form and the tip of your posterior maxillary implant and angles and all that stuff which I don't know. For whatever reason it makes it interesting?

Soren:

it does, yeah, and there's even there's cases out there, too, where people are putting their implants through teeth right.

Tyler:

Yeah, chris, I think you actually presented something like that at the SIN symposium a couple of years ago, where you put a pterygoid through a impacted dermal or something like that.

Chris:

I think I had the first documented case and. Abel put it in his book on I can't remember which one it was as a case study, but guy was younger, didn't have the steroid didn't want to do zygos, and he it's. As soon as you learn how to do pterygoids. Now, all these patients have impacted Maxler once in the beginning. So yeah, so I did that. I did a one-year follow-up on it and everything was fine.

Tyler:

But, yeah, in be done. Yeah, yeah, your follow-up on it and everything was fine. But, yeah, you can be done. Yeah, yeah, so now you can put that posterior implant through the canine and it's just more stability.

Soren:

That's great, exactly right, yeah, yeah I have a case actually next wednesday, and the patient has just a massive canine from the floor of his mandible all the way up and it's like taking out a huge chunk and I'm like he's older I think he's 80, something like that and I'm like I really don't want to take that out. It's going to cause so much more damage than then like what it would help by keeping it. So I think in this particular case I'm pretty sure I can work around it. I think I'm going to use like a 10 millimeter implant and I should be able to go right above it and I in my other implant I'll be on the other side. My problem is I I'm like the biggest, 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 nuts Not taking that canine out.

Chris:

We just need to treat points on that for sure.

Tyler:

Yeah, definitely, and I you know what's asymmetrical is when you break a jaw.

Soren:

Yes, exactly, so that's what like in my head. I'm like, all right, like I would love to take this canine out, put the implants in a perfect position, so I have that nice pretty pano after the fact. However, this one is not the one, so we're either going to have to work around it or I just have to use that canine for extra stability with my implant.

Chris:

Before I did that case I went through and I tried to find other documented cases of implants in teeth and a majority of them are impacted canines, a majority of them are in the maxilla and there's.

Chris:

There was maybe like 10 or 15 really good documented cases over a period of at least five years. They all tried to avoid going into where the nerve, like where the, the vascular canal of the tooth of the nerve was. So I also tried the implant that I put through that pterygoid, the positioning of the tooth. I was able to avoid it because I cut a hole through part of the root but a majority of the crown, so I didn't know if there was any sort of nerve bundle going into the tooth. So I, depending on what your case looks like now, if you just go in, the cases that are are documented they were just going into the cementum of the side of the route, they weren't like blasting through the middle of the route. Yeah, I don't know if that's helpful in your case or not. 80 years old, they've got a lot of tertiary debt going on in there, may or may not.

Soren:

Yeah, I think I'm probably just going to work around it in this situation. No-transcript of implants. They want to get into full arch. What are your recommendations for first getting into full arch Like how many reps should you have? What do you recommend there? And then, after you get into full arch, what are your recommendations for, like, getting into pterygoid implants and then getting into zygote implants, and what courses do you specifically recommend for people who are looking into getting into that style of dentistry?

Chris:

My remote Anchorage journey was when I started doing full arch, up in my very first one, like restoratively. It was in Colorado, and then I did one surgically while I was there, which, if I look back at now and got, what the hell was I thinking? And then, um, and then a majority of them, when I got started, was up in South Dakota and I had tried all sorts of different techniques. I'd done freehand. I started, I did probably every stackable guide system. I was like, oh, maybe this is the answer. Or there's at the time, just not knowing what I, you just don't know, what you don't know, and a lot of. There's so much marketing behind Full Arch and, as a young practitioner trying to figure out what exactly you should be doing, you get sold some stuff that once you figure out what exactly you should be doing, you get sold some stuff that once you figure out maybe this isn't the best way to go about it. So I felt like I was relatively well versed in what was out there for full arch. And then, um, I remember I had a case that my posterior maxillary implant just it failed, came back grafted. It failed, came back grafted, it failed again, came back, 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 about remote anchorage at the time. I'd moved down to Arizona and there's quite a bit more competition down here and so there's probably three or four guys on my street that offer teeth in a day type of services and I could not tell patients. If I don't get adequate stability with your implants, unfortunately you're going to have to heal with a denture for four months. That just wasn't going to fly, so it forces you into.

Chris:

Okay, what are the other things? My first course was out at Ramsey Amin. He'd offered like this private cadaver course on zygomatic and pterygoid implants. Thought that was interesting and then, but I wasn't really sure what I was going to do with it. But it started to give me some vocabulary that my mind could use a little bit, or kind of follow along with what other people were doing. And then went down and did Dan Holtzclaw's, I think, very first course, which was in Dallas. You had guys like Mike Picos there. It was like cutting edge stuff he's learning at the same time I'm learning. I was like, oh, that's cool. And then ended up doing a couple live surgery courses one down in Brazil with Smiler and Rosen and then did Vichy Brumann's course here in Scottsdale. In between the cadaver course and live surgery courses I would line up patients to do in my office.

Soren:

That's smart.

Chris:

So it wasn't ever okay Spend a bunch of money and take this time out and then six months later hadn't haven't used anything, um. So that's how I got into it and at the time I was just I was doing enough arches where I could find arches to practice on or do these things that I felt like needed them. And I think one of the biggest things, or the reasons why to get into it, is, if you're doing full arch, the ability to revise your own cases, which I think is a really big deal. One from just a practitioner standpoint of wanting to be able to provide that, and two, from the patient standpoint, to quickly and efficiently move them from point A to point B without this huge either stop in their treatment or detour where it's. We're not exactly sure what's going on. I can't fix this. I know I told you I'm the guy that you should trust with your treatment and now you got to go see someone else, something along those lines. Yeah, the ability to move cases along and revise your own cases and treat more cases, I think is a really big deal. The other thing is um, I was told, or I will, I will say that there is like some philosophy out there that you should be doing a hundred all in four arches before you even get into remote Anchorage. And those same guys are like well, every case should have pterygoids. Okay, do you want me to do a hundred cases without pterygoids first and then do pterygoids and then have the process before getting even further into other sensitive techniques or difficult techniques? And that's 100% understandable.

Chris:

One of the one of the issues is previously teaching courses or helping teach courses on some of this stuff is that if you teach someone an all on four, they're you've given them a hammer and when they get back to their office, all of the arches look like all-in-four arches and what happens is sure enough. You get a call or you hey, I did the reduction like I was supposed to, I put my implants in and I don't have enough AP spread. And the reason why they get into that is they have not gone through other remote anchorage or treatment planning courses where it's like, hey, that case just wasn't treatment planning correctly, because you also need all of these other tools and I don't know. I would suggest that people get into remote anchorage training early if they want to do it. Do all in four and arches, specifically to learn the value of the treatment plans so that you can stay out of basically the deep end for cases that you don't need to all of a sudden find yourself in.

Chris:

I think one of the biggest advantages of me learning a lot of PROS stuff and joint stuff was not that I wanted to treat all of those cases, but it was to avoid the cases that were going to be a huge headache for me and my team and the patients. I would say go to the live surgery courses, go to the cadaver courses sprinkling some patients, whether or not you're going to start doing those cases right away. But once you have that knowledge, you can't unsee it and when you start looking through your CBCTs you're going to be like this is probably a teri-zygo patient. I shouldn't try to sneak in an all-in-four on this one, something like that.

Chris:

The other thing I would say is take some sinus courses because you need to get comfortable being in the sinus. If you're going to be doing teris and zygos, I'm not saying you need to do additional grafting with these, but if the first time you're getting into the sinus is that you're cutting a slot for your zygote, you're not going to have the same feeling of hey, I've been here before. I'm not worried about this, I'm worried about the orbit. As if you've done a bunch of sinus work and you're like, hey, this is no big deal.

Soren:

If there's an issue, I can repair it this is not a factor.

Soren:

I'm focusing on what I should be focusing on, which is the treatment that I'm trying to provide. Yeah, definitely, I agree a hundred percent, especially with the learning like what remote anchors can do for you and what remote anchors can do as far as treatment planning goes. There's so many doctors out there 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 and they're just looking for that next patient to do a case on, and that maybe that next patient happens to be someone who just has like super pneumatized sinuses and they're, like you said, trying to sneak it all on four on a patient that's going to have canine access holes. And then you're stuck in the situation where the only option you have is you either do one pre one molar, or you just have this really big cantilever and the patient just isn't in the best prosthetic that they could be, or you're just going to be dealing with this patient for the next year and like those 15 appointments that you have where a patient's just frustrated with you they're frustrated that they decided to do the treatment at this clinic it's not worth that 20 grand or whatever you got for the patient's initial surgery. So being able to avoid those patients and avoid those problems for you and your team is going to allow you to do these cases for a much longer period of time.

Soren:

Tyler and I have trained a lot of these doctors for quite a while and saw their progression up, and there's so many doctors that get into this and then they quickly realize, because of problems that they've had with these cases, wow, I do not want to do this anymore. I thought this was what I wanted to do. Maybe they had two or three cases that just didn't go the right way and they had patients really 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 see those cases up front and avoided them, they probably would have been able to do so many more arches, got so much more experience and that way, when one of these problems came up, they're like, okay, let's handle this, we can do this, and it would have just elongated their career in the style of dentistry 100%.

Chris:

I think almost every course that either I'm helping with or that I've attended. Someone will say, hey, what's the next course, what should I be doing next? And I would say it's not necessary. There's no one single course that you're going to learn all this stuff. You've got to take them all and you're going to. You're going to look depending on what like evolution you're at in your career, you'll learn different things from those same courses. I think the biggest thing is just finding a mentor, and so those mentors will help you treatment plan those cases that you're not sure of, because you're 100% right. If you get burned by your first two or three cases, I mean you've just been scarred and you're not going to do those.

Soren:

Yeah, I agree Absolutely. I want to get into as well. And oh, funny thing I wanted to mention too you were mentioning that Mike Picos was at the course you're at when I was, when we went to. Oh Tyler wasn't with me this time, but I was in Portugal for a palatal approach course.

Tyler:

Yeah.

Soren:

Bernardo and Mike Picos came to that one, so it was really cool. I have this picture of Bernardo and Picos both like on both sides of me, while I'm like in there doing like a case, and I was like, oh, this is, it was just like a cool moment for me.

Tyler:

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:

That's awesome yeah, but it was just cool to be there, because it was reassurance that I was like on the right path, of kind of the forefront of new techniques, right. So I'm like, okay, pico's is here, obviously some, I'm in the right course for sure, because he's trying to learn this as well. And it was also cool because he did a whole uh over in europe.

Soren:

Right now, I think subs are like a big thing, like the new sub, right, so he went custom yeah, yeah the custom implants and he went over all of these like mandibular sub cases that he has done over the last 50 years and he showed like follow-ups maybe not 50, I don't know exactly how long he's been practicing, but he's showed follow-ups over 30 years time of all these mandibular sub cases that have worked really well for him. And was just reassuring the group of these custom implants they work. You just, if you plan the case correctly, you do your flap correctly, they can be another powerful tool for patients in this journey.

Soren:

Because, I feel like a lot of patients. They're in this cycle where the first thing is a traditional all-in-four and then if anything happens with that, then what's the next step? You either have to decide. Right now the biggest thing is Zygos, right, but if there could be a solution in between those two where it's maybe we do a custom implant and then if that custom implant doesn't work, then we can get into quad zygote territory. I don't think we've mentioned on this podcast but I know that you've mentioned it to me previously where the number one thing to avoid as long as you can are quad zygos.

Chris:

That's what my mentors have told me, so I just try to do what they tell me. Yeah, you reiterate.

Soren:

So it'd be cool if there was predictable option that we could go to prior to going to that quad. And I don't know for sure if the custom implant is that option. It sounds like it is. I have seen a couple of the cases being done and there is a decent amount of reduction still in a decent amount of slots. But I think that it's going to be a powerful thing in the next 10 years in implant dentistry. It's not approved, obviously, in the US yet, but what are your? Thoughts on that.

Chris:

Yeah, my thoughts are. There's a gentleman named Sam Jurek over in Genesee and he's seen a lot more dentistry than I have and he's like hey, we've already been here and we've seen a lot of maxillary subs fail. Mandibular subs are something different, and I think I've met Bernardo a couple of times and I've had nothing but positive interactions with him, and I think he's a great educator. He speaks well, he carries himself well. I don't agree with everything that he says, though.

Chris:

I had a case yesterday in an office where, first I did a palatal approach, didn't get the prosthetic timing where I wanted it. I thought it was going to be too palatal. I thought it might cringe on the tongue space. Then I tried a tree and sinus and couldn't get the torque that I needed as well as the arch form, with the two anterior implants even angled so I can get my poster one to slide in. It just wasn't going to be as ideal as what I thought the patient needed, so I transitioned and put his eye go in, and is that a case for a unilateral custom implant sub on that side? I don't know, but that doesn't make a lot of sense to me. I think the other thing too is I don't know how much they cost over in Europe, but over here they're very expensive, very, yes. And so imagine if you're like zygomatic implants are $5,000 a piece. Yeah, it'd just be like that doesn't make a lot of sense, and it's just the ration. I understand a little bit of the rationale Now.

Chris:

Here is my take on why he and I haven't had this conversation with Bernardo, but this is my take on it. He was at the Molo Clinic for a number of years and that's where he got a lot of his treatment. He saw a lot of a number of years and that's where he got a lot of his training. He saw a lot of a lot of arches, a lot of patients. My understanding is that they used Nobel's idiomatic implants, nobel's and I don't know the exact approach that those clinics were using. If they're using the original Brandenburg approach, if they're doing a Stella and Warner slot technique, if they were doing extra maxillary approach, if they were doing some Zaga concept or a combination of all of those, I'm not sure. But the way that Nobel zygomatic implants are, you are going to have a higher rate of complication, 100% from the design and the technique and their instrumentation and how you place them versus some of the newer techniques and instrumentations and implants on the market. I'm curious.

Tyler:

When we talk about newer, obviously we're talking slot techniques, extra maxillary techniques. I think a lot of the zygos that Bernardo would have seen and I don't want to speak for him, but during that time when he was at the model clinic were probably intrasinus. And I think you're right about the zygomatic, the Nobel zygomatic implant. What were some of the features of the implant itself and also the technique that?

Chris:

may have led to some negative bias towards that. So the original one that Brandenburg had fabricated, which was at the same time fabricated with the other implants, so it's been around just as long. It's not like a newer thing. Those implants were originally made for cancer resection and trauma patients. If I were to show you some pano. So there's a book called the Osseointegration Book. It's right here. Put up on the screen for YouTube guys, this is one of my favorite books.

Soren:

Okay.

Chris:

And it documents.

Tyler:

That logo is very interesting actually yeah, it's a.

Chris:

This logo is like severe atrophy restored. Have you seen?

Soren:

our. Have you seen the fixed podcast logo?

Tyler:

yeah it's, our it's missing.

Chris:

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 of the original cases what he?

Chris:

does is he goes through and he says this is patient number one and he follows them. So this is like wow, case number one, john, number one by Brandon Mark. And then he shows his follow upup and this is what he does. And here's the original. And guess what? The poster implant fails and guess what he does? He puts in a zygomatic implant, like some of these panels look like today's remote anchorage panels.

Tyler:

It's pretty wild Out of time, so it's crazy.

Chris:

The original implants were machined and they're basically just like long bolts and it's mainly an intrasinus technique. They didn't have angled multi-units at the time. So some of those original um occlusal shots where it's like god, why would someone have the implant coming right like out mid palate or whatever? It was a zero degree abutment.

Chris:

There was no like hey, swing it over 60 degrees yeah, so some of that was just what they had, and then the other part of it was they didn't have great torque with some of that stuff as well, as the end of the implant had a little nipple on it and so they would have this technique where his intrasinus and then they would feel the drill come out and then they would feel the edge of the implant to make sure that they knew that it was in far enough.

Chris:

So you potentially had pressure underneath the tissue that could cause some sort of fistula or something like that. Yeah, so at the time of a hey, if you want to get more, if you want to get better integration because we've had some failures with these let's coat the surface with something and now let's stick it in the sinus, which the surface coating might make sense for integration, but as far as sinusitis and issues with the sinus wasn't probably the right thing to do. Yeah, so I think if you combine those things and you do a high volume of those and you look at some of that stuff, you're like, hey, I think there's a better option and maybe a custom implant would be a better option because you can avoid all these things. But I do think that over time, with extra maxillary technique and pterygoid fixation behind it to give those implants stabilization, I think you can eliminate a lot of those problems you.