WEBVTT
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That sweet.
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So, you know, this is the only picture on this case, but this was probably the most, you know, if somebody was to ask me what, what's kind of been, you know, one of your more surprising cases.
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it would have to be this one for sure.
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Uh, so this, this was like a 85, I don't know, maybe she was 78.
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I don't know.
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Somewhere between that 78, 85 range.
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I did this case about three years ago.
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Uh, postmenopausal female, she
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Yeah,
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right?
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She didn't have a denture.
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And so, you know, generally when our patients have teeth, their, their bone is actually, fairly well.
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Like I, I, I think we have a 95% chance of, uh, you know, utilizing standard implants on patients like that.
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sure.
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But, you know, so took out her failing teeth, prepped the alveo, then just, you know, you hear that just, you know that butter bone all the
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Yeah.
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It's just evaporating.
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Yeah.
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Totally evaporates.
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And you know, again, I do surgery the same way on every patient every time.
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And you know, the key concepts that I teach at my course, and one of the key concepts is bi bicortical stabilization.
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Hmm.
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you know, once, once we do our alveolectomy, we kind of remove one of the cortices.
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You bet, man.
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then our only cortex here is that, you know, kind of lateral nasal wall
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Mm-hmm.
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want to engage our posterior implants with.
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you know, did like a four, oh, you know, 18, you know, I think we got, you know, five newtons and, and, and her, her nasal cortex was so thin,
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Yeah.
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I thought, okay, all right, well let's go from a four to 18.
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Let's throw in a 5 0 18, you know, still absolutely nothing.
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Yeah.
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I was like, I was like, all right, okay, well let's go ahead and mo you know, move on.
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So we then we went to the anterior, uh, and, and really kind of s same thing.
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I went to the nasal crest, uh, you know, went, you know, medi medially there.
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Okay, no big deal.
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We'll go lateral, nasal, absolutely nothing.
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So, you know, so then I'm, then I'm like, okay, all right, well, know that that side's a quad and so let's, let's, let's go ahead and, you know, let's go to the left side and see what we get.
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you know, po left like 70 Newtons.
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You know, like, I was like, man, okay, thank goodness I got
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Yeah.
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Something.
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tilted on the left,
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Yeah.
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and so, you know, uh, then proceed to do the anterior, uh, max left side maxilla nothing, right?
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So I'm just like, oh, man, okay.
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All right.
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So then I'm like, okay, well can we, can we at least get the OIDs So then, you know, boom, nail, nail OIDs bilaterally.
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So I was like,
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yeah,
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high, fives there, you know.
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So then, but you know, this, this patient just out of, out of the blue required a, a maxillary quad almost, you know?
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So,
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yeah.
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Okay.
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Definitely, definitely took a lot of time and, you know, but again, you know, my goal here is not to hope.
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I do not want to then just bury some implants, leave the patient in a denture,
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Mm-hmm.
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you know, uh, for five or six months and then come back and uncover and, and hope that, you know, you have, you know, stability with your implants.
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you know, generally my protocol is, is, you know, I don't hope, I want to know, I want, and that's what I teach and that's, that's why I get these people to, you know, take these advanced courses so that when a, when a, when a standard case comes up and it's just absolutely butter bone on a postmenopausal female, well,
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Yeah.
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able to provide her permanent fixed teeth in a day and two weeks later she's eating a hamburger.
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You know, uh, you
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and I,
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and you can tell even on her lower, her
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I,
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so soft.
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I was just about to say, you, you get done with this upper and you're like, oh, well, surely the, lower will be better.
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yeah.
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Yeah.
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And yeah, and, and definitely it wasn't, I mean, we had to use, I think
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Yeah,
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fives and
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Yeah.
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definitely.
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Yeah.
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You're, you're in the inferior cortical border on all four of those front four implants and, and you actually, uh, crisscross your anterior ones.
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I don't see that very often.
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Yeah.
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is that what I'm saying?
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Yeah.
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Yeah.
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That's, that's.
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um, you know, this, this brings up a really good point.
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You know, the, the, the question sometimes on a mandible is like, okay, well what, what width of an implant are you gonna use?
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Like, if you're gonna use neo dent, is what I like to use, that you have, you have several options.
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You have a four oh, and you have a four three, right?
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Yeah.
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So on a, on a case where, know, you have to pay attention to your drill, right?
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If, if you already know that with your two oh drill or your spade, it is super soft
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Mm-hmm.
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and you know you're to 18 and you really haven't reached that inferior border, that's, that's okay.
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But don't place a four three implant because the challenge that you have, if you place a four three, and then now you need to switch back and you need to place the GM long.
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Yeah.
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Four.
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Oh.
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you have, you have 16 millimeters of your osteotomy that's actually 0.3 millimeters wider than your implant.
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So, so, so on, on a, on a case where you may not wanna just throw in a GM long, but you may wanna try, me try a 4 0 18.
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Mm-hmm.
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a 4 3 18.
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I like this.
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Yeah.
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So you, you try a 4 0 18, and then if you need to use your 25, well then boom, just bust out your GM long drill, you know, drill to drill to 2225, and then now you can put your four oh by 25 in there.
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Yeah.
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Yeah.
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No, that's brilliant.
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We, we were actually, we did a, we just did an episode with, uh, cliff Gratz, who's the product development specialist at, at den.
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And, you know, he was talking about how a lot of where den derives is stability, at least with the GM helix, is the, the threads in the Crest portion are compressive.
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And so if you're not able to engage that with your now GM long implant that is undersized for your osteotomy, you're not getting any of that compression, and now you're just relying on stability from that cortical engagement, which, you know, it'll work, you'll get some torque, but not as much stability of the implant as you would had you not oversized that osteotomy.
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correct.
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Yeah.
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So then, then if you roll with your four, three, and then downsize to a GM long four oh, you're right.
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You're just, you're just
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Yeah,
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AP apical stability,
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right.
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which, works.
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I mean, I've, I've never, I have never had a GM long implant fail.
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And I've, I've used, I've used quite a few,
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Yeah.
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you know, just because we get really good stability down here, it winds up being the same principles as, uh, as zygomatic.
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Right.
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Yeah.
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just because you have just that such a, such a long implant.
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You,
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but, you know, I also.
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case I do, we, we do, we provided that they can do it.
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We do six implants in the mandible.
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mm-hmm.
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And so, uh, you know, I, I pre, I prefer to load I have not seen Crystals, bone loss with, you know, loading the, the, the posterior implants.
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Mm-hmm.
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Yeah.
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so, you know, that, that, that really helps with, with just getting everything very, very fixed.
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Yeah.
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And you're,
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it,
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are you usually using those GM shorts or do you use a lot of the eight millimeters?
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The, the regular gm?
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yeah, I mean, I think my, my, my preference, it, always just depends, you know, I, I go, I go back and forth.
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I, I like the
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Yeah.
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0 7, which is a ti
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Mm-hmm.
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Yeah.
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You know, and, and I like that because you don't buy a different abutment.
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You know, the GM abutments or the GM short abutments are different.
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and it's a more parallel, right?
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A more parallel implant actually gives you more compression
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Mm-hmm.
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implant.
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Mm-hmm.
00:09:24.740 --> 00:09:36.860
so, you know, that's so, so Paulo Malo, what he created was the Nobel Speedy Groovy, and he was like, we get more compression with the Nobel speedy groovy than you do with the noble active, because the noble active was tapered.
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And so, you know, that's, that's where the GM Helix really is a great implant because it's apically tapered.
00:09:45.379 --> 00:09:52.100
But then in, in, in the mid body and the, the coronal portion, is, uh,
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It.
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So it's, it's su super compressive, which is, which is really great.
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Awesome.
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Awesome.
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Yeah.
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I use a lot of, um, four, three by eights and, and five oh by eights in the GMs, but it's
00:10:06.139 --> 00:10:07.639
Typical, typically in the po,
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good.
00:10:09.259 --> 00:10:12.530
typically in the posterior it's, it's all five ohs.
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Um, and you know, I, I've used a lot of the GM shorts, you know, five oh by five five, and then really that 5 0 7 is, is really fantastic.
00:10:23.831 --> 00:10:24.071
Yeah.
00:10:24.071 --> 00:10:24.551
That's nice.
00:10:24.551 --> 00:10:25.331
I might need to try that.
00:10:25.331 --> 00:10:26.801
That's gonna gimme a little bit more flexibility.
00:10:26.891 --> 00:10:27.336
That's really nice.
00:10:27.860 --> 00:10:33.050
But, you know, I would, if I'm leaning to a five oh GM short seven.
00:10:33.620 --> 00:10:39.470
I would rather just use a 5 0 7 tiam max and be able to keep the same
00:10:39.941 --> 00:10:41.261
The same about, yeah.
00:10:41.740 --> 00:10:41.980
Yeah.
00:10:41.985 --> 00:10:42.551
That's, Yeah.
00:10:42.551 --> 00:10:46.091
That, that's kind of what's kept me away from using the shorts is I don't want to use different puppets.
00:10:46.580 --> 00:10:47.030
No, but
00:10:47.086 --> 00:10:47.375
yeah.
00:10:47.570 --> 00:10:57.740
I've, had so many patients where, you know, literally the, the, the nerve is at six mil, six millimeters, seven millimeters, you know, from the crest.
00:10:57.956 --> 00:10:58.375
Mm-hmm.
00:10:58.910 --> 00:11:02.629
so that, uh, five oh by five five works really well.
00:11:03.131 --> 00:11:06.131
And if you're not gonna do any alveo, you can still grab that bi cortical, well.
00:11:06.131 --> 00:11:11.740
not bi cortical, but you still have the cortex to give you stability, which, which, you know, you get a little more success that way.
00:11:12.250 --> 00:11:12.971
So, Yeah.
00:11:15.461 --> 00:11:15.671
Here we.
00:11:17.149 --> 00:11:17.450
Yep.
00:11:17.509 --> 00:11:21.320
So, you know, here we have one of, one of my cases, uh, for sure.
00:11:21.320 --> 00:11:27.590
And, you know, patient came back and he was like, oh, you know, I'm, I'm, I'm speaking kind of nasally.
00:11:28.009 --> 00:11:28.970
And I'm like, okay.
00:11:28.970 --> 00:11:34.160
And he's like, you know, I'm getting some fluid in, but he is like, not all the time, it's, you know, kinda rare.
00:11:34.970 --> 00:11:39.139
So I was like, Hey buddy, we're just, let's just take your prosthesis off and let's look under the hood.
00:11:39.761 --> 00:11:40.051
Yeah,
00:11:40.100 --> 00:11:46.220
know, lo and behold, boom, there's this nice little, you know, hole staring back at me.
00:11:46.220 --> 00:11:48.800
And I'm like, all right, well we're gonna, we're gonna have to fix that.
00:11:48.980 --> 00:11:49.460
So.
00:11:49.615 --> 00:11:50.036
yeah,
00:11:50.870 --> 00:12:00.410
Uh, you know, again, you know, fixing an OAC, you know, my preference is can I close it a penalized CT graft?
00:12:00.865 --> 00:12:01.286
yeah.
00:12:01.460 --> 00:12:02.690
let's hit the next slide.
00:12:02.690 --> 00:12:10.009
I think, I think this particular patient, we were not able to, uh, clo close the hole.
00:12:10.250 --> 00:12:10.700
Yeah.
00:12:11.149 --> 00:12:15.470
So, uh, know, off oftentimes, you know, I, I run a busy clinic.
00:12:15.500 --> 00:12:19.670
I'd love to, you know, just be able to take photos all day long.
00:12:19.670 --> 00:12:20.300
I can't,
00:12:20.516 --> 00:12:20.966
I get it.
00:12:21.050 --> 00:12:22.730
I didn't take a picture of the hole.
00:12:22.730 --> 00:12:27.050
I think in the chat, I've sent several holes that have been like the size of your thumb, you know,
00:12:27.446 --> 00:12:27.985
Yeah.
00:12:27.985 --> 00:12:28.046
Yeah,
00:12:28.310 --> 00:12:32.600
uh, it's like, uh, there's, there's not enough connective tissue in the world that
00:12:32.821 --> 00:12:33.171
right.
00:12:33.230 --> 00:12:33.560
that.
00:12:33.951 --> 00:12:34.291
Of course.
00:12:34.820 --> 00:12:46.490
But so, so, so my protocol is, okay, we're, we're going to, get, get the, rotate the pal, rotate the connective tissue graft over.
00:12:46.879 --> 00:12:48.590
Let me see if that will close it.
00:12:49.040 --> 00:12:55.430
If it won't, then that's when we have, okay, now we're gonna need to advance the buccal flat fat pad,
00:12:55.855 --> 00:12:56.156
Yeah.
00:12:56.269 --> 00:12:57.019
to close it.
00:12:57.019 --> 00:13:01.190
And here, you know, we're able to advance the buccal fat and look how nice that
00:13:01.610 --> 00:13:02.221
Beautiful.
00:13:02.490 --> 00:13:02.781
Yeah.
00:13:03.171 --> 00:13:03.461
Yeah.
00:13:03.470 --> 00:13:04.550
it's not stringy.
00:13:04.550 --> 00:13:05.450
It's not pooled.
00:13:05.450 --> 00:13:08.629
That's, that's what you want your buckle fat pads to look like.
00:13:09.019 --> 00:13:12.530
If, if your buckle fat pads are stringy, they're, they're just gonna die.
00:13:12.750 --> 00:13:13.041
Yeah.
00:13:14.120 --> 00:13:23.465
but so we pull this forward Know, my preference here is that we wind up with a multi-layer closure.
00:13:23.524 --> 00:13:23.825
Okay.
00:13:23.825 --> 00:13:31.865
So we'll have buckle fat, and then this picture to the right is actually the penalized CT graft.
00:13:32.195 --> 00:13:42.695
And so that is gonna go over, uh, we're then gonna create a trans osseous suture so that we can then suture all of that down and make it very stable.
00:13:43.144 --> 00:13:55.355
Sometimes I'll secure, so sometimes I, I will secure the buccal into the vestibule as well.
00:13:56.134 --> 00:14:16.415
Um, but I, I, you know, if, if you can, I, I prefer to get it down to the, uh, maxillary alveolis, so, uh, so buccal fat, connective tissue, and then we'll close it with our mucosa so we get a really nice triple layer, uh, closure there.
00:14:17.725 --> 00:14:18.115
Very nice.
00:14:18.115 --> 00:14:22.316
So the buccal fat, the ct, and just mucosa closing over the top of it.
00:14:22.316 --> 00:14:23.156
That's our Tator.
00:14:23.456 --> 00:14:23.816
Very nice.
00:14:24.155 --> 00:14:24.545
Yep.
00:14:25.046 --> 00:14:25.556
Beautiful.
00:14:26.816 --> 00:14:27.206
Awesome.
00:14:27.506 --> 00:14:31.706
Yeah, you can, I mean, you can see how vascular this tissue is, you know?
00:14:32.396 --> 00:14:32.756
Beautiful.
00:14:33.475 --> 00:14:34.136
And, that's our closure.
00:14:34.136 --> 00:14:34.196
Yeah.
00:14:34.205 --> 00:14:35.165
and there's your closure.
00:14:36.026 --> 00:14:36.296
Yeah.
00:14:36.656 --> 00:14:37.046
Or Damon.
00:14:37.370 --> 00:14:44.780
some, sometimes you have to pay attention to your prosthesis because now you've kind of shortened the vestibule.
00:14:45.211 --> 00:14:45.500
Yeah,
00:14:46.100 --> 00:14:52.850
so you need to relieve your prosthesis a little bit so that you don't wind up cutting into your mucosa
00:14:53.021 --> 00:14:53.311
yeah.
00:14:53.360 --> 00:14:56.360
or, or compressing onto the buccal fat.
00:14:57.379 --> 00:14:59.870
And also, we need to pay attention posteriorly.
00:15:01.040 --> 00:15:24.590
there are several times where I will then do a minor sinus crush posterior to this area that I, I move, I move the, the, you know, maxilla a little more, superiorly so that we still have a lot of restorative space
00:15:25.110 --> 00:15:25.771
Oh, okay.
00:15:25.879 --> 00:15:26.269
you gotta
00:15:26.281 --> 00:15:26.571
Yeah.
00:15:26.629 --> 00:15:33.830
think we're gonna have, we're gonna have, uh, connective tissue, we're gonna have buccal fat, all that can wind up taking up
00:15:33.865 --> 00:15:34.735
Getting pinched.
00:15:35.666 --> 00:15:36.475
Yeah, for sure.
00:15:36.730 --> 00:15:38.516
And, and when do you recall,
00:15:38.750 --> 00:15:39.649
we'll tap that down.
00:15:40.615 --> 00:15:42.176
do you recall, um.
00:15:42.926 --> 00:15:45.865
How, uh, how long postoperative this was?
00:15:46.790 --> 00:15:49.490
Well, this picture here is immediately postoperative surgery.
00:15:49.766 --> 00:15:50.186
No, no, no.
00:15:50.191 --> 00:15:52.766
I, I, yeah, I mean, like, when did he have his initial surgery.
00:15:52.766 --> 00:15:53.906
and when did the OAC present?
00:15:53.906 --> 00:15:55.646
Is that, is that usually an early complication?
00:15:55.646 --> 00:15:55.946
Late?
00:15:56.570 --> 00:15:58.490
It's, it's definitely an early complication.
00:15:58.490 --> 00:16:02.570
It's, it's within, it's, it's within, uh, three months.
00:16:02.841 --> 00:16:03.131
Okay,
00:16:04.399 --> 00:16:04.730
Yeah.
00:16:05.509 --> 00:16:05.690
So,
00:16:07.735 --> 00:16:10.556
So, this is another one I stole, um, from Tribe.
00:16:10.556 --> 00:16:12.011
So this is from, uh, Dr.
00:16:12.011 --> 00:16:12.686
Bruce Smer.
00:16:12.686 --> 00:16:15.956
He shared it in the group, so I assume that he'd be all right with us talking about it.
00:16:15.985 --> 00:16:17.536
Um, and he had, uh, Dr.
00:16:17.536 --> 00:16:19.556
Juan Gonzalez, uh, come in to help with the closure.
00:16:19.556 --> 00:16:21.355
And this can be very much like what you already reviewed.
00:16:21.776 --> 00:16:26.546
Um, you can see this is a really, uh, sizable, you know, OAC we have here on the left.
00:16:26.546 --> 00:16:29.756
And I think, I don't recall the entire history that Bruce, um, shared.
00:16:29.875 --> 00:16:37.886
Um, but I, I think that that was a, a zy igo that had to be, um, extracted and they closed over it, and then it opened back up and now they have a, they're dealing with an oac.
00:16:41.216 --> 00:16:41.605
Yeah.
00:16:41.725 --> 00:16:43.676
So we kinda just kind of, yeah, go ahead, please.
00:16:43.730 --> 00:16:48.259
know, uh, taking, taking out the sinus, uh, tract and taking out the fistula.
00:16:48.956 --> 00:16:49.136
Mm-hmm.
00:16:54.950 --> 00:17:01.399
Just, uh, here, you know, Juan's getting a really nice, uh, uh, distal incision
00:17:02.306 --> 00:17:02.725
Yeah.
00:17:03.926 --> 00:17:07.076
And so he's, he, is he reflecting tissue?
00:17:07.615 --> 00:17:13.766
This is the point of this is to go in from back to front and reflect all the tissue instead of doing it directly over the the defect.
00:17:13.766 --> 00:17:15.086
Is that what's happening here?
00:17:15.470 --> 00:17:15.710
decision.
00:17:15.710 --> 00:17:16.940
Uh, go to the next slide.
00:17:17.276 --> 00:17:17.635
Yeah.
00:17:18.115 --> 00:17:19.975
It shows the whole incision design a little bit.
00:17:19.975 --> 00:17:20.245
Yeah.
00:17:21.109 --> 00:17:21.529
Yeah.
00:17:21.529 --> 00:17:23.899
So, um, you know, they did not.
00:17:24.994 --> 00:17:35.434
They, they wanted to be able to rotate that tissue so he went distal to it so he can actually rotate that tissue more anterior.
00:17:35.965 --> 00:17:36.296
Okay.
00:17:36.715 --> 00:17:37.735
Oh, okay.
00:17:37.740 --> 00:17:37.790
Okay.
00:17:38.155 --> 00:17:38.671
I understand that.
00:17:40.620 --> 00:17:40.911
Okay.
00:17:41.285 --> 00:17:45.004
And then really nice, uh, description here.
00:17:45.004 --> 00:17:45.875
You know, this is great.
00:17:45.875 --> 00:17:49.324
I mean, this is a, you know, across the midline, you
00:17:49.330 --> 00:17:49.750
Mm-hmm.
00:17:49.984 --> 00:17:50.794
incision,
00:17:50.971 --> 00:17:51.390
Mm-hmm.
00:17:52.255 --> 00:17:54.145
Yeah, that makes sense.
00:18:03.754 --> 00:18:06.214
so just ref, ref reflecting there.
00:18:06.580 --> 00:18:07.000
Mm-hmm.
00:18:10.316 --> 00:18:11.245
And there's our wedge.
00:18:11.944 --> 00:18:12.365
Yeah.
00:18:12.365 --> 00:18:15.814
So then that's obviously that, that was rotated from an anterior
00:18:16.045 --> 00:18:16.195
Yeah.
00:18:16.984 --> 00:18:20.164
now rotating that posteriorly and laterally.
00:18:21.326 --> 00:18:25.405
Is there, is there a reason why, I mean, do they typically go that way?
00:18:25.405 --> 00:18:33.025
Like you're in sizing anterior to posterior, and then you're swinging it back versus going the other direction, like back to forward and then you loop it around?
00:18:33.394 --> 00:18:35.164
so that's, that's a really good question.
00:18:35.914 --> 00:18:37.384
where does the blood flow come from?
00:18:38.155 --> 00:18:40.135
Uh, well we come coming from?
00:18:40.135 --> 00:18:41.665
the, the GP ultimately, right?
00:18:42.079 --> 00:18:43.579
Which is in the posterior,
00:18:43.645 --> 00:18:43.826
Yeah,
00:18:43.909 --> 00:18:51.079
So if you, if if, if you, you cut it off at the posterior and then rotate it anteriorly,
00:18:51.505 --> 00:18:51.836
yeah,
00:18:51.919 --> 00:18:54.349
now it's just gonna necros and die because
00:18:54.385 --> 00:18:54.655
yeah.
00:18:54.799 --> 00:18:56.480
it off of its blood supply.
00:18:56.905 --> 00:18:57.385
That makes sense.
00:18:57.390 --> 00:18:58.070
Makes a lot of sense.
00:18:58.339 --> 00:18:59.299
Very good question.
00:18:59.299 --> 00:18:59.509
Yeah.
00:18:59.509 --> 00:19:00.199
Always.
00:19:00.199 --> 00:19:03.559
These are always rotated from an anterior to a posterior.
00:19:03.925 --> 00:19:04.225
Great.
00:19:07.549 --> 00:19:17.899
And then this is just, you know, one doing that lasso kind of that we talked about, where you're gonna, you're gonna go through your buccal fat several times to really get a good web.
00:19:17.899 --> 00:19:20.629
I would call it more of a web than a lasso, but
00:19:21.445 --> 00:19:23.215
Yeah, well, yeah, he is.
00:19:23.215 --> 00:19:24.115
He is in Texas.
00:19:24.235 --> 00:19:25.285
Well, I guess you are too, so
00:19:27.199 --> 00:19:29.209
we got, we got a lot of spiderwebs here, so I
00:19:29.365 --> 00:19:29.905
Sure thing.
00:19:29.995 --> 00:19:30.625
Yeah, that makes sense.
00:19:30.625 --> 00:19:32.846
Dale, there we go.
00:19:32.846 --> 00:19:33.115
Position,
00:19:33.259 --> 00:19:37.740
just, you know, again, just kind of securing that down with a trans osseous suture
00:19:39.566 --> 00:19:47.905
and I assume that in trying to cover this defect, ultimately we want to have quite a bit of BFP, you know, circumferential to the defect.
00:19:47.905 --> 00:19:50.515
Is there any guidance on like how much more we need to overlap it?
00:19:51.375 --> 00:19:55.519
so, know, the, the, the buccal fat will contract.
00:19:56.155 --> 00:19:56.485
Yeah.
00:19:56.779 --> 00:19:59.269
that's kind of one of the disadvantages of it.
00:19:59.846 --> 00:20:00.205
Okay.
00:20:00.319 --> 00:20:05.029
I, I would definitely go double the distance that you need.
00:20:10.924 --> 00:20:34.054
I mean, the, to, to me this is a little risky where, know, if, if the tissues really, so, so, so they, they're, they're beginning to do a split tissue thickness to then advance, advance kind of that lateral and, and kind of, kind of move it medially.
00:20:35.794 --> 00:20:47.584
You know, the, the, the challenge that you can get there is if, if, if you over score it, you can, you can really kind, uh, impede your, your, your blood supply kind of
00:20:47.721 --> 00:20:48.010
Yeah.
00:20:48.394 --> 00:20:49.984
lateral aspect of it.
00:20:51.170 --> 00:20:52.221
Yeah, that makes sense.
00:20:53.494 --> 00:20:55.504
But you need to mobilize the flap.
00:20:56.314 --> 00:21:02.434
so, you know, it's, it's really easy to do this when you're doing arch surgery.
00:21:03.214 --> 00:21:15.784
It, it's oftentimes a lot more complicated whenever you're, uh, fixing a complication from arch surgery because oftentimes, you know, your, your flap hasn't been elevated for as long, it's
00:21:15.985 --> 00:21:16.735
Yeah.
00:21:17.464 --> 00:21:22.384
So, you know, there's, you, you.
00:21:23.074 --> 00:21:29.674
I always think you do more harm to the patient, uh, with a smaller flap.
00:21:30.394 --> 00:21:35.644
And, uh, bigger flaps sounds scary to people.
00:21:35.884 --> 00:21:38.119
They think that, oh my gosh, you know, Mrs.
00:21:38.119 --> 00:21:41.194
Jones is really gonna be pissed if I give her a big flap.
00:21:41.944 --> 00:21:45.244
Well, she's really gonna be pissed if you tear the tissue, you know?
00:21:45.420 --> 00:21:45.711
Yeah.
00:21:46.294 --> 00:21:50.404
and then you're gonna have other, other sutures here or there that are gonna contract.
00:21:50.855 --> 00:22:04.804
So, you know, that's, that's kind of one of the reasons, you know, if you look at, uh, Dan Holtzclaw's remote Anchorage book, I don't like doing of that first molar, kind of lateral incision that he kind of makes.
00:22:05.060 --> 00:22:05.350
Yeah,
00:22:05.524 --> 00:22:09.454
cause o because oftentimes that's gonna be right over,
00:22:09.740 --> 00:22:10.060
I know.
00:22:10.384 --> 00:22:12.034
my, my zygomatic and, and
00:22:12.130 --> 00:22:12.420
Yeah.
00:22:12.454 --> 00:22:22.924
are with a, with an incision running up that hole, uh, you know, ru ru running superior and lateral right over, right over our, our zygomatic.
00:22:22.954 --> 00:22:33.934
So, you know, my preference is, is I just go straight back all the way over, all the way to the plates and, and, and, and then a nice big lateral, uh, pool.
00:22:35.096 --> 00:22:35.695
Mm.
00:22:35.755 --> 00:22:42.895
So there, do you do like a releasing incision at all back there, or is it just going so far distal that you're not gonna have as much tension on your flap?
00:22:43.009 --> 00:22:55.039
Yeah, I mean the, the, yeah, it's, it's so far just, I mean, you, I guess you could say, you know, there, there would be a, a, a, a slight vertical releasing incision in that, uh, ular notch.
00:22:55.560 --> 00:22:55.850
Okay.
00:22:55.961 --> 00:22:56.250
Yeah.
00:22:56.455 --> 00:22:57.775
Kind of like a hockey stick sort of.
00:22:59.240 --> 00:23:02.809
some people don't even have a, a a, a real notch there.
00:23:02.809 --> 00:23:04.669
So really it's just going straight back.
00:23:05.695 --> 00:23:06.145
Yeah.
00:23:06.235 --> 00:23:06.685
Okay.
00:23:06.745 --> 00:23:07.015
Yeah.
00:23:07.015 --> 00:23:19.465
no, I, I, I've definitely been adherent to the, uh, releasing incision up that, up that process there, but so often I've found myself having split tissue right where a fixture is, And you know, it, it's just not a, it's not an ideal situation.
00:23:19.819 --> 00:23:20.149
Yeah.
00:23:21.319 --> 00:23:23.480
And you're compromising blood flow, you know?
00:23:23.545 --> 00:23:23.880
You bet.
00:23:23.880 --> 00:23:24.836
Yeah, of course.
00:23:25.669 --> 00:23:31.819
So, you know, you know, I know, I know Bruce gave us this.
00:23:31.819 --> 00:23:37.730
He, he, he says, you know, obviously they were going for three layers of closure, but then somehow he says they got four.
00:23:37.730 --> 00:23:39.949
I don't know where they got the fourth layer from.
00:23:40.530 --> 00:23:41.780
That was a question that I,
00:23:46.459 --> 00:23:46.970
yeah.
00:23:47.209 --> 00:23:50.599
So, you know, again, just it's kind of the same principles.
00:23:51.289 --> 00:24:00.649
Uh, buckle fat, you know, maybe they're calling that fourth layer, you know, maybe some of the tissue that they advanced over that.
00:24:00.649 --> 00:24:00.829
But
00:24:00.836 --> 00:24:02.395
oh, from the split buckle flap?
00:24:02.395 --> 00:24:02.785
Maybe.
00:24:02.875 --> 00:24:03.265
Maybe.
00:24:03.265 --> 00:24:03.566
Yeah.
00:24:03.745 --> 00:24:04.135
Okay.
00:24:04.586 --> 00:24:05.215
That makes sense.
00:24:05.395 --> 00:24:12.655
Um, I'm curious, would there be any use or utility at all in, in using a, a membrane at all?
00:24:13.024 --> 00:24:13.625
Good question.
00:24:13.625 --> 00:24:15.875
People ask that kind of stuff all the time.
00:24:15.875 --> 00:24:24.274
You know, should I graph, should we, should we do generally in these, the least amount of intervention is best.
00:24:24.961 --> 00:24:25.250
Okay.
00:24:27.355 --> 00:24:27.715
Yeah.
00:24:27.814 --> 00:24:43.654
know, you, you put something there and then, you know, the last thing you want is, you know, now all of a sudden you have something in the sinus and then they get a sinus infection, and then, then, then, then you're back to OAC again after you've already, you know, had all this major, you know, type of work.
00:24:43.654 --> 00:24:45.334
So generally less is more.
00:24:45.955 --> 00:24:47.185
Okay, cool.
00:24:47.785 --> 00:24:48.745
And, and I'm curious too.
00:24:48.745 --> 00:24:55.915
So what if, um, you know, what, if you're in this situation and you use the buckle fat pad during the surgery, what do you kind of have to work with?
00:24:59.674 --> 00:25:01.684
Well that's, that's, that's why I don't,
00:25:02.515 --> 00:25:03.745
Yeah, don't get, don't get in that.
00:25:03.805 --> 00:25:04.495
Just don't do that.
00:25:04.525 --> 00:25:04.826
There we go.
00:25:06.445 --> 00:25:06.836
Fair enough.
00:25:09.655 --> 00:25:10.015
Okay.
00:25:10.135 --> 00:25:13.255
So eCOA is the fourth layer, but I, still count three.
00:25:13.504 --> 00:25:14.884
I, I I count three.
00:25:14.889 --> 00:25:15.454
I I think
00:25:15.566 --> 00:25:15.715
Yeah.
00:25:15.784 --> 00:25:17.559
they're being special here, but that's off.
00:25:17.559 --> 00:25:17.959
That's all.
00:25:19.555 --> 00:25:32.245
Um, and I wanted to throw this one in'cause we, we kind of alluded to this, um, earlier, um, when it comes to, you know, thinning the tissue and people talk about, you know, bleeders and such, we have a really nice video here and you can see quite a, quite a gusher there.
00:25:33.064 --> 00:25:40.414
Yeah, I mean, you know, you could imagine just left untreated, know, even though that's, that's actually a small arterial.
00:25:40.885 --> 00:25:41.365
Yeah.
00:25:43.625 --> 00:25:51.004
you know, probably, I mean, if you were to leave that for about a minute,
00:25:51.711 --> 00:25:52.000
Yeah.
00:25:52.264 --> 00:25:55.115
I mean, maybe less the entire mouth would be full, full of blood
00:25:55.195 --> 00:25:56.425
There it's overflow.
00:25:56.826 --> 00:25:57.994
20 seconds.
00:25:58.255 --> 00:25:58.645
Yeah.
00:25:58.675 --> 00:25:59.155
Right there.
00:25:59.275 --> 00:25:59.485
Yeah.
00:26:00.244 --> 00:26:06.034
so, you know, obviously this patient's under general anesthesia, so I know their blood pre, their blood pressure is low.
00:26:06.941 --> 00:26:07.060
Hmm.
00:26:07.174 --> 00:26:10.564
their blood pressure, there's probably, I bet they're a hundred over 60,
00:26:11.215 --> 00:26:11.605
Yeah,
00:26:11.704 --> 00:26:16.115
be, they could be 95 over, over 60, you know, or
00:26:16.435 --> 00:26:16.795
yeah,
00:26:16.894 --> 00:26:18.304
over over 55.
00:26:18.365 --> 00:26:24.845
But, uh, and, and you know, I mean, imagine encountering that on a wake patient, you know,
00:26:25.795 --> 00:26:27.086
yeah, yeah.
00:26:27.205 --> 00:26:27.535
So,
00:26:27.904 --> 00:26:28.834
they're gonna be freaking out.
00:26:29.635 --> 00:26:30.865
no, no question about it.
00:26:30.925 --> 00:26:35.275
Um, so is your, is your first go there is just electrocautery It's gonna be the quickest thing.
00:26:35.569 --> 00:26:38.029
Totally electrocautery, quickest thing.
00:26:38.750 --> 00:26:45.859
And you know, you so, you turn the power up on the unit, so you just zap it and it's done.
00:26:46.346 --> 00:26:46.735
Yeah.
00:26:46.875 --> 00:26:58.129
you, you need to act fairly quickly on these, you know, if, if you're dealing with a older patient and if they've already lost, you know, a fair amount of blood, which obviously they do in these surgeries,
00:26:58.410 --> 00:26:58.830
Mm-hmm.
00:26:59.119 --> 00:27:06.500
they, they can have, you know, trouble, uh, getting, you can have trouble getting them from the chair into the wheelchair they could pass
00:27:06.505 --> 00:27:06.895
Yeah.
00:27:07.255 --> 00:27:07.645
Oh, you bet.
00:27:07.735 --> 00:27:07.885
Yeah.
00:27:08.444 --> 00:27:21.019
So, you know, it's always, it's always a good idea, postoperatively to at least give your patient a good 500 cc bag of just, um,
00:27:22.405 --> 00:27:22.826
Fluid.
00:27:22.884 --> 00:27:25.399
so, so sodium chloride, just some fluid, right.
00:27:25.399 --> 00:27:29.149
Just to kind of help, you know, with their homeostasis.
00:27:29.695 --> 00:27:30.385
That's a great idea.
00:27:30.505 --> 00:27:31.225
Yeah, I love that.
00:27:34.225 --> 00:27:34.795
Very nice.
00:27:34.879 --> 00:27:35.209
are.
00:27:35.209 --> 00:27:36.919
We just do a nice little zap.
00:27:37.640 --> 00:27:38.060
Mm-hmm.
00:27:38.599 --> 00:27:39.649
Did we, did we do the zap?
00:27:40.346 --> 00:27:44.545
Uh, I think, I think, well it seems like you, I think you had a tip in there that was gonna work on it.
00:27:44.545 --> 00:27:49.826
I don't, I don't think this video had this app, but it looked like you'd actually already done it a few times.
00:27:52.316 --> 00:27:55.165
So do you, um, what is your recommendation on an electrocautery unit?
00:27:56.774 --> 00:27:56.994
Uh.
00:27:59.644 --> 00:28:01.924
I don't know, just, you know, park Hill makes one,
00:28:02.455 --> 00:28:02.875
Yeah,
00:28:03.424 --> 00:28:07.534
I don't even know the brand that we use, but they're, I think that starts with a, a,
00:28:08.035 --> 00:28:09.175
I got an RE one.
00:28:09.574 --> 00:28:09.634
I
00:28:09.715 --> 00:28:09.985
Is that
00:28:10.024 --> 00:28:10.595
what we have.
00:28:10.625 --> 00:28:10.894
I think
00:28:11.005 --> 00:28:11.275
okay?
00:28:11.314 --> 00:28:11.584
have.
00:28:11.615 --> 00:28:11.855
Yep.
00:28:11.855 --> 00:28:12.034
There
00:28:12.086 --> 00:28:13.435
Yeah, it was like 800 bucks.
00:28:13.495 --> 00:28:13.945
Like eBay?
00:28:14.066 --> 00:28:14.336
Yeah,
00:28:14.375 --> 00:28:15.814
those work great.
00:28:16.165 --> 00:28:16.495
yeah,
00:28:16.625 --> 00:28:26.224
Um, you know, the, the, the, the Bantam pros, the, the, the Bovie, that's, that's, that's a really good unit.
00:28:26.224 --> 00:28:31.984
And, and what's nice is you can, you can really customize all of your tips that you can just order from McKesson.
00:28:32.455 --> 00:28:32.905
yeah.
00:28:32.914 --> 00:28:35.524
Uh, so that's, that's also a really good unit.
00:28:36.326 --> 00:28:36.655
Nice.
00:28:39.566 --> 00:28:48.175
Uh, and then on this one, so this, this is one that I found that, um, someone had this is had been a student of your course and they sent this over.
00:28:48.326 --> 00:28:51.865
Um, so patient is looking at an upper all nx.
00:28:52.255 --> 00:28:53.905
Um, and, and I see this a lot.
00:28:53.905 --> 00:28:55.915
You've got this really flared.
00:28:56.980 --> 00:29:01.120
Maxilla here, and I think he will see him kind of rotating our skull here.
00:29:01.120 --> 00:29:16.480
So we can see, I mean, very intact, you know, lower arch, lots of root canals and implants and things, but, so, got some mileage, but up top whole lot of, you know, traumatic inclusion, your teeth have flared out a whole lot, some skeletal class three going on as Well, in addition to that.
00:29:16.900 --> 00:29:20.830
So, you know, the question is, you know, can I treat this person with a single arch?
00:29:20.951 --> 00:29:21.310
Right.
00:29:21.461 --> 00:29:24.820
Um, because am I gonna end up with a huge interior cantilever?
00:29:25.211 --> 00:29:27.040
Is there some other way to set them up on the occlusion?
00:29:27.040 --> 00:29:32.695
I mean, this kind of goes back to that, uh, case two or three we were talking about where we had, you know, some collapse bite.
00:29:32.695 --> 00:29:35.441
We opened it up, we got some more class two characteristic in there.
00:29:35.740 --> 00:29:37.120
How, how would you approach a case like this?
00:29:37.120 --> 00:29:39.971
I know, I know there's more that goes into evaluation, but this is what we have,
00:29:40.115 --> 00:29:44.105
you know, so this, this is, this is a perfect case example.
00:29:44.464 --> 00:29:46.774
So this is all the information that was given.
00:29:47.110 --> 00:29:47.471
right?
00:29:47.475 --> 00:29:48.086
This is all I got.
00:29:48.424 --> 00:29:52.054
you know, I just, I just said, I can't help you.
00:29:52.264 --> 00:29:54.574
Like, I need to see a cef,
00:29:55.066 --> 00:29:55.485
Mm-hmm.
00:29:55.504 --> 00:29:57.994
need to see like facial profile.
00:29:57.994 --> 00:30:02.254
Like, like, like we, we need to see a smiling, a smiling photo.
00:30:02.254 --> 00:30:10.954
Like we have, we have absolutely nothing to go off of, you know, other than all they're doing is looking at tooth position and bone,
00:30:11.915 --> 00:30:12.205
Yeah.
00:30:12.454 --> 00:30:16.684
So it's, it's missing really what the whole full arch patient is,
00:30:17.195 --> 00:30:17.545
Great.
00:30:17.704 --> 00:30:21.184
profile, you know, are they overlo?
00:30:21.514 --> 00:30:23.284
You know, do we need to open'em up?
00:30:23.914 --> 00:30:24.424
You know?
00:30:24.765 --> 00:30:24.885
I.
00:30:25.084 --> 00:30:26.674
also it goes into planning.
00:30:26.674 --> 00:30:32.524
I mean, who, who allowed this patient to spend all of this money on the lower teeth
00:30:32.890 --> 00:30:33.250
Yeah.
00:30:33.605 --> 00:30:34.384
with nothing?
00:30:34.384 --> 00:30:35.644
against it, you know?
00:30:36.025 --> 00:30:37.135
Right, right.
00:30:38.204 --> 00:30:40.459
I mean, I, I would, I would be shocked.
00:30:40.579 --> 00:30:45.559
I would be shocked if you told me, oh, this patient got this work 15 years ago.
00:30:45.559 --> 00:30:48.289
They're a, there's no way, those are like zirconia crowns.
00:30:48.919 --> 00:30:56.569
know, b if you've lost all those upper teeth, you're gonna lose all those lower teeth in a a, a short period of time.
00:30:57.559 --> 00:31:04.669
Um, so, you know, not really having all of the info, it's really hard to see.
00:31:04.669 --> 00:31:13.189
I think, I think what I think the pearl here is if this is all the info that you give, like I need to see a SEF full face.
00:31:13.639 --> 00:31:31.490
I wanna see axial images, um, where, you know, you know, anytime you wanna send something to an advanced doctor, send us the axial, coronal and sagittal images and take the video where you scroll all the way back.
00:31:32.434 --> 00:31:41.464
All the way forward and then come back like, I want to, I wanna, I wanna see you go forward back, and maybe even forward and back again.
00:31:41.464 --> 00:31:43.294
And then let's go to the other one.
00:31:43.294 --> 00:31:46.924
Let's, let's, let's look in the, you know, axial position.
00:31:47.500 --> 00:31:47.890
Yeah.
00:31:48.304 --> 00:31:49.894
you know, all the way down, all the way up.
00:31:49.894 --> 00:31:51.664
Let's, let's look in the coronal position.
00:31:52.595 --> 00:31:56.615
that then really gives us such a better example.
00:31:56.944 --> 00:32:05.164
I mean, I will see people who've been like, oh, I've planned this case and all they're doing is showing like the 3D recon of where their implants are.
00:32:06.154 --> 00:32:08.000
well, I, I have no idea.
00:32:08.000 --> 00:32:11.314
You know, how much, how much buccal bone do you have to your implant?
00:32:11.674 --> 00:32:15.424
You know, where are you in relation to the, the, the crest?
00:32:15.424 --> 00:32:18.004
Where are you in relation to the lateral nasal wall?
00:32:18.586 --> 00:32:18.875
Yeah.
00:32:19.024 --> 00:32:31.084
so there's, there's really so much, you know, that really kind of goes into, uh, advising on a, on a case like this, you know, the, the possibilities here are endless.
00:32:31.209 --> 00:32:31.889
I, I, I,
00:32:31.965 --> 00:32:32.255
Yeah.
00:32:33.244 --> 00:32:35.855
I ultimately can't say anything.
00:32:36.605 --> 00:32:40.954
but I mean, I think that your point is really well taken about like, Hey, this may be a case.
00:32:41.254 --> 00:32:42.514
Let's open'em up.
00:32:43.534 --> 00:32:49.204
see how much restorative space we actually have then, then kind of go from there.
00:32:49.415 --> 00:32:49.836
Mm-hmm.
00:32:51.125 --> 00:33:00.154
you know, don't, don't just look in a tunnel and say, okay, I can do crowns and we can do crowns on your lower teeth, and we'll talk about the upper, upper next.
00:33:00.274 --> 00:33:01.009
I mean, I.
00:33:02.464 --> 00:33:14.524
Whenever, whenever I talk to a patient and we have a consultation, it is only at the very end of the conversation do I even really kinda look in the patient's mouth.
00:33:14.974 --> 00:33:18.634
I'm wanting to find out what are your goals, what are your treatment goals?
00:33:18.904 --> 00:33:20.375
How does all this kind of come in?
00:33:20.375 --> 00:33:25.684
Like we're, we're gonna go macro and we may not even go micro, you know?
00:33:25.744 --> 00:33:28.054
Um, so,
00:33:28.680 --> 00:33:28.971
Yeah.
00:33:30.095 --> 00:33:37.024
you know, when, when you're extracting patients' money outta their wallet, you know, think of the end result, right?
00:33:37.260 --> 00:33:37.680
Mm-hmm.
00:33:38.074 --> 00:33:54.064
one little pearl in talking to patients is if you want to go to the beach, that's great, but you better be specific in what beach you want to go to, because I can take you to a beach in Alaska or I can take you to a beach in Cabo.
00:33:54.655 --> 00:33:55.015
Uh,
00:33:55.234 --> 00:34:04.294
we went, we went to the beach, we did what you asked for, but your expectations were a hundred percent or 180 degrees different from reality.
00:34:04.826 --> 00:34:05.245
yeah.
00:34:05.365 --> 00:34:05.875
I like that.
00:34:06.334 --> 00:34:09.905
always, always something to consider and think about.
00:34:10.615 --> 00:34:11.096
very good.
00:34:11.456 --> 00:34:11.876
Very good.
00:34:12.686 --> 00:34:13.826
Let's see if I got any more.
00:34:14.306 --> 00:34:14.905
I don't think I do.
00:34:15.596 --> 00:34:16.675
Yeah, I think that's my last one.
00:34:16.675 --> 00:34:17.755
That's slide 49.
00:34:18.994 --> 00:34:19.385
Sweet.
00:34:19.976 --> 00:34:20.306
Yeah.
00:34:20.735 --> 00:34:28.295
Well, I think, I think just these are all just examples of learning that, you know, you can be a part of.
00:34:28.925 --> 00:34:35.675
In implant groups that are out there, you know, you know me, I'm not trying to push my stuff.
00:34:35.675 --> 00:34:38.135
There's, there's so many things that, that are out there.
00:34:38.494 --> 00:34:50.015
But also we talk about the stuff in Texas Implant Institute in, you know, our all OnX cadaver course in the Zy, zygoma and OID course, and just in our WhatsApp group.
00:34:50.225 --> 00:34:54.155
So, uh, you know, I would love to help you guys along your journey.
00:34:54.515 --> 00:34:56.885
You know, visit Texas implant institute.com.
00:34:56.885 --> 00:35:03.575
I have some videos on there now, and we also have quite a few videos on, uh, our, our YouTube page.
00:35:03.575 --> 00:35:05.795
So, so, so check those out.
00:35:05.795 --> 00:35:13.954
And, uh, you know, you know, we're, I'm, I'm, you know, me and Tyler and Soren, we're all, you know, very approachable and,
00:35:14.311 --> 00:35:14.601
Yeah.
00:35:14.644 --> 00:35:22.925
know, we, when when you care about the patient, you know, there's always enough to go around, right?
00:35:23.704 --> 00:35:37.055
so, you know, it's ultimately caring, caring about the patient, but it's also caring about the doctor and their journey and not having, you know, just a, a, a waiting room full of complications and a waiting room full of problems.
00:35:38.066 --> 00:35:38.905
Yeah, you bet.
00:35:38.936 --> 00:35:49.946
I mean, I, I, I, you, you've said it perfectly well, and you know, I think that being a part of this community, going to your courses, it, it just needs to be a foundational, um, part of anyone's full arts journey, in my opinion.
00:35:50.006 --> 00:36:00.356
Um, because you just put together such a good group of, um, people, and there's a whole lot of very honest discussion about, um, how to approach cases, what to do about a case when it's gone south, and it, and it's, it's nothing personal.
00:36:00.356 --> 00:36:01.856
There's not any judgment attached to that.
00:36:01.856 --> 00:36:03.655
But I, I have, I learned something from that.
00:36:04.226 --> 00:36:05.816
Uh, that group every single day.
00:36:05.876 --> 00:36:09.896
And it's, it's encouraged me to go back, um, Texas implants to do more courses there.
00:36:09.896 --> 00:36:13.675
And, um, you know, we certainly don't really have any incentive to be singing your praises.
00:36:13.675 --> 00:36:20.396
It, it really just has been such a foundational part of our development and, uh, you know, I just appreciate you coming back on here to keep sharing what you share.
00:36:20.396 --> 00:36:22.076
I mean, you were an incredibly busy doctor.
00:36:22.135 --> 00:36:24.086
You know, you're having third arch months and things like that.
00:36:24.086 --> 00:36:33.865
You're teaching courses, you're doing all these other things, um, being expert witness and all that, and you still take time to go in and, you know, help me make a little PowerPoint with all these different case examples to, to teach people.
00:36:33.865 --> 00:36:35.936
And, and I think that's just a really admirable thing that you do.
00:36:35.936 --> 00:36:38.606
And, uh, I really appreciate you, you know, giving us your time and expertise.
00:36:39.105 --> 00:36:39.265
Sweet.
00:36:40.346 --> 00:36:40.736
Awesome.
00:36:41.096 --> 00:36:45.056
Well, this certainly won't be the last anyone sees of, of Clark Damon on the Fixed podcast.
00:36:45.056 --> 00:36:47.546
He's, he is been a repeated guest and certainly a highly valued one.
00:36:47.726 --> 00:36:48.956
Hope you guys really appreciated.
00:36:49.016 --> 00:36:55.796
You know, the series that we put together, um, you know, with all these, you know, visual aids with all these cases, I think, you know, this is what we really wanted to do with this podcast.
00:36:55.826 --> 00:37:01.256
Uh, up to this point, it's kind of been a little bit of a challenge getting some of the media, um, aspect into, um, these podcasts.
00:37:01.256 --> 00:37:05.306
So we've mostly just been talking about stuff, but I hope you guys appreciate the video content.
00:37:05.336 --> 00:37:10.796
Um, it's certainly, uh, a labor of love to put it all together, but, uh, I think this is really, um, really helpful.
00:37:10.826 --> 00:37:11.846
I, I think it's productive.
00:37:11.846 --> 00:37:14.126
I certainly learned from it and, uh, you know, Dr.
00:37:14.126 --> 00:37:16.166
Damon has, has been very gracious in giving us this time.
00:37:16.166 --> 00:37:19.916
So, um, hopefully we'll be back, um, with some more video content for you guys.
00:37:19.946 --> 00:37:21.536
And, uh, you know, let us know how you like it.
00:37:21.536 --> 00:37:28.646
Let us know how we can change it, make it a little bit more interactive, um, and, and make it more educational for you so you don't have waiting rooms, uh, full of complications.
00:37:28.646 --> 00:37:29.096
Just like Dr.
00:37:29.096 --> 00:37:29.516
Damon said.
00:37:30.365 --> 00:37:30.715
Sweet.
00:37:30.920 --> 00:37:31.400
All right.
00:37:31.400 --> 00:37:31.670
Well,
00:37:31.766 --> 00:37:31.976
Awesome.
00:37:32.090 --> 00:37:32.780
on everybody's journey.
00:37:32.780 --> 00:37:32.900
Sweet.
00:37:33.206 --> 00:37:33.776
You got it.
00:37:33.836 --> 00:37:34.286
Thank you.
00:00:46.721 --> 00:00:47.076
That sweet.
00:00:47.810 --> 00:00:59.090
So, you know, this is the only picture on this case, but this was probably the most, you know, if somebody was to ask me what, what's kind of been, you know, one of your more surprising cases.
00:00:59.930 --> 00:01:01.969
it would have to be this one for sure.
00:01:02.600 --> 00:01:07.939
Uh, so this, this was like a 85, I don't know, maybe she was 78.
00:01:08.420 --> 00:01:08.750
I don't know.
00:01:08.750 --> 00:01:11.000
Somewhere between that 78, 85 range.
00:01:11.000 --> 00:01:12.830
I did this case about three years ago.
00:01:13.760 --> 00:01:16.909
Uh, postmenopausal female, she
00:01:17.131 --> 00:01:17.421
Yeah,
00:01:17.780 --> 00:01:18.110
right?
00:01:18.110 --> 00:01:19.430
She didn't have a denture.
00:01:20.599 --> 00:01:27.680
And so, you know, generally when our patients have teeth, their, their bone is actually, fairly well.
00:01:27.680 --> 00:01:36.530
Like I, I, I think we have a 95% chance of, uh, you know, utilizing standard implants on patients like that.
00:01:36.956 --> 00:01:37.346
sure.
00:01:37.610 --> 00:01:47.120
But, you know, so took out her failing teeth, prepped the alveo, then just, you know, you hear that just, you know that butter bone all the
00:01:47.216 --> 00:01:47.665
Yeah.
00:01:47.996 --> 00:01:48.805
It's just evaporating.
00:01:48.986 --> 00:01:49.286
Yeah.
00:01:49.475 --> 00:01:50.225
Totally evaporates.
00:01:50.225 --> 00:01:55.145
And you know, again, I do surgery the same way on every patient every time.
00:01:55.145 --> 00:02:02.525
And you know, the key concepts that I teach at my course, and one of the key concepts is bi bicortical stabilization.
00:02:03.271 --> 00:02:03.350
Hmm.
00:02:03.695 --> 00:02:08.284
you know, once, once we do our alveolectomy, we kind of remove one of the cortices.
00:02:08.490 --> 00:02:09.191
You bet, man.
00:02:09.335 --> 00:02:14.555
then our only cortex here is that, you know, kind of lateral nasal wall
00:02:14.771 --> 00:02:15.191
Mm-hmm.
00:02:15.215 --> 00:02:17.944
want to engage our posterior implants with.
00:02:19.264 --> 00:02:30.784
you know, did like a four, oh, you know, 18, you know, I think we got, you know, five newtons and, and, and her, her nasal cortex was so thin,
00:02:31.441 --> 00:02:31.730
Yeah.
00:02:31.775 --> 00:02:34.444
I thought, okay, all right, well let's go from a four to 18.
00:02:34.444 --> 00:02:39.094
Let's throw in a 5 0 18, you know, still absolutely nothing.
00:02:39.411 --> 00:02:39.701
Yeah.
00:02:39.784 --> 00:02:44.495
I was like, I was like, all right, okay, well let's go ahead and mo you know, move on.
00:02:44.495 --> 00:02:49.504
So we then we went to the anterior, uh, and, and really kind of s same thing.
00:02:49.504 --> 00:02:54.485
I went to the nasal crest, uh, you know, went, you know, medi medially there.
00:02:56.164 --> 00:02:57.515
Okay, no big deal.
00:02:57.515 --> 00:03:01.205
We'll go lateral, nasal, absolutely nothing.
00:03:03.455 --> 00:03:13.504
So, you know, so then I'm, then I'm like, okay, all right, well, know that that side's a quad and so let's, let's, let's go ahead and, you know, let's go to the left side and see what we get.
00:03:14.735 --> 00:03:20.914
you know, po left like 70 Newtons.
00:03:20.944 --> 00:03:24.094
You know, like, I was like, man, okay, thank goodness I got
00:03:24.221 --> 00:03:24.510
Yeah.
00:03:24.510 --> 00:03:25.110
Something.
00:03:25.745 --> 00:03:26.944
tilted on the left,
00:03:27.581 --> 00:03:27.871
Yeah.
00:03:27.875 --> 00:03:38.944
and so, you know, uh, then proceed to do the anterior, uh, max left side maxilla nothing, right?
00:03:38.944 --> 00:03:40.745
So I'm just like, oh, man, okay.
00:03:40.745 --> 00:03:41.075
All right.
00:03:41.344 --> 00:03:48.754
So then I'm like, okay, well can we, can we at least get the OIDs So then, you know, boom, nail, nail OIDs bilaterally.
00:03:48.754 --> 00:03:49.295
So I was like,
00:03:49.311 --> 00:03:49.600
yeah,
00:03:49.685 --> 00:03:52.444
high, fives there, you know.
00:03:52.444 --> 00:03:59.465
So then, but you know, this, this patient just out of, out of the blue required a, a maxillary quad almost, you know?
00:03:59.465 --> 00:03:59.914
So,
00:03:59.920 --> 00:04:00.211
yeah.
00:04:00.681 --> 00:04:00.971
Okay.
00:04:01.685 --> 00:04:10.685
Definitely, definitely took a lot of time and, you know, but again, you know, my goal here is not to hope.
00:04:11.134 --> 00:04:17.555
I do not want to then just bury some implants, leave the patient in a denture,
00:04:18.040 --> 00:04:18.461
Mm-hmm.
00:04:18.935 --> 00:04:27.995
you know, uh, for five or six months and then come back and uncover and, and hope that, you know, you have, you know, stability with your implants.
00:04:29.164 --> 00:04:48.875
you know, generally my protocol is, is, you know, I don't hope, I want to know, I want, and that's what I teach and that's, that's why I get these people to, you know, take these advanced courses so that when a, when a, when a standard case comes up and it's just absolutely butter bone on a postmenopausal female, well,
00:04:48.880 --> 00:04:49.170
Yeah.
00:04:49.264 --> 00:04:55.144
able to provide her permanent fixed teeth in a day and two weeks later she's eating a hamburger.
00:04:55.144 --> 00:04:57.394
You know, uh, you
00:04:57.446 --> 00:04:57.806
and I,
00:04:58.384 --> 00:05:00.605
and you can tell even on her lower, her
00:05:00.985 --> 00:05:01.166
I,
00:05:01.205 --> 00:05:01.865
so soft.
00:05:02.216 --> 00:05:06.176
I was just about to say, you, you get done with this upper and you're like, oh, well, surely the, lower will be better.
00:05:07.355 --> 00:05:07.835
yeah.
00:05:07.955 --> 00:05:08.404
Yeah.
00:05:08.465 --> 00:05:12.575
And yeah, and, and definitely it wasn't, I mean, we had to use, I think
00:05:12.806 --> 00:05:13.076
Yeah,
00:05:13.264 --> 00:05:13.894
fives and
00:05:13.975 --> 00:05:14.306
Yeah.
00:05:14.365 --> 00:05:14.816
definitely.
00:05:15.176 --> 00:05:15.446
Yeah.
00:05:15.446 --> 00:05:22.645
You're, you're in the inferior cortical border on all four of those front four implants and, and you actually, uh, crisscross your anterior ones.
00:05:22.645 --> 00:05:23.515
I don't see that very often.
00:05:24.245 --> 00:05:24.605
Yeah.
00:05:24.750 --> 00:05:25.375
is that what I'm saying?
00:05:25.375 --> 00:05:25.615
Yeah.
00:05:26.096 --> 00:05:26.395
Yeah.
00:05:26.635 --> 00:05:27.265
That's, that's.
00:05:27.710 --> 00:05:31.940
um, you know, this, this brings up a really good point.
00:05:31.940 --> 00:05:39.259
You know, the, the, the question sometimes on a mandible is like, okay, well what, what width of an implant are you gonna use?
00:05:39.259 --> 00:05:44.539
Like, if you're gonna use neo dent, is what I like to use, that you have, you have several options.
00:05:44.539 --> 00:05:46.909
You have a four oh, and you have a four three, right?
00:05:47.605 --> 00:05:47.966
Yeah.
00:05:48.379 --> 00:05:55.190
So on a, on a case where, know, you have to pay attention to your drill, right?
00:05:55.909 --> 00:06:01.639
If, if you already know that with your two oh drill or your spade, it is super soft
00:06:01.770 --> 00:06:02.191
Mm-hmm.
00:06:02.929 --> 00:06:08.600
and you know you're to 18 and you really haven't reached that inferior border, that's, that's okay.
00:06:10.129 --> 00:06:21.049
But don't place a four three implant because the challenge that you have, if you place a four three, and then now you need to switch back and you need to place the GM long.
00:06:21.625 --> 00:06:21.956
Yeah.
00:06:21.956 --> 00:06:22.286
Four.
00:06:22.286 --> 00:06:22.676
Oh.
00:06:22.820 --> 00:06:32.389
you have, you have 16 millimeters of your osteotomy that's actually 0.3 millimeters wider than your implant.
00:06:33.200 --> 00:06:43.340
So, so, so on, on a, on a case where you may not wanna just throw in a GM long, but you may wanna try, me try a 4 0 18.
00:06:43.811 --> 00:06:44.230
Mm-hmm.
00:06:44.509 --> 00:06:46.100
a 4 3 18.
00:06:46.311 --> 00:06:46.750
I like this.
00:06:46.821 --> 00:06:47.110
Yeah.
00:06:47.240 --> 00:07:00.860
So you, you try a 4 0 18, and then if you need to use your 25, well then boom, just bust out your GM long drill, you know, drill to drill to 2225, and then now you can put your four oh by 25 in there.
00:07:01.931 --> 00:07:02.350
Yeah.
00:07:02.561 --> 00:07:02.740
Yeah.
00:07:02.740 --> 00:07:03.370
No, that's brilliant.
00:07:03.370 --> 00:07:10.061
We, we were actually, we did a, we just did an episode with, uh, cliff Gratz, who's the product development specialist at, at den.
00:07:10.120 --> 00:07:19.931
And, you know, he was talking about how a lot of where den derives is stability, at least with the GM helix, is the, the threads in the Crest portion are compressive.
00:07:20.500 --> 00:07:37.600
And so if you're not able to engage that with your now GM long implant that is undersized for your osteotomy, you're not getting any of that compression, and now you're just relying on stability from that cortical engagement, which, you know, it'll work, you'll get some torque, but not as much stability of the implant as you would had you not oversized that osteotomy.
00:07:38.174 --> 00:07:38.664
correct.
00:07:38.815 --> 00:07:39.105
Yeah.
00:07:39.105 --> 00:07:45.799
So then, then if you roll with your four, three, and then downsize to a GM long four oh, you're right.
00:07:45.799 --> 00:07:46.580
You're just, you're just
00:07:46.806 --> 00:07:47.096
Yeah,
00:07:47.570 --> 00:07:49.310
AP apical stability,
00:07:49.475 --> 00:07:49.826
right.
00:07:50.060 --> 00:07:50.899
which, works.
00:07:50.899 --> 00:07:55.070
I mean, I've, I've never, I have never had a GM long implant fail.
00:07:55.580 --> 00:07:58.220
And I've, I've used, I've used quite a few,
00:07:58.706 --> 00:07:58.995
Yeah.
00:07:59.899 --> 00:08:07.129
you know, just because we get really good stability down here, it winds up being the same principles as, uh, as zygomatic.
00:08:07.190 --> 00:08:07.580
Right.
00:08:08.015 --> 00:08:08.306
Yeah.
00:08:08.480 --> 00:08:12.169
just because you have just that such a, such a long implant.
00:08:12.716 --> 00:08:12.936
You,
00:08:13.549 --> 00:08:16.279
but, you know, I also.
00:08:17.225 --> 00:08:20.705
case I do, we, we do, we provided that they can do it.
00:08:21.034 --> 00:08:23.075
We do six implants in the mandible.
00:08:23.265 --> 00:08:23.686
mm-hmm.
00:08:24.034 --> 00:08:39.514
And so, uh, you know, I, I pre, I prefer to load I have not seen Crystals, bone loss with, you know, loading the, the, the posterior implants.
00:08:39.755 --> 00:08:40.176
Mm-hmm.
00:08:40.605 --> 00:08:40.895
Yeah.
00:08:41.195 --> 00:08:47.975
so, you know, that, that, that really helps with, with just getting everything very, very fixed.
00:08:48.551 --> 00:08:48.880
Yeah.
00:08:48.911 --> 00:08:49.211
And you're,
00:08:49.294 --> 00:08:49.355
it,
00:08:49.600 --> 00:08:52.961
are you usually using those GM shorts or do you use a lot of the eight millimeters?
00:08:53.020 --> 00:08:53.980
The, the regular gm?
00:08:54.335 --> 00:09:02.375
yeah, I mean, I think my, my, my preference, it, always just depends, you know, I, I go, I go back and forth.
00:09:02.419 --> 00:09:03.125
I, I like the
00:09:03.130 --> 00:09:03.431
Yeah.
00:09:03.485 --> 00:09:05.524
0 7, which is a ti
00:09:05.576 --> 00:09:05.995
Mm-hmm.
00:09:06.865 --> 00:09:07.155
Yeah.
00:09:07.700 --> 00:09:11.120
You know, and, and I like that because you don't buy a different abutment.
00:09:11.120 --> 00:09:14.180
You know, the GM abutments or the GM short abutments are different.
00:09:15.320 --> 00:09:17.210
and it's a more parallel, right?
00:09:17.509 --> 00:09:22.190
A more parallel implant actually gives you more compression
00:09:22.576 --> 00:09:22.995
Mm-hmm.
00:09:23.210 --> 00:09:23.810
implant.
00:09:24.245 --> 00:09:24.666
Mm-hmm.
00:09:24.740 --> 00:09:36.860
so, you know, that's so, so Paulo Malo, what he created was the Nobel Speedy Groovy, and he was like, we get more compression with the Nobel speedy groovy than you do with the noble active, because the noble active was tapered.
00:09:37.310 --> 00:09:44.990
And so, you know, that's, that's where the GM Helix really is a great implant because it's apically tapered.
00:09:45.379 --> 00:09:52.100
But then in, in, in the mid body and the, the coronal portion, is, uh,
00:09:52.125 --> 00:09:52.346
It.
00:09:53.720 --> 00:09:58.399
So it's, it's su super compressive, which is, which is really great.
00:09:59.141 --> 00:09:59.531
Awesome.
00:09:59.740 --> 00:10:00.071
Awesome.
00:10:00.071 --> 00:10:00.161
Yeah.
00:10:00.161 --> 00:10:05.740
I use a lot of, um, four, three by eights and, and five oh by eights in the GMs, but it's
00:10:06.139 --> 00:10:07.639
Typical, typically in the po,
00:10:08.110 --> 00:10:08.291
good.
00:10:09.259 --> 00:10:12.530
typically in the posterior it's, it's all five ohs.
00:10:12.649 --> 00:10:23.780
Um, and you know, I, I've used a lot of the GM shorts, you know, five oh by five five, and then really that 5 0 7 is, is really fantastic.
00:10:23.831 --> 00:10:24.071
Yeah.
00:10:24.071 --> 00:10:24.551
That's nice.
00:10:24.551 --> 00:10:25.331
I might need to try that.
00:10:25.331 --> 00:10:26.801
That's gonna gimme a little bit more flexibility.
00:10:26.891 --> 00:10:27.336
That's really nice.
00:10:27.860 --> 00:10:33.050
But, you know, I would, if I'm leaning to a five oh GM short seven.
00:10:33.620 --> 00:10:39.470
I would rather just use a 5 0 7 tiam max and be able to keep the same
00:10:39.941 --> 00:10:41.261
The same about, yeah.
00:10:41.740 --> 00:10:41.980
Yeah.
00:10:41.985 --> 00:10:42.551
That's, Yeah.
00:10:42.551 --> 00:10:46.091
That, that's kind of what's kept me away from using the shorts is I don't want to use different puppets.
00:10:46.580 --> 00:10:47.030
No, but
00:10:47.086 --> 00:10:47.375
yeah.
00:10:47.570 --> 00:10:57.740
I've, had so many patients where, you know, literally the, the, the nerve is at six mil, six millimeters, seven millimeters, you know, from the crest.
00:10:57.956 --> 00:10:58.375
Mm-hmm.
00:10:58.910 --> 00:11:02.629
so that, uh, five oh by five five works really well.
00:11:03.131 --> 00:11:06.131
And if you're not gonna do any alveo, you can still grab that bi cortical, well.
00:11:06.131 --> 00:11:11.740
not bi cortical, but you still have the cortex to give you stability, which, which, you know, you get a little more success that way.
00:11:12.250 --> 00:11:12.971
So, Yeah.
00:11:15.461 --> 00:11:15.671
Here we.
00:11:17.149 --> 00:11:17.450
Yep.
00:11:17.509 --> 00:11:21.320
So, you know, here we have one of, one of my cases, uh, for sure.
00:11:21.320 --> 00:11:27.590
And, you know, patient came back and he was like, oh, you know, I'm, I'm, I'm speaking kind of nasally.
00:11:28.009 --> 00:11:28.970
And I'm like, okay.
00:11:28.970 --> 00:11:34.160
And he's like, you know, I'm getting some fluid in, but he is like, not all the time, it's, you know, kinda rare.
00:11:34.970 --> 00:11:39.139
So I was like, Hey buddy, we're just, let's just take your prosthesis off and let's look under the hood.
00:11:39.761 --> 00:11:40.051
Yeah,
00:11:40.100 --> 00:11:46.220
know, lo and behold, boom, there's this nice little, you know, hole staring back at me.
00:11:46.220 --> 00:11:48.800
And I'm like, all right, well we're gonna, we're gonna have to fix that.
00:11:48.980 --> 00:11:49.460
So.
00:11:49.615 --> 00:11:50.036
yeah,
00:11:50.870 --> 00:12:00.410
Uh, you know, again, you know, fixing an OAC, you know, my preference is can I close it a penalized CT graft?
00:12:00.865 --> 00:12:01.286
yeah.
00:12:01.460 --> 00:12:02.690
let's hit the next slide.
00:12:02.690 --> 00:12:10.009
I think, I think this particular patient, we were not able to, uh, clo close the hole.
00:12:10.250 --> 00:12:10.700
Yeah.
00:12:11.149 --> 00:12:15.470
So, uh, know, off oftentimes, you know, I, I run a busy clinic.
00:12:15.500 --> 00:12:19.670
I'd love to, you know, just be able to take photos all day long.
00:12:19.670 --> 00:12:20.300
I can't,
00:12:20.516 --> 00:12:20.966
I get it.
00:12:21.050 --> 00:12:22.730
I didn't take a picture of the hole.
00:12:22.730 --> 00:12:27.050
I think in the chat, I've sent several holes that have been like the size of your thumb, you know,
00:12:27.446 --> 00:12:27.985
Yeah.
00:12:27.985 --> 00:12:28.046
Yeah,
00:12:28.310 --> 00:12:32.600
uh, it's like, uh, there's, there's not enough connective tissue in the world that
00:12:32.821 --> 00:12:33.171
right.
00:12:33.230 --> 00:12:33.560
that.
00:12:33.951 --> 00:12:34.291
Of course.
00:12:34.820 --> 00:12:46.490
But so, so, so my protocol is, okay, we're, we're going to, get, get the, rotate the pal, rotate the connective tissue graft over.
00:12:46.879 --> 00:12:48.590
Let me see if that will close it.
00:12:49.040 --> 00:12:55.430
If it won't, then that's when we have, okay, now we're gonna need to advance the buccal flat fat pad,
00:12:55.855 --> 00:12:56.156
Yeah.
00:12:56.269 --> 00:12:57.019
to close it.
00:12:57.019 --> 00:13:01.190
And here, you know, we're able to advance the buccal fat and look how nice that
00:13:01.610 --> 00:13:02.221
Beautiful.
00:13:02.490 --> 00:13:02.781
Yeah.
00:13:03.171 --> 00:13:03.461
Yeah.
00:13:03.470 --> 00:13:04.550
it's not stringy.
00:13:04.550 --> 00:13:05.450
It's not pooled.
00:13:05.450 --> 00:13:08.629
That's, that's what you want your buckle fat pads to look like.
00:13:09.019 --> 00:13:12.530
If, if your buckle fat pads are stringy, they're, they're just gonna die.
00:13:12.750 --> 00:13:13.041
Yeah.
00:13:14.120 --> 00:13:23.465
but so we pull this forward Know, my preference here is that we wind up with a multi-layer closure.
00:13:23.524 --> 00:13:23.825
Okay.
00:13:23.825 --> 00:13:31.865
So we'll have buckle fat, and then this picture to the right is actually the penalized CT graft.
00:13:32.195 --> 00:13:42.695
And so that is gonna go over, uh, we're then gonna create a trans osseous suture so that we can then suture all of that down and make it very stable.
00:13:43.144 --> 00:13:55.355
Sometimes I'll secure, so sometimes I, I will secure the buccal into the vestibule as well.
00:13:56.134 --> 00:14:16.415
Um, but I, I, you know, if, if you can, I, I prefer to get it down to the, uh, maxillary alveolis, so, uh, so buccal fat, connective tissue, and then we'll close it with our mucosa so we get a really nice triple layer, uh, closure there.
00:14:17.725 --> 00:14:18.115
Very nice.
00:14:18.115 --> 00:14:22.316
So the buccal fat, the ct, and just mucosa closing over the top of it.
00:14:22.316 --> 00:14:23.156
That's our Tator.
00:14:23.456 --> 00:14:23.816
Very nice.
00:14:24.155 --> 00:14:24.545
Yep.
00:14:25.046 --> 00:14:25.556
Beautiful.
00:14:26.816 --> 00:14:27.206
Awesome.
00:14:27.506 --> 00:14:31.706
Yeah, you can, I mean, you can see how vascular this tissue is, you know?
00:14:32.396 --> 00:14:32.756
Beautiful.
00:14:33.475 --> 00:14:34.136
And, that's our closure.
00:14:34.136 --> 00:14:34.196
Yeah.
00:14:34.205 --> 00:14:35.165
and there's your closure.
00:14:36.026 --> 00:14:36.296
Yeah.
00:14:36.656 --> 00:14:37.046
Or Damon.
00:14:37.370 --> 00:14:44.780
some, sometimes you have to pay attention to your prosthesis because now you've kind of shortened the vestibule.
00:14:45.211 --> 00:14:45.500
Yeah,
00:14:46.100 --> 00:14:52.850
so you need to relieve your prosthesis a little bit so that you don't wind up cutting into your mucosa
00:14:53.021 --> 00:14:53.311
yeah.
00:14:53.360 --> 00:14:56.360
or, or compressing onto the buccal fat.
00:14:57.379 --> 00:14:59.870
And also, we need to pay attention posteriorly.
00:15:01.040 --> 00:15:24.590
there are several times where I will then do a minor sinus crush posterior to this area that I, I move, I move the, the, you know, maxilla a little more, superiorly so that we still have a lot of restorative space
00:15:25.110 --> 00:15:25.771
Oh, okay.
00:15:25.879 --> 00:15:26.269
you gotta
00:15:26.281 --> 00:15:26.571
Yeah.
00:15:26.629 --> 00:15:33.830
think we're gonna have, we're gonna have, uh, connective tissue, we're gonna have buccal fat, all that can wind up taking up
00:15:33.865 --> 00:15:34.735
Getting pinched.
00:15:35.666 --> 00:15:36.475
Yeah, for sure.
00:15:36.730 --> 00:15:38.516
And, and when do you recall,
00:15:38.750 --> 00:15:39.649
we'll tap that down.
00:15:40.615 --> 00:15:42.176
do you recall, um.
00:15:42.926 --> 00:15:45.865
How, uh, how long postoperative this was?
00:15:46.790 --> 00:15:49.490
Well, this picture here is immediately postoperative surgery.
00:15:49.766 --> 00:15:50.186
No, no, no.
00:15:50.191 --> 00:15:52.766
I, I, yeah, I mean, like, when did he have his initial surgery.
00:15:52.766 --> 00:15:53.906
and when did the OAC present?
00:15:53.906 --> 00:15:55.646
Is that, is that usually an early complication?
00:15:55.646 --> 00:15:55.946
Late?
00:15:56.570 --> 00:15:58.490
It's, it's definitely an early complication.
00:15:58.490 --> 00:16:02.570
It's, it's within, it's, it's within, uh, three months.
00:16:02.841 --> 00:16:03.131
Okay,
00:16:04.399 --> 00:16:04.730
Yeah.
00:16:05.509 --> 00:16:05.690
So,
00:16:07.735 --> 00:16:10.556
So, this is another one I stole, um, from Tribe.
00:16:10.556 --> 00:16:12.011
So this is from, uh, Dr.
00:16:12.011 --> 00:16:12.686
Bruce Smer.
00:16:12.686 --> 00:16:15.956
He shared it in the group, so I assume that he'd be all right with us talking about it.
00:16:15.985 --> 00:16:17.536
Um, and he had, uh, Dr.
00:16:17.536 --> 00:16:19.556
Juan Gonzalez, uh, come in to help with the closure.
00:16:19.556 --> 00:16:21.355
And this can be very much like what you already reviewed.
00:16:21.776 --> 00:16:26.546
Um, you can see this is a really, uh, sizable, you know, OAC we have here on the left.
00:16:26.546 --> 00:16:29.756
And I think, I don't recall the entire history that Bruce, um, shared.
00:16:29.875 --> 00:16:37.886
Um, but I, I think that that was a, a zy igo that had to be, um, extracted and they closed over it, and then it opened back up and now they have a, they're dealing with an oac.
00:16:41.216 --> 00:16:41.605
Yeah.
00:16:41.725 --> 00:16:43.676
So we kinda just kind of, yeah, go ahead, please.
00:16:43.730 --> 00:16:48.259
know, uh, taking, taking out the sinus, uh, tract and taking out the fistula.
00:16:48.956 --> 00:16:49.136
Mm-hmm.
00:16:54.950 --> 00:17:01.399
Just, uh, here, you know, Juan's getting a really nice, uh, uh, distal incision
00:17:02.306 --> 00:17:02.725
Yeah.
00:17:03.926 --> 00:17:07.076
And so he's, he, is he reflecting tissue?
00:17:07.615 --> 00:17:13.766
This is the point of this is to go in from back to front and reflect all the tissue instead of doing it directly over the the defect.
00:17:13.766 --> 00:17:15.086
Is that what's happening here?
00:17:15.470 --> 00:17:15.710
decision.
00:17:15.710 --> 00:17:16.940
Uh, go to the next slide.
00:17:17.276 --> 00:17:17.635
Yeah.
00:17:18.115 --> 00:17:19.975
It shows the whole incision design a little bit.
00:17:19.975 --> 00:17:20.245
Yeah.
00:17:21.109 --> 00:17:21.529
Yeah.
00:17:21.529 --> 00:17:23.899
So, um, you know, they did not.
00:17:24.994 --> 00:17:35.434
They, they wanted to be able to rotate that tissue so he went distal to it so he can actually rotate that tissue more anterior.
00:17:35.965 --> 00:17:36.296
Okay.
00:17:36.715 --> 00:17:37.735
Oh, okay.
00:17:37.740 --> 00:17:37.790
Okay.
00:17:38.155 --> 00:17:38.671
I understand that.
00:17:40.620 --> 00:17:40.911
Okay.
00:17:41.285 --> 00:17:45.004
And then really nice, uh, description here.
00:17:45.004 --> 00:17:45.875
You know, this is great.
00:17:45.875 --> 00:17:49.324
I mean, this is a, you know, across the midline, you
00:17:49.330 --> 00:17:49.750
Mm-hmm.
00:17:49.984 --> 00:17:50.794
incision,
00:17:50.971 --> 00:17:51.390
Mm-hmm.
00:17:52.255 --> 00:17:54.145
Yeah, that makes sense.
00:18:03.754 --> 00:18:06.214
so just ref, ref reflecting there.
00:18:06.580 --> 00:18:07.000
Mm-hmm.
00:18:10.316 --> 00:18:11.245
And there's our wedge.
00:18:11.944 --> 00:18:12.365
Yeah.
00:18:12.365 --> 00:18:15.814
So then that's obviously that, that was rotated from an anterior
00:18:16.045 --> 00:18:16.195
Yeah.
00:18:16.984 --> 00:18:20.164
now rotating that posteriorly and laterally.
00:18:21.326 --> 00:18:25.405
Is there, is there a reason why, I mean, do they typically go that way?
00:18:25.405 --> 00:18:33.025
Like you're in sizing anterior to posterior, and then you're swinging it back versus going the other direction, like back to forward and then you loop it around?
00:18:33.394 --> 00:18:35.164
so that's, that's a really good question.
00:18:35.914 --> 00:18:37.384
where does the blood flow come from?
00:18:38.155 --> 00:18:40.135
Uh, well we come coming from?
00:18:40.135 --> 00:18:41.665
the, the GP ultimately, right?
00:18:42.079 --> 00:18:43.579
Which is in the posterior,
00:18:43.645 --> 00:18:43.826
Yeah,
00:18:43.909 --> 00:18:51.079
So if you, if if, if you, you cut it off at the posterior and then rotate it anteriorly,
00:18:51.505 --> 00:18:51.836
yeah,
00:18:51.919 --> 00:18:54.349
now it's just gonna necros and die because
00:18:54.385 --> 00:18:54.655
yeah.
00:18:54.799 --> 00:18:56.480
it off of its blood supply.
00:18:56.905 --> 00:18:57.385
That makes sense.
00:18:57.390 --> 00:18:58.070
Makes a lot of sense.
00:18:58.339 --> 00:18:59.299
Very good question.
00:18:59.299 --> 00:18:59.509
Yeah.
00:18:59.509 --> 00:19:00.199
Always.
00:19:00.199 --> 00:19:03.559
These are always rotated from an anterior to a posterior.
00:19:03.925 --> 00:19:04.225
Great.
00:19:07.549 --> 00:19:17.899
And then this is just, you know, one doing that lasso kind of that we talked about, where you're gonna, you're gonna go through your buccal fat several times to really get a good web.
00:19:17.899 --> 00:19:20.629
I would call it more of a web than a lasso, but
00:19:21.445 --> 00:19:23.215
Yeah, well, yeah, he is.
00:19:23.215 --> 00:19:24.115
He is in Texas.
00:19:24.235 --> 00:19:25.285
Well, I guess you are too, so
00:19:27.199 --> 00:19:29.209
we got, we got a lot of spiderwebs here, so I
00:19:29.365 --> 00:19:29.905
Sure thing.
00:19:29.995 --> 00:19:30.625
Yeah, that makes sense.
00:19:30.625 --> 00:19:32.846
Dale, there we go.
00:19:32.846 --> 00:19:33.115
Position,
00:19:33.259 --> 00:19:37.740
just, you know, again, just kind of securing that down with a trans osseous suture
00:19:39.566 --> 00:19:47.905
and I assume that in trying to cover this defect, ultimately we want to have quite a bit of BFP, you know, circumferential to the defect.
00:19:47.905 --> 00:19:50.515
Is there any guidance on like how much more we need to overlap it?
00:19:51.375 --> 00:19:55.519
so, know, the, the, the buccal fat will contract.
00:19:56.155 --> 00:19:56.485
Yeah.
00:19:56.779 --> 00:19:59.269
that's kind of one of the disadvantages of it.
00:19:59.846 --> 00:20:00.205
Okay.
00:20:00.319 --> 00:20:05.029
I, I would definitely go double the distance that you need.
00:20:10.924 --> 00:20:34.054
I mean, the, to, to me this is a little risky where, know, if, if the tissues really, so, so, so they, they're, they're beginning to do a split tissue thickness to then advance, advance kind of that lateral and, and kind of, kind of move it medially.
00:20:35.794 --> 00:20:47.584
You know, the, the, the challenge that you can get there is if, if, if you over score it, you can, you can really kind, uh, impede your, your, your blood supply kind of
00:20:47.721 --> 00:20:48.010
Yeah.
00:20:48.394 --> 00:20:49.984
lateral aspect of it.
00:20:51.170 --> 00:20:52.221
Yeah, that makes sense.
00:20:53.494 --> 00:20:55.504
But you need to mobilize the flap.
00:20:56.314 --> 00:21:02.434
so, you know, it's, it's really easy to do this when you're doing arch surgery.
00:21:03.214 --> 00:21:15.784
It, it's oftentimes a lot more complicated whenever you're, uh, fixing a complication from arch surgery because oftentimes, you know, your, your flap hasn't been elevated for as long, it's
00:21:15.985 --> 00:21:16.735
Yeah.
00:21:17.464 --> 00:21:22.384
So, you know, there's, you, you.
00:21:23.074 --> 00:21:29.674
I always think you do more harm to the patient, uh, with a smaller flap.
00:21:30.394 --> 00:21:35.644
And, uh, bigger flaps sounds scary to people.
00:21:35.884 --> 00:21:38.119
They think that, oh my gosh, you know, Mrs.
00:21:38.119 --> 00:21:41.194
Jones is really gonna be pissed if I give her a big flap.
00:21:41.944 --> 00:21:45.244
Well, she's really gonna be pissed if you tear the tissue, you know?
00:21:45.420 --> 00:21:45.711
Yeah.
00:21:46.294 --> 00:21:50.404
and then you're gonna have other, other sutures here or there that are gonna contract.
00:21:50.855 --> 00:22:04.804
So, you know, that's, that's kind of one of the reasons, you know, if you look at, uh, Dan Holtzclaw's remote Anchorage book, I don't like doing of that first molar, kind of lateral incision that he kind of makes.
00:22:05.060 --> 00:22:05.350
Yeah,
00:22:05.524 --> 00:22:09.454
cause o because oftentimes that's gonna be right over,
00:22:09.740 --> 00:22:10.060
I know.
00:22:10.384 --> 00:22:12.034
my, my zygomatic and, and
00:22:12.130 --> 00:22:12.420
Yeah.
00:22:12.454 --> 00:22:22.924
are with a, with an incision running up that hole, uh, you know, ru ru running superior and lateral right over, right over our, our zygomatic.
00:22:22.954 --> 00:22:33.934
So, you know, my preference is, is I just go straight back all the way over, all the way to the plates and, and, and, and then a nice big lateral, uh, pool.
00:22:35.096 --> 00:22:35.695
Mm.
00:22:35.755 --> 00:22:42.895
So there, do you do like a releasing incision at all back there, or is it just going so far distal that you're not gonna have as much tension on your flap?
00:22:43.009 --> 00:22:55.039
Yeah, I mean the, the, yeah, it's, it's so far just, I mean, you, I guess you could say, you know, there, there would be a, a, a, a slight vertical releasing incision in that, uh, ular notch.
00:22:55.560 --> 00:22:55.850
Okay.
00:22:55.961 --> 00:22:56.250
Yeah.
00:22:56.455 --> 00:22:57.775
Kind of like a hockey stick sort of.
00:22:59.240 --> 00:23:02.809
some people don't even have a, a a, a real notch there.
00:23:02.809 --> 00:23:04.669
So really it's just going straight back.
00:23:05.695 --> 00:23:06.145
Yeah.
00:23:06.235 --> 00:23:06.685
Okay.
00:23:06.745 --> 00:23:07.015
Yeah.
00:23:07.015 --> 00:23:19.465
no, I, I, I've definitely been adherent to the, uh, releasing incision up that, up that process there, but so often I've found myself having split tissue right where a fixture is, And you know, it, it's just not a, it's not an ideal situation.
00:23:19.819 --> 00:23:20.149
Yeah.
00:23:21.319 --> 00:23:23.480
And you're compromising blood flow, you know?
00:23:23.545 --> 00:23:23.880
You bet.
00:23:23.880 --> 00:23:24.836
Yeah, of course.
00:23:25.669 --> 00:23:31.819
So, you know, you know, I know, I know Bruce gave us this.
00:23:31.819 --> 00:23:37.730
He, he, he says, you know, obviously they were going for three layers of closure, but then somehow he says they got four.
00:23:37.730 --> 00:23:39.949
I don't know where they got the fourth layer from.
00:23:40.530 --> 00:23:41.780
That was a question that I,
00:23:46.459 --> 00:23:46.970
yeah.
00:23:47.209 --> 00:23:50.599
So, you know, again, just it's kind of the same principles.
00:23:51.289 --> 00:24:00.649
Uh, buckle fat, you know, maybe they're calling that fourth layer, you know, maybe some of the tissue that they advanced over that.
00:24:00.649 --> 00:24:00.829
But
00:24:00.836 --> 00:24:02.395
oh, from the split buckle flap?
00:24:02.395 --> 00:24:02.785
Maybe.
00:24:02.875 --> 00:24:03.265
Maybe.
00:24:03.265 --> 00:24:03.566
Yeah.
00:24:03.745 --> 00:24:04.135
Okay.
00:24:04.586 --> 00:24:05.215
That makes sense.
00:24:05.395 --> 00:24:12.655
Um, I'm curious, would there be any use or utility at all in, in using a, a membrane at all?
00:24:13.024 --> 00:24:13.625
Good question.
00:24:13.625 --> 00:24:15.875
People ask that kind of stuff all the time.
00:24:15.875 --> 00:24:24.274
You know, should I graph, should we, should we do generally in these, the least amount of intervention is best.
00:24:24.961 --> 00:24:25.250
Okay.
00:24:27.355 --> 00:24:27.715
Yeah.
00:24:27.814 --> 00:24:43.654
know, you, you put something there and then, you know, the last thing you want is, you know, now all of a sudden you have something in the sinus and then they get a sinus infection, and then, then, then, then you're back to OAC again after you've already, you know, had all this major, you know, type of work.
00:24:43.654 --> 00:24:45.334
So generally less is more.
00:24:45.955 --> 00:24:47.185
Okay, cool.
00:24:47.785 --> 00:24:48.745
And, and I'm curious too.
00:24:48.745 --> 00:24:55.915
So what if, um, you know, what, if you're in this situation and you use the buckle fat pad during the surgery, what do you kind of have to work with?
00:24:59.674 --> 00:25:01.684
Well that's, that's, that's why I don't,
00:25:02.515 --> 00:25:03.745
Yeah, don't get, don't get in that.
00:25:03.805 --> 00:25:04.495
Just don't do that.
00:25:04.525 --> 00:25:04.826
There we go.
00:25:06.445 --> 00:25:06.836
Fair enough.
00:25:09.655 --> 00:25:10.015
Okay.
00:25:10.135 --> 00:25:13.255
So eCOA is the fourth layer, but I, still count three.
00:25:13.504 --> 00:25:14.884
I, I I count three.
00:25:14.889 --> 00:25:15.454
I I think
00:25:15.566 --> 00:25:15.715
Yeah.
00:25:15.784 --> 00:25:17.559
they're being special here, but that's off.
00:25:17.559 --> 00:25:17.959
That's all.
00:25:19.555 --> 00:25:32.245
Um, and I wanted to throw this one in'cause we, we kind of alluded to this, um, earlier, um, when it comes to, you know, thinning the tissue and people talk about, you know, bleeders and such, we have a really nice video here and you can see quite a, quite a gusher there.
00:25:33.064 --> 00:25:40.414
Yeah, I mean, you know, you could imagine just left untreated, know, even though that's, that's actually a small arterial.
00:25:40.885 --> 00:25:41.365
Yeah.
00:25:43.625 --> 00:25:51.004
you know, probably, I mean, if you were to leave that for about a minute,
00:25:51.711 --> 00:25:52.000
Yeah.
00:25:52.264 --> 00:25:55.115
I mean, maybe less the entire mouth would be full, full of blood
00:25:55.195 --> 00:25:56.425
There it's overflow.
00:25:56.826 --> 00:25:57.994
20 seconds.
00:25:58.255 --> 00:25:58.645
Yeah.
00:25:58.675 --> 00:25:59.155
Right there.
00:25:59.275 --> 00:25:59.485
Yeah.
00:26:00.244 --> 00:26:06.034
so, you know, obviously this patient's under general anesthesia, so I know their blood pre, their blood pressure is low.
00:26:06.941 --> 00:26:07.060
Hmm.
00:26:07.174 --> 00:26:10.564
their blood pressure, there's probably, I bet they're a hundred over 60,
00:26:11.215 --> 00:26:11.605
Yeah,
00:26:11.704 --> 00:26:16.115
be, they could be 95 over, over 60, you know, or
00:26:16.435 --> 00:26:16.795
yeah,
00:26:16.894 --> 00:26:18.304
over over 55.
00:26:18.365 --> 00:26:24.845
But, uh, and, and you know, I mean, imagine encountering that on a wake patient, you know,
00:26:25.795 --> 00:26:27.086
yeah, yeah.
00:26:27.205 --> 00:26:27.535
So,
00:26:27.904 --> 00:26:28.834
they're gonna be freaking out.
00:26:29.635 --> 00:26:30.865
no, no question about it.
00:26:30.925 --> 00:26:35.275
Um, so is your, is your first go there is just electrocautery It's gonna be the quickest thing.
00:26:35.569 --> 00:26:38.029
Totally electrocautery, quickest thing.
00:26:38.750 --> 00:26:45.859
And you know, you so, you turn the power up on the unit, so you just zap it and it's done.
00:26:46.346 --> 00:26:46.735
Yeah.
00:26:46.875 --> 00:26:58.129
you, you need to act fairly quickly on these, you know, if, if you're dealing with a older patient and if they've already lost, you know, a fair amount of blood, which obviously they do in these surgeries,
00:26:58.410 --> 00:26:58.830
Mm-hmm.
00:26:59.119 --> 00:27:06.500
they, they can have, you know, trouble, uh, getting, you can have trouble getting them from the chair into the wheelchair they could pass
00:27:06.505 --> 00:27:06.895
Yeah.
00:27:07.255 --> 00:27:07.645
Oh, you bet.
00:27:07.735 --> 00:27:07.885
Yeah.
00:27:08.444 --> 00:27:21.019
So, you know, it's always, it's always a good idea, postoperatively to at least give your patient a good 500 cc bag of just, um,
00:27:22.405 --> 00:27:22.826
Fluid.
00:27:22.884 --> 00:27:25.399
so, so sodium chloride, just some fluid, right.
00:27:25.399 --> 00:27:29.149
Just to kind of help, you know, with their homeostasis.
00:27:29.695 --> 00:27:30.385
That's a great idea.
00:27:30.505 --> 00:27:31.225
Yeah, I love that.
00:27:34.225 --> 00:27:34.795
Very nice.
00:27:34.879 --> 00:27:35.209
are.
00:27:35.209 --> 00:27:36.919
We just do a nice little zap.
00:27:37.640 --> 00:27:38.060
Mm-hmm.
00:27:38.599 --> 00:27:39.649
Did we, did we do the zap?
00:27:40.346 --> 00:27:44.545
Uh, I think, I think, well it seems like you, I think you had a tip in there that was gonna work on it.
00:27:44.545 --> 00:27:49.826
I don't, I don't think this video had this app, but it looked like you'd actually already done it a few times.
00:27:52.316 --> 00:27:55.165
So do you, um, what is your recommendation on an electrocautery unit?
00:27:56.774 --> 00:27:56.994
Uh.
00:27:59.644 --> 00:28:01.924
I don't know, just, you know, park Hill makes one,
00:28:02.455 --> 00:28:02.875
Yeah,
00:28:03.424 --> 00:28:07.534
I don't even know the brand that we use, but they're, I think that starts with a, a,
00:28:08.035 --> 00:28:09.175
I got an RE one.
00:28:09.574 --> 00:28:09.634
I
00:28:09.715 --> 00:28:09.985
Is that
00:28:10.024 --> 00:28:10.595
what we have.
00:28:10.625 --> 00:28:10.894
I think
00:28:11.005 --> 00:28:11.275
okay?
00:28:11.314 --> 00:28:11.584
have.
00:28:11.615 --> 00:28:11.855
Yep.
00:28:11.855 --> 00:28:12.034
There
00:28:12.086 --> 00:28:13.435
Yeah, it was like 800 bucks.
00:28:13.495 --> 00:28:13.945
Like eBay?
00:28:14.066 --> 00:28:14.336
Yeah,
00:28:14.375 --> 00:28:15.814
those work great.
00:28:16.165 --> 00:28:16.495
yeah,
00:28:16.625 --> 00:28:26.224
Um, you know, the, the, the, the Bantam pros, the, the, the Bovie, that's, that's, that's a really good unit.
00:28:26.224 --> 00:28:31.984
And, and what's nice is you can, you can really customize all of your tips that you can just order from McKesson.
00:28:32.455 --> 00:28:32.905
yeah.
00:28:32.914 --> 00:28:35.524
Uh, so that's, that's also a really good unit.
00:28:36.326 --> 00:28:36.655
Nice.
00:28:39.566 --> 00:28:48.175
Uh, and then on this one, so this, this is one that I found that, um, someone had this is had been a student of your course and they sent this over.
00:28:48.326 --> 00:28:51.865
Um, so patient is looking at an upper all nx.
00:28:52.255 --> 00:28:53.905
Um, and, and I see this a lot.
00:28:53.905 --> 00:28:55.915
You've got this really flared.
00:28:56.980 --> 00:29:01.120
Maxilla here, and I think he will see him kind of rotating our skull here.
00:29:01.120 --> 00:29:16.480
So we can see, I mean, very intact, you know, lower arch, lots of root canals and implants and things, but, so, got some mileage, but up top whole lot of, you know, traumatic inclusion, your teeth have flared out a whole lot, some skeletal class three going on as Well, in addition to that.
00:29:16.900 --> 00:29:20.830
So, you know, the question is, you know, can I treat this person with a single arch?
00:29:20.951 --> 00:29:21.310
Right.
00:29:21.461 --> 00:29:24.820
Um, because am I gonna end up with a huge interior cantilever?
00:29:25.211 --> 00:29:27.040
Is there some other way to set them up on the occlusion?
00:29:27.040 --> 00:29:32.695
I mean, this kind of goes back to that, uh, case two or three we were talking about where we had, you know, some collapse bite.
00:29:32.695 --> 00:29:35.441
We opened it up, we got some more class two characteristic in there.
00:29:35.740 --> 00:29:37.120
How, how would you approach a case like this?
00:29:37.120 --> 00:29:39.971
I know, I know there's more that goes into evaluation, but this is what we have,
00:29:40.115 --> 00:29:44.105
you know, so this, this is, this is a perfect case example.
00:29:44.464 --> 00:29:46.774
So this is all the information that was given.
00:29:47.110 --> 00:29:47.471
right?
00:29:47.475 --> 00:29:48.086
This is all I got.
00:29:48.424 --> 00:29:52.054
you know, I just, I just said, I can't help you.
00:29:52.264 --> 00:29:54.574
Like, I need to see a cef,
00:29:55.066 --> 00:29:55.485
Mm-hmm.
00:29:55.504 --> 00:29:57.994
need to see like facial profile.
00:29:57.994 --> 00:30:02.254
Like, like, like we, we need to see a smiling, a smiling photo.
00:30:02.254 --> 00:30:10.954
Like we have, we have absolutely nothing to go off of, you know, other than all they're doing is looking at tooth position and bone,
00:30:11.915 --> 00:30:12.205
Yeah.
00:30:12.454 --> 00:30:16.684
So it's, it's missing really what the whole full arch patient is,
00:30:17.195 --> 00:30:17.545
Great.
00:30:17.704 --> 00:30:21.184
profile, you know, are they overlo?
00:30:21.514 --> 00:30:23.284
You know, do we need to open'em up?
00:30:23.914 --> 00:30:24.424
You know?
00:30:24.765 --> 00:30:24.885
I.
00:30:25.084 --> 00:30:26.674
also it goes into planning.
00:30:26.674 --> 00:30:32.524
I mean, who, who allowed this patient to spend all of this money on the lower teeth
00:30:32.890 --> 00:30:33.250
Yeah.
00:30:33.605 --> 00:30:34.384
with nothing?
00:30:34.384 --> 00:30:35.644
against it, you know?
00:30:36.025 --> 00:30:37.135
Right, right.
00:30:38.204 --> 00:30:40.459
I mean, I, I would, I would be shocked.
00:30:40.579 --> 00:30:45.559
I would be shocked if you told me, oh, this patient got this work 15 years ago.
00:30:45.559 --> 00:30:48.289
They're a, there's no way, those are like zirconia crowns.
00:30:48.919 --> 00:30:56.569
know, b if you've lost all those upper teeth, you're gonna lose all those lower teeth in a a, a short period of time.
00:30:57.559 --> 00:31:04.669
Um, so, you know, not really having all of the info, it's really hard to see.
00:31:04.669 --> 00:31:13.189
I think, I think what I think the pearl here is if this is all the info that you give, like I need to see a SEF full face.
00:31:13.639 --> 00:31:31.490
I wanna see axial images, um, where, you know, you know, anytime you wanna send something to an advanced doctor, send us the axial, coronal and sagittal images and take the video where you scroll all the way back.
00:31:32.434 --> 00:31:41.464
All the way forward and then come back like, I want to, I wanna, I wanna see you go forward back, and maybe even forward and back again.
00:31:41.464 --> 00:31:43.294
And then let's go to the other one.
00:31:43.294 --> 00:31:46.924
Let's, let's, let's look in the, you know, axial position.
00:31:47.500 --> 00:31:47.890
Yeah.
00:31:48.304 --> 00:31:49.894
you know, all the way down, all the way up.
00:31:49.894 --> 00:31:51.664
Let's, let's look in the coronal position.
00:31:52.595 --> 00:31:56.615
that then really gives us such a better example.
00:31:56.944 --> 00:32:05.164
I mean, I will see people who've been like, oh, I've planned this case and all they're doing is showing like the 3D recon of where their implants are.
00:32:06.154 --> 00:32:08.000
well, I, I have no idea.
00:32:08.000 --> 00:32:11.314
You know, how much, how much buccal bone do you have to your implant?
00:32:11.674 --> 00:32:15.424
You know, where are you in relation to the, the, the crest?
00:32:15.424 --> 00:32:18.004
Where are you in relation to the lateral nasal wall?
00:32:18.586 --> 00:32:18.875
Yeah.
00:32:19.024 --> 00:32:31.084
so there's, there's really so much, you know, that really kind of goes into, uh, advising on a, on a case like this, you know, the, the possibilities here are endless.
00:32:31.209 --> 00:32:31.889
I, I, I,
00:32:31.965 --> 00:32:32.255
Yeah.
00:32:33.244 --> 00:32:35.855
I ultimately can't say anything.
00:32:36.605 --> 00:32:40.954
but I mean, I think that your point is really well taken about like, Hey, this may be a case.
00:32:41.254 --> 00:32:42.514
Let's open'em up.
00:32:43.534 --> 00:32:49.204
see how much restorative space we actually have then, then kind of go from there.
00:32:49.415 --> 00:32:49.836
Mm-hmm.
00:32:51.125 --> 00:33:00.154
you know, don't, don't just look in a tunnel and say, okay, I can do crowns and we can do crowns on your lower teeth, and we'll talk about the upper, upper next.
00:33:00.274 --> 00:33:01.009
I mean, I.
00:33:02.464 --> 00:33:14.524
Whenever, whenever I talk to a patient and we have a consultation, it is only at the very end of the conversation do I even really kinda look in the patient's mouth.
00:33:14.974 --> 00:33:18.634
I'm wanting to find out what are your goals, what are your treatment goals?
00:33:18.904 --> 00:33:20.375
How does all this kind of come in?
00:33:20.375 --> 00:33:25.684
Like we're, we're gonna go macro and we may not even go micro, you know?
00:33:25.744 --> 00:33:28.054
Um, so,
00:33:28.680 --> 00:33:28.971
Yeah.
00:33:30.095 --> 00:33:37.024
you know, when, when you're extracting patients' money outta their wallet, you know, think of the end result, right?
00:33:37.260 --> 00:33:37.680
Mm-hmm.
00:33:38.074 --> 00:33:54.064
one little pearl in talking to patients is if you want to go to the beach, that's great, but you better be specific in what beach you want to go to, because I can take you to a beach in Alaska or I can take you to a beach in Cabo.
00:33:54.655 --> 00:33:55.015
Uh,
00:33:55.234 --> 00:34:04.294
we went, we went to the beach, we did what you asked for, but your expectations were a hundred percent or 180 degrees different from reality.
00:34:04.826 --> 00:34:05.245
yeah.
00:34:05.365 --> 00:34:05.875
I like that.
00:34:06.334 --> 00:34:09.905
always, always something to consider and think about.
00:34:10.615 --> 00:34:11.096
very good.
00:34:11.456 --> 00:34:11.876
Very good.
00:34:12.686 --> 00:34:13.826
Let's see if I got any more.
00:34:14.306 --> 00:34:14.905
I don't think I do.
00:34:15.596 --> 00:34:16.675
Yeah, I think that's my last one.
00:34:16.675 --> 00:34:17.755
That's slide 49.
00:34:18.994 --> 00:34:19.385
Sweet.
00:34:19.976 --> 00:34:20.306
Yeah.
00:34:20.735 --> 00:34:28.295
Well, I think, I think just these are all just examples of learning that, you know, you can be a part of.
00:34:28.925 --> 00:34:35.675
In implant groups that are out there, you know, you know me, I'm not trying to push my stuff.
00:34:35.675 --> 00:34:38.135
There's, there's so many things that, that are out there.
00:34:38.494 --> 00:34:50.015
But also we talk about the stuff in Texas Implant Institute in, you know, our all OnX cadaver course in the Zy, zygoma and OID course, and just in our WhatsApp group.
00:34:50.225 --> 00:34:54.155
So, uh, you know, I would love to help you guys along your journey.
00:34:54.515 --> 00:34:56.885
You know, visit Texas implant institute.com.
00:34:56.885 --> 00:35:03.575
I have some videos on there now, and we also have quite a few videos on, uh, our, our YouTube page.
00:35:03.575 --> 00:35:05.795
So, so, so check those out.
00:35:05.795 --> 00:35:13.954
And, uh, you know, you know, we're, I'm, I'm, you know, me and Tyler and Soren, we're all, you know, very approachable and,
00:35:14.311 --> 00:35:14.601
Yeah.
00:35:14.644 --> 00:35:22.925
know, we, when when you care about the patient, you know, there's always enough to go around, right?
00:35:23.704 --> 00:35:37.055
so, you know, it's ultimately caring, caring about the patient, but it's also caring about the doctor and their journey and not having, you know, just a, a, a waiting room full of complications and a waiting room full of problems.
00:35:38.066 --> 00:35:38.905
Yeah, you bet.
00:35:38.936 --> 00:35:49.946
I mean, I, I, I, you, you've said it perfectly well, and you know, I think that being a part of this community, going to your courses, it, it just needs to be a foundational, um, part of anyone's full arts journey, in my opinion.
00:35:50.006 --> 00:36:00.356
Um, because you just put together such a good group of, um, people, and there's a whole lot of very honest discussion about, um, how to approach cases, what to do about a case when it's gone south, and it, and it's, it's nothing personal.
00:36:00.356 --> 00:36:01.856
There's not any judgment attached to that.
00:36:01.856 --> 00:36:03.655
But I, I have, I learned something from that.
00:36:04.226 --> 00:36:05.816
Uh, that group every single day.
00:36:05.876 --> 00:36:09.896
And it's, it's encouraged me to go back, um, Texas implants to do more courses there.
00:36:09.896 --> 00:36:13.675
And, um, you know, we certainly don't really have any incentive to be singing your praises.
00:36:13.675 --> 00:36:20.396
It, it really just has been such a foundational part of our development and, uh, you know, I just appreciate you coming back on here to keep sharing what you share.
00:36:20.396 --> 00:36:22.076
I mean, you were an incredibly busy doctor.
00:36:22.135 --> 00:36:24.086
You know, you're having third arch months and things like that.
00:36:24.086 --> 00:36:33.865
You're teaching courses, you're doing all these other things, um, being expert witness and all that, and you still take time to go in and, you know, help me make a little PowerPoint with all these different case examples to, to teach people.
00:36:33.865 --> 00:36:35.936
And, and I think that's just a really admirable thing that you do.
00:36:35.936 --> 00:36:38.606
And, uh, I really appreciate you, you know, giving us your time and expertise.
00:36:39.105 --> 00:36:39.265
Sweet.
00:36:40.346 --> 00:36:40.736
Awesome.
00:36:41.096 --> 00:36:45.056
Well, this certainly won't be the last anyone sees of, of Clark Damon on the Fixed podcast.
00:36:45.056 --> 00:36:47.546
He's, he is been a repeated guest and certainly a highly valued one.
00:36:47.726 --> 00:36:48.956
Hope you guys really appreciated.
00:36:49.016 --> 00:36:55.796
You know, the series that we put together, um, you know, with all these, you know, visual aids with all these cases, I think, you know, this is what we really wanted to do with this podcast.
00:36:55.826 --> 00:37:01.256
Uh, up to this point, it's kind of been a little bit of a challenge getting some of the media, um, aspect into, um, these podcasts.
00:37:01.256 --> 00:37:05.306
So we've mostly just been talking about stuff, but I hope you guys appreciate the video content.
00:37:05.336 --> 00:37:10.796
Um, it's certainly, uh, a labor of love to put it all together, but, uh, I think this is really, um, really helpful.
00:37:10.826 --> 00:37:11.846
I, I think it's productive.
00:37:11.846 --> 00:37:14.126
I certainly learned from it and, uh, you know, Dr.
00:37:14.126 --> 00:37:16.166
Damon has, has been very gracious in giving us this time.
00:37:16.166 --> 00:37:19.916
So, um, hopefully we'll be back, um, with some more video content for you guys.
00:37:19.946 --> 00:37:21.536
And, uh, you know, let us know how you like it.
00:37:21.536 --> 00:37:28.646
Let us know how we can change it, make it a little bit more interactive, um, and, and make it more educational for you so you don't have waiting rooms, uh, full of complications.
00:37:28.646 --> 00:37:29.096
Just like Dr.
00:37:29.096 --> 00:37:29.516
Damon said.
00:37:30.365 --> 00:37:30.715
Sweet.
00:37:30.920 --> 00:37:31.400
All right.
00:37:31.400 --> 00:37:31.670
Well,
00:37:31.766 --> 00:37:31.976
Awesome.
00:37:32.090 --> 00:37:32.780
on everybody's journey.
00:37:32.780 --> 00:37:32.900
Sweet.
00:37:33.206 --> 00:37:33.776
You got it.
00:37:33.836 --> 00:37:34.286
Thank you.
