Learning from the Giants: Dr. Jerik's Insights on Subperiosteal Implants: Part 3

A perfect snap-fit without a single screw will get any clinician’s heart racing—but what does that moment really mean ten years later? We take a hard look at custom subperiosteal implants and ask where they truly belong: why well-designed mandibular subs can solve brutal atrophy with durability, and why maxillary applications remain a minefield of thin bone, complex loading, and fragile claims. Along the way, we strip the shine from marketing slides and focus on what actually carries cases across the finish line—passivation, surface finishing, serviceable prosthetics, and designs that respect mucosa, biomechanics, and maintenance.

We walk through the real trade-offs between milling and DMLS, why the cheapest print can become the most expensive complication without proper finishing, and how remote frameworks, tripodial mandible designs, and meso bars distribute force where bone will accept it. We debate embedded MUAs versus removable, make the case for overdentures in extreme resorption, and share the uncomfortable truth about U.S. liability, FDA constraints, and evidence gaps that can leave clinicians exposed. Records and planning matter more than ever, and a multi-app digital pipeline only works when the data is precise and the clinician leads the design intent—not the other way around.

Credentials, community, and communication shape outcomes as much as titanium. From rescue stories to cautionary tales, we outline a professional path that prioritizes serviceability, hygiene, and legal defensibility while still embracing the progress that PSIs promise. If you’re weighing subs for your practice, this is the field guide you need: what to adopt now, what to delay, and how to prepare for the AI-enabled future without outsourcing your judgment. If this resonates, follow the show, share it with a colleague, and leave a review—then tell us: fixed or removable for the severely resorbed mandible, and why?

Chapters

• 1:19 Setting The Stage: Subs Versus Root Forms
• 1:41 Education Paths And Lab Realities
• 2:34 FDA Status, Liability, And Lab Options
• 4:02 Milling Vs Printing: Cost And Finishing
• 5:34 Passivation, Surface Prep, And Biocompatibility
• 7:07 Course Cases And Teaching Moments
• 7:45 Snap-Fit Stability And Screw Philosophy
• 9:19 Maxilla Plate Logic Vs Occlusal Loads
• 11:21 Design Pitfalls: Bulk, Mucosa, And Legacy Lessons
• 13:36 Outcomes Over Hype: Longevity And Evidence
• 15:13 Toolchain Troubles: Exocad To Mesh Mixer
• 16:56 Economics, FDA Pathways, And Pricing
• 19:01 Bias, Education, And Paying It Forward
• 20:14 Where Subs Fit: Mandible Versus Maxilla
• 21:46 Data, AI, And Defining Success
• 23:09 Removable MUAs, Meso Bars, And Repairs
• 25:09 Tripodal Mandible Designs And Load Sharing
• 27:04 Fixed Isn’t Always Better: Hygiene And Stress
• 29:07 Overdentures, Patient Care, And Practicality
• 32:01 Records, Prosthetics, And Design Time
• 33:41 Legal Risk And Evidence Gaps In The U.S.
• 35:45 Credentials, Community, And Risk Management
• 38:04 Complications, Mentors, And Team Saves

Transcript

SPEAKER_00: 0:40

My name is Dr. Tyler Tolbert, and I'm Dr. Soren Poppy. And you're listening to the Fix Podcast. Your source for all things implant dentistry. I was just going to ask next, like if you are, if you are looking to do a mandibular sub, right? A patient that's super resorbed in the mandible, we can't do root form implants, or if you do, you know, they're coming out the canines and you're gonna have a huge cantilever. What uh what are first steps that a doctor takes to get proper education on um doing the surgical side of subs? And then what um labs or what resources do you recommend for the prosthetic side?

SPEAKER_04: 1:15

So Root Lab is no longer taking new doctors for subs, they're phasing out, and I'm sure it's probably uh inherent to the legality of it. They're not FDA approved. They use FDA-approved alloys, but you know, that implant's not FDA approved. Uh, I do have another lab where I have some retired employees from Root Lab have lots of experience with uh subparol skills that I've also put in my two cents on design, and you know, they run it by me. And I say, here, why don't we do this or that? Uh America's dental lab, but it's 100% analog. You know, Nate Farley and I have been doing some digital designs, uh, and we're working with some companies to uh do direct laser metal centering. Uh I like the milled ones. Uh Ramsay MN has done two milled ones with his lap tech. Uh beautiful implant. Uh the last one in particular, I loved it. And he had it where it was fixed, attachable. He could, you know, screw retain his teeth on top of it. Uh but you know, his lab technician, I think it took him 24 hours to mill this thing. And you know, I've spoken with several milling facilities, and you know, you have to program it to mill this thing, and it's just cost prohibitive for milling. So direct laser metal centering is definitely the way the most cost-effective way, but then you come up with a rougher product, which has to be finished, and then you know, then they come up with well, what what are you gonna do? You're gonna sandblast this, acid edge it. Uh, you know, implants have to be passivated. Uh a lot of people don't even know that's a process. They have to be passivated uh so that they're biocompatible, uh, have to have all the form material and metals removed from them. So it's a process of acid washing. Uh Nate Farley does a beautiful job. He researched it, and he and I printed out a couple and delivered uh both of them a few months ago at one of the Full Arch Masters, the first subcourse that we did at his office in Phoenix. Uh, you know, we'll probably run that course again. Uh I also teach for Orca. I placed one last year uh as a demonstration surgery in the OR. Uh, and it was great because we popped this thing in, and it was a cast chrome cobalt, uh cobalt chrome aluminum cast by America Stenlab in Kansas. And we snapped this thing in, and it just you could hear it literally pop in. I have no screws in it, and I'm pulling up on it, it won't come out. That's great. Yeah. And so everybody's like, you gotta have a bunch of screws in these things, four inches vibe. I literally put one screw in it just to show people how to put a screw in it. It didn't need a screw, but Juan Gonzalez is wandering around like he is, you know, and I said, Juan, come take this implant out. And he starts pulling up on it, goes, I'm gonna break the jaw, you know. So I mean, these things can fit great, and screws are really there just for primary stability on mandibular subs. Yeah, and maxillary subs, it's a different game. If you look at a PSI, you know, they're more in the analogy of okay, this is what a bone plate that we use for fractures, and oral surgeons understand. Yeah, I've never I've never placed one in my life, okay. I mean, I understand why they use them, and I think if I was on a desert island and somebody had a broken jaw, I could probably, you know, screw it up pretty bad, but get them back together. But you know, at what point does that technology and that technique cross over to now I'm gonna put a strut on it attached to it, do a permeacle as opposed to the MUA attached to it? How does that orthopedic plate function under load? Okay, and how many screws in one millimeter, half millimeter thick membranous bone are gonna resist occlusal loading? Okay, and so when I hear people in the podium say it's titanium, it's new technology, we've cured all the problems, all the old PSI or plastic implants that never worked. And this is this is great. Come to my company, we're gonna make an implant for you that you're gonna live happily ever after. It I think it's very disingenuous because I don't think we're there, especially on the maxilla. And a lot of the designs I see on the mandible are very poor designs. You know, there's too much metal uh at the crest, there's too much metal underneath the mucosa, it's not remote enough away from your mucosa. And I think that uh, you know, call me old school. I am, you know, I'm a boomer. But I just think that we take what I gleaned from people who've been doing it decades before me and have peer-reviewed published you know, studies on it and decades of successful implementation of these subparalysteal implants and bring a little bit of that into what we're doing today with PSI. Don't just sweep it under the carpet.

SPEAKER_01: 6:35

Well, you know, I I think you know, you you uh kind of jeer at yourself by saying, you know, I'm I'm a boomer, right? But I mean, as you said earlier, you've you know you've got patients that have been in prostheses that you delivered three decades ago. And so your processes and your planning um clearly for quite some time has been pretty sound. I think something that's happening with a lot of my generation of full arch folks is that we celebrate very quickly, right? I mean, it's literally like we we go and make the post the same day and we say, hey, we do this now. But I, you know, I mean I did a quad zygo yesterday. Do I say I I do quad zygos? Well, I don't think I can really say that until I've got one five, ten years out that's you know, doing okay. I can't say I do it because I did it yesterday, you know.

SPEAKER_04: 7:15

Well, yeah, you could do it. You know, and then you know you guys keep trying to nail me down. I feel like a politician because I keep dodging your questions. I've been an expert witness for defense, and they try to nail you down to yes or no. And I'm always yes this or no that, you know. And and in and truly, that's the way it is with these implants. Yes, this, no, that. You know, what do you do in this scenario? It's all patient-specific implementation. There's not a black and white, there's just lots and lots of area of gray. Now, my hope for you guys and for myself and dentistry is that it becomes less gray and more black and white. And I think we'll get there. You know, the technology's improving, printing of the implants improving. You know, we got to come up with a program to design these easy. We can't do it easily with Exacat. We've got to take it through three or four different programs to get what the result we want. Uh, you know, I want to visit with some of these foreign designers and see what they're doing, see if they've got something better than what we've got. But you know, you can't have a prostodont spending 24 hours designing this thing and then wanting to pay$5,000 for it. Yeah. Yeah. You've got to be able to delegate this design technique uh to a technician, you know. Right. And uh they're very expensive. I mean, you know, uh people complain about the KLS price and you know, being 20 grand, I see it. You know, I mean, you know, uh, we tried to start up a company, we looked at uh FDA approval, got a consultant, and you know, you're talking hundreds of thousands of dollars just to get the process started. And you know, I'm like, I don't need this, you know. So, you know, my thing is you know to work with the doctors, work with the companies, and try to to to see what we can do to to remedy the situation where there's not just one FDA-approved implant in the United States. Yeah, multiple. And then you know, we need education nationally for the doctors to understand it, but we have to understand that all this is going to be biased. Some doctors are KLLs for certain companies, some have a uh you know a motive to this, you know, and and to me, I'm in a point in my career where it's time to pay it forward, you know.

SPEAKER_01: 9:45

Yeah, no, I mean I I can certainly appreciate that. And I I think that, you know, uh as far as where you know these uh customs will will fit into the full arts world, is like, you know, as we've stated many times, you know, the maxillary stuff, it's it's it's as gray as gray could really be. The mandibular stuff makes a lot of sense. I see, I mean, I see patients all the time where I think, man, I don't have a solution for this person uh for their mandible, and I don't have a lot of backup plans like we do in the Maxilla. I know that a sub could really work, but at the same time, I also understand that there's just not a whole lot of lab options that really make a whole lot of economic sense for these patients. And I really do hope that that'll improve. I do think certain advents that we're seeing will benefit that. I think that one day, you know, you won't have anybody having designed anything for 24 hours because AI will be faster than any of us ever could be, right? Um, but we we do need the data to support that, right? AI works off of data, and and I appreciate that there's people like yourself that you know have cases that have been in the mouth for a long time. You've been able to parse out some of the you know tried and true design aspects of these. And hopefully uh we'll see, you know, in the near future mandibular subs at the very least becoming a more viable option because there's there's just a huge, I think there is a lot of opportunity for that. There's a there's many patients I've seen very recently that I just told them I just don't have a solution for you. I know it could work, but I I it's not viable right now. I can't do it for you, you know.

SPEAKER_04: 11:03

Well, you know, and there are there are people placing them and designing them, most of it's in Europe. It's completely completely different climate than it is here in the States.

SPEAKER_03: 11:12

Of course, yeah.

SPEAKER_04: 11:13

We just need to really watch and really analyze that design and really analyze the data. You've got to do a deep dive and say, okay, what's your definition of success? You know, what what do you consider a complication? What do you consider a failure? You know, uh, how many of the patients had infections? You know, how many of them did you have to do revisions on? What kind of revisions did you do do? You know, how many permecosal sites did you have? How thick were they? And one of the things that I'm working with companies now is like, okay, let's say we do a design and and you want an MUA coming out. Well, the guys were having the MUA be part of the substructure of the implant, okay? So you you screw on your zirconia or PMMA or tie bar or whatever on top of it, and you had the famous abutment screw fracture inside your implant, and now you're trying to fish that thing out and you can't get it out. I've literally been in a course where we put the implant in and the MUA, we couldn't get the abutment screw to fit into it, and it had been milled, you know, and it's like okay. You need to have a removable MUA to build your implant so that if you do break the abutment screws or what you can't. And so, you know, one of the things we're looking at is what adding MUAs, removable genaso bars, or that you need to ask about. And you know, uh I went to an IDS meeting in Germany in Cologne and spoke to several companies that are making them, and it was amazing how many companies had their own sub version of sub. And you know, through the language barrier talking to them and stuff and and speaking about these things, and then when you say, wouldn't it be a good idea if this was removable? And you know, I'd get 10 reasons why no, it's not, you know, or we can't do it or shouldn't do it or whatever. And I'm like, Well, you're not practicing dentistry like I do, and see shit break, you know, and you know, you need to have a back door on this stuff, and so it's little things like that that you really it's that comes back, you don't know what you don't know, you know, and so people want to do away with the meso bar and go to MUA, but is it removable? What happens if you break your abutment screw? What happens if one segment of the implant, if you've got it in multiple pieces, becomes unbonded, unintegrated from the bone, but it's say still in a nice capsule and is functional. You know, is that EMA going to hold your prosthes, or are you gonna keep having abutment screws brain? Right, you know, meso bar would hold all that together. So on the mandible, the tripodial cell, world-famous tripodal, it comes out of the ramus, goes back into canine, canine goes back into the ramus. You've got wings here, you got wings here, the meso bar holds all three pieces apart, totally avoids that molar region where all the problems are. Well, that meso bar serves a function, you know. So you really don't want to get away from it just to go to MUAs.

SPEAKER_00: 14:38

Can you is there can you not put MUAs on top of that bar? Exactly.

SPEAKER_04: 14:43

That's what and I said that earlier. I don't miss it, but yeah, we're working on MUAs on top of that.

SPEAKER_00: 14:49

Okay.

SPEAKER_04: 14:50

And you know, and even you can do it with MUAs that are Nobel compliant, or even put ball attachments on it and go with an overdenture. You know, and you also have to consider what's the amount of bone loss on a subpatient versus an AOX patient. I mean, everybody's wanting to do FP1s now, you know? And compare an FP1 patient to a subpatient who's got eight millimeters, or like the one I did in Guatemala, the ridge is five millimeters tall. I got 35 millimeters of bilateral dehiscit nerves I got exposed and uncovered. And I mean, it's it's crazy. So does that patient need a fixed arch screw retained? Or do they would they benefit from something they can remove at home, get to it and cleanse it, and something that's got some old rings, got some plastic, got some give to it, that doesn't send all that stress through your implant. And so that was the rationale, because that's all we had back then was over interest, but the rationale was you know, get your occlusion where it's not traumatic, give plastic teeth there, and you know, do o-ring attachments, don't screw it down, so it has a little bit of give and plate to it, so you don't overload this implant. And so, you know, today it's a psi, it's bond of the bone. I got 15 screws holding in. We're gonna use 20 degree T. We're gonna use zirconia, and yeah, the patient's never gonna be able to take it out. Maybe they'll come back and see the hygienist once every year, maybe they want, and hopefully, the soft tissue underneath that subscription surviving.

SPEAKER_00: 16:29

That's a lot of prayer. A lot of miracles in one in one mouth.

SPEAKER_04: 16:35

I mean, make this thing removable, they get to it, and we didn't have sonicares when I started. We had some company in Benton Arkansas in uh Arkansas made rhododenses, go around to it, and we used to have them use that. Sonic care came out, it's like a world life changer, okay? Yeah, you know, removable overdicture. Yeah, you know, just pop it on, pop it off, and then the buckle flange helps protect the tissue, keep the food out. It only comes out when the patient pulls it out, right? Yeah, I tell my students, and I'm like, overdinger is not a problem for the patient, it's not hard sell. You first of all, you tell them the benefits of it, and that it's not gonna come out unless you take it out. They don't have the problem with it. People who have a problem with it is the dentist. Yeah, and I'll be like, I've got a problem with it. I don't want to do them because I can't make it my lab. I gotta send it off to Kansas to my guys, yeah, you know, and I love working with them, they're great guys to work with, but it's just a pain in the butt. It'd be much easier to do MBA.

SPEAKER_01: 17:39

Yeah, I think we're we're trying to hit a home run where a single would do. And I think you made a good comment about that patient in Guatemala. You know, does this person really need screwed-in teeth? I mean, this person has a fala, you know, does this point you think they'd be happy just to have teeth that last a long time that have mitigated all these risks? Like, do they really need to be fixed?

SPEAKER_04: 17:56

Uh, you know, does it just put a sub with the Simon O. Uh, we did a uh analog design. So it was waxed up, it was pulled off the model, it was invested in cast, chrome cobalt balloon by the guys in uh Kansas. I played a little joke on him, I did O and H in the front.

SPEAKER_03: 18:22

He got a little nervous and he said, I can't put that in the patient's head.

SPEAKER_04: 19:03

So the measlebar was a little jacked up. But it was we got it fixed, you know. And that's the where I say it's you gotta get your prosthetics right, you gotta get your records to your lab right, and it all has to be transposed right. And that's where Nate Farley comes in as a prosthetist. I mean, this guy's records were incredible. He's like got the patient caught and rolled, he's verified that everything's seated, and then he's stitching everything in Exocad, he's taking it over to Blender, he's taking it over to mesh mixer, and I mean, the guy spends hours on these things. I mean, his design should cost$20,000. Yeah. I mean, it's stupid.

SPEAKER_00: 19:45

Um, I one one more question I have about about subs, and you know, we've talked a lot about how um, especially like you know, younger doctors who are just jumping into it, they're they're going to these lectures and they're hearing that you know the customized sub is like the new best thing. It's better than zygo's, better than this and that. Um, and you know, you're you're pushing people uh away from that, which makes total sense. I another thing that I want to just probably mention is especially in in the US, and we've talked about patients being litigious, um, these subs, like they're if if something happens to the patient, you know, they there's nothing that the doctor has a stand on, correct? Like they're they're in in in hot water no matter what. And and and and my understanding is that's in the mandibular subs as well, correct?

SPEAKER_04: 20:31

Yeah, well, I mean, yes, I mean there is there is literature review, albeit old, that shows a high success rate with properly made mandibular subs with the proper occlusion. You know, I can get you literature review on that, okay? I get you a study or two on the maxillary subs showing the success rates on that, you know. But current literature on long-term success rate of these new implants is just not, I don't, I wouldn't feel comfortable. Put it this way: I wouldn't want to be your defense expert and tell you you're gonna win. It's gonna be a lot easier to be the plaintiff's expert and just crucify you on the stand. Like, how many of these done? And where'd you learn to do this? And where's your loop? And where's you know, where's where's the studies? Where's all this stuff? It's not gonna be there, you know. Is it FDA approved? It's not, unless it's KLS. And I'm not a fan of their design at all. So, you know, when I was your age, you know, very aggressive, trying to do all the latest and greatest and newest stuff, and I'm still pretty aggressive, you know. I mean, I'm a boomer and I'm 100% digital. I got a lab upstairs. But my old mentor, Dr. Joe, and he used to he's in the middle of nowhere, Arkansas. He used to say something on the look on the podium. He'd have people international come in to hear him because he was such a brilliant man. And he said, I'm from Wynn, Arkansas. You can't get there from here. Okay. I mean, yeah, he's in the middle of nowhere, but you literally can't get there from where you're at now, you know. Yeah, yeah. But he would say, you know, the cutting edge, the sword of the cutting edge cuts both ways, you know. So you know, you can be on the cutting edge, the leading edge of technology, but realize you can also get cut from that leading edge. Sure. Just be prepared for that. So, you know, my thing is is you know, work closely with and have a good community wherever you are, ENT, oral surgeon, prostodontist, periodontists, whoever you have, to work with Yoniks and don't just do this fly by nine.

SPEAKER_02: 22:41

Yeah.

SPEAKER_04: 22:42

You know, and understand that you have to have a relationship with that patient. And that's the beautiful thing about practice in Arkansas. I mean, everybody's like, you know, practice in Arkansas. I mean, I got 3.3 million people in the entire state. I have to market two-thirds of the state to get enough patients. Okay. And I literally have patients drive hours to get here, you know, and now with the internet and Google uh location, and it's it's it's a nightmare marketing, you know, just these patients and stuff. But you know, you you deal with these practices, and you I'm getting losing my train of thought here, guys.

SPEAKER_01: 23:20

No, no, you're fine. Um, yeah, I mean, something that you were kind of alluding to, you know, when considering getting into this, and you know, I think about it a lot is you kind of you know, you have to really ask yourself uh why it is that you would want to do this, right?

SPEAKER_04: 23:33

I guess that you got me back. So my thing is have a community, have a relationship with the patient, and you know, you've got to be able to let them know that things can happen, but you're there for them. And you know, I have a little saying with my patients, we're like the Marines here, we don't leave anybody behind. And even if it costs me money, I'll redo the case. And you know, my thing is you got to come in for recall and you got to be responsible and you got to do what we tell you to do. If you go away two, three, four, five years, you're done. I mean, you own it, okay? But if I've got a patient's coming in every six months for recall, even if they're out five, ten years, I mean, I'm not sure as hell not charging the full fee. And most of the time it's we're friends, and you know, the wife's bringing us brownies every Christmas or something, and you know, the wonderful thing about practicing in a state like Arkansas is the mentality of the patient is not so adversarial. And you know, don't trust me, we've got lawyers and we all get thumped, okay? But especially back when I got started, it wasn't as much of a problem. And you know, uh that's one of the things I empathize with you guys that are in bigger states, bigger cities, with more competition, more people trying to pull the rug out from you. And that's why I encourage people go get your fellow, go get your ABOI, you know, and uh, you know, I have not had to go to court. I have had some records called for, and you know, people this and that, but I've never successfully been litigated and sued. Um I'll go when I say that, but I've been an expert witness, and you know, they start saying, Well, he's a fellow of this and diplomate of this and that, and you know, even if it doesn't mean anything to the royal surgeon down the street from you, it means something to the jury, okay, that you've done an extra step. And I'm not saying go out and get bogus credentials from you know organizations that don't actually test you and see what you really do know, but get bona fide credentials, be proud of them, and promote them, you know, and they can come back and they can help you. I really feel like they can be, you know. So if you're gonna do these implants, dot your I's, cross your T's, have a community, have credentials, have doctors that are in your corner that you can go explain to. I mean, uh, I told you guys later, I mean, earlier today, the complication for the pterygoid in Dan Heltz Claw's book. Infratemporal faucet. That's me. One of my first ones. Yeah, I'm that guy.

SPEAKER_01: 26:15

I was wondering if you're gonna say this on that.

SPEAKER_04: 26:18

Hey, behavior.com. I'm like, you're really gonna do I'll make you contributing after. I said, No, you can leave my name out of that one, you know. All the adopts said, this can happen to anybody. I'm 30 plus years in my career, and you know, I'm I'm like, Yeah, okay, I've seen this, I understand the concept, I got this, and I screwed it up, and it's in the infratum for fossa. And you know what? I go across the yard to my next door neighbor who's moral surgeon, and I'm like, head down, and he's like, dude, it's not a big deal. I put thirds there all the time. We got you. Come back to my office in two weeks, we'll get it out. We had out five minutes, it was a non-issue. Told the patient immediately she had a few little moments of trismus. It wasn't a major complication, but it could have been a really big issue. But if I'm a young doctor and I've got this massive bilateral orental fistula and this failing implant on an 80-year-old who's gonna have to go to the hospital, go to the ENT, probably gonna have to go to an oncological ENT and get a bone graph, a flap graph, to restore maxilla obturator. It's a big deal. Yeah, and I wouldn't want to have to defend that. You know, so yeah, there's some trophies to get on your walls, and there's some trophies to let some of the people that can take the risk and tolerate the risk. Maybe this needs to be done in institutions, maybe this needs to be done in foreign countries, and you know, let's get some studies out and see where it's at. But yeah, I don't have all the answers for you on the maximum. I mean, I can tell you what to do on a mandible all day long. But I think I know what I would do, but I've been 39 years and I've only done demonstrations of uh surgeries on other people's patients.

SPEAKER_01: 28:11

That says something.

SPEAKER_03: 28:14

Not in your house. Not in my house.

SPEAKER_01: 28:17

Yeah, I mean it yeah, and I think that really I mean it goes back to um kind of what I was saying earlier, and it that lent to your point as well. Is you know, you you have to ask yourself, you know, why are you interested in doing this? Like what is really the point? What are you after? You know.

SPEAKER_04: 28:32

So John Minochetti, AAID past president 10 in his study. He's reporting on A. Codings, 100% success right now. What's his definition of success? I don't know. He wasn't in there, you know. Uh Arthur Mosin, another AAID past president. Uh, I used some slides for him. I said, Art, give me some old subslides. I don't have any Max Larry subs. Do you? He goes, Oh shit. I mean, that's what he said. He goes, Oh shit. Yeah, I did. How'd it go? Well, he said, I got one that lasted 20 years. And so we we put that one up, you know, and what do you think he did? It took it out and he put in quad zygot. Yeah, you know, but how long are quad zygo cases gonna last now? How long is my AOX gonna last now? You know, I mean, when I got into this, Mish, we had everything between the middle frame was A, B, C, D, E, five implants. And depending on whether you did three, five, two, whatever, you had locations for it, you connected it with the meso bar, you did an overdensure on it. And then poly mola comes out and blows everything up. And you know, we start doing AOX, and I never looked back. Early, early adopter, you know. And I remember I was in my actual ABOI board examination, and there was a doctor from Kentucky, Sharon, I believe, the he was a GP, and he was one of the first people, and he and his partner, the Paradonist, were teaching for Nobel, were some of the first people, and he was telling me what he was doing. I'm like, you lost your mind. You know, these are tilted implants, you can't load these off axis because that was the big thing back then. And then when you get thinking about all your lateral incisors and centrals and stuff, that's all loaded off axis.

SPEAKER_02: 30:21

Yeah.

SPEAKER_04: 30:22

And you know, I mean, and that's what I'm saying. Be a student of your trade, of your craft, be an expert in all aspects of it, you know. So with these subs, don't just let somebody blindly say, Yeah, these works call. Joe's Dental Lab over here, or Joe's manufacturing facility over here, they've got this 19-year-old from Italy that's going to design it, or this other 19-year-old from Portugal that's going to design it, and it's all going to be great. Kumbaya.

SPEAKER_02: 30:54

Yeah.

SPEAKER_04: 30:55

You need to be the doctor. Same reason I don't like guides. And I gave a lot of students, you know, that were taking their exams and said, tell me about your design on your guide. Well, send it to the lab. Okay. Well, they sent it back and I told them that it was okay. And you know, to me, you know, I was, I did like 10 guides with teeth in an hour when it first came out. We did our first guided surgery on TV in like 55 minutes. Okay. I designed those guides. They were printed in Sweden and sent over. Okay. But if you're going to do guides, you need to understand and you need to be very much into that. If you're going to do sub-implants, you need to know the uh the design. You need to be able to tell that technician, no, we need to come a little more interior with that strut. Uh we need to put the permeocosal post here. Uh the substructure needs to be a little thinner, a little more delicate. You know, and the answers I've been looking at, and I've done some very sophisticated AI research on, you know, is how thin can we go with titanium and it not break. You know, and another great thing that Dr. Liljohn used to say is statistics don't lie, but liars use statistics. Okay. And I'm gonna I'm gonna update it and I'm gonna say AI, or excuse me, finite element analysis doesn't lie, but liars use finite element analysis to justify what they're doing, you know? And I've never had a subparalisteal implant break. Now I've got a ton of examples from the 70s that they had casting defects and this and that. And of course, it's a harder all of it, cobalt chrome aluminum. How thick does titanium have to be to survive? And if you use these protected occlusal schemes that I'm promoting here, you know, does it really have to be as thick as they are? You know, so there's a lot of things that's gonna be really interesting to see the next five and ten years how it pans out. But I do think PSIs are here to uh to stay. I think they have their place. I think that it's wonderful that they're coming back, but I just want to promote a cautionary still tell, especially if you're early on in your career. Yeah, you know, I'm gonna have a lot better, easier time defending myself and getting cooperative care from other specialists than a young surgeon is who's just trying to make a name for himself.

SPEAKER_01: 33:37

Yeah, I mean, I think that you know, sometimes on the show when we, you know, talk about uh maybe this isn't avant-garde, but when we start talking about more exotic types of implant treatment, people want to listen to it so they can learn how to do it. Um, but you know, maybe that's not the most valuable thing you can come away with. Maybe it's a lot of good reasons not to do it and just wait on it, learn more, take your time, get your credentials right, and and do it maybe when the time is right, when it's appropriate. Um, but there's there's plenty of work to be done, short of getting into these gray areas and doing you know people want to know.

SPEAKER_04: 34:09

I mean, literally, I was going to Nate's office to help him put in a sub, and Ryan had this maxillary sub, and the patient's sick, we can't get it in. Uh, we think she's not gonna make it, but uh, we're gonna put in two subs. But then one of the oral surgeons says, Hey man, I got one I needed to have done. I was like, Well, there's three subs. It's like Ryan, you need to do a course. Yeah, so he literally put it online, and within a day and a half, it was full. Wow. Okay. And everybody came to Phoenix tonight, it's got a great facility, and we had close circuit TV, and you know, we we put in two of the three that we had scheduled, and it was great. And like Orca, you know, there's a need and there's a want, but it's the ability to get the patients to the residents, to get the records, to get the designs, and they've even got manufacturers that will donate. I've got two right now that will jump right in the middle of this. And so, you know, we're in talks, or Simon and them are in talks. I'm not part of the board there, but you know, there's been discussion of bringing subairoster course to ORCA. Okay. You know, but you guys that watching the podcast, it's going to be the same message there, and it was the same message at Full Archmasters. There's safe things to do, and there's not some there's not proven things to do yet. Just see where you are in your career and how much risk are you willing to assume for a particular patient. You know, if you're your mom or dad or aunt or uncle, you know, or sister or whatever, then you know, you can assume more risk. But uh, yeah, if it's a full fee paying patient that you have no connection with, you need to be very careful. Yeah.

SPEAKER_01: 35:59

Yeah. No, that that makes a lot of sense. Well, well, Dr. Jerry, uh, you know, we have uh covered you know decades of of learning in the uh world of CSIs, PSIs, um, and and learned so much from your experience. And uh, you know, I'm leaving with more questions than answers, I think, in a very good way. I have a lot more that I need to learn um about this modality, and uh, I really appreciate you spending the time to come on and and talk about it. You know, I was just curious if you had any other you know, closing thoughts or encouraging uh sentiments for you know other full art surgeons out here, anyone listening to the podcast that might be interested um learning more about your work or whatever else that it is that you do with Orca and all those good things.

SPEAKER_04: 36:39

Well, uh, you know, I'm I'm available, uh, I'm on a lot of uh different threads and stuff, but uh I'm more than willing to look at some things and and help point people in the right directions, hopefully. Uh, you know, uh there are other doctors that have done this. Dr. Picos, I know he's done 200. I think he and I are gonna do something. We're gonna be speaking at the upcoming Orca Symposium in Las Vegas in January. Be there. Yeah. Okay. Thank you. Uh, you know, uh Ramsey Amin has done several subs. He's I think speaking at the AID meeting uh that's coming up in November. I don't know what the topic is on that or what what he's covering, but uh we're if he's gonna go in the PSIs or what, but he's got some material there. And you know, we're looking to try to bring this more to uh you know to to the pup to the other to the dentist group, you know, one group or the other. And you know, I don't have a lecture facility or organization. Uh I'm a heart gun. You know, I mean I I enjoy doing this. I don't need to run the show. Uh I I love giving back. I love being with the young docs and and and meeting new people and making the connections. And you know, uh just uh keep on Facebook, look at your Orca, look at your Full Archmasters, Adam Hogan. He may do something with his stuff, you know. Uh I've even been in talks with Maud Institute, you know, we may do something with these guys. So there's lots of good learning opportunities. Vichy Berman uh has done a number of subs, and his uh experience with the PSIs is more than mine. And again, you know, he's he's the expert of experts, KOL. Uh he can weather the storms of the failures, and you know, let's see what happens with the work that Vichy. But you know, he and I worked in the past very closely on designs. Even he and I and Nate have done some implants together. You know, that that's how we all got tied up together. Nate had a patient that needed an implant, and so we we did that. But uh I wish I had better resources we did that, but uh I wish I had the orca uh just for everybody. But uh, you know, come to Ramsey and uh we'll get some information. We'll I'm sure there'll be a course come up and we'll get the information out there and everybody comes come see us.

SPEAKER_01: 39:57

Yes, sir. Well we appreciate your time. Thank you so much.