Zygomatic Implants: Digital Surgery for Complex Full-Arch Cases | Dr. Vishtasb Broumand | EODP #32

00:00:00:03 - 00:00:18:04 Speaker 1 My wife is asking. Seems the best surgeon for nomadic and patient specific. And I came up. I was very happy. I was like beautiful nationally. I was like, thank you. AI you're doing. I don't even have to market anymore. They no longer have to wait a few years 00:00:18:05 - 00:00:21:12 Speaker 1 Nowadays, cancer patients can sleep and wake up with teeth. 00:00:21:12 - 00:00:22:27 Speaker 1 But if you can't upload it to 00:00:22:27 - 00:00:25:24 Speaker 1 the portal, guess what? You're not getting a design bat. 00:00:25:29 - 00:00:43:26 Speaker 1 And the world of implant dentistry and digital dentistry. You have to be ready to invest. Embrace new technology and innovation. Otherwise you fall 00:00:43:28 - 00:01:05:08 Robert Welcome back to the Evolution of Dental Podcast, brought to you by Evolution Dental Science. We share the stories of the people and the technology shaping the world of dentistry. I'm your host, Rob Norton. Today's guest brings something completely different to the table. So some patients get told that nothing can be done. My guest trained under the legendary doctor Robert Marks. 00:01:05:08 - 00:01:20:05 Robert He came up through the tumor and reconstructive surgery side of things, and now he rebuilds cases that everyone else walks away from. Zygomatic implants. Full arch. The future of digital surgery. Welcome, doctor. Vichy belonged to the podcast. How are you today? 00:01:20:07 - 00:01:30:00 Vishy Oh. Good morning. I'm doing great. Thanks for having me on the show. Thanks for having me on. Oh, yeah. Thank you for your kind introduction. And thanks for being here. I'm excited to be here with you guys. 00:01:30:02 - 00:01:38:22 Robert It's before we before we jump into all the cool clinical stuff. I got to ask oral surgeon for the Diamondbacks. How did that happen? 00:01:38:25 - 00:02:05:04 Vishy Yeah. You know, it's interesting. I got asked to to treat a baseball player. Absolute from the Boston Red Sox. And they were playing bad fastball hitting. And then they asked me if I wanted to be the team surgeon. And I was pretty excited, but I said, sure. I read before you know it, I was working with different teams there. 00:02:05:04 - 00:02:06:05 Vishy I was in town. 00:02:06:07 - 00:02:31:04 Robert I do really want to dive into some things about zygote and the patient specific implants. I think that's a very fascinating new, new frontier for this industry. But before we get into that, I do want to ask, like what originally drew you toward a maxillofacial constructive surgery anyway? Because you didn't start there. You started with, you know, working with Doctor Marks and how did you end up where you are now, I guess, I suppose is what I'm trying to ask. 00:02:31:05 - 00:02:52:27 Vishy Still, you know what? I was doing more of the head and neck reconstruction, where we're doing a lot of reconstruction, but it was cancer defects, head of the cancer these and it was trauma related injuries. Or just get on to those or I wasn't doing a lot of these big implant pieces. And I actually had one of my cancer patients that had a doorway constructed. 00:02:53:01 - 00:03:13:02 Vishy And, you know, he asked me if I could do these dead older plants as well. And I did his influence on that. Silverman turned out it turned out beautiful. And then I thought to myself, you know, this is something really good to add to my arsenal, where I don't have to send the patients out to place their advice. 00:03:13:03 - 00:03:32:20 Vishy So I remember this for patient types. He made his his wife was an oncologist that I worked with and said, hey doc, my teeth just fell out. And I thought to myself, yeah. I was like, yeah, how is this possible? Send me your this is before right before the iPhone would come out. It was I had a Palm Pilot instead of a picture of my heart. 00:03:32:20 - 00:03:58:08 Vishy Get out. Sure enough, the internets were all six implants in an episode were attached to the restoration, and they looked like they had, like, will rotate around them. So these nano tapered, these nano type plants were failing really badly a year later. So anyhow. And then so at that point my patient lost all the balloon, their maxilla, and I had very good options on what to do with this patient. 00:03:58:08 - 00:04:21:28 Vishy So I had to teach myself how to do. There were very few people that were doing zygomatic implants at that time. So I took both of their courses and they weren't. They were on plastic models. One was in Miami, Florida. There was an emergency and one of those at the Waldorf in New York City. They were both on plastic models into that. 00:04:22:01 - 00:04:44:17 Vishy And boy, I thought, oh, this can't be that hard. And so this patient, this first patient that I did, a quad zygomatic, and now it's nearly 20 years. It's been 20 years. And, it took me nine hours. It was not fun. I'm so I mean, just imagine, because there was no one there to wrap my Nobel by care rep said, hey, doc, I can help you with this. 00:04:44:21 - 00:05:06:14 Vishy And he basically scrubbed in with me and helped me out. And it was it was challenging. I didn't I was Julian for this tiny little as I go with long implants that are like three inches long. So nine hours later the anesthesiologist was upset. But that was my first one. And I thought to myself, hey, there's a big need for more people to do this. 00:05:06:14 - 00:05:27:17 Vishy So I started offering that to all my weakness surgery patients to like anyone that had a cancer or trauma defect. Now I do lots of gunshot wounds to the face as well, or patients come into the faces blown off for whatever reason. Then we struck the hard sorts and then I get into my teeth. So that's become a big part of my practice. 00:05:27:20 - 00:05:30:23 Robert You said you do a lot of gunshot wounds. 00:05:30:26 - 00:05:53:13 Vishy Yeah. I mean, come on, come in. Either self-inflicted or they, for whatever reason, where they must take violence David Stockman face and they've lost Harding tissue. Antique teeth are always part of it to go. So we construct patients as well and give them a get one teeth getting their live that. 00:05:53:14 - 00:06:07:03 Robert What is your digital workflow look like? I mean you mentioned before that you were starting off with a Palm Pilot, and we didn't have the same technology when palm pilots were premier as we do now. So like, how has that changed for you and what's your. Can you walk us through your digital workflow? 00:06:07:04 - 00:06:34:29 Vishy When evolve came out to my office and at that time the digital dentistry was kind of new, right? And we were all just kind of learning. So I remember at that time Josh brought his pick dental, and I had just gotten a big dental after four months of waiting. Right. And we had a medic five inch oral scanner, which was just slow and archaic. 00:06:35:01 - 00:07:04:01 Vishy Now it's just not a give it to my kids to play with. Anyone want to play with it? It's kind of like a PS2 versus a PS5, right? For all of our patients that's on. We would be like conversions. And so, you know, I kind of have to think, you know, obviously Ryan Dunlop for convincing me that I needed to consider digital dentistry if I was going to become a force and the full art world, the big horses like the Boris did. 00:07:04:02 - 00:07:23:09 Vishy And I know you've always very much involved in education and all the other guys on the West Coast, Ryan and some, some other guys, Art Morales, all doing big digital courses. And obviously there's so many workflows, right? It caught everyone by storm. Now it's not if you're not digital, you're not you're not doing something right. Pretty much right. 00:07:23:10 - 00:07:55:25 Vishy And that's what the, the the thought thought is. So for me every patient was getting an input wall scan back then with our at five. Now I've switched over to the trio's five obviously, because even when blood in a in your field, it picks everything up very well. I know that time. If I'm not going to lie to you for for our breadcrumbs or breadcrumbs or things that we use, you know, we didn't have all these companies with these fancy fiducial markers. 00:07:55:27 - 00:08:14:11 Vishy We were just using bone screws, you know. So remember my background was reconstruction. So I told the guys, I've never told them, Josh and Andy, they're like, I mean, we got 30 cases. We don't have enough power to mark this guy. So I was like, no worries, I'll just take the plates and screws. So that put people's faces back together and they will sandblast. 00:08:14:11 - 00:08:22:13 Vishy And so the scanner will not kick off the reflection. And those, they look like Home Depot screws, but they weren't coding. 00:08:22:15 - 00:08:30:13 Robert That's very clever though. I mean, you use the bone screws, you sandblast them so you get good read on it so it doesn't give you reflected scatter. Yeah. That's that's pretty clever. 00:08:30:17 - 00:08:51:19 Vishy Yeah. It was a lot of innovation I got to tell you. But I mean there was nuances because they weren't designed for this. They didn't have enough geometry at times to be picked up. I remember it was a work in progress. It was it was such a fun time because we were innovating together. There was really only evolved that, that I knew of. 00:08:51:22 - 00:09:11:08 Vishy Yeah. Back then our workflow was pretty archaic. But yeah, nowadays every I use I have the I can, I have the pick and I have the micro mapper. And as far as my printers now I'm using the, the the split ray obviously the max I you know, it's always good to have options. We've been very pleased with the painter's. 00:09:11:10 - 00:09:30:07 Vishy I have not used the Einstein Center, my Einstein printer sister's paperweight. I'm sure you guys are the same. Right. But yeah, it's it's you know, it's interesting in the world of implant dentistry and digital dentistry, you have to be ready to invest. I mean, I have to be ready to embrace new technology and innovation. Otherwise you fall behind. 00:09:30:08 - 00:10:03:16 Vishy So that's one of the things that my digital workflows constantly evolving. And, you know, I know there's many ways to to skin a cat for say, I'll never love animals, but, you know, it's a bigger speech. You know, I became the editor would be clinics and the Atlas of Horror myself. The I put together a volume for the Wall Street on digital workflows, and I took ten of the leading experts from around the world to each explain their own workflow. 00:10:03:16 - 00:10:25:11 Vishy And they all did. Some of them still do. You scan volumes and then you sort of Queen and some UCT scanners, you know, there's so many workflows out there and I fully realize that you just have to use what works for you, what works best for your patients. So I don't judge anyone's workflow. I don't say this is better because it's not. 00:10:25:14 - 00:10:50:15 Vishy And you know, when I go to Europe, I realize how different they are than us. I just lectured a few weeks ago at the J dental Dental Implant offense, and there was 2000 people there, and they were all talking about how photogrammetry can make mistakes and how they they circumvent that and how they prevent mistakes that photogrammetry. 00:10:50:17 - 00:10:54:16 Robert Oh, I didn't see you there. Hey, y'all. It's Robert with the Evolution of Dental podcast. 00:10:54:16 - 00:11:14:01 If you love these stories and you want to see more guests, more content and help the show, please remember to share it. Like it? Subscribe to our channel and hit that little notification bell if you're watching on YouTube so you can get notified of our new episodes. New episodes drop every Friday. Follow us on all the socials. You'll see all the latest content. 00:11:14:02 - 00:11:16:21 Looking forward to seeing you there. 00:11:16:23 - 00:11:36:19 Robert It's kind of like having a toolbox full of different tools. I mean, sometimes you can use different tools for the same purpose, and having different workflows available to you means that you can draw on having a whole bunch of different things in your arsenal. One of the things you pointed out that I really like is that, and that I've been seeing as somebody who trains people on digital industry a lot. 00:11:36:20 - 00:11:53:29 Robert The one of the things I've been seeing more and more in the recent past is more oral surgeons and process getting into doing their own either designs or using CAD as a communication tool with the lab. How does that fit into your workflow and what you teach? 00:11:54:01 - 00:12:15:20 Vishy When we did the course, Josh was doing it. Obviously almost all the designs at that time. It was overwhelming because he was doing 910 miles on his blade. So one of our dentists that was Mike, Sam, who was my partner in the courses, was helping Joshua the designs. And I had to tell you, Mike fan was amazing because Josh was so impressed. 00:12:15:21 - 00:12:39:10 Vishy He was man, where did you learn how to design? And he was I just told my thoughts and you and I both know that mastering education is very difficult. I almost find it harder than the surgery sometimes. So yeah, I and it's funny enough, when I work with the restorative docs, obviously there's other apps that allow you to change it. 00:12:39:12 - 00:13:01:22 Vishy Like I think there's other apps to allow you to to make some modifications in design, but I don't do any of it myself. I look a little ab to it. So and it's interesting early on, Mike, fan and Josh think you should probably learn the design, but boy. Like I said, you know we're using the three shape software or exo CAD. 00:13:01:25 - 00:13:19:20 Vishy It's not it's not as easy as it seems. You know, having a great digital designer as a is is very important to success of your full art. So obviously I don't do it myself. I talk to the labs and obviously there's so many labs nationwide now, whether it's on WhatsApp or they're portals. 00:13:19:23 - 00:13:51:25 Robert I mean, that's totally fair. It is. It can be. It can be very daunting to look at some of these, some of the software like especially exo CAD, because one of the things that is my favorite and one of the things that is the real powerhouse of the software for folks that are really into it, is also one of the things that is the most confusing for people who are just getting into that, and that is that the beauty of Exochus is that there's almost always two or more ways to do any one thing, you know, and it goes back to what you were talking about earlier about, well, what workflow is the best? 00:13:51:26 - 00:14:13:01 Robert Well, what works best for you, right. And kind of learning and mastering, not just, well, okay. This is the way to do it through Exo cab, but there's several different pathways through or as you were just saying, lean into where your skill is and if if that is not where your passion and skill is, then maybe leave that to the lab and find someone to partner with. 00:14:13:05 - 00:14:28:28 Robert It's something in this episode sparks your interest and you'd like to learn more about it. Please feel free to drop us a DM or click the link in our bio to schedule a free one on one consultation with yours truly, and we can discuss exactly how you can utilize and leverage that within your own practice or your own lab. 00:14:28:29 - 00:14:31:05 Robert I'm looking forward to speaking with you. 00:14:31:08 - 00:14:57:04 Vishy I think every time I have a new doctor planning for my live courses, you know, they tell me. Oh, I have this is my world flow. And then I see my workflow and they see it's a little different. Like I, I put in a, you know, guess, scan bodies in an Excel. Sometimes I'll use the same scan while I was in the mandible that I'm going to introduce the need technology with Jay Dental, who's the client company, and we have some great scan bodies for Blue Shield for users. 00:14:57:11 - 00:15:18:26 Vishy And we still on the mandible. Now I do my trio scan and then we set up a lab. Whatever lab the doctor is working with. And we take out the teeth to our total grammar tree. And I, you know, some days I use the I cam, some days Nikon mapper, some days tick. And you know, it's interesting a lot of his doctors that come to me as I still don't have photogrammetry. 00:15:18:26 - 00:15:36:22 Vishy So that's the missing for a lot of doctors that I work with, because I noticed that some of them still don't have little brown. And I have all different. I have all three ones. I think, you know, a lot of people are now saying, oh, you can start doing photogrammetry on the iPhone. But I mean, obviously there's a cost to everything. 00:15:36:22 - 00:16:04:01 Vishy I'm pretty happy knowing that I have all three of my disposal sometimes right at the same time. We're doing our surgery. There's someone next door eating a niece of the Taos, or, you know, they're ready to go to their finals and someone's doing. People want to be called assays, too. And so I think it's important to have all the tools, like really special, if you're going to be doing digital work towards. 00:16:04:01 - 00:16:25:01 Robert Something that the implant companies might not love as much, though, and I think is a pretty interesting segue. There is the patient specific implants, since that kind of is outside of the known territory here. Where where did that start entering into your practice, and how do you see that fitting in, in, I guess, the greater implant world at large? 00:16:25:02 - 00:16:29:20 Robert Like where do you see that as being necessary is every patient need is patient specific implant. 00:16:29:26 - 00:16:50:11 Vishy No. In the in the late 80s when when in my specialty and were myself distributed when we started developing a region fixation where I was somewhat coming with a broken jaw and said wiring them and you put plates and screws and rigidly flips them pretty quickly, realized, well, what if we can add and confirm to give these placements teeth, right? 00:16:50:13 - 00:17:12:25 Vishy So and by 2012 and 13, the first thing they did in this playlist, Martin, they added abutments onto plates. So that way patients that had cancer reconstruction or a gunshot wound, instead of going through big bone grafting in the later implant placement, could grow through it all at once. But remember what these patients with implants. The design is key. 00:17:12:26 - 00:17:42:23 Vishy So I am seeing failures when the design is poorly done because you're putting in plate and fixing a broken jaw, and now you're adding teeth on there and you get Michael movements. So that's essentially what we're seeing is as patients, the complication you see from patients Pacific implants. So either if the lack of soft tissue or design. But if he's been there for a while, we just added it to our Arsenal playing tennis group. 00:17:42:25 - 00:18:08:19 Vishy And I think for me personally, it's been it's been fantastic. I'm hearing about 20 or so a year that I have now been with a couple of my own complications. I've had to remove one of the 30 placed. Generally speaking, I don't use implants and I don't do patient specific implants on smokers. I, I don't like to patients that are not feels. 00:18:08:21 - 00:18:24:09 Vishy So for me smoking is a big name. So I don't I don't do these kind of big stories because I don't like that failures. I know a lot of colleagues say, well, I just made them for three months, but guess what? A lot of people go back to it and then they become failures and they come to me. 00:18:24:09 - 00:18:50:26 Vishy So patients I think are a big vital component. Those are even more challenging when. So I always tell people on like, you know, if you want to learn full arch, that's great. But if you want to learn zygomatic implants, you have to masterful arch. And if you want to learn patient specific implants, you really have to master all of the remote Anchorage before you can start doing teeth, because it's a big sugary. 00:18:50:27 - 00:19:13:15 Vishy You need a big slap. You almost always need general anesthesia. But you know, some of the companies are getting into it. You're realizing they're leading. They're using some business. And right now, the only FDA approved one is Class Martin. And I've been using that quite a bit on the K on the form. So it's a it's a great product but it's still pricing. 00:19:13:16 - 00:19:39:04 Vishy No you're talking about $25,000 up to it for some of these patients. So you know unfortunately for some of our patients that become a victim of bullard's failures, then they have to pay for all this. So not everyone can afford it. Luckily, sometimes we can go through medical insurances and a bit is paid for. But that's not always not. 00:19:39:07 - 00:19:56:01 Robert One of the things you said a minute ago was you see a lot of failures due to bad design. What what do you think constitutes or leads to a bad design? Like how would you classify that? What are you able to identify that early or is that something you see kind of looking back on something after it's already in place? 00:19:56:02 - 00:20:18:17 Vishy Well, you know, it's interesting because. Yes. So we actually wrote a couple of chapters and articles on this in the on on digital workflows and design. So Sam, Jared is a very good friend of mine. He's a dental Denison, Arkansas based where he does tons of subareas and I don't know any general dentist is going to be. He taught me all about the design. 00:20:18:23 - 00:20:35:14 Vishy And Sam is a you know, every time I get a case that I run the design by, then tell me it was good, it is bad. So, you know, you have to make sure your permanent struts are in the right area. I mean, the part that comes from a plate into the mouth, you have to have a connective tissue or rabbit. 00:20:35:14 - 00:20:58:25 Vishy You have to have keratinized tissue around it. So, you know, the same thing that leads to dental implant failure, which is a Perry implant and also need to solve periostracum specific. And so you have to get soft tissue. You have to have a good polished surface that exposes into the just in case you get exposed to the not fail, you got to have screws that come loose that don't break. 00:20:58:27 - 00:21:17:16 Vishy And you want to have the what we call the permanent closure struts come in the right area. You know, you want to have good care, not as tissue around it, most of them. So the designers oftentimes that are designing the plating companies, they don't understand occlusion. They don't. They've not been in the mouth. They don't see what I see in the patient's mouth. 00:21:17:16 - 00:21:39:11 Vishy So you have to work with the designers. So let's look at the US. And when you're doing a case, whether it's design or full art or design for a patient specific insulin, it's important to communicate with the designers, to tell them what the patient's needs and wants are and what you need and want from them when they design. 00:21:39:18 - 00:21:41:15 Vishy Have plans. 00:21:41:17 - 00:21:54:02 Robert Yeah, we talk about that a lot on here is the necessity of having an open line of communication back, back and forth between the clinic and the and the designers at the laboratory. And that being really the pathway to success, they're. 00:21:54:04 - 00:21:57:09 Vishy Absolutely, very important. 00:21:57:11 - 00:22:16:07 Robert And what it's another thing you mentioned earlier was you have all three photogrammetry options there. Makes me wonder, do you have a favorite among them. Why why all three? And is it just because you got one in the other and then the next or one work better than the others for you? 00:22:16:09 - 00:22:38:03 Vishy Yeah. It's interesting. So we would we did great with our pick. Dental pick was awesome. It was the pioneer. Obviously I made the mistake of letting someone borrow it and they dropped it and it stopped working. Oh, no. Yes. At that time, I contacted Adrian and I needed to get the pick fixed. Except for months, obviously. You remember there was a it was just doing both. 00:22:38:04 - 00:23:03:04 Vishy We didn't get parts and pieces for these. So at the time a lot of people had started using Guy Canada. I can was amazing that for cameras it's the accuracy is it's anonymous. So I purchased the I can and then at that time, you know we were doing so many cases running flags the scan bodies or flags and the autoplay when you just didn't have enough time. 00:23:03:04 - 00:23:25:25 Vishy So we're going to start using was Micron Map or Micron Mapper because it was easy to use. You could scan as well. But for our finals we always use the eye campus. The precision and accuracy seem to be superior because, you know, you can get some flexion and you have more gear temps. But with finals, whether this model would be only or with a bar, you wouldn't have something as dead on pass it. 00:23:25:25 - 00:23:53:10 Vishy And no. So basically in my practice to use on the days to use the pick or we use the micron map or depending on how many of these, we have all of our files. For our files we use the the I cam this because, you know, you found that you get a more passive there. Remember I'm doing zygote interrogates sometimes trans nasals and 6 to 8 implants. 00:23:53:10 - 00:24:01:25 Vishy So I find that it's it's accuracy because it's got four cameras versus three I don't know. Is that what you find as well what he does through. 00:24:01:27 - 00:24:30:22 Robert Well, I mean, first off the passage fit is key. Like if you don't have it perfectly passive fit. And that's such a hard thing to get. The more implants you have, you know, on the, on the arch, the harder it is to get that perfect passive fit with, with less accurate technology. So something like I am or micron map or pick systems, any photogrammetry is going to be superior than just using a integral scanner for that kind of thing, especially in that I, I can't really say I have a favorite among them. 00:24:30:23 - 00:24:58:10 Robert As far as what I've seen, I think a lot of it comes down to the skill of the data acquisition from what I've seen, because I've seen good results from lesser and then bad results from better, and it really comes down to what's in the hand, which honestly kind of brings me to like another thought there, which is the digital workflow versus the actual chair side surgical experience. 00:24:58:11 - 00:25:12:05 Robert Like where do you think one kind of bleeds into the other? Like how much of what is a factor versus, you know, what makes the biggest difference? You think the technology or is it the chair side experience working with in the surgery? 00:25:12:13 - 00:25:33:17 Vishy I think both of them are. And no third component it's in very important is the customer support we get. Right. So like when someone designing would evolve, I know for a fact that if they run into an issue they called when we got when you guys are working through that issue, because I see that happen. We remote in he fits the problem work or any lab you're working with. 00:25:33:17 - 00:26:04:21 Vishy And but I mean, this is the thing I've gotten away from doing the restorations myself now. So I leave it out to the restoring doctor. I'm like, what are you working with? Because I can work with anyone. So what's happening is nowadays sound like so my soul, my doctors work with you guys, some of my doctors work with other labs and they, I always ask for say, how is your customer support from your lab, from your photogrammetry company, and from your screening printer and your your scanner? 00:26:04:22 - 00:26:28:22 Vishy Because that what that is, what makes a big difference is because sometimes technology doesn't work. Yeah. I mean, you won't believe this, but I still have impression coping in my practice. They're collecting dust. We haven't used them in a long time. So if I ever have to. You know, the last time we did a conventional conversion are the wireless in our building went out and the whole neighborhood. 00:26:28:28 - 00:26:45:22 Vishy And we didn't get wireless back up to three days because they were doing construction and we were doing a full arch case. If you don't have you can do photogrammetry, you can do a great scan and you can do your IO scan. But if you can't upload it to the portal, guess what? You're not getting a design back. 00:26:45:23 - 00:27:11:14 Vishy So I mean, man, I mean, talk about going above and beyond. And he did a conventional conversion therapy minutes and we delivered. The patient got a great experience. Patient didn't know of all of our struggles during that surgery. You know, it was I remember during our course that we did Josh was doing a design for a case where the patients had such an ill fitting denture. 00:27:11:14 - 00:27:35:20 Vishy It was just awful, right. The mandible. So Josh is like, hey, it's the only way we can make these case work is if we make we design a new lower denture for this patient as well. So can we do it? It was well it's two in the morning, but I don't see why not. So we was Josh designed a obviously the maxilla was perfect but he designed a lower denture as well that we printed that next morning, obviously with an iron stein. 00:27:35:21 - 00:27:57:04 Vishy Imagine how long that took the print, right? 90 minutes. But the patient was like, oh my God. Not only do I have a nice upper, now I have a nice lower. So it's it's it's the customer service. So it's going above and beyond. And you have to work with a technology company that does that. Really all the companies that I've worked with now are great. 00:27:57:05 - 00:28:06:27 Vishy The patient experience and the doctor experience. And of course a lot of experience is all important, but they all have to come together to deliver a good product. 00:28:06:29 - 00:28:21:19 Robert Yeah, absolutely. The there's a lot of those printers out there gathering dust right now. People are struggling to find resin to just, you know, eke out a little bit of more life out of them after that whole debacle with the desktop health thing. 00:28:21:21 - 00:28:24:11 Vishy You can get it anymore. 00:28:24:14 - 00:28:44:29 Robert No, you really can't. There's like a secondary market of people who are struggling to get it. And that's that's that once those are gone. That's it. Because of the way they that comes back to the customer support thing especially, it's the way they designed that ecosystem, you know, where you can't go outside of their resins. And there's once once that's gone, you know it's over. 00:28:45:01 - 00:29:18:10 Robert Whereas some of these other ones like like sprint Ray, for example, or Sieger or other ones where they, they have their own resins, but then they also have introduced third party, and they have such a broad and powerful support network there that you can trust that that's not going away anytime soon. But in that kind of technology kind of makes me think like the can you think of a type of patient that you might have considered completely, even even with your skill, completely unreadable just a few years ago, that now, with the technology available is something you could easily rehabilitate. 00:29:18:14 - 00:29:40:05 Vishy Oh yeah. I mean, the of the random bowl was a massive challenge for us. I mean, the mandible that's only six millimeters or less. What I was doing for those patients is I was doing a big bone graft, and we called a tent pole procedure, where we would go from under the neck, pack a ton of bone in there and build up the bone and place them plants. 00:29:40:05 - 00:29:56:11 Vishy And then we at the same time sometimes. So we basically place a ten only at our implant back up, and the implant only had five millimeters of bone. So we had five millimeters of the exposed threads. We would take in a hip graft and packing hip bone around the implant about six months later, exposing it into the world. 00:29:56:13 - 00:30:22:26 Vishy Man, we can do things for them that we could never have done before. That's incredible. Patient. Yeah. Digitally designed size. They're their game changer, remember. So some people are saying oh the size should be your go to for your atrial maxilla. What else about I don't agree because cost is a big thing and so is skill in my hands up and do a quads in less than 90 minutes. 00:30:23:02 - 00:30:46:04 Vishy But the scientists a couple of months of planning and fabrication and the cost so but for the for the very, extremely atopic mandible, the Sci is given to the same thing with the extremely zygomatic. Remember the extremely Goma that was not a candidate for the implant. Only three millimeters since those cells. 00:30:46:07 - 00:30:50:21 Robert What was that like delivering one of those for the first time? I mean, that had to feel like a game changer. 00:30:50:23 - 00:31:12:25 Vishy Oh for sure. I mean, I remember I was like, man, we providers. I mean, his patients cry. It was almost one of the impossibilities. It wasn't considered in the realm of dentistry deliberately for these patients. And of course, for now, with the size class and most of the implant companies are providing you with the PMO temp and with the final. 00:31:12:26 - 00:31:27:29 Vishy So it's built into their cost, obviously, but it's nice to to be able to do that. But you have to have a good design and a good design is key. You wanted to get files and get to that stage design. 00:31:28:02 - 00:31:42:21 Robert Speaking of design, a lot of designs going to AI now. What are your what are your thoughts on that? And have you had any experience with AI in a way that you practice dentistry, whether it's the design itself or even just tools like Claude or ChatGPT? 00:31:42:23 - 00:32:03:21 Vishy Oh yeah. Let me tell you something, AI. It has been a game changer. I was very cautious and a little lucky enough, but my wife convinced me. She goes, you know, I've noticed that when I look at your notes in your practice, sometimes they're not that great. And then you spend the night in the office at an hour or two after surgery typing notes, he said. 00:32:03:22 - 00:32:22:28 Vishy She said, so she got these AI devices where it records everything I say, and it goes directly into the patient's chart. So I'm in a room, I assistance to ask my doctor. What are you doing now? And I'm asking me that. But that's because the AI is transcribing me. And AI has been a huge part of our documentation now. 00:32:23:03 - 00:32:45:03 Vishy And patient charting because almost I mean, even now we have a beautiful, perfect chart for every single consult and surgery. But obviously I have not thinking of the energy of burdens, and I imagine that's going to be a big part of our design full arc as well. Are you guys using it a lot now? 00:32:45:05 - 00:33:05:17 Robert Well, yeah, we we helped we helped develop some of the AI design programs with XO, CAD. We got, you know, the beta release for a lot of that and, and used it heavily in the lab and had some critiques because, well, as you noted earlier, the European approach to dentistry, the American approach and dentistry are not always 1 to 1. 00:33:05:17 - 00:33:27:17 Robert And so we had to kick back some of it. And then the newer versions of it. Now, mind you, we're still it's still limited to three units, right. The three unit bridge is the biggest thing you can get the AI to generate, but the adults that we're seeing now are genuinely impressive. And we're less of a crutch, like where you're like, oh, well, we can use the AI instead of a designer. 00:33:27:21 - 00:33:46:23 Robert Know one of the things at least xo cad I really like is there. They heavily believe that you really need to have a designer involved, so they'll let the AI carry it through like 85%. And then the the technician still has to go through and finalized and make sure that this is indeed what they actually are looking for. 00:33:46:26 - 00:34:04:09 Robert But the results are impressive and allows our it allows our technicians to concentrate more on the full art stuff, the stuff where you really need the heavy skill and hands on experience design, and then the single unit posteriors can be pushed away to the AI to do the majority of the work, that we can come back and finalize it. 00:34:04:10 - 00:34:04:21 Robert You know, that. 00:34:04:21 - 00:34:23:09 Vishy Kind of absolutely, absolutely. You know, I want to bring up two fields in Europe. One, I left it on these little workflows, of course, for large. One of the biggest criticisms I got was, you know, you guys use all this photogrammetry in America. Why aren't you using face scanners? So they are big onto fake scandals in jar relation scanners. 00:34:23:09 - 00:34:46:27 Vishy So they basically use a bike plate. As long as they are seated they have the patient the jaw side by side. So they get a bite scans. And of course the other thing is in AI, you know, I is a game changer and helps you you know, it leads out the misinformation. I love it because my wife is asking. 00:34:46:29 - 00:34:53:03 Vishy He's the best surgeon for side and patient specific. And and I came up, I was very happy. I was like. 00:34:53:04 - 00:34:55:17 Robert Oh man, beautiful nationally. 00:34:55:17 - 00:35:17:25 Vishy Now I was like, thank you. AI you're doing I don't even have to market anymore. It's going to change the way we do things. I think that, I mean, you guys are pioneers. I mean, evolve is is been at the forefront from day one, and I'm so grateful for the opportunity I had to work with Josh and in Indianapolis. 00:35:17:28 - 00:35:33:05 Vishy I think what you guys are doing is is amazing. You know, staying at the forefront, educating young doctors that you're getting older doctors and showing them how we can change people's lives. As long as he worked together and implement the latest embrace and technology. 00:35:33:08 - 00:35:50:11 Robert Well thank you. That's very kind of you to say. And we have blessing to work with people just like yourself. And speaking of innovating technology stuff, what what do you see coming up in like the next 5 or 10 years? What are you excited about and where do you see some of this digital technology going? 00:35:50:14 - 00:36:08:04 Vishy So the digital technology is already implemented. Just people don't hear about it, but I do. These are called John a day. I don't know if you're familiar with John, a day where I place implants into the patient's leg bone while it's still attached to their legs. So it's I go to the CBO, I play symptoms in the fibula. 00:36:08:04 - 00:36:29:20 Vishy And then because I've digitally designed this using virtual surgical planning, this works. I'll have to send you the article I wrote on this. And then we bring it up to the patient's face and they wake up with T. So nowadays patients had were a victim of gunshot wounds, cancer or tumor surgery. They no longer have to wait a few years to go without teeth. 00:36:29:21 - 00:36:42:02 Vishy Now days cancer patients can go to sleep and wake up with teeth without missing a beat. So AI has really helped us tremendously measure that. We map out the buildings and the vessels and it's just technology. 00:36:42:02 - 00:36:42:25 Robert But now. 00:36:42:28 - 00:37:06:02 Vishy Using AI, we can get better designs and virtual surgical planes. So I think it's just been taking the world of implant and even make it even better. And I'm hoping they can use AI to about, you know, get rid of us yet, but I hope it will still be needed to carry out the great surgeries and restorations. But man, it's changed everything for me. 00:37:06:03 - 00:37:15:27 Vishy I mean, the John A day is something I've been doing several years now, especially by implementing AI. Now it's going to be no one goes home without you. 00:37:15:29 - 00:37:30:01 Robert I love that. That's incredible. I absolutely love that you've trained over 250 surgeons. Would it be crazy to propose coming back for another episode so we can walk through one specific case? I think that'd be really cool. 00:37:30:03 - 00:37:35:17 Vishy I love that, I would love that we could do that for sure. And I love that. It'll be fantastic. 00:37:35:20 - 00:37:50:01 Robert Let's do it. Thank you so much for being here, Doctor Vichy. We really, really love this conversation. Unbelievable and incredible information here. Where can people find you online if they want to learn about your courses, your practice, your social media? 00:37:50:03 - 00:38:14:29 Vishy Oh yeah. Well, my my social media, my Instagram is burning. The surgery, my my practice website is com and my training courses are Doctor Vichy so they can learn about debugging and patient specific ones. So yeah I'm pretty active on social media and I respond to quickly to messages and emails. But yeah, I love being a part of education. 00:38:14:29 - 00:38:16:15 Vishy It's been fantastic. 00:38:16:17 - 00:38:20:23 Robert Axel. That's awesome. And thank you again for being a part of this. 00:38:20:26 - 00:38:26:16 Vishy Oh, thank you again for having you guys. I look forward to doing it again and then then seeing you guys again soon. 00:38:26:19 - 00:38:47:22 Robert Thank you. And thank you, everyone else for joining us for this episode of the Evolution of Dental Podcast. Please look for us on all the social media platforms as Evolution of Dental Podcast. We're also on all of the podcast streaming platforms as well. Remember to like, subscribe, share the show with your friends. It helps more than you know and never stop evolving.