Latest / Straumann® ProTalk / Pioneering zygomatic implants: Dr. Carlos Aparicio and the birth of the ZAGA philosophy

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Pioneering zygomatic implants: Dr. Carlos Aparicio and the birth of the ZAGA philosophy · Straumann® ProTalk

0:00
Carlos: At that moment was like, can we do that?
0:02
Exactly.
0:04
George: Carlos, you are really one of the pioneers of zygomatic implant dentistry.
0:09
You created the ZAGA philosophy, the ZAGA concept.
0:13
Andreas: How can I become a part of ZAGA center?
0:14
Carlos: We tried to select not to accept everyone in the means that, we
0:19
want an office patient center that has shared, has learned this philosophy
0:26
by attending at least one course.
0:28
We don't want everyone being there.
0:31
We want the best ones.
0:48
George: Welcome to ProTalk.
0:49
Welcome to the Pulse of Dentistry.
0:51
My name is, George, and together with my co-host Andreas, we are
0:54
very pleased to welcome here in Basel, Dr. Carlos Aparicio.
0:59
Welcome, Carlos.
1:00
Carlos: Thank you.
1:01
It's a pleasure to be here and to share this moment with.
1:04
Both of you.
1:05
George: The pleasure is totally ours.
1:07
So thanks a lot for making it, to Basel.
1:10
Now, Carlos, you are really one of the pioneers of, zygomatic implant dentistry.
1:15
You are a lifelong innovator and a very passionate educator.
1:20
You created the ZAGA philosophy, the ZAGA concept, and with this also,
1:26
Clinical network of over 70 ZAGA centers as of today and counting and growing.
1:32
With this, I think you really redesigned how zygomatic treatment is done today.
1:39
Now for today, I think we have the chance to discuss with you multiple
1:43
topics and learn a lot about, yourself, your personal journey, particularly
1:48
also how a single patient can change the track of a professional career.
1:52
And then we also would like to dive into the ZAGA centers,
1:56
how you build them, what's your educational- let's say philosophy.
2:00
And last but not least, for everyone very much interested also
2:03
talk about zygomatic implants.
2:05
So in today's podcast, our listeners, they will have the chance to learn
2:09
a lot about, zygomatic treatment.
2:13
Now, before we dive into, those, details, Carlos, for those who
2:18
don't know you that well, who is Carlos Aparicio in just one minute.
2:22
Carlos: Wow.
2:27
That's a difficult question really.
2:31
I'm a human being,
2:35
that has values.
2:38
I'm a very fortunate human being.
2:42
I have a very nice family, good friends.
2:47
I have
2:50
good health.
2:52
Thanks, God.
2:52
So important.
2:54
And which is a very good start.
2:57
And, I have also the privilege of having what the -Japanese people they call
3:06
'Ikigai', which means I have an illusion in life, so I'm a big privileged man.
3:14
George: That sounds also like a very, solid foundation and a good
3:17
start and also to achieve a lot right as you have been doing.
3:22
let's go back a bit in time.
3:25
What drew you to dentistry in the first place?
3:29
Carlos: Oh,
3:32
evolution.
3:33
Evolution.
3:34
So I'm a medical doctor, so I - my father and my grandfather,
3:39
they were dental technicians.
3:41
And I told to myself, Carlos, you will never be dentist, you'll never be dentist.
3:49
I wanted be a medical doctor.
3:51
Because, dentistry is something like a- something that, it was
3:56
not so much important to me.
3:58
So I became a, family doctor.
4:03
I work as a family doctor for about, three and a half years.
4:09
but I was taking care of about 28 small villages.
4:14
28. I said.
4:15
Two, eight.
4:16
So can you imagine the size of those villages in the
4:20
mountains of northwest Spain?
4:24
The thing is that, there was one phone for the 28 villages.
4:30
One phone for 28 villages means that nobody has phone.
4:35
George: There is no communication as you know it today.
4:37
Carlos: There is no communication.
4:38
no.
4:39
and with my first salary, I bought a motorbike, a mountain motorbike,
4:44
because it was not possible to arrive-
4:47
George: To be fast enough.
4:48
Yeah.
4:49
Carlos: Some of the villages, they have no even electricity.
4:53
So it was like a hard way.
4:55
The nearest, hospital was at about, four hours.
5:00
The nearest ambulance was at about, if you are, you were lucky enough the
5:06
ambulance to be in place was at about 40 minutes to come up, and if the
5:13
ambulance pick up the patient, yeah.
5:15
George: Go down and take
5:16
- Carlos: then go to the hospital.
5:17
Hospital.
5:17
Yeah.
5:17
So that was the most difficult part, the diagnosis.
5:20
If you fail a diagnosis, you think, oh, okay, I can take care of this patient.
5:24
Okay.
5:25
And you fail, you are in trouble.
5:27
If you send the patient to the hospital, this means that it needs
5:33
five hours to get into the hospital.
5:35
Wait there, and then somebody tell, oh, that's nothing.
5:40
I don't understand how your doctor send it to me and then so
5:44
it's like a one day in a back.
5:47
So it was not so easy.
5:49
And, on top of this social security gave me one very good instrument,
5:56
It was how do you call the, book of receipts, that was my instrument.
6:01
So not even the stamp.
6:04
I had to buy my stamp.
6:05
So any, anything more?
6:07
George: A prescription block?
6:08
Carlos: Precision block.
6:09
Thank you.
6:10
So any diagnostic tool, everything I have to buy it.
6:14
So I became an expert and more expert, in analysis, blood analysis, urine analysis.
6:22
So I bought a machine to make a electrocardiograms.
6:27
And finally, for finally, I thought this was too much.
6:30
Maybe my father was right, maybe I should change, but this is too much to me.
6:37
It's too much.
6:37
And then I moved from this part to Barcelona to study dentistry.
6:41
Oh, okay.
6:41
That was the origin.
6:43
Very interesting.
6:43
Okay.
6:44
George: Evolution.
6:45
Evolution.
6:46
and, to extend on this, then I think there must have also been a very specific
6:49
moment where you came to zygomatic implants and, I just saw in one of
6:55
your recent books that you mentioned.
6:57
A very specific young patient, 18-year-old Inácio.
7:01
And that, of course, sparked my interest.
7:02
Maybe you can share a bit about the story of, what, is this in terms of your career.
7:08
Carlos: Okay, let's, but.
7:10
I wouldn't, of course I'm going to answer the, question, but
7:14
allow me to fill up the gap.
7:16
Between, I came into dentistry and then this patient because I told you that I
7:22
will never, I thought I would never be a dentist because it's something fasting.
7:28
But when I came into dentistry, I started to enjoy this.
7:34
This field of medicine, which goes, is a, it's a medical field, field.
7:39
And, I started, to meet you is to love you.
7:44
And then I started to really appreciate all the good things that dentistry has.
7:50
It's like a manual job.
7:54
It is an intellectual job.
7:56
You are able to see the results, almost immediate.
8:01
You have, you are treating with patients with, human beings, so
8:06
you receive feedback quite easy.
8:09
And also two more things that are to me are important.
8:12
You are your own boss, usually, at least in my time.
8:17
Today is much more difficult but yeah, I was my own boss and, and you get a
8:21
nice amount of money for your work.
8:23
So it's like a perfect job.
8:25
It was at a perfect job, It happened that, because I started to love it, I
8:31
went to many courses during my studies.
8:33
I went to many short courses, continue education courses.
8:39
So it happened that,
8:42
in the last year for my dental education,
8:48
we met somebody coming from us.
8:52
He mentioned it during an continuing education course.
8:57
He mentioned about implants and somebody called, and it happened that at this
9:04
moment, so we were just finishing.
9:08
At this moment, my partner at that time wanted to study Periodontics
9:14
and he managed to go to Michigan
9:20
university, and he was an special guy.
9:23
So instead of going to the pub, having beer, etc, he went to the library
9:29
and he found out this paper 15 year report, maybe you remember this
9:34
paper very from 81, published in 81.
9:37
This was 83 and he made a copy of this paper.
9:44
Didn't he forget a couple of, sheet, but that, but then we
9:50
started reading the paper.
9:51
What was that?
9:52
What was that?
9:52
What's that?
9:53
This is like a miracle.
9:54
We can place implant and the implant stay there for five,
9:57
10 years, 15 of integration.
9:59
15 years.
9:59
Wow.
10:00
That's also integration.
10:01
That was like a miracle.
10:03
So we wrote, the author what was, Ragnar Adell of this 15 years
10:08
paper and asked for education.
10:12
And they, so they asked us for a CV and we were almost students, but the good
10:20
thing is that since we have so many, continuing education courses, diplomas, so
10:26
we send many diplomas of two days, one day education, continuous education courses.
10:33
So they admitted us there to the first schools in the, in, Guttenburg and, then
10:40
once they admitted us, we thought this was like a three day course only, and either
10:45
you apply for, surgery or for prosthetics.
10:49
And then we said, this is, too short.
10:52
Can we go for a month?
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And they say, yes you can.
10:56
So we applied for a student residence there and and then we were admitted.
11:03
And the funny thing is that, we were there and then one day our teachers
11:10
and the school arrived there and they saw, okay, but what are you doing here?
11:16
What are you doing here?
11:17
And the good answer was, if you haven't been so good teacher, I wouldn't be here.
11:24
And that's the history.
11:25
So this is how we started with implant dentistry.
11:28
And then one day Inácio, in the late eighties, Inácio, which is, at that
11:36
time he was a youngman of 17 years old.
11:40
He underwent a failed orthognathic surgery.
11:44
So he lost all the premaxilla.
11:47
Wow.
11:47
From premolar to premolar.
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So he was telling us that after the surgery, three weeks after it
11:53
started moving with tooth movement and then suddenly, a block of white
11:58
thing with the teeth in came up.
12:02
So at the end, he ended up with, loosening the whole premaxilla and
12:07
with, oral national communication of about 15, 17 millimeters, big one,
12:13
big communication, 18 years old.
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So it's, it, was like a pity and he knock out door and said,
12:19
okay, can you fix me that?
12:20
We said, oh, wow.
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There was the, first period of regular implants.
12:27
So we thought, okay, let's call our mentor.
12:30
We called Per-Ingvar Brånemark, he came and we were able to arrange
12:35
the paperwork for him and we came there and, it happened that,
12:42
at that time Eugene Keller from the Mayo Clinic.
12:45
He used to be the chairman of the maxillofacial department of the Mayo
12:49
Clinic was spending a sabbatic year.
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George: Was also there.
12:53
Carlos: Yeah.
12:53
Spending a sabbatic year to learn regular implant.
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That's amazing, isn't it?
12:59
It's amazing.
13:00
So if Eugene was able to close the communication and Per-Ingvar
13:05
Brånemark machine himself couple of implants in his office.
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He used to have a, that's a very long one, like a machine.
13:12
Yeah.
13:13
Really himself too.
13:14
yeah, himself.
13:15
So it's,
13:17
and with those, implants, remotely anchored, he was able
13:21
to fix, a graft, hip graft.
13:24
And then we performed the rehabilitation in Barcelona.
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And at the end, the bad thing is that, we, the rehabilitation,
13:33
we have to keep the open bite.
13:36
Because there was a, bad diagnosis.
13:38
It was an incompetence of the upper lip, so.
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George: What an incredible story.
13:45
Wow.
13:46
Carlos: Yeah.
13:46
And we, but the story is like incredible itself but the good thing
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for me is that I learned two things from this story that really changed
13:56
my professional life, and the first thing is that, you can place implants
14:02
in non-parallel, in non perpendicular direction to the CHO cell plate.
14:07
You can tilt implants and those implants still work.
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This was the beginning of tilting implants.
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Now, today is as it's like regularly,
14:17
George: it's well known, accepted, and proven.
14:19
Carlos: But at that moment was like, ah,
14:21
George: can we do that?
14:22
Carlos: Can we do that?
14:23
Exactly.
14:24
And of course the second thing I learned and changed my life is that, you may.
14:29
Get some remote anchorage for your implant outside of the mouth.
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and those two things changed my life.
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Totally.
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George: And that was, in early, eighties, right?
14:40
Carlos: That was, no, late eighties.
14:42
Late eighties.
14:43
Late eighties.
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George: Late eighties, but still very early for that type of, treatment concept.
14:47
Oh, yes.
14:48
Thanks a lot for sharing that.
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I think that's a fascinating story.
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maybe a last question to round up, the more personal, side
14:56
of, who are, who you are.
14:59
Outside of dentistry, what gives you energy?
15:02
where do you actually, recharge and what you like to do outside of dentistry?
15:07
Carlos: Outside of dentistry, I like sailing.
15:10
I like very much sailing.
15:13
I like yoga.
15:15
I try, I've been intermittent yoga performer from since,
15:20
my twenties till now.
15:22
So I keep a nice flexibility, and I try to go to the gym, three, four
15:30
times, as did this morning, sorry.
15:31
Yeah.
15:31
As this morning.
15:32
As this morning because it give me some extra energy.
15:35
So that's all.
15:36
But, I have at the same time, I telling you this, I can do this now
15:42
because now I'm, like a free bird.
15:46
In a moment, I had a conversation.
15:49
I have four children, two and two kids and girls.
15:54
The second girl in a moment told me, daddy, I remind you behind a computer.
16:03
This is my reminds of you.
16:05
So meaning that, since I was on the private.
16:10
And at the, same time, I was looking forward to have some
16:13
science behind to publish.
16:15
You don't publish, from Monday to Friday.
16:19
You prob to you publish on Saturday.
16:21
On the weekend.
16:22
Yeah, on the weekend.
16:26
I'm not re I'm not regretting at all.
16:28
I'm not regretting, I'm just, clarify that things are not coming like this.
16:36
They come by.
16:37
It's hard work.
16:37
Yeah.
16:38
By
16:38
Andreas: hard
16:38
Carlos: work.
16:39
Andreas: It's hard work and I think it's a lot of, reflection probably as
16:43
well if I look in your journey, because starting from the patient Inácio,
16:47
where you learn about dental implants, you learn about zygomatic implants.
16:50
It must be quite, have been quite a journey in zygomatic implants.
16:55
You, taught yourself, you placed a lot of zygomatic implants,
16:59
but then there must have been a very reflective moment because.
17:03
You turned all your experience in, what you called protocolized approach
17:09
to zygomatic implants, which you know, fits the surgical approach of zygomatic
17:14
implants to the specific patient anatomy.
17:18
And I think everybody knows this under the abbreviation, ZAGA.
17:22
So tell us more.
17:24
how did you get to this, very special treatment protocol and philosophy?
17:30
what was the journey behind and were the people that influenced you on the way?
17:34
Carlos: So thank you for the question because it is, again, it's an evolution.
17:45
Our first experience with the remote anchors was the story of Inacio,
17:50
and then there was like a void.
17:53
And during this void I was placing, incline tilted implants
17:59
and, collecting the results.
18:01
So we were able to publish about the results on tilting implants.
18:06
So I was able to develop Three dimensional vision of my implant placement.
18:14
At that time, we didn't have those nice, planning sewers like we have today.
18:20
So I have to develop like a 3D vision and, and, Let's see.
18:27
Let's say that, I was prepared by placing tilted implants to receive the hard
18:33
knowledge of, of the psycho implant.
18:38
So I receive, and standardized manner, or I standardized.
18:42
I received
18:46
the, first course of psycho implants in 98, from the hand of,
18:53
my good friend Chantal Malevez.
18:55
But that was a very intuitive teaching.
18:59
So we received like a plastic thing, in the shape of , school.
19:04
Yeah.
19:05
But was thick like this.
19:07
And they told us you have to make a hole from here and.
19:11
You have to up there so that was the, teaching?
19:14
Yeah.
19:16
we didn't know the why of everything.
19:19
We didn't know about the late complications specifically, but, I was
19:25
able to stick to the original receipt during few years until, we got the first
19:36
complications and then we, I tried to, understand from where the complications
19:42
were arising and then when they suddenly I realized something very simple.
19:48
So simple that I think, I thought I was, Carlos, you were stupid.
19:52
One day I realized that you and me, we are different.
19:57
And I was trying to use the same formula for all my patients and I said, oh,
20:03
Carlos, this is, it's not going to work.
20:05
This is again, natural.
20:09
and then this day that I realized that there are differences between
20:13
human beings, especially in this field of matic implant because,
20:21
At that time, the, first indication was, people, Aden lose people from.
20:26
But, after a while, this, this first indication was.
20:34
widen it by other, failed treatments like in failed implant treatments,
20:41
failed gratin procedures, et cetera, which gives you a very,
20:47
a very, non-uniform anatomy, let's call it, where you may
20:54
find bone discontinuities.
20:55
You may find.
20:56
Big differences between the left and the right side of the patient.
21:00
So you have to adapt a very variable anatomies.
21:04
So at the end you understand that I'm using the same formula
21:07
for those kind of anatomies.
21:09
So that was the really, the beginning.
21:13
I have to say also that the, during those first years, even, let's
21:17
say if we were like a hundred.
21:21
I'm inventing like a hundred, surgeons that were trained in the
21:25
first time, 80 or 85, they gave up.
21:29
Because of the complications.
21:31
Because of the complications, it was hard to understand from
21:34
where the complications came.
21:36
So from this.
21:38
When we started by little change in the protocol, the first thing we
21:43
changed is that whenever we find very concave maxilla, then we thought, okay,
21:48
maybe we can use this, velar bone, remaining velar bone and go outside.
21:55
And then finally we came up with this ZAGA concept, which is the acronym
21:59
of Zygoma Anatomy Guided Approach.
22:02
Andreas: There was a very reflective and, strong journey that you went through.
22:06
You protocolized it, and you published it also in a, very well
22:09
known book, early two thousands.
22:12
So everybody can read about, the ZAGA approach to zygomatic implants.
22:16
But education was always a passion that you had, right?
22:20
how many zygomatic surgeons have you trained?
22:22
Do you have any estimate for over the last years?
22:26
Carlos: no, but, maybe we can ask it, but, we have a nice, ZAGA group of, just.
22:32
Yeah, that I think we are in this ZAGA group.
22:35
We are like, not all I, I haven't trained on, not all of them, but on
22:41
the group we are like 750 people.
22:46
Andreas: so creating the, concept, writing it down teaching.
22:51
And then what I really find impressive if is your network of ZAGA centers, I
22:56
think it's says you told, you mentioned it through, in the introduction, it's
22:59
70 plus ZAGA centers still growing.
23:03
So what is a ZAGA center?
23:05
How, can I get into a ZAGA?
23:07
How can I become a ZAGA center?
23:09
Carlos: It's like a select club of offices, that, have the patient first.
23:16
Center of the patient health following this philosophy and, to
23:22
answer precisely to your question.
23:25
Of course, they must go to the internet and to the website, the ZAGA centers.com
23:31
to see specifically what's, what are the requirements to be part of the network.
23:36
But we try to select not to accept everyone.
23:40
We try to be selective in the means that, we want a, an office.
23:46
patient center that has, shared, has learned this philosophy by attending
23:51
at least one course, and they are going to present a few cases, few
23:57
patients treated with this, philosophy.
24:01
And then there is like a committee of, what we call ZAGA experts,
24:05
ZAGA mentors that are going to just their, application and they
24:11
will decide whether or not you are.
24:13
Huh.
24:14
Andreas: So it's almost like an accreditation process.
24:16
Carlos: Yes.
24:16
Because quality stamp.
24:18
Exactly, We don't want everyone being there.
24:22
We want the best ones.
24:23
Andreas: Yeah.
24:23
normal, I think that's a very interesting network.
24:26
Also, for all our listeners that are interested in matic implants, 70
24:29
centers, then you have 10 mentors, I mean yourself, your training very
24:33
intensively still, every, year and, getting a training at this certification.
24:38
I think that's a way to go.
24:40
I have one question that I have to ask you on, zygomatic implants If we are
24:45
at this point is, what are, let's say what is, because it's a topic that is
24:49
discussed very let's say critically also in the medical field and the dental field.
24:55
What is one of the biggest misconceptions that you see, on
25:00
zygomatic implants that you all would like to, clean up in this podcast?
25:04
Carlos: Misconceptions.
25:08
I would say
25:11
maybe the first one is the indication.
25:15
So you are professional of dental care.
25:19
Oral care, you must care about teeth, you must care about it.
25:25
So I'm against, forcing the indication of matic implant.
25:30
I'm against of cutting bone.
25:32
I'm against of extracting teeth unless it is the type necessary.
25:38
So I'm against of, social media, I'm against of Trends.
25:45
you want to be a good dentist today, you have to place zygomatic implants,
25:49
otherwise, you are not a good dentist.
25:51
So I'm against showing off how good I am.
25:54
This is what I'm against too.
25:56
I think, this is a very powerful tool that must be used when indicated
26:04
and, you must succeed.
26:06
You must succeed at the first shot.
26:09
There is just one shot.
26:10
For those patients because it's, The indication is the extremely
26:16
atrophic maxilla, so there is not gonna be a second chance.
26:20
You must succeed the first shot.
26:23
And this is gonna be like a miracle for these people because there is,
26:28
you are facing the last opportunity to recover a fixed tissue.
26:32
Yes, and only professionals, and of course, the person that is
26:37
suffering from this kind of atrophy can understand what this means.
26:41
This means that you cannot go to the swimming pool because
26:44
you will lose the, your denture.
26:46
You cannot have a sexual relations.
26:50
there are so many, heightened problems on those people, so we have to be
26:58
very responsible and, act use them.
27:01
Use this powerful tool when necessary, just when necessary, and use it
27:05
understanding, what are the limitations of course, of this kind of treatment.
27:11
And the patient must understand that, the condition he or she's showing up.
27:17
It's not because of us, is the condition.
27:21
And we will try to do our best.
27:24
For they to recover the fixed data, but they have to understand also all
27:27
the leaks involved on this procedure.
27:31
Andreas: So it's a very conscious, very mindful and also very serious, oh yes.
27:35
Approach to the use of zygomatic implants, which I think is a, good jump off
27:39
point to, to dive into the, material.
27:42
Yeah.
27:42
George: Let's go a little bit deeper into Implantology and Carlos, you, are
27:47
one of the people that actually can oversee four decades of implantology.
27:55
Sorry to say it like this.
27:56
so it, started with, also integration and now you, you went through the entire
28:01
journey up until today where we have a very broad coverage of indications
28:05
and also quite successful protocols.
28:07
When you look back, what surprised you most on, in that journey in terms of
28:11
implantology, did it go the way you expected it or what was actually for you?
28:17
Totally unexpected.
28:24
Carlos: yeah, it's interesting.
28:25
First of all, to now you made me refreshing on my journey.
28:31
I was pioneer on regular implants.
28:35
Actually, we opened the first office exclusively devoted to implant dentistry.
28:42
Who and dentist didn't know our office was open previous
28:47
to the Brånemark one, so yes.
28:50
Before the Brånemark one.
28:51
Okay.
28:52
Before the Brånemark center.
28:53
We opened the office because I, when I learned from him implant, there was
28:57
like, it was the Gothenburg University.
29:00
So I don't remember exactly, but imagine on the five floor was
29:04
the surgical department, and the third floor was the prosthetic.
29:07
And outside was the lab.
29:10
The lab.
29:10
So we made everything in one and open an office exclusively devoted.
29:15
To implant dentistry.
29:18
George: Not a lot of, different products available at that point in time.
29:21
Carlos: So no, just one type of implant.
29:24
And, so I started my career like that.
29:28
My dental career like this, and I'm finishing my career
29:34
being expert on what to do when implants fail.
29:39
When regular implants fail.
29:40
So this has been my journey.
29:42
So this means that during my journey, I saw, another point is very interesting.
29:47
One is that, at the beginning we were forced by the company
29:55
to treat 20 full arches.
30:01
20 full arches, for one year at dental previous to be able to
30:07
buy implants for the upper jaw.
30:11
George: Okay?
30:12
Carlos: So the beginning was you have to treat 20 there after 20 were 12.
30:18
But, a number of, full arches previous to, to
30:23
George: sell, to go to the upper jaw.
30:24
Carlos: To go to the upper jaw.
30:26
And then.
30:28
Time after it came, the single implant course and then the partial.
30:38
George: It did not start with a single implant.
30:41
Carlos: yeah.
30:41
So this is curious that there are now is full art, is
30:46
consider like The most advanced.
30:50
And we started by the full artist, then single and then partials.
30:55
And then we came back to the four axis.
30:58
George: So that's certainly a very surprising Yeah, this is great.
31:02
To, something to think, eh, exactly.
31:04
to see the whole evolution of, of implant dentistry.
31:07
Now, let's go a bit deeper on zagomatic implants.
31:11
you have been involved in the development of specialized sematic
31:15
implants very closely also with us, and, they are now the ZAGA flat and
31:21
ZAGA round are a direct translation of your philosophy into a product.
31:27
Can you explain a bit more, how you develop that, concept linked to what
31:32
we discussed before in terms of, fitting the treatment to the, to the
31:37
patient and not the other way around?
31:40
Carlos: The concept is about, what is the problem of my patient?
31:45
What is the problem?
31:47
So I am going to treat you why?
31:49
The problem is my patient is suffering from extreme atrophy, maxillary atrophy.
31:56
That's the problem.
31:57
My patient has little bone or no bone or discontinuous bone.
32:02
What I was taught is your first action is to make a window.
32:08
So to make a osteotomy in the shape of a window and then you take out some
32:15
bone and then you place an implant that should have an intra path.
32:20
So you go from the pal intra sinus and then you get the maxi.
32:26
So what I learned is that for this to place one implant, you
32:31
should make two osteotomies.
32:34
Does it make sense?
32:36
No.
32:37
So if the problem of my patient is maxillary atrophy, why should
32:42
increase the atrophy of this patient by taking out this window or late?
32:48
The slot technique that again, was a osteotomy in the shape of slot
32:53
previous to implant placement, and then the osteotomy necessary to
32:57
place the implant so it doesn't.
33:00
Make any sense to do that.
33:02
So you start thinking and thinking, and then you see other,
33:09
let's call it companies that they say, or professionals, they say, okay, you
33:15
go and you get anchored on this zygoma and you have to discard the available.
33:20
Alveolar bone is marvelous.
33:22
We have to respect modern nature.
33:24
If the problem of this patient is atrophy, why should we discard bone?
33:29
Let's take profit of it.
33:31
So we find out in a study that, we were able to classify in groups
33:38
the different types of atrophies.
33:42
and then we got five groups of patients showing maxillary atrophy.
33:48
We call them, ZAGA from ZAGA four, doesn't matter the name.
33:53
The important part is that there's a fact.
33:57
And the fact is that maxilla are different and maybe we can classify them for
34:02
the surgeon to better understand what is the pathology of this patient, or
34:06
what is the anatomy of this patient.
34:08
So we found, and the question is why you have two different types of implants.
34:14
We found that sometimes you have, you are very lucky because you find like
34:19
a few millimeters of Alveolar bone.
34:22
If instead of discarding those few millimeters of Alveolar
34:26
bone, you go through them and you have an adequate implant design.
34:32
Having threats on the neck of the implant, you will be able to
34:36
transmit the atory load to that through the threats to the bone.
34:41
And then you will be able to maintain this bone and if you are able to maintain
34:45
this bone, you will be able to offer some support for soft tissue fibers to attach.
34:52
So you when suffer, you will escape from, soft tissue
34:57
recession, soft tissue infection.
34:59
So it's about, I should understand that connected tissue fibers, they
35:05
need bone to attach, they don't like titanium to attach, they like bone.
35:10
If we are able to maintain this bone, if we are able to go through.
35:16
What we call tunnel osteotomy in this small alveolar
35:19
segment, and we use the right.
35:22
Implant design offering threats on the neck because if there are
35:26
no threats, there are no stimulus.
35:29
Atory forces cannot be transmitted to bone.
35:32
And if you have a bone that is not working, what is going to happen?
35:36
That's going to resolve a trophy?
35:38
Exactly.
35:39
Atrophy.
35:40
So it's about understanding the problem, classifying the problem,
35:45
understanding the anatomy.
35:48
And then being conservative, understanding the physiology of the sharp tissues
35:54
and choosing the right implant design.
35:56
In this case is the ZAGA arm.
35:59
But what happened when I'm not so lucky and I not able to find this
36:05
small triangle, small amount of avelar.
36:08
Because sometimes the atrophy, like in cases, the atrophy is so big, it's so
36:14
heavy that we have like a paper seat bone or even we don't have bone, so
36:19
we cannot go through the bone like in regular implants because there is no
36:24
bone, we cannot go through the bone.
36:26
So we had to, we have to balance this,
36:33
we had to equate between escaping from.
36:35
Sinus problem and escaping from soft tissue problems.
36:39
And then what we do is like a channel on this, lateral wall,
36:45
we try to hide the implant.
36:46
We have, we tried this implant not to protrude against the soft tissue.
36:51
We try this implant not to compress the vascularity of the sub tissue that will
36:56
provoke later on, sub tissue recession.
37:00
By using this channel and by using again, the right implant section of design.
37:06
So we, so then we use the flat design in order to extend the surface we are
37:11
offering against the soft tissue in order not to protrude, not to compress,
37:15
not to ize the soft tissue, vascularity, not to provoke some tissue recession
37:21
and posterior, maybe infection.
37:24
And because we are, because we know that this may happen.
37:28
Because this is not like a hundred percent formula.
37:32
It's little by little.
37:33
You are creating the fundamentals for escaping from the problem.
37:38
But because we know that on top of this, we may have a problem, we are
37:43
using machine surfaces in this level.
37:46
Because if you use a rough surface, once it gets contaminated, you
37:51
cannot get rid of bacteria.
37:52
It's not possible.
37:53
It's not possible.
37:54
So it's about using the right technique, individualizing, using the right implant
38:00
design, understanding the physiology.
38:02
George: Could you even imagine patient specific implants for-
38:09
Carlos: thank you.
38:10
because, when I'm lecturing, I. I think that those implants, the
38:15
ones we are using, the, Straumann ZAGA, zygomatic implants are
38:19
site-specific implants already.
38:23
Of course, we can be even more ambitious,
38:29
preparing the in implant previous to the surgery.
38:31
But I think this is, something like, in an ideal world maybe, but in the
38:37
practical world, is too much difficult because, the lens, everything is well,
38:46
George: yeah, you also need to have selected right one, you need
38:48
to have it in stock, et cetera.
38:49
So there's a lot of comes-
38:50
Carlos: you will kill me from, the commercial point
38:53
of view, you will kill me.
38:54
George: A lot of SKUs.
38:56
let's switch gears a little bit also, moving into, let's
39:01
say the future a bit more.
39:04
besides also investing a lot into the development of hardware.
39:09
We also spend quite some time in developing software solutions,
39:12
for, treating patients.
39:14
And how do you see actually the use of, let's say, surgical data and AI
39:20
influencing how you do treatment today?
39:24
You were saying before, we didn't have a planning software.
39:27
Now of course you have a planning software.
39:28
Now the next level is that AI will also be able to help you plan, but what type
39:34
of developments would you foresee for the near future, coming out of digitization
39:39
of, treatment modalities and concepts?
39:43
Carlos: I have not the, crystal ball, but, I will appreciate having, more
39:51
help, even more help in understanding the anatomy previous to the surgery.
39:57
although we have a very nice,
40:00
So always now to quantify the implant direction.
40:05
I think the, for Nobel people, you can, we can, I can foresee that,
40:13
could be nice thing to incorporate,
40:17
ai.
40:18
Inside those programs to maybe to advise them, okay, this implant,
40:24
you are placing this implant here, but maybe because this implant is
40:29
a little bit out, you are risking.
40:31
So incorporating this.
40:34
I can see it very easily.
40:36
So it is, nothing that, that is far away and it'll help a lot, especially
40:42
for, for filling, filling up the gap between the theory And the practice.
40:50
Actually, we try to help, Nobel Sergeants and by, by preparing them,
41:01
Like a 3D model.
41:02
A double 3D model, one naked, so as it is And the other with the implant printed.
41:11
So we do the three, the planning and we print the implants on
41:16
the 3D model together with PDF,
41:19
George: So they know actually how it is planned and exactly where it needs to go.
41:23
Carlos: It is not a prescription because we, of course, it recommendation from
41:27
the legal point of view, we cannot make a prescription, but we send a a
41:31
model, a second model with the implant printed, which are usually we prepare.
41:37
We, usually, no, we do the, yeah.
41:39
George: Excellent.
41:41
Thanks a lot for sharing all of those insights.
41:43
Andreas, I think we had a, very interesting and, deep conversation.
41:47
If you reflect on what stood out for you, What would you mention?
41:52
Andreas: So first of all, thanks for sharing, Carlos.
41:54
I think what stood out for me is, you know your story about being a family doctor
41:58
and a physician, in the north of Spain, and then you know, the willingness to
42:02
change and adapt your personal direction.
42:05
Even I imagine it was a tough decision, but it was not your
42:09
way and not your journey.
42:11
So you decided, and it was, very courageous.
42:13
You decided to change and to adapt for better.
42:16
And I think that was a, an interesting one, is that a
42:18
willingness to change and adapt.
42:20
Then I think, your patient centricity for me stood out.
42:24
And your curiosity, that with Ignacio what you learned about this and your curiosity
42:29
to wanting to learn more about dental implants and then learning more about
42:33
zygomatic implants, wanting to progress the standard of care for zygomatic implant
42:39
up to a point that you protocolized, and, actually created a new philosophy that.
42:46
I think it's the fundamental ZAGA philosophy is a fundamental of, a very
42:51
standardized, high quality treatment in a very challenging indication.
42:56
So thank you for that and thanks for sharing, Carlos.
42:58
Thank you.
42:59
Carlos: Thank you for the opportunity.
43:02
as I told you at the beginning, this is my ikigai I, this is my solution
43:05
for life to- and my privilege to be able to share this knowledge and,
43:12
to let something when I not be here.
43:18
George: Thanks a lot, Carlos.
43:18
Also, from my side, it has been a very interesting and deep conversation where
43:23
we learned a lot about you and also how you see things and, learn a lot
43:27
about a fascinating individual that actually drives forward a entire field.
43:31
So thanks a lot for that.
43:33
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43:36
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43:39
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