Latest / Straumann® ProTalk / Fear comes from not knowing the fundamentals: Dr. Ed Bedrossian on zygoma and biomechanics

Transcript

Fear comes from not knowing the fundamentals: Dr. Ed Bedrossian on zygoma and biomechanics · Straumann® ProTalk

0:00
An educated man knows how much he doesn't know.
0:02
Once you think you know everything, that's the beginning of you going down.
0:07
Then, you know nobody went from zero to a hundred in one second.
0:12
It takes time.
0:13
It's very fascinating that you are overseeing now more than three
0:16
decades of evolvement of implantology.
0:19
Fear and anxiety comes from lack of knowledge, and once you have the
0:23
knowledge and you understand how it works, the fear and anxiety goes away.
0:28
so you had this, let's say, beautiful combination of teaching and practicing
0:32
as a clinician from the beginning.
0:34
Absolutely.
0:34
Since today.
0:35
Absolutely.
0:37
my entire basis of thinking is based on biomechanics.
0:43
No matter what you do, there's occlusal forces that are being placed on whatever
0:48
it is that you're reconstructing.
0:50
Most people expect the answer to be yes, but I think my mindset always was anything
0:56
that said to me, I asked the question why.
1:14
Welcome to ProTalk.
1:16
Welcome to the Pulse of Dentistry, and today in this episode, George
1:20
and myself are very happy to welcome, Maxillo Facial Surgeon by training
1:26
and someone that has been very active in the pioneering times of implant
1:31
industry and was breaching it over to the modern field of especially very complex
1:37
work in atrophied maxilla situation.
1:40
Welcome professor, Dr. Ed Bedrossian.
1:43
Welcome Ed.
1:44
Thank you.
1:44
Thank you for having me.
1:46
Thanks for coming all the way over from the US.
1:49
it's our pleasure to have you here today in Basel.
1:51
And today, in this episode, you will learn about the mindset that you need to have to
1:57
approach these type of very complex work.
2:00
You will learn about zygomatic, about, immediacy, and of course how the
2:05
future will carry these topics forward.
2:09
Great to have you, Ed, and, to start with, and before we dive into the
2:13
mindset and the technique and, everything that you brought to implant industry,
2:18
who is Ed Bedrossian in one minute?
2:22
I, as you said, I'm a maxillofacial surgeon by training.
2:26
I grew up in England and came to the US after high school and did all my training.
2:34
College, dental school, oral surgery residency in San Francisco area.
2:38
So that was very convenient and good.
2:41
I decided to open my own practice from scratch, so my, chief of my program
2:47
started to laugh when I said that.
2:48
I said, why are you laughing?
2:50
He said, you gonna start from scratch, all the competition.
2:54
I, and I was young, so I said, so what should I do?
2:57
He said, I think you should come and teach.
2:59
I said, okay.
3:00
So from day one.
3:02
Every Monday for 30 years I was at the residency program and four
3:07
days in private practice and have been involved with education and
3:11
private for my entire career.
3:15
So.
3:15
you had this, let's say, beautiful combination of teaching and practicing
3:20
as a clinician from the beginning
3:21
Absolutely.
3:22
Since today.
3:23
Absolutely.
3:25
I think, if you are involved in that kind of an environment,
3:29
everybody thinks you are.
3:31
Doing a lot of teaching, but really you're doing a lot of learning.
3:35
It forces you to stay on subject.
3:38
So it's been probably more beneficial for me than it's been for anybody else
3:42
that has been interacting with me.
3:44
Yeah.
3:45
And let's go back to right the beginning of your career.
3:48
How did you decide to become a dentist?
3:50
All to be precise.
3:51
I maxillofacial surgeon.
3:53
That's very interesting because in England they have a system where everything
3:57
is based on Oxford and Cambridge.
3:59
So when you're 12, we have an interview.
4:00
They decide if you're gonna go into arts or into sciences.
4:04
So I decided to go into sciences and I don't know, it's just dentist when
4:11
we're talking to the family, because yeah, you're a doctor, but you don't
4:14
have to deal with life and death.
4:16
It's safer, much more comfortable life.
4:19
So it was just like a child.
4:21
Okay, that's what I'm going to be.
4:23
So when I went to dental school.
4:26
the first week I enjoyed what they were teaching, but not very much
4:33
And from cultural background, you've been a dentist since you were 12.
4:37
They called you a dentist.
4:40
I looked for what else is interesting.
4:42
And the maxillofacial department was extremely interesting.
4:46
So from first week of dental school, that was my aim.
4:51
What would you have to do to be able to enter a residency
4:54
and what kind of different procedures are done in dentistry?
4:57
So, that's how I ended up in maxillofacial.
5:01
but it has changed a lot in the last 30 years.
5:05
our training was, as I've, I encouraged my son to be a
5:09
prosthodontist, not a maxillofacial.
5:12
And one of the reasons is because the, Workflow of the maxillofacial
5:18
is very different today.
5:19
Before it was all major facial surgery, TMJ.
5:24
Orthognathic and such.
5:25
But with, insurance issues with medical and everything else you
5:31
became limited in who could.
5:34
Afford those kind of procedures.
5:36
And so to make a living you had to do something and extractions and implants and
5:41
reconstruction became a good way to go.
5:45
And by literally, it was dumb luck that I thought implant
5:50
dentistry will be the future of.
5:53
Maxillofacial at least.
5:55
And so from day one, I, when my instructor said, come and teach,
6:00
I, I created this from nowhere.
6:03
It was no thought or anything.
6:05
It just ad-libbing a implant.
6:09
A clinic.
6:10
So Mondays was just implants at the hospital and slowly over time, I
6:16
brought in the restorative, then the laboratory, then the protocols, and it
6:20
developed into a very strong implant.
6:24
Teaching part of the residency program,
6:27
and if we, go back to this time, we have to say this was not when
6:31
implant industry was, let's say, fully established and fully developed.
6:34
It was in its very early stage.
6:36
In 1983 was when Pi Branemark came to Toronto and they had the first Toronto
6:42
meeting where basically he introduced implants to the dental world, 1983.
6:49
I graduated in 1990.
6:51
So it wasn't very far.
6:54
I did not attend the 83.
6:55
I was too young.
6:56
But after 90, this, was basically the beginning of implant world and there
7:03
was no such thing as study clubs.
7:05
Nobody knew what a study club was and implants.
7:07
So establishing a study club and just using common sense to know.
7:12
It to have a group together, to have a, plan and somehow an
7:17
organized way of learning was the way to figure this field out.
7:22
And, by grace of God it worked out.
7:25
It, worked out well.
7:27
It's very fascinating that you're overseeing now more than three decades
7:31
of, evolvement of implantology and maybe coming back to your teaching activities.
7:38
I doubt that actually.
7:40
You were the one that profited most, I believe that also the other ones Ed a lot.
7:45
but maybe Ed, were there some turning points, in those three to four
7:50
decades that really changed how you look at clinical decision making?
7:54
And how did it actually also change how you taught Implantology?
7:58
Yeah, I, the answer to that question is yes and no.
8:02
Most people expect the answer to be yes, there's major changes,
8:07
but I think my mindset always was.
8:11
I must have been a terrible child from my mother because anything that
8:14
said to me, I asked the question why?
8:17
So from the beginning, why would you put an implant?
8:21
How would you restore it?
8:22
Why would you restore it this way?
8:24
That was my mindset.
8:26
So really in the last three decades, things haven't changed.
8:30
If you stay.
8:31
Honest and true to fundamentals, understanding why you're doing what
8:35
you're doing, then things usually turn out to be quite predictable.
8:40
But what has changed is maybe the tools.
8:43
a more elegant way of doing something.
8:45
Instead of drawing on a tracing paper on an x-ray to figure out what size
8:50
implant you're gonna use, now you have a
8:53
Digital.
8:53
Three dimensional digital workflows and animations and such things.
8:58
So it is allowed.
9:01
Maybe teaching to be easier, more.
9:07
user friendly, but at the same time maybe makes the student a little bit lazier.
9:13
Because they expect the machine to figure it out when the
9:17
machine is as good as user.
9:20
yeah, that's a good point.
9:20
And, we probably will have the chance to touch upon it's, say the
9:23
digital evolution a bit, later on.
9:27
you, say that a lot of the things actually stay the same, but, still if you look
9:31
at the last three to four decades, particularly when it comes to, full art
9:35
reputation of, severely atrophied maxilla,
9:39
There haven't been, let's say, from the get go all the tools available.
9:43
So maybe can you elaborate a bit on Yeah.
9:46
was there an early point and, you said you were very fascinated by
9:50
the, Oromo facial surgery itself, but was there a point where you said.
9:55
There is a chance to do things graftless.
9:57
Yeah.
9:57
So let's start to use specialty implants.
10:02
actually, the treatment of the denal severely atrophic maxilla was probably
10:07
a major turning point, in the past.
10:12
The way to reconstruct the severely atrophic maxilla, the way we do
10:16
it today with zygoma implants, for example, used to be with major grafting.
10:20
Exactly.
10:21
And the major grafting was actually.
10:24
Quite difficult because the graft had to be, prosthetically driven, if you will.
10:29
But that idea of prosthetically driven wasn't well understood,
10:32
so a lot of people did not do it.
10:35
So a lot of patients did not have their severely atrophic, maxilla reconstructed.
10:40
and then one of the ones who chose to have it reconstructed by grafting.
10:46
As most people know, you cannot put a denture while the bone graft is healing.
10:51
So the patients had to go without a denture without
10:54
While the graft was healing.
10:56
For some reason, majority of patients are females.
10:59
And to be able to ask a female to have go through a major grafting and not
11:04
wear teeth for six months or seven months prohibited the treatment of many
11:09
of these patients in private practice, in a university hospital setting.
11:13
It was a different clientele, but in private practice.
11:17
There was a void treating the dens maxilla.
11:20
So with the introduction of Zygoma implants and the Graftless concept,
11:25
not only it allowed treating these patients with less invasive techniques,
11:31
but allowed you to let them have their.
11:35
At the time, we didn't do immediate loading.
11:37
First it was two, two stage zygomas, right?
11:40
But at least they could wear their denture.
11:42
And then with the evolution of immediate loading, you could go
11:45
ahead and put the implants in and give them a fixed prosthesis.
11:48
And even better, the next evolution was a terminal dentition where you
11:52
could extract and put the implants in, whether it's zygoma or tilted,
11:57
and give them a provisional.
11:59
So allowing the patient to basically.
12:01
Be functional and socially acceptable during their
12:05
treatment is a major revolution.
12:07
In being able to treat a lot of patients.
12:10
Can you draw your personal picture a little bit on how did you actually
12:14
get to treat your first Zygoma case?
12:17
from what we see today and from where, in the nineties in
12:20
Implantology was there is a long way.
12:22
And how was your personal journey to this, treating those kind of very complex cases?
12:27
Yeah.
12:28
I was very lucky to meet Professor Branemark and, very lucky that he actually
12:35
took me under his wing and was mentored by him, so I spent a lot of time with
12:39
him, doing the maxillofacial implants for cancer patients, the eyes and the
12:44
nose, the zygoma implants, because the zygoma implant began with the Maxillectomy
12:49
patient and the oncology patient.
12:51
And then it evolved into the intact maxilla.
12:54
So being, be able to be mentored by the man who, invented it, not only
12:59
just the hardware, but his influence of the mindset of the clinician.
13:06
Why are you doing what you're doing?
13:09
The, empathy for the patient and knowing that you're doing all
13:12
of this to take care of a human being, is what I learned from him.
13:17
So that was my, My biggest, luck and my biggest, learning was being
13:24
able to spend a lot of time with him going to Brazil three, four times a
13:28
year and just working with him and absorbing everything that he had to do.
13:34
When was the first Zygomatic implant, actually, that you placed?
13:37
1995, I think.
13:40
Yeah, that the 96 was the first year we brought it to the North America market.
13:47
I and actually trained a very select group.
13:52
And in 97 we met, in Spokane, Washington.
13:56
Kenji, Gucci was a maxillofacial surgeon that met PI in Germany when
14:02
he was in the army, and that was the connection of bringing PI over.
14:07
And, we trained about 20 maxillofacial from all over the us.
14:13
and, It slowly began.
14:16
It was not well accepted at the beginning.
14:19
Because it was just different.
14:22
The idea of immediate loading, full arch rehabilitation, fixed
14:25
prosthesis was like foreign.
14:28
everything was removable, there was over dentures, whatever.
14:32
it was very complete mind.
14:33
Different mindset.
14:34
Like today, everybody wants fixed, everybody wants it right now.
14:37
It wasn't, the case.
14:38
It was not the case then.
14:40
Some people at that time thought, my first presentation of the zygoma
14:44
at the American Association of Maxillofacial Surgeons meetings,
14:47
raise some eyebrows.
14:48
People raise some eyebrows.
14:49
who is this guy?
14:50
Yeah.
14:51
Yeah.
14:51
And I can imagine.
14:52
Yeah.
14:54
if, you, look at the tools and classification principles that are
14:58
offered today to clinicians, I think it's a totally different, I would say.
15:03
Baseline that we have, and it's much easier also to, probably start, one of
15:07
the things that we should quickly talk about is also your, classification, the
15:12
ocean classification in terms of zones.
15:15
So you develop this concept of, three and probably four zones.
15:19
That was later, added.
15:22
That says, if there is bone or if there is no bone, this is how you
15:25
should actually place implants.
15:27
is there enough bone for straight implants?
15:30
Should you tilt them, et cetera.
15:31
And also you're, very strict in terms of.
15:35
Position of implants, number of implants and splinting, which all I
15:38
think comes then together as a concept.
15:41
Can you elaborate a bit on how you came to the Petro Ocean classification zone
15:45
and how you still it, to use still today?
15:49
The, same classification?
15:50
Yes.
15:51
The way it came about was, I think most people will relate to this.
15:56
When you are in the middle of developing something, you going with the flow.
16:02
You don't see how you are systematically going through
16:06
it, if that makes sense or not.
16:08
One day, one, one, we had 6:00 AM to 8:00 AM treatment planning
16:13
sessions at the residency program.
16:15
For some reason, that day, that morning, we had some guests who were
16:19
sitting behind my residents and I And my resident was presenting and,
16:24
he was not calling it zones, but he was talking about it and the.
16:29
Guests were like, Ooh, that's a great way.
16:32
I could hear 'em saying that, but I ignored it.
16:34
By the third or fourth time, they said, Ooh, that's a nice way.
16:37
I turned around and said, what's a nice way?
16:39
They said, do you have a very systematic way of looking at these patients?
16:45
I said, really?
16:46
And anyway, so when they, it's not
16:47
everyone doing it like
16:48
this.
16:48
Yeah.
16:48
And then when they left, I, when the, it finished that rest of that
16:53
day, I looked and I said, oh my God, there is a systematic way.
16:57
So to be able to communicate it, we came up with the zones, and then the, FP one,
17:04
FP three, we came to a transition line.
17:06
All of those things now that was in our head that we were
17:09
just automatically doing it.
17:11
We.
17:12
Line item that, so it became a protocol.
17:15
And again, it doesn't change.
17:18
fundamentals don't change.
17:20
it's anatomy.
17:21
It's, it is anatomy.
17:22
It's the same thing.
17:23
So it's the same.
17:23
It's a true as it is true today.
17:26
Whether you're using digital or analog treatment planning, using
17:28
the same fundamental principles
17:32
maybe to follow up and also, link to the digitization.
17:37
Your concept was based on panoramic radiographs, and now a lot of people
17:42
have the possibility to access a conium C three-dimensional data.
17:45
Can it be easily, translated?
17:48
Yeah.
17:50
everything has its own place.
17:51
The zones, excuse me, is for looking at it.
17:56
So you have a max, a atrophic.
17:58
Maxilla.
17:59
The first step is to look at a two dimensional ex radiograph.
18:03
Depending on the zones, you decide whether it's tilted concept or it's
18:07
zygoma, or it's axial implants.
18:09
So that's your initial.
18:12
Guess, let's say this is what I'm going to do to confirm you can do it.
18:17
You need to make sure that there's enough volume of bone.
18:20
That's where the 3D comes in.
18:23
Yeah.
18:23
Radiographs come in and then the zaa classification.
18:28
Is a very nice interpretation of the 3D anatomy, which basically tells the
18:34
ziga concept, basically shows you or makes you look at the lateral curvature
18:39
of the maxillary wall and the degree of medial resorption of the alveolis.
18:44
So if you are not very much.
18:46
resorbed or, and you are a con convex, the lateral maxillary wall.
18:50
You're a Z zero.
18:51
If you are a very hourglass maxilla with a lot of medial
18:56
resorption, you're a ZA four.
18:57
So by using the zones, is a two dimensional radiographic
19:02
interpretation, whereas the ZA is the three, three-dimensional
19:06
radiographic interpretation.
19:08
So it allows you to know, because without the.
19:12
Remember when I was doing zygomas comb beams and cts were not that
19:15
available, so we were going off of two dimensional radiographs and then
19:20
intraop anatomy and surgical knowledge.
19:25
So whether the middle of the Zygoma implant was inside the
19:28
sinus or outside the sinus, you recognize that during surgery?
19:33
with the three Ds now being readily available, knowing that the zaa concept
19:39
of, looking at the radiograph is a way of evaluating, you can preoperatively.
19:45
Already know whether you're going to be in the sinus, out the sinus or not.
19:49
So it's just a much, the digital, workflow allows you to see things and maybe
19:57
practice the surgery in your mind on the monitor before you actually get to it.
20:02
so beyond this classification, which became pretty much just the standard way
20:06
of looking at these cases and selecting.
20:09
The basic implant concept.
20:11
What is your guiding concept today when you are placing zygomatic implants, when
20:16
you approach your own cases, or to phrase it differently, what is the concept
20:21
you are teaching learning clinicians that, that you do very often at?
20:25
Yeah.
20:26
my entire basis of, thinking is based on biomechanics.
20:32
No matter what you do, it's very nice to, physically do it.
20:38
This is not a static situation.
20:41
There's occlusal forces that are being placed on whatever it
20:45
is that you're reconstructing.
20:46
So for example, on the Zygoma implant, all the literature and the systematic
20:53
reviews and all the, protocols that have clearly demonstrated this to be a
20:59
very predictable procedure is based on what I call quad cortical stabilization,
21:05
stabilizing the zygoma alveolar ridge.
21:08
And at the Zygoma and all the literature, like from Frank Renoir shows that
21:13
it's the first six millimeters of any implant, whether it's tilted, zygoma,
21:17
axial, that takes all the forces.
21:20
So the engagement of the implant at the maxillary alveolar ridge is critical.
21:26
So once you know that, now you adapt the.
21:31
Patient to you.
21:33
Try to get your pa, give the best biomechanical surgical
21:38
procedure To your patient.
21:40
And if the patient is totally resorbed and you cannot engage the
21:44
alveolar bone, then you know you have a biomechanical limitation and you
21:49
just advise the patient, for example.
21:52
Please don't bite an apple rest of your life.
21:55
Not because, the misconception is you can reconstruct severe
22:00
atrophic maxus and have that patient function as if they were normal,
22:06
fully functional.
22:06
Yeah, that's not
22:08
the
22:08
case.
22:08
It's very similar to somebody who is an amputee.
22:12
their amputee from their hip down.
22:15
They have an artificial leg.
22:16
you cannot, I'm sure there are Olympic, athletes that have an
22:21
amputation, but that's not the norm.
22:23
That's very exceptional.
22:25
So you have to, it's our job as clinicians to educate our patients On the existence
22:32
of their anatomical defect and the limitations of their reconstruction.
22:39
So, what, are the then some of the.
22:42
Design principles from a prosthodontic perspective.
22:45
Yeah.
22:46
What is it that you're teaching there?
22:49
simplifying, when you have command of a subject, you can explain
22:53
it in a very simplified way.
22:55
Everybody talks about loading, what does loading mean?
22:58
It's
22:59
centric occlusion and lateral excursion.
23:04
Whether you have four implants in an arch or 16 implants in an
23:07
arch, it's the first and the last implant that take all the loads.
23:13
If you have a cantilever, you double the load.
23:16
On the first and the last.
23:17
So it doesn't matter if you have 16 implants.
23:19
You doubling the load on the terminal implants.
23:22
So you try to maximize your anterior posterior distribution.
23:27
For the purposes of eliminating cantilevers for no other reason, but that
23:32
exactly.
23:32
And then, so once you've understand those prosthetic, loads, load
23:37
distributions, then you can modify the number of implants and distribution
23:42
of implants to meet that criteria
23:45
On that topic, I wonder, how is the collaboration with your son
23:49
almond, changing the, game for you?
23:53
What is it that you learn?
23:54
From him because he's a trained prosthodontist, right?
23:57
Has a bit of different focus and a bit of different background and,
24:01
what are the topics that he would come to you and, ask you for?
24:05
For advice.
24:07
Yeah, all father son relationships, he has a lot to teach me.
24:13
No, he is, he spent a lot of time with me, since high school
24:19
on vacations and everything.
24:20
So he's seen all on forest and Zy Gouss evolve.
24:24
as my assistant, he would spend a lot of time, so he is understood these concepts.
24:29
He saw the analog conversion and then, when he went to prosthodontics, he
24:34
went in there with a lot of knowledge.
24:36
And then obviously the, program he went to, university of Washington is one
24:41
of the best in the country and they teach him the basics extremely well,
24:45
and he has a very critical mindset.
24:49
And very, he jokes around saying, you used to get mad at me for
24:56
playing with the video games.
24:59
See how now it pays off?
25:01
Oh,
25:01
this is what
25:02
we also hear.
25:03
Yeah,
25:04
exactly.
25:04
We hear this all the time.
25:05
Yeah.
25:06
So, he is exceptionally quick and understands and can figure
25:11
his way out on ocad, on coag, agnostics, whatever the program is.
25:18
I'm very happy to have him do those things for me.
25:20
He's not very happy to have me ask him to print my models for me and
25:24
do, but no, it's, a give and take.
25:27
It's a lot of fun, a lot of fun working together.
25:29
And the best part, because we again, are of the same mindset and, it's,
25:34
I say a, he knows I'm saying apple.
25:37
I say B, he knows I'm saying whatever.
25:39
So we do things without.
25:41
Too much of a problem.
25:43
Yeah.
25:43
Not only this in practice, but you're also teaching to get on lecturing to
25:46
Yes.
25:46
Yes.
25:47
That's incredibly.
25:48
Last week we were at the American Academy of Fixed Prosthodontics and we presented,
25:53
zygoma implants from the patient treatment perspective, but he presented the RevX
25:59
and the exact, and the photogrammetry, the three different ways of making the
26:04
final prosthesis and the audience seeing.
26:09
We did a smile in the box.
26:10
We did a, a axial implant.
26:12
We did a zygoma, different three patients, and for the, audience to see
26:18
the clinicians, to see the different surgical approaches, different patients.
26:21
And then the three different ways of doing the digital final prosthetics.
26:27
just shows that hey, you can actually seamlessly work with a colleague and
26:31
everything just makes sense from A to Z.
26:35
and hopefully they can.
26:37
Form teams like ours,
26:40
And you're also publishing together.
26:41
There's a book that you published together, the immediacy and concept
26:44
also together with Larry Preft.
26:47
That I think you for many years collaborate very closely with.
26:50
Yes.
26:51
what's special about this book, immediacy concept, because it was published in
26:54
2022, and I know you embarked on this field of immediacy very early on.
26:59
Yeah.
26:59
So what's special about this book?
27:02
again, people who know me, they know that I. I, I'm very
27:09
honest about why I do what I do.
27:12
the BLX implant is by far the best designed implant right now, especially
27:18
with initial stabilization, with the, loads that are being placed on a non osse
27:23
gated implant with immediate loading.
27:25
So what we did in that book is, made sure that all the science of bone physiology.
27:33
contact osteogenesis distance, osteogenesis the surface.
27:37
like the sl, why is SL active?
27:39
The best surface?
27:40
Not the best surface, because somebody just says so.
27:42
You have to scientifically show that it is and contrast it to the next one.
27:47
That is not.
27:49
so we have all of that information in the book.
27:51
We have all the information about the protocols for
27:55
example, aesthetic evaluation.
27:57
What are the criteria to have an aesthetic anterior implant, simplified,
28:03
like placed, we talked about different implants when you would do the zones.
28:08
And we tilted versus zygoma and then.
28:12
this, the, once you de, once you have, described the hardware and the
28:18
science behind it, the rest of the book starts not putting it together.
28:22
So this is how you treatment plan from a prosthetic point of view.
28:25
This is how you do their chapters on how you do the surgery.
28:28
And then there's chapters on how you do the corrected cast
28:31
and the final prosthesis.
28:34
So that book is, really the bible of immediacy.
28:39
Not because we wrote it, but all the.
28:43
I asked very many of my colleagues who are really the leading people
28:47
in the field to contribute chapters.
28:51
Larry Armand, PAOs, Costas, hr, a lot of people, Danny Boozer,
28:58
a lot of people have chapters in there talking about the T-L-X-B-L-X
29:03
and giving all the information.
29:04
So it's basically a consolidation of all the scientific literature that's there.
29:11
Written in a very clinically applicable, language so you can read
29:16
it and know why you're using it.
29:19
So a book, very worth reading.
29:23
what do you think is, the, importance of mindset if, you approach immediacy?
29:28
Yeah.
29:30
The mindset is treating your patient well.
29:35
If your mindset is taking care of your patient, then I think automatically
29:40
you start looking for predictable.
29:43
You start discriminating the literature.
29:45
You don't do things just because it's sexy and it's what
29:49
everybody is talking about you.
29:51
You ask the why question, and once you understand the protocols.
29:58
then you learning how to do it for most people, I think is easy.
30:03
The hardest part is knowing what to do.
30:07
And, once you understand all those, your mindset becomes, I think, wholesome
30:13
and your, outcome becomes predictable.
30:16
But if you're doing things hoping that it will work.
30:21
yeah, that's the wrong mindset.
30:23
Yeah.
30:23
Because the answers are there.
30:26
going a little bit back into our early conversation.
30:28
Earlier you said what have I seen evolved in my career?
30:33
The first, it's, funny because it's three phases and I've
30:37
been doing it for 30 years.
30:39
It's three decades, but it just matches perfectly.
30:42
So I was the, when I graduated, it was the error of.
30:46
Hoping that the piece of metal would stick to bone.
30:51
Hoping, yeah.
30:52
So if the implant was solid, it didn't matter what angle it was in.
30:57
So it was all surgical based.
31:00
Then we realized, oops, it does create some prosthetic issues.
31:05
So the second decade in the two thousands, it was the era of.
31:12
Understanding biomechanical forces on the implants, understanding, how to place the
31:17
implant so it could be actually restored.
31:20
And I think the term prosthetically driven was.
31:23
Evolve at that time.
31:25
it's a very old term now.
31:27
everything is prosthetically driven, but at that time it had a significant meaning.
31:32
It meant don't put the implant cocke because that's not the right way to do it.
31:36
So it was that, and then the next decade became the, the.
31:43
Very generous, hopeful, soft tissue management things, which kind of faded
31:49
away because we figured out that you can only do so much with soft tissue.
31:54
So what basically happened over the last three decades is we understood
31:58
bone, we understood prosthetic forces, we understood what was
32:03
what overloaded the implant.
32:05
So the implant number, distribution, angulation, all that was, was, perfected.
32:11
So today we really have a complete understanding of, implant reconstruction.
32:18
And it's not everybody looks at it as if it's just the surgery.
32:24
If I can relate it to building a building.
32:27
The architect's drawing is critical to the foundation's
32:31
men's design of the foundation.
32:35
The foundation and the architectural drawing and the supports and
32:38
all that go together and how it resists wind and whatever.
32:42
So it's the same in the mouth.
32:43
The prosthetic, fundamentals, the surgical fundamentals have to match and you have
32:49
to make sure that they amalgamate together and then your outcome is predictable.
32:53
It's not.
32:54
By accident
32:55
maybe to close this chapter on, then we move on to digital Which
32:59
you also covered in your book.
33:01
Sure.
33:02
how do you explain the, question that we get very often from people that feel
33:08
still today, immediacy, psychometrics, and all of those treatments are aggressive
33:16
and, risky after all those years.
33:18
And the evidence we have, how do you explain this?
33:23
I understand it, and I, don't that's what they said about implant placement.
33:27
In the first case, when I was placing delayed implants in the
33:32
molars, not immediate, even delayed, the other university in my town,
33:39
was like, what are you doing?
33:40
Putting implants in a molar?
33:43
You're crazy.
33:45
that's on single implants healed sites.
33:47
Which today is, the gold standard for somebody who's beginning to do implants.
33:52
That's the most predictable, easy things to do.
33:55
So I understand, fear and anxiety comes from lack of knowledge, and once you have
34:02
the knowledge and you understand how it works, the fear and anxiety goes away.
34:09
Being s it is respectable.
34:11
I, respect people who are being, cautious.
34:16
But, yeah, so it's just understand it.
34:20
The literature is there.
34:21
If you have, a question, ask the question and we'll give you the answer.
34:25
it's not like before where we were not sure what we were doing.
34:29
We were, we knew always what we were doing, but we couldn't back it up.
34:32
Now with the data, is available.
34:35
The immediate immediacy is over 20 years old.
34:38
25 years, maybe even.
34:40
It's not a new concept, but more and more people are being introduced to it and
34:45
more younger people are coming and I would like to see universities teaching it more.
34:51
Then the young people coming out will not be so surprised and so scared
34:55
'cause they would already known it.
34:57
So if we can.
34:59
Emphasize it in schools curriculums And have the faculty know about it,
35:03
therefore teach it, then that anxiety level of the new graduate will be less,
35:09
and hopefully they will accept it.
35:11
But it's definitely a, it's not an experimental procedure, which a healed
35:15
implant was considered 30 years ago.
35:18
No.
35:18
Yeah.
35:19
case selection is still important, but,
35:21
yes.
35:23
you could, do, you could know all the right.
35:26
Rules and apply it incorrectly, then you will.
35:29
Yeah.
35:30
So case selection.
35:31
Basically treatment planning.
35:34
If you were to ask me what are the phases of treating a human being
35:37
with implants is treatment planning, surgical, prosthetic, it starts with
35:44
treatment planning, but everybody starts with either surgical or prosthetic.
35:49
it is backwards.
35:49
No, it's all with the treatment plant.
35:51
If you treatment plant it, you basically case selected it.
35:55
You knowing the treatment planning process, this is not appropriate for
35:59
this patient, therefore you eliminate it.
36:01
And that's called case selection.
36:03
So it's all about treatment planning, but the genes of a dentist is
36:11
wanna do something, It's exit.
36:13
Yeah.
36:14
it's, we are very mechanical, we wanna do things.
36:17
But if you do it with the knowledge, then it's predictable.
36:21
You're talking about the architect basically first.
36:23
First on paper.
36:24
Let's plan it before you build the fundamental.
36:26
Yeah.
36:26
Yeah.
36:27
So let's switch gears a bit and talk about digital and also the, future of dentistry.
36:32
And we already touched upon it a little bit, but how has digital planning
36:36
actually changed the way how you approach these complex maxillary cases?
36:42
Yeah.
36:42
And are there some tools that really.
36:46
In your review changed the outcome to the positive, and are there
36:49
other digital tools that actually is maybe creating overconfidence?
36:56
The over I address the overconfidence part first.
37:00
no digital tool substitutes your analog brain.
37:05
The digital tool is as good as the person using it.
37:09
Like a computer as good as the person inputting the information.
37:12
So that's the bad part where you, may get this, false confidence, thinking that
37:19
the machine's gonna think for you, but.
37:22
If you are a true believer of fundamental concepts, and you know
37:27
it, digital Sur digital, tools are fantastic in maxillofacial surgery.
37:34
When we do LeFort one osteotomies, the way we used to do it is we would get stone
37:38
models mounted on the articulator, cut the model, the stone model section, it.
37:45
Then with sticky wax, move it to where it's supposed to be.
37:48
Sticky wax it.
37:49
And that was called model surgery.
37:52
You said, I'm gonna expand the maxxi of five millimeters,
37:55
I'm gonna bring it forward.
37:56
So you cut it, cut the model, you expanded it, you added wax, and
37:59
you said, yeah, that's a good idea.
38:01
Or I should expand one more millimeter.
38:04
today you don't have to do model surgery.
38:07
You can actually print the patient's skull, you can do the zygoma
38:11
surgery or the model surgery.
38:15
As many times as you want.
38:16
You wanna, I was gonna do it this way.
38:18
Oh no, I, wanna move the platform further back and get a bigger AP distribution.
38:23
You can do it on the same model or you can very easily print another model and do it.
38:27
So it allows you to do the surgery as many times as you want.
38:31
So when you go to do the surgery on the patient, there's no surprises
38:36
and maybe you've even made a better decision than you initially thought.
38:41
So it, just.
38:43
Makes the, it just makes you a better clinician.
38:46
Are you using today, with, your hands, and I would say experience
38:51
also these type of technologies to prepare yourself for surgery?
38:55
Or is it something that, at one point you don't need it anymore
38:59
because you have so much experience?
39:02
I, always did these cases without it, so I have the experience, I don't need it.
39:06
But, the fact that I can have a son who can print it for me
39:12
makes it attractive,
39:12
made it make, makes it quite attractive to have it.
39:15
Yeah.
39:15
And I think it would be false to say even the day you think you are that good.
39:24
Is the day you're gonna make the mistake.
39:27
During the surgery, the you are done.
39:30
When the last suture goes in from the beginning to the last suture, even the
39:34
best experienced person can make the most.
39:37
Worst complication.
39:39
If you're not going into surgery with some kind of anxiety, knowing that you can mess
39:45
this up, I think it's a wrong mindset.
39:48
You have to go there saying anything can happen.
39:51
So you are cons, you're concentrating, you are not thinking of other
39:55
things, you're not joking, you're doing everything perfectly,
39:59
knowing that you can mess it up.
40:00
So if you have the opportunity.
40:03
Even as, a experience I have right now on, on very difficult cases, quad zygoma
40:08
cases or such, I will print the model and I would basically confirm what I
40:14
was going to do was the right thing or tell myself, ah, maybe I could move
40:18
this, or maybe I, so no, it's, a one.
40:21
No, you cannot be arrogant.
40:23
having a model surgery is definitely going to add to your, To your, but I have one
40:30
thing, just for fun to tell your audience.
40:34
Don't make the mistake I made, I had one week, three cases, I printed
40:39
three models for efficiency sake.
40:42
I had the camera because I take pictures of it to use for my lectures.
40:46
I set up the cameras, I took.
40:49
Pictures of all three cases and I did not write down the nuances.
40:54
Which one?
40:54
No, the nuances of each one.
40:57
The next day when the first surgery came, I couldn't remember what was the nuance on
41:01
this one because yeah, so even if you have three cases back to back, do separate the
41:06
model surgery on one proper finish that.
41:09
Then do the map because then what you did stays fresh in your mind, right?
41:14
Yeah.
41:14
You can sometimes be overly efficient.
41:16
And
41:18
so, linking also, the digital planning to the patient, what's
41:21
your thought on guided surgery?
41:24
guides for, regular implants, but also guides for matic implants.
41:29
Yeah.
41:30
there was, there is a, guided, truly guided zygoma.
41:36
Truly guided, means.
41:38
The drills are guided, the implants are guided, everything is guided that exists.
41:43
myself and two other colleagues in 2007 to 2011 actually did an FDA.
41:52
challenge on that, where in my first book, before the immediacy, I have
41:57
step by step of that instrument.
41:59
But for some reason that instrumentation was shelved because it was.
42:06
Too early.
42:07
We did it in, 2000 and most people were not even thinking zygoma.
42:12
But it does exist.
42:13
It doesn't exist today.
42:15
The guidance that are being done right now are basically the initial drill template.
42:21
The rest of it is all freehand.
42:23
So it would be very nice to have a true guided 'cause I've done it.
42:26
It works.
42:27
It's very nice.
42:29
but in single implants and in, pro arch and such guided surgery is very nice.
42:36
it, it's, really an advanced procedure.
42:39
It's not for the, whereas people think it's for the
42:42
beginner, for you to do guided.
42:44
What it robs you from is the tactile ation and the actual, you're not seeing things.
42:50
Even with, Navigation.
42:54
Even with, robotics, you are not engaged.
42:57
You are hoping that this thing, so it does away, take away
43:00
some of the tactile sensation.
43:02
But my message would be, if you're doing guided, you must be able to.
43:08
Do
43:09
analog if the guide drops, if the guide breaks, if something doesn't work.
43:15
If you can't do that, then you yourself are in a, in, a bind.
43:21
And I would never tell, teach somebody to do guided and, knowing that
43:27
they don't know how to do analog.
43:29
So it's, again, it's a, it's like a computer versus a pen.
43:34
It's a very elegant way to do something.
43:38
But it has its drawbacks.
43:40
Guided is not as accurate as we think.
43:42
If it was, then why aren't the abutments prefabricated into the prosthesis?
43:48
Because the.
43:49
Deviation X, Y, Z is picked up in the direct, picking
43:53
up the puppets in the mouth.
43:55
So as long as you know that, then you make fair statements.
43:59
Guided surgery is a very elegant way to do it.
44:01
If you choose to do it fine, but to say it's the best way, it's the most
44:05
accurate way, it's the, it's not true.
44:09
yeah, again, we go back to fundamentals.
44:11
Know the fundamentals, and then if you want to use a guided
44:14
surgery, it's absolutely fine.
44:16
It's very nice.
44:19
Ed, you're also in a lot of editorial boards and you have
44:22
seen, knowledge expanding, but also maybe change in certain ways.
44:27
What is one trend that you're quite excited about and maybe what is one
44:31
trend where you think it's overrated?
44:36
again, like, I said, the wording of articles, like in for guided
44:44
surgery where oh, it's the best, is the, this, it's the most accurate.
44:48
Those are not fair statements because I try not to make absolute statements
44:53
because an absolute statement means if you're not doing what I'm saying,
44:58
then you're doing something wrong.
45:00
I would not wanna put somebody else in that position.
45:02
I like doing analog surgery because that's what I've done.
45:05
It's faster.
45:06
I can do it faster, I can do it, whatever.
45:09
But that's me.
45:10
You wanna do it?
45:10
Guided.
45:11
That's fine.
45:12
Four implants, biomechanically is enough.
45:16
You wanna put six in?
45:18
Okay.
45:19
You wanna put 10 in?
45:20
Now I look at you and say why, but I don't say it's wrong.
45:25
But to say four is inadequate.
45:28
That's the trend that, I don't, I, wish that this, that in the
45:33
literature we continue presenting.
45:37
True information, not getting too excited and saying six implants or
45:42
doing this, So as long as the literature stays honest, and then as we get more
45:47
complicated digital, as the treatment of the fully Denist patient or the severely
45:53
resort patient with the zygoma becomes more popular, more and more people are
45:57
writing articles and making statements.
46:02
The reviewers, if the, wrong reviewer looks at an article and maybe doesn't
46:07
understand it and okays it sometimes and it has happened, things get in
46:11
the literature that shouldn't be.
46:14
So I'm a little worried about advanced surgery being reviewed
46:17
by non advanced reviewers.
46:19
That might be, would be my worry.
46:21
But at the same time, I'm happy because advanced surgery is getting exposure.
46:26
and the reason why I'm happy is because.
46:30
As more clinicians know that Quad Zygoma, for example, is available then if they
46:36
don't know how to do it or they don't wanna do it, they know how to refer it.
46:40
As opposed to not even knowing that's a possibility.
46:42
That's a Yeah.
46:45
Good.
46:46
Yeah, that's, an interesting topic on, how to deal with peer
46:49
reviewed, journals, et cetera.
46:50
Now also that AI is coming in, and it's quite easy to write the text.
46:56
That sounds very convincing, but then, you need to have someone that
46:59
checks the fundamentals very properly.
47:01
Yes.
47:02
to look a little bit more into the future at, so maybe five, 10 years from now, and
47:06
we touch upon, your father-son relations.
47:09
So basically he's already the next generation.
47:11
Yes.
47:13
What would you foresee for the severely atrophied maxilla
47:17
in the next five to 10 years?
47:19
And maybe what would you hope that your son or the generation of your son
47:23
would do differently than we do today?
47:27
Yeah, I, thought about it because, innovation has to go on and, there's
47:32
gotta be a better way of doing something.
47:34
But sometimes my short answer to your question is not much.
47:43
Else, but it doesn't mean stop looking for doing it better.
47:49
What, we are doing right now with, the surgical reconstruction of the
47:53
severely atrophic cases that could not be done before what we're doing
47:57
with the prosthetic rehabilitation, that makes it very aesthetic,
48:00
very functional, is amazing.
48:02
The zirconia, the color, the, all the products and all their
48:06
innovations are very nice.
48:08
what we are doing with this severely atrophic maxilla is giving them teeth.
48:12
Is, I know it's not heart surgery, but it's quite life-changing it.
48:18
It really affects the psychology of the patients.
48:20
It's wonderful with very minimal long-term issues and the
48:25
complications that we're having.
48:28
Screw loosening.
48:29
The zirconia fracturing.
48:30
And if you really look at the why it's misfit.
48:35
It's overloading.
48:37
It's some of the missing of the fundamentals.
48:40
So what can we do in the future?
48:44
Go back to the beginning.
48:45
Reemphasize fundamentals.
48:48
And you can make the stronger zy as zirconia, but if there's a misfit,
48:53
even the strong zirconia will factor.
48:54
It's still the misfit.
48:55
Misfit.
48:55
Yeah.
48:57
I'm not sure, can we put tooth buds and genetically grow teeth and maybe, yeah.
49:04
But yeah.
49:05
But I think we should look at innovation.
49:07
But today, right now, what I see is, continue on the.
49:11
Industry support on modifying instruments and, whatever it is
49:17
that we need to be able to match the science that we know works.
49:22
And having, again, industry facilitate, meetings where the clinicians can
49:29
come together and spread the news, because it's very difficult to get.
49:34
700, 1000, 2000 people in one room and have a symposium Without industry support.
49:40
So yeah, continuing that is, and then as one genius comes up with a
49:46
new thing that I'm not even thinking of, I'm very happy to entertain it.
49:50
Yeah, that's good.
49:51
So that's a good pitch actually, to.
49:55
Our last chapter, we wanted to speak about you as a speaker,
49:59
as an educator, and as a mentor.
50:01
And I understood from the beginning that you've been
50:04
actually an educator from day one.
50:07
Day one.
50:07
So you had four days in the
50:08
Yeah.
50:08
In practice, one day teaching.
50:12
I would like to start with the following question.
50:14
what is for you the difference between a good surgeon and a great surgeon in
50:20
this, in the field that we spoke about?
50:23
A good surgeon and a great surgeon.
50:28
I think, a great surgeon, just like a educated man.
50:36
An educated man knows how much he doesn't know.
50:40
If you, once you think you know everything, that's the
50:43
beginning of you going down.
50:46
So a great surgeon.
50:48
Thanks God that he.
50:51
Was successful in doing the surgery because everything, any, every,
50:56
at any moment things can go wrong.
50:59
a great surgeon, just like a good surgeon, hopefully follows
51:04
fundamental principles, treatment planning, and does everything right.
51:08
and just recognizing that, you can make a mistake and knowing how not
51:14
to make it and being aware of that.
51:16
And just being humble and that's what makes the great surgeon, knowing
51:20
that there's still room to learn and getting into arguments, which I'm
51:24
very good at doing is not a bad thing.
51:28
Yeah.
51:29
And I debate because I can learn a lot.
51:32
From you and you can possibly learn from me.
51:34
So debates are good.
51:37
as long as you have a goal, the horizon is to come up with a
51:42
Good solution.
51:44
So, what is the, ideal way, if I would be a young clinician and, I want to embark on
51:50
a journey that you and Armand on and say, look, I would really like to master this.
51:54
Complex, reconstructions and doing life changing things to patient,
51:58
especially in the atrophic maxilla.
52:01
What for you is the, best path for me to get there?
52:05
Yeah.
52:06
it has to be in you.
52:07
part of the previous question was a great surgeon.
52:11
You have to have passion.
52:13
you have to have passion to do the right thing.
52:16
It has to.
52:17
It cannot be money.
52:19
It cannot be, oh, look at me, I can do zago.
52:22
It cannot be all of those ego things.
52:24
You have to have the passion to do the right thing.
52:27
You have to get satisfaction after, having helped somebody,
52:32
even if they didn't thank you.
52:34
You have to know that, wow, this is a great service.
52:37
Imagine if that was me, or imagine if my mother needed that procedure.
52:42
So if you have the passion, and you just, Your time will come
52:49
if you want to be a educator.
52:51
If you want to be a speaker, if you want to be a, role model for others
52:55
to follow, then you know nobody went from zero to a hundred in one second.
53:01
it takes time, and time is again educating yourself.
53:06
Knowing what you're doing, practicing getting the experience and just everybody
53:10
just like me, have what I'm doing.
53:12
I'm basically paying it forward.
53:14
I learned from somebody.
53:16
And now I'm basically, I'm not teaching anybody what I know.
53:20
I'm teaching everybody what somebody taught me.
53:23
And if you can keep that open mind and be humble and passionate,
53:28
I think everything will just.
53:31
Come into.
53:31
Yeah, come into play.
53:33
What I find very impressive in the field that we speak about that is that
53:36
I still see very experienced surgeons and clinicians that are still going to
53:42
courses and conferences all the time.
53:44
They never stop learning.
53:46
That's very impressive because at one point you could say, look,
53:49
you have seen it, you have learned it, and you know how it works.
53:52
Yeah.
53:53
But, my impression is that these people, the, greatest surgeons,
53:57
that they always continue learning.
53:58
Yeah.
53:58
Because, like I, I talk to, a lot of my colleagues who say, why should I go?
54:06
I know, and I say to them, if you learn one thing, one thing, Out of
54:12
that four hour thing, it was worth it.
54:15
It
54:15
worth, it
54:15
doesn't, and it could be the simplest thing.
54:19
It could be the way your front desk greeted the patient before
54:22
the surgery because they were so anxious, et cetera, et cetera.
54:25
That kindness, that protocol that you have on greeting patients brings the
54:29
blood pressure down during the surgery.
54:31
Everything is fine.
54:32
There's always something to learn.
54:34
It's impossible.
54:36
Ah, there's always also something to learn not to do.
54:40
Yeah.
54:40
Yeah.
54:41
So you see this thing, you go, oh my God, thank God I'm not doing it.
54:45
But if you go in and you learn 15 things, you might wanna go home and
54:50
question, what is it that I'm doing?
54:52
Am I the right conference
54:54
or am I doing the right thing?
54:57
Exactly.
54:57
Do I have the right, patience in my, yeah.
55:00
Yeah.
55:00
Yeah.
55:00
So thanks a lot that, that already brings us to the end.
55:03
And, as usual, I would like to ask my colleague, George, what,
55:07
what stood out for you in this, 50 minutes of exciting conversation?
55:11
A lot actually, Ed, so I, have a mental picture basically of your journey
55:17
that, maybe might be, accurate or not, but, I, think it's, for me, it's a
55:22
good summary of the conversation that we had to, had, the chance to have.
55:25
So I think for you, it started always with.
55:29
First of all, you were very clear that you wanted to become
55:31
an OF surgeon from the get go.
55:33
And I believe also this, mindset, having the right mindset was very important.
55:38
And, we dis discussed about the importance of putting the patient first.
55:42
And the second thing that we just discussed is about the passion,
55:46
Passion for doing the things right.
55:48
and I think this then also led to a lot of systematic thinking that,
55:53
you look into literature, you try to analyze and distill the essence
55:57
you're good at also creating then some recipes that other can profit from.
56:02
And that actually, we, talked a lot about this, fundamentals that are there.
56:07
But at the flip side, you also need to have this.
56:11
Openness to constant, constantly also questioning, let's say these
56:14
fundamentals and learn new things.
56:16
And that brings me to the, to this last point, which, I think
56:19
you're very passionate about.
56:21
And, I didn't know, but very fascinating.
56:23
So from the get go, you started educating and you dedicated a day per week,
56:28
which is a lot to actually bringing what you learned to other people.
56:31
Yeah.
56:32
And this combination, I think of critical thinking, having the
56:35
mental capacity to break down.
56:39
Complex topics into something that people can take away.
56:42
I think that was, for me, a, great highlight of the conversation.
56:46
Very well summarized.
56:47
Thanks a lot.
56:48
No, thank you.
56:48
And I just, I want the audience to also know that although this is a, Straumann
56:53
podcast, working with the right team, including commercial is very important.
57:02
I use the Straumann products or I use the protocols, or I
57:07
help develop the protocols.
57:09
You can have the right protocols, but if you don't have the right tools,
57:13
you don't have the right support, you don't have the right, like we
57:15
talked earlier, T&E, that allows to bring all these clinicians together.
57:21
Then we are working in little silos and being able to provide
57:25
this in the US or globally.
57:28
It's, very helpful to my profession.
57:30
So I wanna thank industry you guys for creating this podcast or
57:34
everything else that you guys do.
57:36
'cause it's very, important.
57:38
Thanks a lot for the feedback, Ed, and I think that's, close to our
57:41
heart that we support in the way that you can focus on what matters most.
57:46
And that's, treating the patients and you don't need to worry left and right
57:49
about support and this stuff working, but we, try to make this happen for you.
57:55
So thanks for joining today.
57:56
Thank you for the conversation.
57:57
It's pleasure, really loved it, loved the energy of it.
58:00
And to our listeners, if you loved the episode as much as we did, if you
58:06
learned something and it sparked some new ideas, then please recommend it to
58:09
any colleague that you might think of.
58:12
And otherwise, please continue following us on Apple Podcast, on
58:16
Spotify, on YouTube, wherever you want.
58:18
And we are always happy to have your feedback.
58:21
Please drop us a direct message or interact with us on
58:24
Straumann Instagram channel.
58:26
So thanks a lot for listening in and see and hear you next time.
58:30
Thank you, Ed.
58:30
Thank you, George.
58:31
Thank you.
58:32
Thanks.
58:32
Thank you.