Latest / Straumann® ProTalk / Clinical Edition: Inside the ZAGA clinical approach with Dr. Carlos Aparicio

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Clinical Edition: Inside the ZAGA clinical approach with Dr. Carlos Aparicio · Straumann® ProTalk

• 0:00
  Carlos: Instead of trying to adapt the patient to our technique, we should adapt
• 0:05
  the technique to the patient's anatomy.
• 0:07
  Christian: What are the most common risks and complications that you
• 0:10
  see if you stick to this very rigid one size fits all, for example.
• 0:14
  Carlos: Complications related with soft tissues, which means soft tissue
• 0:19
  recession, soft tissue infection, and the second one is related with sinus.
• 0:25
  So sinusitis, rhinosinusitis on possible oro-antral communication.
• 0:31
  What we like to teach is not how to treat those complications, but how
• 0:39
  we may prevent those complications.
• 0:45
  Christian: Welcome to Straumann ProTalk Clinical, where vision, skill, and science
• 0:49
  converge to disseminate knowledge and shape the future of implant dentistry.
• 0:54
  Today we're diving into the evolution of zygomatic implants and how each
• 0:59
  time more individual characteristics matter so much more than the
• 1:04
  rigid one size fits all approach.
• 1:08
  Today I'm joined by a true pioneer whose name is a synonymous of zygomatic
• 1:13
  implants and true passion for education.
• 1:17
  Professor Carlos Aparicio, thanks for coming to Straumann ProTalk Clinical.
• 1:21
  Carlos: Thank you, Chris.
• 1:22
  Thank you, Chris.
• 1:23
  It's really an honor to be here.
• 1:25
  Thank you.
• 1:26
  Christian: I will start by setting the foundation we often hear that zygomatic
• 1:32
  implants is often the last results.
• 1:36
  How is the role of zygomatic implants and therapy in a full large context
• 1:40
  in today's modern implantology?
• 1:46
  Carlos: Thank you for the question because I think it's a very relevant one.
• 1:50
  The placement of the zygomatic implants must follow a true indication.
• 1:56
  The indication is atrophic maxilla.
• 2:00
  This atrophic maxilla.
• 2:03
  The origin of this atrophy could be the loosening of a tooth because of
• 2:10
  infections, and also could be the failure of previous treatments like
• 2:15
  implant treatment or graft procedures.
• 2:20
  So previous, considering the placement of a zygomatic implants, we must consider
• 2:27
  the placement of a regular implant.
• 2:31
  Of course now it is very common to tilt implants.
• 2:36
  In order to find some bone where it is.
• 2:40
  So this is why we say that you may place a regular implant.
• 2:45
  Please try first, a regular implant in such a way we are
• 2:51
  keeping this tool as a last resort.
• 2:54
  That's the meaning of the last resort.
• 2:58
  Christian: And how does the ZAGA philosophy help differ from
• 3:02
  traditional implant placement in the zygomatic indication?
• 3:10
  Carlos: Allow me to tell you a short story.
• 3:12
  Christian: Please do.
• 3:14
  Carlos: I learned a zygomatic implants well, as you know, the idea of zygomatic
• 3:20
  implants comes from Professor Per-Ingvar Brånemark, but he didn't like too much to
• 3:25
  teach himself in order to really, to teach how to he delegate into Chantal Malevez,
• 3:36
  a nice and good preferred surgeon, maxillofacial surgeon, that on top of
• 3:42
  this, she does per prosthetics too.
• 3:47
  At the very beginning we learned a receipt that was an universal receiver.
• 3:53
  As you said, one size fits all, one size fits all.
• 3:58
  That's a perfect definition.
• 4:00
  So we tried to maize this receipt.
• 4:05
  So we were following during the first years following perfectly what we learn.
• 4:12
  Try not to get apart from these teachings.
• 4:16
  But we observe that we got some complications from
• 4:21
  the original receipt, and
• 4:27
  I guess that about 85% of the first surgeonss receiving
• 4:31
  this knowledge gave up.
• 4:35
  Why?
• 4:36
  Because of the original complications.
• 4:38
  They frustrated.
• 4:39
  They frustrated.
• 4:40
  Totally frustrated though they were, we were surgeons placing on the
• 4:46
  selection of the first surgeons.
• 4:48
  We were surgeons placing more than 2000 regular implants a year, so I
• 4:54
  think we can call us per surgeons.
• 4:59
  What happened is that after a while, I realized a very simple, a very
• 5:06
  simple thing, and that simple thing is that you and me, we are different.
• 5:12
  And we are different for him or for her also.
• 5:16
  So there are differences between human beings and still there are even more
• 5:23
  differences between atrophic marilla because those atrophic marilla,
• 5:28
  the original of this atrophy, as I said before, is very variable.
• 5:34
  Can come from just for the tooth loosening, but usually they come from
• 5:39
  previous treatment failures, like implant failures of reacting procedures.
• 5:43
  So at the end, there is no regular anatomy.
• 5:49
  So finally, I understood that instead of trying to adapt the technique.
• 5:55
  Sorry.
• 5:56
  Vice versa.
• 5:57
  Instead of trying to adapt the patient to our technique, we should adapt the
• 6:02
  technique to the patient's anatomy.
• 6:04
  And that was the fundamental of ZAGA.
• 6:07
  And after this, we understood that this is not only the technique of the implant.
• 6:14
  Placement is about adapting the incision, adapting the flap, adapting.
• 6:22
  The whole procedure to the patient's anatomy, even the
• 6:27
  implant itself should be adopted?
• 6:29
  No, if for regular implantology, we have like hundreds of implant designs.
• 6:40
  At that time, we just had one design for a very much complex anatomy.
• 6:46
  Can you imagine we have to go through an alveolar bone that many
• 6:50
  times there is no alveolar bone, just few remains of velar bone.
• 6:55
  Then we have to go to proceed to the maxillary wall.
• 6:59
  How many shapes has or may have?
• 7:02
  The maxillary wall even is concave, convex, thin, thick.
• 7:08
  And then finally we should anchor on the zygomatic bone.
• 7:12
  So we have to go through many different anatomies and have
• 7:16
  only one type one implant design.
• 7:18
  That was not logical.
• 7:20
  Exactly.
• 7:20
  Not logical.
• 7:21
  So this is the origin of ZAGA trying to adapt the whole
• 7:25
  procedure to the patient anatomy.
• 7:27
  Christian: I like this very much because all of us who are passionate
• 7:30
  about implant dentistry and have followed zygomatic therapies for a
• 7:34
  while, we have seen the evolution extra maxillary through the sinus outside
• 7:41
  the sinus in many configurations.
• 7:44
  And always been with a sense of too risky.
• 7:49
  But now we see how you have adapted and evolved putting the
• 7:53
  patient in the center always.
• 7:55
  Not putting the technique in the center and the patient is just
• 7:59
  something that is sitting there.
• 8:01
  And for doctors there are.
• 8:04
  Still hesitant to be very patient centric to adapt to the techniques.
• 8:09
  What are the most common risks and complications that you see
• 8:12
  if you stick to this very rigid one size fits all, for example?
• 8:19
  Carlos: Of course we divide the complications into
• 8:24
  intrasurgical complications or.
• 8:27
  Maybe early complications and late complications.
• 8:31
  I don't think it is necessary to talk too much about intrasurgical complications
• 8:36
  like orbit invasion or, because I guess that every surgeon has skills enough
• 8:42
  to escape from those complications.
• 8:45
  But the hiding complication to me is the one that is going to appear to show up.
• 8:53
  In the future, not tomorrow, not in one month, but in six months in one year.
• 9:00
  And those complications mainly are two.
• 9:05
  There is a complication related with soft tissues, which means soft tissue
• 9:11
  recession, soft tissue infection, and the second one is related with sinus.
• 9:18
  So sinusitis, rhinosinusitis on possible oraloro-antral
• 9:23
  communication communication.
• 9:25
  Those are the two late complications that we are afraid
• 9:33
  what we like to teach is not how to treat those complications, but how
• 9:41
  we may prevent those complications.
• 9:44
  Because in this patient.
• 9:47
  There's always what I call the risk balance.
• 9:51
  Whenever you like to escape from the soft tissue complication, you
• 9:55
  are inclining the balance for the rhinosinusitis and vice versa.
• 9:59
  Whenever you try to escape from rhinosinusitis , you are
• 10:03
  knocking the door for the soft tissue complication infection.
• 10:07
  So it's about knowing which resources you have to.
• 10:14
  Deal with this so much atrophic maxilla for this patient that
• 10:18
  has no bone on the maxilla.
• 10:20
  And with this implant placement that is forced to be sometimes in an aerial
• 10:27
  path and how we are going to prevent the complication of soft tissue
• 10:34
  recession or infection of the sinus.
• 10:38
  So this is the trick.
• 10:42
  Christian: And you cover now the compo, the potential complications
• 10:45
  surgically wise, and we have this patient that has been restored.
• 10:50
  What are the most common technical complications that come restoratively
• 10:54
  wise over the period of time in terms of anterior posterior spread?
• 10:58
  How do you consider this and how this affect the prosthesis afterwards?
• 11:10
  Carlos: Media
• 11:13
  make the trends of of the life and also in dentistry, they make trends.
• 11:22
  I can't say that we were the very beginning of zygomatic implants.
• 11:29
  We were told to place some, a few regular implants on the front.
• 11:33
  I either,
• 11:36
  on the pristine bone or using a gratin procedure too, plus
• 11:41
  two posterior psycho implant.
• 11:43
  This was the original teaching of pi er after a few years, we
• 11:49
  started with a quad procedure, which means that it is a quadruple
• 11:53
  placement of zygomatic implants.
• 11:56
  Two zygomatic implants on the right, two zygomatic implants on the left.
• 12:01
  The ideal spread of those implants anterior posterior spread.
• 12:05
  It's about placing the anterior implant of the position of the lateral incisor.
• 12:12
  And the posterior on the position average on the posterior, on the position of
• 12:18
  the second premolar, first molar distal.
• 12:22
  Second premolar missile first molar.
• 12:26
  This is a position we would like to have it a little bit more posterior, but
• 12:30
  usually mouth opening lower than tissue.
• 12:34
  Long instruments are going to limit this position better.
• 12:40
  The good thing is that you are able to place an implant on the
• 12:44
  position of the lateral incisor.
• 12:47
  And a second implant of the position of the second premolar, first molar.
• 12:52
  The AP distribution is enough to have a regular, at least
• 12:59
  first molar to first molar.
• 13:00
  So 12 teeth without any problem.
• 13:05
  And this is not going to give you any.
• 13:08
  Problems.
• 13:09
  And on the on, on the prosthesis, I started answering your question
• 13:15
  about the tendency of social media, because placement of two
• 13:21
  matic in implant is not easy.
• 13:23
  It requires some skills.
• 13:25
  So now it's like the tendency of either placing those two implants in
• 13:33
  a very parallel position, which is easier, but then you are creating a.
• 13:38
  Lung can deliver anterior or missial, and that can deliver posterior, so then
• 13:43
  you need some BL regular blash there and tego in implant on the posterior.
• 13:50
  So either this procedure or.
• 13:53
  Placing just one psycho implant and then you have to go for a rogate implant or an
• 14:01
  implant on the nose, which is not which has no long-term proven long-term results.
• 14:08
  So those are the tendencies today.
• 14:13
  There's a of a give and
• 14:13
  Christian: taking to both possibilities.
• 14:15
  So you don't see many prosthetic complications, no fractures
• 14:19
  or anything like that?
• 14:20
  No.
• 14:21
  Similar to any other full-arch therapy.
• 14:23
  Exactly.
• 14:23
  Technically speaking, restorations should be safe ex Exactly.
• 14:27
  Carlos: So at the end, if you are able to get a good implant,
• 14:32
  stability for sure, and a good ap anterior, posterior spread.
• 14:40
  Then the final result is gonna be very similar, especially if you
• 14:45
  follow the ZAGA philosophy of trying.
• 14:51
  You must know what is your goal when performing an
• 14:55
  osteotomy for implant placement.
• 14:57
  And the goal in this case is first to achieve maximum primary stability
• 15:03
  of an prosthetically driven implant.
• 15:06
  So we want our implant platform to be either on the crest or very
• 15:11
  close to the center of the crest.
• 15:14
  So the prosthesis, the final prosthesis is gonna be very
• 15:17
  similar to a regular rehabilitation.
• 15:20
  Christian: And just to wrap this, because we often see.
• 15:23
  Especially because of the length of the implant, right?
• 15:27
  There is a, there's a pre assumption.
• 15:29
  There will be some movement potentially.
• 15:33
  Will this affect the restorative scheme?
• 15:35
  How does that
• 15:36
  Carlos: work?
• 15:36
  That's very interesting question.
• 15:43
  The first answer we published together with Professor Thomas aum a paper that is
• 15:51
  called All Criteria in order to establish which criteria we should use to determine.
• 15:58
  The success of failure of a zygomatic implant.
• 16:02
  One of those or criteria is the, or is the acronym moon of
• 16:08
  offset renal cities infection
• 16:15
  renal cell status and stability.
• 16:18
  So stability one matic implant.
• 16:21
  As you say, you can find a little movement.
• 16:24
  Sometimes, not always, but sometimes, and this little
• 16:28
  movement may arise from either
• 16:35
  the destruction of the total destruction of the alveolar bone.
• 16:39
  So meaning that the implant is the implant.
• 16:42
  I call it occipital part.
• 16:44
  This part of the implant is not supported either by alveolar bone or.
• 16:50
  Palatal bone.
• 16:51
  So the implant has only the anchorage.
• 16:54
  Okay, on the Zygoma.
• 16:55
  And so the implant is like this.
• 16:58
  They are in my zygoma.
• 16:59
  And then because there is no support here, yep, you can bend it, there's an arm.
• 17:03
  So you're creating a very long arm.
• 17:07
  So the now you can get some little movement.
• 17:10
  So the principle for the cyma is, please don't destroy the LAR bone.
• 17:15
  Be conservative, which is what we call ZAGA, minimally invasive osteotomy.
• 17:21
  So you have to place the implant platform, the implant posterior part
• 17:28
  of the platform, supported edit by a bone or by palatal bone in the case.
• 17:37
  But say that
• 17:40
  we are totally against of those philosophies that say.
• 17:45
  Yeah, your first axion should be destroy the LAR bone I see.
• 17:50
  And then get Anchorage up there wherever you can anchor.
• 17:53
  This is if the problem of this patient is maxillary atrophy, why should I increase
• 18:00
  the problem of the patient by destroying?
• 18:04
  And necessarily destroy more.
• 18:07
  And this applies also to this window osteotomy that we, I was talked to
• 18:15
  perform this window osteomy, but we must understand that when Professor Broer
• 18:22
  had the brilliant idea of this treat.
• 18:25
  At that time, he had no ERs diagnostic.
• 18:28
  So the, they have no CVCT, they have ct, but with a very very humble.
• 18:40
  So managing the ct, they have no 3D models.
• 18:44
  So the tools they had.
• 18:47
  For diagnosis.
• 18:48
  They were very limited.
• 18:50
  So he said, okay, let's stay on the same side.
• 18:53
  Let's make a hole first in order to see my dream.
• 18:57
  But today this is an emotional osteotomy.
• 18:59
  Yeah, emotional.
• 19:00
  We don't need to destroy bone.
• 19:03
  And the same saying with locked technique, they make an slot previous to the
• 19:08
  so and slot osteomy previous to the osteotomy necessary to place the implant.
• 19:14
  So why?
• 19:15
  Two osteotomies for one implant placement.
• 19:18
  There is no sense.
• 19:19
  Imagine we are placing a regular implant.
• 19:22
  What is our goal?
• 19:24
  Our goal is to under prepare.
• 19:26
  Yeah, in order to achieve maximum primary stability.
• 19:29
  So what is the meaning of destroying bone, especially in a patient
• 19:33
  suffering for axillary atrophy?
• 19:35
  There is no meaning.
• 19:36
  Christian: Yeah,
• 19:37
  Carlos: no meaning.
• 19:40
  Christian: Thanks for clarifying.
• 19:41
  So in your point of view now, giving a recap primarily we should aim of course
• 19:47
  for the anchorage, but to have the coronal part of deep, supported this
• 19:52
  will potentially minimize any arm force stabilizing the prosthesis minimizing
• 19:58
  technical complications over the time.
• 20:00
  Exactly.
• 20:01
  Exactly.
• 20:01
  Did I get that right?
• 20:02
  Carlos: That's the full idea.
• 20:04
  We are.
• 20:05
  Now we have a new paper that will hopefully will appear in soon.
• 20:12
  Let's call soon.
• 20:13
  It's in the process of review, but it's accepted where we are demonstrating
• 20:19
  how is a fin element analysis study.
• 20:25
  And we are, we are working with two models
• 20:33
  one representing what we call the ZAGA three situation, which
• 20:37
  is about the 20% of the cases.
• 20:40
  And the second model represents a ZAGA four situation, so maximum atrophy, which
• 20:46
  represents about 60% of the population.
• 20:49
  So this is about, altogether they represent 80% of the atrophy Marcilla.
• 20:56
  Posterior atrophy, ma. And then we are applying three techniques to each model.
• 21:03
  The oversight of osteotomy.
• 21:06
  The atomy that is not achieving support on this posterior part.
• 21:11
  So only anchor anchorage up there.
• 21:13
  The original surgical technique following the PI protocol and
• 21:20
  the SGA protocol adapting the.
• 21:22
  And the osteomy to the patient anatomy.
• 21:25
  So we've been able to see that when following, of course, with the extra
• 21:31
  macary techniques, it's not necessary to add too much because it's it's
• 21:36
  a very dangerous, it is very common that this big level arm ends up.
• 21:44
  With a implant fat fatigue fracture.
• 21:46
  But then when following the original surgical technique and at the same time
• 21:53
  dealing with the most atrophic maxillas, the end result is that the part of
• 22:01
  the al elbow bone that is supporting.
• 22:04
  Or contracting.
• 22:05
  This long level arm is very thin because the atrophy is big.
• 22:11
  So it's about one or two millimeters of bone supporting the atory load.
• 22:16
  Yeah.
• 22:17
  What happened today?
• 22:19
  Nothing.
• 22:20
  Two more.
• 22:20
  Nothing.
• 22:21
  But in one year, two years.
• 22:23
  This is more about a bone is, has a concentration of
• 22:28
  atory load and at the end.
• 22:31
  It will be resolved.
• 22:32
  And after this, what is going to happen after this?
• 22:37
  It comes the oral anal communication, the infection of the sinus, which
• 22:41
  was about 26% of the cases of Pi er.
• 22:45
  Wow.
• 22:45
  As he reported.
• 22:46
  Yeah.
• 22:47
  Yeah.
• 22:48
  This is the percentage of the original PI RMR paper.
• 22:53
  Christian: That's a perfect segue to our next topic because we have a
• 22:57
  section called, it's not what we think.
• 23:00
  It's what we know.
• 23:01
  Yes.
• 23:02
  Evidence matters.
• 23:03
  Correct.
• 23:03
  And I asked you.
• 23:05
  To highlight one article that it was impactful for you in your
• 23:09
  career that either opened your eyes or helped you pave and shape
• 23:15
  your career towards this direction.
• 23:18
  And you shared with me the article Reconstruction of the Premaxilla with
• 23:22
  autogenous iliac bone in combination with the osteo integrated implants
• 23:27
  in collaboration with Dr. Oli.
• 23:29
  Killer, but also the one and only Professor Brandmark.
• 23:33
  It must be quite an experience.
• 23:34
  I would like you to share what was it like to work with Professor
• 23:38
  Brandmark and how and why this paper is so meaningful to you.
• 23:43
  This
• 23:44
  Carlos: is a paper reflecting the my, our first collaboration with Professor Piar.
• 23:50
  And this is the history of gentleman, 18 years old man that suffer
• 23:59
  surgery and orna surgery.
• 24:01
  So the ortho alternate Orna surgery failed.
• 24:05
  And this was 80, 87 around, so the late eighties we started with
• 24:13
  regular implants on the, in 84.
• 24:18
  And open an office exclusively devoted to regular implants in 85, which is where
• 24:24
  we were like crazy guys at that time.
• 24:27
  Crazy guys.
• 24:28
  So no dentist in Spain knew about the modern implant dentistry.
• 24:34
  We were waiting for referrals patient, but was like a crazy thing.
• 24:39
  But I dunno how this gentleman.
• 24:42
  Came.
• 24:43
  So the result of this orthotic surgery was he lose the whole pre.
• 24:49
  For promoter two promoter, he got on 15 millimeters, communication, nose, mouth.
• 24:57
  Wow.
• 24:58
  So it was like a disaster.
• 24:59
  A disaster.
• 25:00
  All of
• 25:00
  Christian: out of
• 25:01
  Carlos: an orthotic surgery.
• 25:02
  All because failed alternative surgery.
• 25:05
  So it looks like the surgeon made a maxillectomy and then he
• 25:11
  tried to, lowered the maxilla.
• 25:14
  Yeah.
• 25:14
  And then the va, he lost the vascularity.
• 25:18
  Wow.
• 25:18
  And then got an necrosis.
• 25:20
  How sad.
• 25:21
  So Inacio, came to us and then we were like, woo.
• 25:28
  So it was and then we called Per-Ingvar Brånemark and he said,
• 25:33
  okay come here, come to Gutenburg.
• 25:35
  We said, Ooh.
• 25:36
  He seems to be very sure.
• 25:40
  But yeah, we were able to.
• 25:42
  Arrange the paperwork for Inacio and social Security
• 25:47
  pay for I nephew to go there.
• 25:49
  P er didn't charge anything.
• 25:52
  And he himself, he made two implants, long implants with a machine
• 25:56
  he used to have in the office.
• 25:59
  He turned the two implants and nothing was also double lucky because at that
• 26:05
  time, that, at that time was, the, he was the dean of the maxillofacial
• 26:13
  department at the at the Mayo Clinic, Eugune was spending a sebbatic year
• 26:22
  in order to learn regular implants.
• 26:26
  I'm going to repeat it because so the big boss of the maxillofacial
• 26:31
  department of the Mayo Clinic, Minnesota is spending one sabbatic year in
• 26:36
  order to place a regular implant.
• 26:38
  Not zygomatic implant.
• 26:39
  No.
• 26:39
  A regular implant.
• 26:40
  It's the opposite.
• 26:41
  It is like the opposite of today.
• 26:46
  But yeah, the thing is that Eugune Keller was able to close their,
• 26:50
  the communication nose, her mouth, Per-Ingvar Brånemark er got a hip
• 26:58
  graft and he secured the graft with those two implants, two long implants.
• 27:06
  So after this and then we finally, we place we perform the rehabilitation
• 27:14
  finally in Barcelona to these men.
• 27:18
  And the lessons I learned.
• 27:21
  Now, today, maybe you are going to smile, but the first lesson I learned is that
• 27:27
  no matter if you place an implant in a non perpendicular direction to the
• 27:33
  occlusal plane, no matter if you place an implant in a tilt direction, it may work.
• 27:39
  That was the first thing.
• 27:40
  No, we were amazing.
• 27:41
  So the are not like this are like this.
• 27:45
  Oh.
• 27:46
  And they are working.
• 27:47
  Yeah, incredible because at that time there were instruments in order to place
• 27:54
  implants totally parallel, perpendicular to the occlusal plane like this.
• 27:58
  That was out of the box.
• 28:01
  And the second thing is that there was the possibility to anchor, to remotely anchor
• 28:07
  and implant and still working there.
• 28:09
  So those were the two lessons I learned from this.
• 28:13
  Patient that really changed my career, totally changed my career.
• 28:18
  Christian: And this is what sparked this fire to remote encouraging Exactly.
• 28:22
  Dedication in throughout your career.
• 28:25
  Carlos: I will say that first we started inclining implants.
• 28:30
  That was the first step because everything is.
• 28:33
  It is not like America, a light like this.
• 28:35
  It's an evolution.
• 28:37
  So first we started inclining implants and developing like a 3D inside of my head.
• 28:45
  No, A 3D vision inside.
• 28:47
  So I'm climbing the simple implant like this, and I will
• 28:50
  get anchored behind the canine.
• 28:53
  For instance, I'm going to escape from a sinus grafting.
• 28:57
  So that was the starting.
• 28:58
  And we prepare, we, we like.
• 29:02
  Without knowing, we were preparing for the psycho implants.
• 29:06
  And finally the psycho implants in a regular manner came in 98.
• 29:10
  In 90, but during this time, we publish on tilted implants.
• 29:15
  So it's as a preparation.
• 29:16
  As an evolution.
• 29:17
  Yeah.
• 29:17
  And,
• 29:17
  Christian: and to everybody who's interested in this paper, we're gonna
• 29:20
  leave the link to PubMed where this paper is published, available to everybody
• 29:25
  just to click and go through and see.
• 29:28
  This amazing paper from 1993 from Professor Carlos, Carlos
• 29:34
  Aparicio, and Professor Bre.
• 29:36
  Mark, of course, with collaborators.
• 29:39
  We have another section, as you said, the experience and things that you faced.
• 29:45
  That is called experience taught.
• 29:48
  This.
• 29:51
  Of course we cannot be too critical in ourselves because the knowledge
• 29:55
  base we had a few years back is not the same as we had there.
• 29:58
  So in our heads, those were the right decisions for the right moment.
• 30:04
  But in retrospect, knowing what you know now, is there any case that pops
• 30:08
  through your head that you say, oh.
• 30:12
  Time is the best educator.
• 30:13
  I wish I knew back then what I knew now, and I would've come
• 30:17
  differently to that patient.
• 30:22
  Carlos: I, I think I cannot tell you one specific case about a part of
• 30:26
  the one we has just comment that he really changed my perception because
• 30:31
  it's been, again, an evolution.
• 30:33
  Yeah.
• 30:34
  So then you try to.
• 30:37
  To follow the original receipt.
• 30:40
  You follow?
• 30:40
  I don't want to change anything.
• 30:42
  I want to maize what I learned, but you get a problem.
• 30:47
  And then the good point is that and I'm very proud of that in my office.
• 30:57
  I had the rule and the rule was, whenever you have a problem, take a picture.
• 31:04
  Take a picture now, don't fix it.
• 31:06
  Take a picture.
• 31:07
  And then you have the opportunity to think about the problem.
• 31:11
  So the idea behind this is about
• 31:17
  this is a new technique.
• 31:18
  Not anymore, but at that time there was a new technique nobody is teaching me.
• 31:24
  So we should learn about our experience and we should separate.
• 31:29
  Topic by topic, we cannot put all together and try to get, no,
• 31:35
  we have this problem, so let's analyze why, what is the theology?
• 31:41
  And then you take one thing and then maybe you can vary just one
• 31:46
  thing and wait and see the results.
• 31:50
  Wait and you see the result.
• 31:52
  But yes.
• 31:54
  One time as one thing at a time, not a EU body, like two or three things.
• 32:01
  You cannot deduct from where the problem or from where the solution right arises.
• 32:09
  Christian: Yeah, sometimes we cannot remember every single patient,
• 32:12
  but we can tell how your head was thinking at certain periods.
• 32:17
  And with the evolution now, things completely different.
• 32:20
  Yeah.
• 32:21
  Carlos: Yeah.
• 32:21
  The thing is that the, at the beginning you get a problem and then you don't
• 32:24
  know why, and then you think, oh.
• 32:26
  Shit, probably.
• 32:29
  And then I the, the normal human being is then, so you try to look
• 32:36
  to the other side, you go, yeah, but I like to go back, right?
• 32:40
  To go back and to think oh, that's, and this is when you bring.
• 32:46
  The problem to the weekend?
• 32:48
  Yeah.
• 32:48
  Or, and then your head is thinking, thinking, and at the end, maybe
• 32:54
  you get the solution or not.
• 32:57
  We
• 33:00
  in our office we have a protocol.
• 33:03
  And the protocol, one of the protocols we have is that one person
• 33:08
  was collecting all the emergencies happening in the, and what was the
• 33:15
  treatment and what was the origin?
• 33:17
  And then we were reviewing all the month emergencies.
• 33:20
  One day was reviewing emergencies, so what was the emergency?
• 33:26
  What happened, what was the treatment?
• 33:29
  Who did it and which department?
• 33:32
  And then there was like a discussion about the emergency.
• 33:36
  Can we do something for the next thing?
• 33:38
  Cannot.
• 33:40
  So it is the way you have to learn, you have to put some order in order to learn.
• 33:45
  Otherwise it's maybe you are inspired, you learn or maybe you
• 33:49
  are not inspired and you don't.
• 33:52
  Christian: And I like very much your rule in the office to take picture.
• 33:55
  Yeah.
• 33:56
  If you don't document, it becomes only a fisherman story.
• 34:00
  It's a something that maybe happened nobody can prove.
• 34:04
  So I like this learning mindset.
• 34:07
  I would like to shift gears a little bit more.
• 34:10
  If we look future orientation, we have quite an evolution in
• 34:15
  zygomatic treatment therapies.
• 34:17
  Now looking future oriented, how do you see the biggest shift will
• 34:23
  be it could be either in implement itself or how digital technologies,
• 34:28
  for example, helping us get from point A to point B or artificial
• 34:33
  intelligence may be helping you predict.
• 34:36
  Some pitfalls.
• 34:37
  How do you see this rapid digitalization and looking into
• 34:42
  the future of zygomatic therapies?
• 34:47
  Carlos: It's not easy to answer the question because we don't know.
• 34:51
  Yeah, that's the first thing.
• 34:53
  And the second reason is difficult is because the huge variability of
• 35:02
  anatomy you may found and usually.
• 35:06
  Those differences are arising from previous failures, as we just comment.
• 35:12
  Previous implant failures, previous ratin failures procedures.
• 35:18
  So this means that it is quite common to find, for instance, bone discontinuities
• 35:26
  that makes any guided solution like
• 35:33
  I will be very grateful if we are able to develop more diagnosis tools.
• 35:40
  Yes, diagnostic tools.
• 35:42
  So I'm so happy using the software to quantify.
• 35:47
  I'm so happy using 3D models to plan I to make a, like a rehearsal surgery.
• 35:56
  We have today, maybe we had commented, we have a amazing 3D models that we all
• 36:05
  we are fabricating in house, in inside a headquarters because this
• 36:08
  is a a very powerful tool, right?
• 36:12
  Maybe, aI can help us in diagnosis could be.
• 36:20
  I'm not very confident in guided systems.
• 36:24
  Why?
• 36:25
  Because this big variability of anatomical situations
• 36:33
  to me guided the surgeries.
• 36:37
  For, especially for talking about matic implants is maybe can be
• 36:42
  adequate for never are easy, but for, allow me to say more simple
• 36:51
  matic implant placement where you have some kind of bone or some.
• 36:56
  Little amount of bone.
• 36:57
  Yeah.
• 36:58
  Maybe for this you can use it as guided, but when it comes to situation, the very
• 37:03
  frequent situation where you almost don't have bone, or where you have this like
• 37:10
  paper sheet bone that you try to cut it and you find this sound, this horrible
• 37:15
  sound because it's not possible to cut this paper sheet, then it's, I think it's.
• 37:21
  I cannot see the utility of those guide disease.
• 37:24
  So in resume, I will be very grateful if we develop more diagnostic
• 37:30
  tools, more so words, things that make the surgeon more comfortable
• 37:37
  at the moment of the real surgery.
• 37:39
  Yeah,
• 37:40
  Christian: I like because your expectations are quite realistic.
• 37:43
  It's almost pretty much a present, huh?
• 37:45
  Oh, yes.
• 37:46
  Oh yes.
• 37:47
  Carlos: Thank you,
• 37:47
  Christian: Professor Aparicio.
• 37:49
  It was an honor to learn from you today.
• 37:52
  Thank you.
• 37:52
  Thank you very much for stopping by and participating in Straumann
• 37:56
  and ProTalk clinical with us, and to all of you interested to learn
• 38:01
  more about zygomatic therapies, the ZAGA concept, and throughout the
• 38:07
  whole ZAGA I would do that again.
• 38:11
  Philosophy?
• 38:11
  No, it was the ZAGA Centers.
• 38:16
  And to all of you interested to learn more about zygomatic therapies, the
• 38:20
  ZAGA concept, and all the ZAGA centers.
• 38:23
  Also learning with Professor Apio.
• 38:25
  Make sure you click on the link that will appear in the video description and
• 38:29
  you have access to this amazing network.
• 38:32
  Professor Aparicio.
• 38:33
  It was a pleasure to have you with us.
• 38:35
  It was
• 38:35
  Carlos: also my pleasure and I really thank you for the opportunity to share
• 38:40
  a little bit more about the ZAGAl philosophy, which I think is a very
• 38:46
  powerful tool, especially for these people that are desperate, that are facing the
• 38:53
  last opportunity to recover a fixed dium.
• 38:56
  This is really the last opportunity.
• 38:58
  There is only one shot.
• 39:00
  We have to be successful in this unique shot.
• 39:04
  So thank you.
• 39:05
  Thank you very
• 39:06
  Christian: much.
• 39:07
  Carlos: Thank
• 39:07
  Christian: you.
• 39:08
  And to all of you, remember if this content was valuable to you,
• 39:13
  make sure you like and you comment and you share to your friends.
• 39:17
  Sharing is caring.
• 39:18
  And till the next episode, ciao.