Arch Goals: A Master Guide to Your First 1000 Arches

“It takes 100 arches to know what the heck you’re doing and 1000 arches to become an expert”. 

My clinical director told me this when I first began my All-On-X journey, and it has been forever etched in my brain. 

I remember thinking that it would be impossible to actually cut 1000 arches. 

Well, 1000 arches have come and gone.

Looking back, I wanted to share with you… in an ideal setting… if, in theory I could… how I would have structured those 1000 arches for maximal learning, impact, and growth as a surgeon.

While I cannot go back in time, my hope is that a surgeon fresh on their AOX journey may glean some insight and wisdom on how best to direct their learning and focus for surgical success. 

I want to preface this by saying: 

I do not think you need to do 1000 arches to be qualified to do AOX surgery. 

I understand that the numbers listed below may seem unrealistic for those in a traditional private practice – but these are and should be realistic numbers for those that work in an AOX center. 

Remember also, that if I could have, this is how I would have tailored my learning. I had zero experience with AOX surgery when I started. You’re training, experience and skillset may be different than mine. 

Regardless, take this information as a general outline for AOX learning objectives and tailor it to your practice and your AOX volume. Or disregard it all together if you want, I won’t take offense.

I am a believer that the following “Master Guide” is the best way for a new surgeon to start performing All-On-X surgery. This is especially true for those at an All-On-X focused practice. 

In order to truly control this learning process it would be preferable you have the following: 

1. A consistent volume of arches. 

I think that consistency is the key. Whether it’s 10 arches a month or 50 arches a month, if you are consistently practicing this skill, you will get better at it. 

2. The opportunity to learn from more experienced surgeons. 

3. The ability to choose skill-level appropriate cases. 

You should not do every case that walks in your office when you first start. This can actually hamper confidence and growth. 

4. Hands on opportunities in which to learn how to treat failed cases. 

There is often a big learning curve in conceptual treatment planning and clinical skill regarding how to rescue an AOX case. Mentorship and hands on experience will expedite this surgical skill.  

While not all of these variables can always be accounted for, most of them can be in some fashion. 

So, if we theoretically could control the above… here’s how I would outline an AOX surgeon’s first 1000 arches. 

Arch Goals: A Master Guide to Your First 1000 Arches

0-100 Arches

“It takes 100 Arches to know what the heck you’re doing…”

1. Learn how to assess a CT scan and treatment plan an AOX case in 5 minutes or less per arch.

2. Understand how a smile line affects surgical bone reduction requirements.  

3. Learn and prioritize surgical procedural steps and flow so that you begin to consistently perform your surgery the same way, in the same order, every time. Don’t worry about being “fast”. Worry about being consistent.

4. Efficiency Goal: By arch 100, you should be able to consistently finish an arch in 90 minutes or less. 

100-250 Arches

1. Improve treatment planning efficiency and CT scan assessment to 2.5 minutes or less per arch (5 minutes for a double arch). 

2. Learn how to consistently optimize osteotomy preparation and implant size selection to achieve a composite torque of >120 N-Cm and an individual implant torque of >30 N-Cm, on both routine and complex cases. 

3. Spend time with your restorative doctors, asking questions and learning how to prosthetically optimize your surgical outcome. At this point you should not be simply placing your implants “where the bone is”. Understand what your restorative doctor needs from you for the best prosthetic outcome – and start to be able to consistently deliver it.

4. With that thought in mind, you should begin to actively focus on achieving close to optimal abutment and screw access positions. This is not easy and takes practice. You will not improve this skill if you do not focus on it. Now is the time…

5. Start to expand your surgical toolbox to leave yourself outs. Think ahead…what will you do if something doesn’t go well in surgery or post operatively? Plan for your plan to change. 

6. Understand how occlusion and jaw relationship affect the prosthetic and therefore your planned implant placement and angulation.

250-500 Arches 

1. Focus on and improve your surgical closure. 

Now that you do not have to think so much about other surgical aspects, really work to perfect your suturing technique. This is so important, and so often overlooked. 

2. You have a significant amount of arches under your belt. At this point, you should have a case acceptance goal of 90% or greater.

This means you now have the skills to treat >9/10 patients that walk in your door. This assumes the patients are optimized medically for surgery.

3. Develop confidence with treating failed implants or rescuing cases.

Being able to “remove and replace” an AOX implant is a skill that is developed. If you don’t have opportunities where you are – seek out an experienced surgeon to learn from. It’s time on your journey for you to master this skill.

4. Efficiency Goal: By arch 500 you should be able to consistently finish an arch in 75 minutes or less.

5. Learn and begin performing pterygoid implants.

While I love pterygoid implants, I believe it is optimal that surgeons wait until this point to begin placing them.

Why? 

This allows you to develop other skills and tools in your toolbox to get you out of a jam (ie, palatal root implants, using different angulations, palatal bone, trans-sinus etc.) – and in this way pterygoid implants really become icing on the cake, allowing you to handle virtually any case. 

When surgeons begin performing pterygoid implants (and zygomatic implants) too early, it is my opinion that they rely too heavily on these and cannot problem solve a case if these are not an option or if the case does not go as planned. 

In this way, cases may be routinely over-treatment planned because surgeons lean only on this one skill. While I am a huge advocate of pterygoid implants, I also recognize that there are, at times, better “prosthetically-driven” surgical options if you have the tools in your toolbox. In order to have these tools though, you have to develop them early on. 

Furthermore, I  find that it’s easier for surgeons to focus on learning advanced techniques when they are truly confident with the “basics”. Trying to learn everything at once can be overwhelming and lead to poor outcomes and a decrease in operator confidence. 

I want to note that I am not saying that you need to wait years before learning and placing pterygoid implants. Your volume in your practice will most likely differ – adjust accordingly. Remember, this is a theoretical exercise, imagining we could control everything for optimal learning…

The important thing here is to note the progression of experience, more so than the arch “count”. I prefer surgeons to be able to begin their journey with case selection and honing a toolbox that is well rounded and does not rely solely on any one implant.

500-750 Arches 

1. Improve treatment planning efficiency and CT scan assessment to 1 minute or less per arch (2 minutes per double arch).

This means you can look at a CT scan you have never seen before and treatment plan that case surgically, in its entirety, in under 2 minutes. 

2. While similar, a separate evolving skill should be the ability to look at a failing AOX case, assess the CT scan and treatment plan the “rescue or re-do” case in 2 minutes or less. 

3. At this point, you should have a case acceptance goal of 90-93% or more. 

4. The two main points of focus at this point in your career are: 

Being able to essentially “look” at an AOX scan or case and know almost instantly how you will treat it. 

Having the skillset to tackle almost any case that walks in your door. 

750 – 1000 Arches 

1. Efficiency Goal: By arch 1000 you should be able to consistently finish an arch in an average time of 60 minutes.

You may have arches that you finish in 30-40 minutes. However, in my experience, a quality full arch surgery with an emphasis on impeccable closure, will normally take ~50-70 minutes. 

2. At this point, a good goal is a case acceptance of 93% or more (*Note that I am referring to immediately loaded cases).

In my opinion a 100% case acceptance rate is not realistic, nor should it be your goal.

There are patients that simply require treatment options outside of traditional AOX surgery – such as severely atrophic mandibles or patients better served with delayed load cases and grafting. There are also instances where you may be able to clinically perform the surgery despite the complexity, but the patient simply has unrealistic expectations. 

For these reasons, an acceptance rate of 93% or higher is a more realistic goal (albeit not easy to achieve).

3. With your extensive experience, now your implants aren’t just placed in the bone. Rather, they are placed in a strategic way to optimize ideal abutment angles and create strategically placed screw access holes on the prosthetic.

This is not easy to do each and every time. I still work on this daily and have areas to improve.

But this…this is what makes a great surgeon. This is what makes referrals want to work with you.

You have enough experience now that you are not just trying to “get through” your arch. Now, you are perfecting your arch and creating a prosthetically driven surgery. This is what will separate you from the rest. 

4. End each surgery with impeccable closure.

When you begin doing AOX surgery your cases can take a long… long time. You are tired by the end and stressed out. Closure can be the last thing on your mind.

But, that’s not you anymore. You are very experienced after 750 arches and you should be finishing your surgeries within a consistent time frame and not be exhausted at the end.

Now you have the energy and focus left to create an impeccable closure. Your tissues should lay flat, well approximated around your abutments and look as clean as possible. This does help with healing and should be a priority.

Your closure is also your surgical signature. This is your final sign off and this is what your referring doctors will see. So start to take real pride in it.

5. Learn proper zygoma implant technique and placement principles. 

Should you desire to place zygoma implants, in my opinion, now is the time. 

I know this will bring an uproar of disapproval… Everyone and their mother seems to want to learn zygomatic implants their first day out of dental school. However, I disagree with this (and you can disagree with me too…that’s ok). 

I am not against zygoma implants. They definitely have indications in AOX surgery. But here is my thought process as to why I think it is beneficial to learn zygomatic implants at this point in your AOX career: 

• I feel it is incredibly valuable to have a well rounded toolbox and add zygoma implants to that toolbox…as one of the last tools. 
•  In my opinion, many inexperienced doctors learn zygoma implants too early in their AOX career. Since they do not yet have a well rounded AOX toolbox, zygoma implants become the default…even when they are not truly indicated. 
• This over-treatment can predispose those patients to complications that may not be necessary.
• With greater experience comes the ability to discern which AOX patients truly require zygomatic implants, and which can benefit more from one of the other skillsets you have developed.  
• I also feel that learning to manage basic AOX complications is important before having to tackle zygomatic implant complications. 
• It is important to learn “what works and what doesn’t work” with basic AOX surgery, all the way down to patient selection, before moving to zygomatic implants.     
• For reference, I want to point out that I did not actually learn zygoma implants until I had completed 1,350 arches. And before learning zygoma implants I was treating ~97.0% of the cases that walked in my door with an immediately loaded prosthetic. 
• • • • •  

Looking back on my career to this point, if I could have…this is how I would have structured my first 1000 arches for maximal learning, impact, and growth as a surgeon.

I understand this is only possible in an ideal setting, and in reality none of us practice in this “ideal surgical bubble”. However take from this Master Guide what you can and apply it to your setting.  

Keep in mind, in writing this outline, I am not trying to create an AOX surgeon as fast as possible. 

This is how I would create the best AOX surgeon.

The most versatile, well trained, all-around – All-On-X surgeon.

This takes time, and focus. 

I wish you the best on your All-On-X journey. I hope this path my help guide you and give you even the gentlest of nudges in the right direction. 

Matthew Krieger DMD