Dr. Emil Verban taught himself to place implants without taking a $20,000 continuum. Learn how he did it and how to offer affordable implant options to your patients.
Listen to the Show on iTunes
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Listen to the Audio Here:
Audio Howard Speaks Podcast #29 with Emil Verban
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Watch the Video Podcast Here:
Video Howard Speaks Podcast 029 with Emil Verban
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Links and References From the Show:
Dr. Verban's Drill-Stops: Verban Drill-Stops
International Team for Implantology (ITI): iti.org
Simple, Advanced, Complex (SAC) Classification/Assessment tool: link
Planmeca ProMax 3D CBCT: link
Dr. August De Oliveira CE on Dentaltown: link
Dr. Arun Garg: implantseminars.com
Implant Direct: implantdirect.com
Blue Sky Bio: blueskybio.com
Osstell meter for measuring implant stability (Dr. Verban likes a reading of 70+): osstell.com
enCore allograft: link
Grafton DBM: link
Dr. Emil Verban's Bio:
Dr. Emil M. Verban received his Doctor of Dental Surgery Degree from Loyola University School of Dental Science in 1976. He has been in full-time practice of General Dentistry, in Bloomington, Illinois with a special interest in cosmetic and implant dentistry. Dr. Verban is a nationally recognized leader, lecturer and educator in implant and restorative dentistry. He has developed and patented surgical products which greatly increase safety and precision for implant surgery. He has advanced training and is certified in intravenous sedation. He has published numerous articles on implant dentistry and is on the Editorial Board for the Journal of Implant and Advanced Clinical Dentistry. He has been President of the Mclean County Dental Society and Chairman of the Peer Review Board of Mclean County. Dr. Verban is a member of the American Dental Association, American Academy of General Dentistry, American Academy of Perio, American Academy of Osseointegration and International Team of Implantology of which he is a certified speaker.
Transcript (Download here)
Howard Farran: Well, today it is going to be a very fun hour. Emil
Verban, thank you
so much for joining me today.
Emil Verban: My pleasure.
Howard Farran: I am really excited about this, because you are a legend
in
implantology. And when I got out of
school, no you truly are. And when I got out of
school, placing an implant with a 2D
panel, I mean, sometimes you would lay a flap and
you would think you had an inch of
bone and it would be this little paper ridge and you
had to dissect out where the omental
foramen was and you are always worried about
the anterior loop and sometimes you
would put a little pilot drill down there and you
would stop and take an x-ray or two
or three different angles. And now everybody is
talking about, you know, these 3D
x-rays, how we have gone from 2D to 3D. They are
talking about surgical guides and all
of that stuff. But before we get into all of that, what
you have been doing for 38 years, I
want to start this interview with, pretend that we are
talking in our audience, 5,000
dentists, they just graduated from school in May. And
they are entering probably the worst
economy for a long time. I think all of the
recessions you and I have lived
through, they were kind of like a bouncing ball. They
dropped and bounced back up, they
dropped and bounced back up. We went through
several of them. And this ball just
kind of like dropped and it has just been laying there
on the floor for five or six years.
It is kind of crazy. So let’s start this interview with,
since you have been doing this 38
years, I have been doing this 27 years. What would
you tell the graduating class and
then lead that into the dentists that have been out
there for ten years in this flat
dental office in a city that is not gaining, it is not losing, it is
just flat? There are 19,022 towns
spread across America and they just say, “Dude,
what is going on?” Should they try
something new? Should they get into implantology?
Some of them are looking at a
machine, these 3D x-ray machines that are literally the
price of a house. My first house cost
$96,000 in 1987. Now these 3D machines are
$100,000 minimum. So give them some
fatherly advice. Give them your Vince
Lombardi dental speech.
Emil Verban: Well, I think Howard, that if a young graduate does not
get involved in
implant dentistry, they are going to
have a limited upside to the development of their
practice. With the baby boomers, the
aging of the baby boomers, that segment of the
population is the segment that has
the money. And they don’t want to be like their
grandmother and grandfather. They don’t
want to wear dentures and partials. And they
will seek out implant treatment if
the implant treatment can be rendered in a cost
effective manner, not only for the
dentist, but also for the patient. I think that you will
see in the future implant fees
trending down, not trending up, because it is like the law
of supply and demand. If there are
only a few number of people who are doing the
procedure, they can charge whatever
fee that they so desire. But there are more and
more general dentists that are
getting involved in implant dentistry, rightfully so. And I
think that with that number and
increase, especially with the younger graduates that
now are getting a little bit of
exposure to implant dentistry in dental school, whereas I
never received any education
whatsoever in implant dentistry when I graduated in 1976.
In fact, going back to the ‘80s when
Branemark brought over the osteointegration
theories, I wanted to get involved
with implant dentistry, but there was a restriction from
taking the Branemark course. It was
only offered in dental schools and you had to be
either an oral surgeon or a
periodontist in order to take the class. So I was not able to
take the class. So basically I had to
learn implant dentistry, basically I think I am
somewhat self-taught in the sense
that I traveled around, I visited other offices. I read
numerous books, but I think I am
basically self-taught. And I think that, you know, I
don’t think that you have to go and
take a $20,000 continuing course in order to be able
to place dental implants. Do you know
how many companies sell implants in the United
States, Howard?
Howard Farran: How many?
Emil Verban: 90.
Howard Farran: Wow.
Emil Verban: 90 companies sell dental implants and there are probably
340 different
types of implants that are available.
So I understand that there is a tremendous amount
of confusion out there as to which
implant system an individual would want to get
involved with, where do they get
their training and how do they get their training in a
way that they don’t break the bank,
and let alone thinking of purchasing a $100,000 3D
machine. I think the 3D technology is
fantastic technology, but I do not think that you
absolutely necessarily have to have
it in order to place dental implants. You know, I
think 80% of all dental implants that
are placed are single units, 80%. Well, you open
any magazine and you see this all one
four, the BruxZir, the full arch appliances, but
that is not the bread and butter
routine implant case that is out there. It is a lower first
molar, that is the most prevalent
tooth that is lost. And I think 80% of the implants are
single units and I think I read where
70% of those 80% are posterior, and 30% are the
lower first molars. So the lower
first molar is the most prevalent implant that is placed
and it can be the easiest implant to
place. So I think young dentists have to go in a
progression to learn this. They have
to learn to separate which cases they should get
involved in, and which cases they
should not get involved in. And I think that the
organization that is out there, the
ITI, the International Team of Implantology, they have
a series of textbooks that are all
evidence based consensus reports and they have a
classification of implants called the
SAC Classification, which is simple, advanced,
complex and the parameters that goes
with each one of those. And I think it is like
anything else, I mean even an oral
surgeon in their residency or a periodontist in their
residency, at one point in time it is
the very first implant that they place. It is the first flap
that they have laid. So they have the
advantage in those programs of being able to
have someone looking over their
shoulders while they are doing the procedures to get
them up the learning curve. So I
think that taking the responsibility to self-teach yourself
is very important. And I don’t think
there is one course that is out there or a magic
bullet, an implant that can be 100%
successful. You know, the funny thing Howard is
that all implants integrate. I mean,
there have been studies no matter what type of
implant system that is used, 95% to
97% success rate with the implants, whether it be a
Straumann implant, whether it be a
Zimmer implant, whether it be a Blue Sky Bio
implant, whether it be a Megagen
implant. All of the implants integrate, it is just a
matter of what kind of support you
are going to get with whatever system that you are
using. And I think the bigger brand
name companies, they at one time kind of had a
corner on the market, but I think
that is starting to change some. I think that Dr. Niznick
with the Implant Direct has been, I
think the downturn in the economy was the biggest
thing to happen to Implant Direct,
because he was going to have an Internet based
company and produce a product and
sell a product and significantly undercut the
competition. And people I think were
reluctant at first to get on board with that product,
but then like anything else, as time
went on, on a ground roots basis, the use of that
implant has significantly grown just
because people have realized that you don’t have to
spend $425 for an implant. You can
spend $170 to $150 for an implant and have the
same success rate as far as
integration is concerned. So I think that for the younger
graduates they need to get involved
with learning surgery. And you know, everyone
wants to place implants, but you have
to learn how to make incisions, you have to learn
how to reinforce tissue, you have to
learn how to drill in bone. And there is a learning
curve involved and like anything
else, with each particular case that you do, your skill
set is going to increase. So probably
the best advice I could find would be to take a
basic course, decide on what implant
system you want to go with and then find an
individual that you can mentor with
to increase your knowledge and bounce treatment
plans off of prior to getting
involved. Do you play golf, Howard?
Howard Farran: I do not. I was on the high school golf team.
Emil Verban: Well you know, it is kind of like this. Like if you were
to take a golf lesson
and go out on the range and hit like
a seven iron and keep hitting the same shot over
and over and over, you could take a
lesson doing golf that way. Or you could take a
playing lesson. And a playing lesson
would be you would play a round of golf with a
pro. The pro would help you and prep
you prior to each shot that you are going to hit.
So like an example would be, okay, if
you were going to hit a seven iron and you were
like 150 yards away and you knew how
far you were, but then 20 yards out there, there
was this tree limb. So the pro would
say, “Well now, you can hit the 150 yard club, but
you are going to have to make some
modifications in it.” And that is kind of like what
implant dentistry is. There are all
kinds, each case is so different, a different set of
circumstances that you have to see
before you get involved in it. You know, it is kind of
like an art appreciation class. You have
to kind of visualize and see what problems you
are going to encounter before you get
into them. And even before you have a lot of
experience, you still always run into
scenarios that you have to revert back to your
basics in order to do the case. So I think
it is good if you can find a mentor, if you can
decide on what system that you want
to use and you can take some basic surgery
courses. Just on Dentaltown itself,
there are a tremendous amount of clinicians out
there that are so willing to share
their knowledge and expertise. And I think Dentaltown
probably is and can be one of the
most valuable resources. YouTube is out there, all
kinds of videos are available. A lot
of dentists have channels that you can go to and
view their cases. And some people learn
by reading, some people learn by watching,
some it is a combination. So you kind
of have to figure out which way you learn best
and go from there.
Howard Farran: We have people viewing these from every single country in
Earth and
I think it is interesting how when
the United States with the nine specialties recognized
by the American Dental Association,
these kids walk out the school and the ortho
departments keep the ortho out of the
curriculum and the oral surgeons keep the
implants out. I think it is
interesting how in more poor countries like Brazil and India and
China, the actual general dentists
place more implants per month than American
dentists. And I believe you are
absolutely right how the cost of these implants
plummeting with Dr. Branemark from
Sweden where IKEA is, that company turned into
Noble BioCare after the Nobel Prize.
And they were just bought by Danaher, which
owns Implants Direct. What did you
think of that move?
Emil Verban: I think it is a way that they can segment the market and
address the
needs of different sectors. So they
are going to probably use that to push their implants
to different individuals based on the
requests of the doctor. You know, there are
specialists that are out there that
would not use a Blue Sky Bio implant. They wouldn’t
use the implant, because it is a
clone implant. But the success rate of that implant is
the same as a Straumann. So the
specialists may not use that implant because if there
is 2% of the cases could possibly
fail, they don’t want to have their referring individual
know that they are using a clone
implant. They would prefer to use the brand name
implant. So obviously a lot of the general
dentists feel as if the brand name implant is
the only way to go. But there is a
significant difference in the cost of those implants
.
Howard Farran: We had an oral surgeon on here from Dentaltown, Jay
Resnick, and
that 2% he said that he does 100% surgical
guide, because since he has referring
dentists, if only 2% of his are
angled wrong and he is placing them, you know, he will go
through 100 pretty quick. He just
doesn’t even want 2%. What are your thoughts on
surgical guides? What percent of
yours are surgical guide versus free-handed for a
lower first molar, which is the most
common single implant you said.
Emil Verban: I mean, I use surgical guides all of the time.
Howard Farran: But what percent for a single?
Emil Verban: Well probably 90% of the singles. Now when you are talking
about
surgical guides, are you talking
about a CT generated guide or are you talking about a
model based guide?
Howard Farran: Well for our viewers, please explain the difference.
Because that is
one of the biggest threads, you see
these threads on Dentaltown, model based. Like I
said, I was so excited to interview
you today, because when you look at Dentaltown, this
is where CEREC was so hot five, six,
seven, eight years ago and then ten years from
that it was lasers and then ten years
from that it was intraoral cameras. Right now what
you are talking about, that is where
the ball is of this dental football game. Everybody is
talking about do I get this $100,000
machine? Do I make a surgical guide based on a
CT scan? Do I make it on a model?
Explain the difference and what your thoughts are
on all of that.
Emil Verban: Well, I mean I think that you can purchase a 3D machine
and that 3D
machine that you purchase, you might
use that 3D machine more for regular dentistry
than you would for implants. I have a
Planmeca ProMax 3D machine. I take extraoral
bite wings on children, on adults. I
take 2D panels and I also take CBCTs with the
same machine. So the return on
investment on that machine is really good, because
you can take these extraoral
bitewings on children and they look like vertical bitewings
and they are extremely clear and you
can diagnose interproximal decay on them. So
with that particular machine, yeah,
it is an investment. But it is going to allow you to
have that ability to fully analyze in
three dimensions the ridge, as well as utilize it to
place, with that knowledge, place
dental implants. So like an example, I posted a case
on a close family member where I did
an implant. So I had a cone beam. I had a cone
beam and the ridge was 10 mm, it was
a lower second molar, the ridge was 10 mm
wide. I was going to place a 4.8
diameter implant. I didn’t feel as if I needed a CT
generated guide if I knew and I could
see where the first molar was, where the second
molar was that I was going to place
the implant. A simple model-based surgical guide
was sufficient for me to keep me
centered in the position I wanted to be to place the
implant. I mean, I was 12 mm from the
inferior alveolar nerve and I had 2.5 mm of
space on each side. So in order to
make a surgical guide, I just made it on a model with
some acrylic. And I have got a
product that I developed and patented that I use and sell
to many dentists all over the world.
It is a drill stop. And so my drill stop prevents me
from drilling deeper than I want to
go and also with the advent of guided surgery, you
can form the guide around the drill
stop that will allow you to control all three dimensions
with your placement. There is a
dentist, Michael Ravens, who has done a lot of
fantastic work using Blue Sky Bio’s
free software than you can download and has a way
to scan a model, superimpose the
model of your scan over your cone beam and
generate a model from that and make a
surgical guide. But you know, that takes time to
do that and there is some added
expense in it. And it is fantastic, but I think you can do
the same thing with just simple,
model-based guides as long as you have an idea of
what the anatomy is underneath the
tissue. You had mentioned that, well, when you
first got out you laid a flap and
then there was this tiny ridge. Well, now there is no need
if you have a 3D machine, there is no
need to have any surprises whatsoever. The only
surprises that you can have is
sometimes the 3D machines have scattered, there are a
lot of crowns, adjacent teeth with
adjacent crowns. So it is sometimes hard to get the
full visualization of the anatomy of
the ridge due to the scatter. But guides can be made
and I would highly recommend that
guides be made for all dentists when they first start
practicing and placing implants.
Howard Farran: Any chance I could get you to commit right now to create
an online
CE course showing how you do that,
going through the steps, using the product that
you sell?
Emil Verban: Sure, I could do that. That wouldn’t be a problem at all.
I would be
happy to do that. I mean, I have a
lot of people that call me all of the time and I just
point them in a direction of how to
use the product. I used to teach classes in my office,
like five doctors at a time for two
days, kind of like Jerome Smith does in Louisiana.
And Jerome is a fantastic implant
dentist. And he is kind of out of the same mold that I
am in the sense that he was kind of
like self-taught and we do IV sedation. So we do all
of the cases. But he would be another
individual that you should talk to at some time.
He told me a funny story one time
about how you went to visit him in Louisiana I think.
Howard Farran: And I am going again next week. Yeah, we were down there
and
then we went fishing for red bass out
in the Gulf. I love Jerome.
Emil Verban: Jerome is a great guy.
Howard Farran: And when everybody is whining about the economy, there is
he is
Lafayette, Louisiana, which
Louisiana, Mississippi and Alabama, they are usually near
the bottom of the list in economic
performance and whatever and there he is out there
placing 50 to 100 implants a month
for 30 years of his life. It is amazing.
Emil Verban: Well I think that the economics, people have to take a
strong, hard look
of the economics of implant
placement. I mean, I hear numbers of an individual that
goes and needs a single tooth implant
replaced and it is going to cost them $5,000.
Some offices are going to charge
$5,000 just for the surgery. So I think there is a price
point in our fees that if you want to
be able to do a lot of implants, you are going to have
to be competitive with your pricing.
Howard Farran: And it should be. I mean, I remember when I got out of
school, Noble
Biocare, it was $500 for the implant,
but every little thing you bought was another $50 to
$75 from a helium bottom and a screw
and just nickeled and dimed you to death and
these prices have plummeted in
implants. And in economics, the first thing they teach
you is price, elasticity in price is
the number one variable on the elasticity of demand. If
you raise your price, you are going
to sell less and if you lower your price, you are going
to sell more. It is price elasticity
and a lot of dentists would do twice as many implants if
they could just cut their costs in
half. And it is amazing how the number one market
share leader in every company in
America is a low-cost provider. Southwest Airlines,
number one in airlines, lowest price.
IKEA furniture, where Branemark is from in
Sweden, lowest price furniture. You
know, Wal-Mart, lowest cost distributor by getting
rid of the middle man. I also think
it is interesting you bought a Planmeca, which is out
of Helsinki, Finland, and they are 3D
and they just made a huge investment in E4D out
in Dallas, Texas. It is like all of
dentistry is going 3D and CAD/CAM.
Emil Verban: Yeah, there is a movement that way, definitely there is a
movement that
way. But I think there is a
difference between the types of implants that you use. Okay,
so there are bone level implants as
you well know and tissue level implants. So tissue
level implants are far more easy to
restore in my opinion than bone level implants in the
posterior area of the mouth. So to
give you an example, you could use a Blue Sky Bio
tissue level implant that,
unfortunately they just raised the price of their implants from
$95 up to like $105 I think or $110.
But that same implant, for $110, you could place a
Straumann implant for $355. So there
is $200 of profit margin right there for you. And
your success rate will be the same
with both implants.
Howard Farran: Okay, I am going to stop you and interrupt you and start a
whole new
feed to the fire. These dentists,
they are usually introverts. They are usually, what got
you into dental school was getting A’s
in math and physics and chemistry and biology,
so they are usually shy. They are
usually introverts. There are a ton of them out there
that have been watching all of this
3D x-rays, all of these big threads on those. Let’s
start going specific advice. Let’s
say I am a dentist, I have been out of school five
years. The first thing I want to do
is I want to take a course. Can you actually name
courses? I mean, would you recommend
that he goes and see his oral surgeon or
would you recommend that first he
chooses the implant system and works backward
from that? So start naming, give
someone a Betty Crocker Cookbook recipe. What
implant system? Does he need a CBT,
what machine? Should he make model-based
surgical guides or CT based surgical guides?
Emil Verban: I think that if you wanted to go with a company that has a
lot of options
for you, it could be Implant Direct,
because Implant Direct sells all of the types of
implants. They sell the clone
compatibles, they sell Nobel compatible, they sell Zimmer
compatible, they sell Straumann
compatible. So, you know, you can buy everything in
one location.
Howard Farran: And for the younger kids, just tell them a couple of
minutes about
Jerry Niznick, because for older guys
like us he has been a legend. He is the founder of
Implant Direct and he has been a
legend in implantology. He is like another Branemark,
wouldn’t you say?
Emil Verban: Oh yeah, well Jerry Niznick developed the internal
connection. So he
developed the internal connection
that he then sold to Zimmer, the patents to Zimmer,
and then when the patents ran out on
that internal connection, then Zimmer had a
facility that was available. He
bought the facility and started Implant Direct. So his goal
was to be the largest seller of
implants at a moderate price so more consumers could
actually afford implant dentistry.
Howard Farran: And he is out there in LA, isn’t he?
Emil Verban: Yeah, well he is retired now, because Danaher bought out.
Howard Farran: So to make things simpler, faster, easier, you would
recommend
Implant Direct because it is a
low-cost?
Emil Verban: Right, I would recommend Implant Direct, or say Blue Sky
Bio. Now the
difference between Implant Direct and
Blue Sky would be that Implant Direct is a little bit
larger, they have a little bit more
continuing education. They offer courses, Dr. _____
August, he has a couple of threads on
Dentaltown and he has been a big contributor to
implant dentistry for the general
practitioner. So they have courses that are available.
They have a two day course and then
they have added courses after that that are more
sophisticated. But when you break it
down, in a lower first molar region where you have
an abundant amount of bone, that is a
simple implant. Then you are not going to add a
lot of implants into your practice
unless you learn and know how to do sinus lift
procedures, crestal sinus lift
procedures, because you limit your availability of where
you can place the implant. So with
some of the simpler techniques that are available
now for crestal sinus lifts, you are
just going to expand the number of case opportunities
for you to place implants. So in all
of those courses, there are certain doctors that teach
individual courses. One of the good
courses that is available out there is a Arun Garg.
He has got fantastic continuing
courses. So you want to try and find a course that is,
you know, close to your geographic
area so you don’t have to spend a tremendous
amount of money in airline travel and
everything. If fact, now they even have courses
where you can go to the Dominican
Republic, Honduras, different places and you can
have hands-on placement of implants.
That is how you are going to learn extremely
fast.
Howard Farran: And so you recommend the hands-on courses?
Emil Verban: I definitely recommend the hands-on courses.
Howard Farran: So is August, is he mainly teaching for Implant Direct?
Emil Verban: I don’t think he is mainly teaching for Implant Direct. I
think I have seen
his name on the site. He teaches
certain courses for them, but I don’t think he is only
teaching just for them. He is also
involved with CEREC, so he teaches how to integrate
and how to use the newer technology
to develop surgical guides.
Howard Farran: With the Galileos?
Emil Verban: Yeah, with the Galileos.
Howard Farran: Well talk about that for a second, because that is a big
deal. Apple,
your iPhone, you think of Apple as a
closed system and you think of Google and
Microsoft as an open system. So
Serona owns the Galileos CBCT and the CEREC
CAD/CAM. You went with an open
system, Planmeca. So when a doctor is looking at
a 3D x-ray machine, going from
two-dimensional x-rays to three-dimensional, would you
recommend a closed system like
Galileos and Serona and CEREC, or would you
recommend an open format like
Planmeca and E4D?
Emil Verban: You want me to make some enemies today, don’t you? Okay.
Howard Farran: I don’t think it is enemies.
Emil Verban: I have got an Apple, I have got an iPhone. I am talking on
a Macintosh
MacBook Pro right now. I love Apple
products. But I think that you lock yourself in. I
mean, a phone and a computer are a
little bit different than an x-ray. So I mean I think
that that is the reason that Planmeca
bought E4D, so that they could compete with the
closed system. So they are still an
open system, but they can compete with what the
closed system Serona has right now
with putting together the intraoral scanning
together with the DICOM that you get
from the cone beam to be able to generate
surgical guides. But you know, I
think that guided surgery is overrated.
Howard Farran: Really?
Emil Verban: Yes.
Howard Farran: Why is that? I have not heard that before.
Emil Verban: Well, I think that, well I have only had a cone beam for
two years. And I
have placed thousands of implants
more without a cone beam than with one. Now that
information has definitely helped me
in I would say improving my placements, but I think
what the cone beam did for me was it
allowed me to – ten years ago you had to work to
sell cases to patients. Now with the
cone beam, you have eliminated any doubt that
they have if this is good for me,
because you can put the x-ray up on the screen, you
can show them where you are going to
place the implant. You can go through the
whole planning of it. It relieves any
doubt that they have in mind and they are
impressed with the technology.
Howard Farran: Oh, they are impressed.
Emil Verban: They are. I mean, so if I take a cone beam, and like I
said, the nerve is
four millimeters or five millimeters
away from where you are working and you have three
millimeters on each side, I mean, I
don’t think you need to do that case guided. You
can do a model based guide for that.
Howard Farran: I am going to stop you here, because to our viewers out there
at every
level of age group in every country,
you are throwing around terms of model based
surgical guides versus CT guides. Can
you kind of explain that more to the person who
doesn’t understand what the
difference is and which one should they be doing?
Emil Verban: Well I think that there is nothing wrong with doing fully
guided surgery.
Obviously there is nothing wrong with
it. There is a cost involved in that and in many
cases, that cost, in my opinion, is
not justified if you have a certain level of experience.
If you do not have a certain level of
experience, then maybe that can be a safety net for
you, because the guided surgery, the
guide itself will help keep you on the trajectory
that is within a safe zone so that
you know that the model, the guide is controlling the
trajectory of the implant and it is
also going to help control the depth of the implant. So
it is going to be a safety net for
new dentists getting involved placing them. But that is
not the same thing, Howard, as using
guided surgery to dumb down the complexity of
implant dentistry or to be doing
flapless surgery, because there is a big move out there
to doing flapless surgery and I think
it is hyped and marketed by some companies. But I
do very few flapless surgeries.
Howard Farran: But back to making the actual surgical guide, they could
be made on
a model and they can be made CAD/CAM.
What are your thoughts on the difference in
those? Mostly more expense? And
furthermore, have you seen Armen’s system,
Armen Mirzayan?
Emil Verban: Right, no I have seen his system. Yes I have.
Howard Farran: So what do you think of a surgical guide, like on the
Dentaltown
thread, the Blue Sky surgical guide
made on models versus something that is designed
CAD/CAM?
Emil Verban: I mean, I think what Michael is doing with the Blue Sky
plan and having
the models printed out that are your
plan, I think that is a good way to go, I really do.
But I think that some of the approach
that they are using could be even simplified even
more than what it is doing. But you
also have to take into consideration that, you know,
anything with computers, garbage in,
garbage out, so you have got to be precise and
accurate and understand the software
and understand what you are doing in order to go
that route and take and stitch the
models together and overlay the scan of the model of
the mouth to the DICOM image that you
have on your computer system. So there is a
learning curve with that, but it is a
good way to go for many people and it gives them a
great sense of security. I just was
not trained that way. I would open things up,
visualize it and then go from there
with the implant placement. And I still like to see the
bone, and again, I do very little
flapless surgery.
Howard Farran: Now what 3D CAT scan machine do you think they should buy?
If
you are a dentist out there in the
middle of Parsons, Kansas, and he is at the ADA
Convention. Now how many companies
are selling a 3D CAT scan CBCT for dentistry?
Emil Verban: I don’t know, there are at least a dozen.
Howard Farran: Yeah, so help that young kid out. He is 30 years old, he
is in San
Antonio right now and he is like, “What
do I get and why?”
Emil Verban: I would only get a cone beam machine that you can also
take panoramic
2D panels with and you can also take
extraoral bitewings with. I would want to do all
those three things with one machine.
If you can do all of those three things with one
machine, you are going to have a
bigger use of that machine. I mean, I use my cone
beam on endodontics all of the time,
because you are able to take a limited view of the
tooth, you are able to see the
anatomy and it is a humbling experience when you take
3D films of some of your old endo
cases.
Howard Farran: Yeah, the first time I took, I got a Carestream, and the
first time I took
a 3D of my root canal fill, I was all
excited to see it. And I was going through the slides
and I was just like, “Oh my God.” I
mean, it is just like wow. That is a humbling
experience. And when the endodontists
are telling us that missed canals are the
number one cause of root canal
failure and you sit there and numb up the tooth and
before you go in there to go through
that tooth and just sit there and think, wow, there is
absolutely another canal over here.
And once you see that, it is just like you find it
instantly.
Emil Verban: Correct. I mean, do you take extra-oral bitewings with
your 3D machine?
Howard Farran: You know what, I am so sorry. The hygienists and the
assistants do
that.
Emil Verban: I am not specifically saying you, but in your system, do
you go into a
room and they have it up on your
system and it is a bite wing that they took extra-orally
with the machine? Are they taking
intra-oral bitewings?
Howard Farran: You just caught me, I have to tell you, I don’t know. I
don’t know, but I
will find out on Monday. Jan has been
with me 27 years and I don’t know what she is
doing. But it is all digital on the
screen.
Emil Verban: But I think that is a big drawing card. In some of the
machines, you can
do it and other machines you can’t.
Howard Farran: And then some people are getting all legalese saying that
it is
insurance fraud, because technically
according to the ADA, a bitewing has to be inside
the mouth and the sensor was outside
the mouth. I am just like, “Okay, whatever.”
Emil Verban: That I don’t know.
Howard Farran: Yeah, that is crazy talk. So you would recommend starting
with a
company like Implant Direct, Blue Sky
Bio, looking at what CE courses, probably lecture
first, and then you would definitely
recommend the hands-on. You talk about Arun
Garg, yeah, he is a good friend of
mine. I have lectured for his group and he is opening
up a hands-on center in the Dominican
Republic. I don’t know why the Dominican
Republic is exploding, but it seems
like every time I turn around I hear of more people
doing a Dominican Republic. Is Arun
tied with an implant company or does he
recommend anyone specifically?
Emil Verban: I don’t think he is tied in to one particular company. I
think that is one of
the problems where some of the
courses in the past, the course was really structured to
push the sale of one particular brand
or one particular system. And so, you know, to
disseminate the knowledge and the
information is an expensive project. And I think
that, you know, Blue Sky Bio, Sheldon
and Albert Zickmann, when they first came on
board with their company, they really
didn’t want to have people that are just getting
involved in the profession and
placing implants. They would say, “Go take a Straumann
course and kind of learn how to do it
and use those companies to get your feet wet.
And then once you kind of know what
you are doing and you don’t feel as if you need a
rep next to you while you are doing
that or help you order all you need, then just go
online and buy our product.”
Howard Farran: Now you are in Bloomington, Illinois. That is a suburb of
Chicago?
Emil Verban: Well, Chicago is a suburb of Bloomington, Howard. No,
Bloomington is
approximately 120 miles south of
Chicago.
Howard Farran: So you are halfway to Effingham then?
Emil Verban: Yes, probably.
Howard Farran: About halfway to Effingham. And how big is your town and
what
percent, you have been talking about
implants the whole time. You are a general
dentist, what percent of your
practice is implants? Are you doing other things, too?
Emil Verban: I have a general practice, so I practice by myself. I don’t
have an
associate. And I probably, I mean, I
do endo, I do sedation dentistry, IV sedation. I
have a nurse anesthetist that comes
into my office on more complicated cases. So
implant dentistry is not all I do and
I don’t think you can, as a general practitioner, just
do implant dentistry. But you know, I
probably place over 200 to 250 implants a year.
Howard Farran: That is an amazing amount. That is a very amazing amount.
So you
are doing molar endo, too. Are you
doing the CBCT after each fill to look at? Are you
doing it before the endo or after?
Emil Verban: I am only using it when I have problem cases or especially
for
retreatments, yes. You know, it is a
good way to have a film and, you know, now I am
beginning to question whether or not
I want to take a panel and bitewings on some new
patients or whether or not I just
want to take a cone beam and using that for diagnostic
purposes. Because it is truly amazing
how many asymptomatic periapical lesions you
see on cone beams anymore.
Howard Farran: I am wondering, I am two-thirds down, I am 40 minutes
down. I only
get you for 20 left. I want to switch
to a whole different area. You know, a lot of people
who talk about implants, like say Jay
Resnick, oral surgeon. They just place them, they
never restore them. On the restoring
side of them, it is a huge debate about loading an
implant immediately. Some people want
it in there for three months, some people six
months. There are different types of
bones. Will you tell these young dentists about
different types of bone and when can
you do a single-visit implant and a crown and they
walk out with a loaded tooth and when
that is a horrible idea and you want to let that
thing settle in the bone and
osteo-integrate for a long time. Can you go in that direction
for a while?
Emil Verban: Sure, I mean, I could use the analogy that I use with my
patients when I
say that there are three types of
bone in the mouth. There is oak, pine and balsawood.
And so oak is more the lower mandible
and anything is successful in the lower
mandible. Pine would be more the
anterior maxilla and balsa would be more the
posterior maxilla. So with that in
mind, I think it is very difficult to do immediate
placement, immediate loading in the
posterior area unless you have posterior stops
distal to the implant that you are
placing. And when you make that, you can keep the
tooth out of occlusion. I think the
more things that you try to do, obviously the greater
number of risk factors you can bring
into the success of the case. I have done many
anterior placements with immediate
provisionals, but you have to have…
Howard Farran: Are you talking about upper or lower?
Emil Verban: Both. Immediate placement of extraction, immediate
placement and a
provisional, walk out with a tooth
all in the same day. But I think you have to exercise
common sense. You have to have a
posterior support. You have to have a way that in
excursions and protrusive and lateral
movements, you can free the opposing arch from
touching that implant provisional.
Howard Farran: So you are saying that if it is a single tooth implant and
you have a
tooth taking the force behind in a
posterior stop and in front for a protrusive lateral, all of
the movements, and the tooth was out
of occlusion, you could load that day or have
cosmetically a tooth there for many
cases?
Emil Verban: You could, but I usually don’t do that in the posterior
area. I know people
that do, but I don’t do it in a
posterior area, because if you can’t see it, why take that
risk?
Howard Farran: And how long would you let that osteointegrate before you
would
bring them back to load it? What is
your protocol on that?
Emil Verban: I have a machine that is called an Ostell, and I don’t
know if you are
familiar with that, Ostell meter. So
it is a machine that measures, gives you an ISQ
reading, which in an implant
stability quotient, and it tells you how stable that is
electronically. I mean, you can place
an implant…
Howard Farran: Will you spell that out? Does it have a www?
Emil Verban: Yeah, O-S-T-E-L-L.
Howard Farran: O-S-T-E-L-L.
Emil Verban: Yes, Ostel.
Howard Farran: Dot com?
Emil Verban: Yes.
Howard Farran: Okay, Ostel.com. And so you will get a reading?
Emil Verban: You will get a reading. So that reading will allow you to
know whether or
not this is a candidate you can do an
immediate provisional on. If you don’t have
enough stability with the implant,
then you cannot do an immediate provisional on that
particular…
Howard Farran: And on your Ostel machine, what reading do you want to
see? What
number are you looking for?
Emil Verban: I am looking for a number of a 70 or more.
Howard Farran: A 70 or more, okay.
Emil Verban: Right. And so also with that machine, you can place an
implant and you
can take a reading the day you place
the implant. Say like an upper posterior bicuspid.
You take a reading and the reading
says it is 55. So then you bring the patient back in
five weeks. If you do a one-stage
procedure where the healing cup is open, and you
could unscrew the healing cup, screw
in and take another reading. If initially your
reading was 55 and five weeks or six
weeks later you have got a reading of 30, you are
probably going to have a failure. But
if your reading is say up to 65 or 70, then you
could go ahead and load that implant.
Howard Farran: And you have been placing implants for 38 years. So tell
these
inexperienced people, what are the
failures usually? Is it a smoker currently smoking?
What if they stopped smoking five
years ago? Talk about age factor. You know,
obviously a 25-year-old would heal
better than a 50-year-old, who would heal better
than a 75-year-old. Is there an age
limit where you stop placing implants?
Emil Verban: No, last week I placed an implant on a 93-year-old.
Howard Farran: Wow. And I noticed in some of the ads in Phoenix, Arizona
for the
plastic surgeons, some of the people
that are kind of famous around town, even in their
ads, they say you must stop smoking
for four weeks prior to surgery. And I saw that in
the paper and I thought, wow that is
amazing. The guy is doing external marketing
trying to get new patients, but he is
throwing a big red flag out there. You know, if we
are going to do this, you are going
to have to quit smoking for four weeks. Is smoking a
big problem in your experience?
Emil Verban: Well, I think that if you had a choice you would rather
place an implant
on a non-smoker than a smoker, but I
personally have not seen a greater failure rate on
smokers that in non-smokers.
Personally, myself I have not seen that.
Howard Farran: And what about age? So age and smoking isn’t really, you
are not
seeing age and smoking being a
variable?
Emil Verban: No. Age is a variable when you don’t want to place an
implant in too
young of an individual.
Howard Farran: Say that again.
Emil Verban: Age is a factor where you do not want to place an implant…
Howard Farran: If they are still growing?
Emil Verban: If they are still growing or if they still have passive
eruption, especially in
the anterior region. So for a girl,
that would be, you know, 18 or 19, but for a boy 21 or
22 sometimes.
Howard Farran: So what trends or commonalities do you see in your history
of failed
implants?
Emil Verban: I think where you try to push the edge of the envelope too
much. Where
you extract the tooth and you do an
immediate placement and maybe you didn’t get as
good of initial primary stability as
what you needed to, but you went ahead and did it.
So probably, and then cases where
just for whatever reason, and sometimes it is totally
unexplainable why the implant fails.
Howard Farran: So if you were going to pull a tooth on me and you are
saying pulling
the tooth and placing the implant you
have had a history where sometimes that is not
the best idea. Would you pull the
tooth and let it heal up for how long or would you pull
the tooth and put in a bone graft?
Would it be real, synthetic? Would you harvest it
somewhere else? Talk about that.
Emil Verban: Well, if you were to come in and you had, say, a lower
first molar
extracted and it needed to be
extracted and the buccal plate was intact, you didn’t
fracture the buccal plate. And I
would say, “Well Howard, do you want to replace this
with an implant?” Oh yeah, I want to
replace this with an implant. “Okay, well if you tell
me, Howard, you want to replace this
with an implant, we will go back in in five weeks
and we will place an implant. But if
you can’t tell me that you are going to follow through
with this, then it would be good to
bone graft the site to give you the option for implant
placement down the road. But if you
commit now to the implant, we won’t do the bone
graft. You will save yourself $350 and
you can apply that to the placement of your
implant.”
Howard Farran: Okay, so first of all let’s say I can’t afford this until
next year. What
would you bone graft it with?
Synthetic, real, human cadaver? What would you do the
bone graft with?
Emil Verban: Well, I use a wide variety of products. I use a
demineralized, freezedried
bone. There is a product called
Encore that is a combination of mineralized and
demineralized that I use. There is
another product called Grafton. I have tried, there
are different manufacturers of the
bone. I don’t know if it is significantly different. I think
they all…
Howard Farran: For a lower molar, would you place a membrane? Would you
do a
bone graft and put a membrane?
Emil Verban: I don’t use a membrane unless I have to repair a fractured
buccal plate.
Howard Farran: Okay, and if you are not using a membrane, would you use
resorbable gut or a synthetic where
they have to come in and have the suture removed?
Emil Verban: It depends. If it is not an issue for the patient to come
back, you could
use silk, cheap silk if you wanted
to. Or you could use Cytoplast sutures or a nylon
based product. I don’t think that
whatever type of suture material you are using in a
situation like that you are going to
be able to look back a year later and say, “Oh, you
used silk here. You used a Cytoplast
suture here.” I don’t think you are going to be
able to tell that.
Howard Farran: Okay. So we are down to just eight minutes. What other
advice or
something that you want to talk about
that I am not smart enough to ask you to talk
about?
Emil Verban: Well, you know I have always been, and people that have
been on
Dentaltown and followed some of my
cases that I have put on, one thing that I have
noticed is, oh, ten years ago on
Dentaltown if you were a general practitioner and you
were involved in implant dentistry,
you were catching a lot of rift from the specialists that
you were involved with this. They
were trying to pin you to the wall, why did you do this
and this and that. So there have been
some heated discussions with various people
that the moderator basically had to
step in and calm these people down. So I think that
one thing that I have noticed on
Dentaltown and a credit to you and the whole site is
that now you are really seeing a
community of people that share ideas, that are not
excessively critical, not nearly as
critical as what they used to be towards each other,
because it is more of a sharing
environment and it is a tremendous place to learn and
learn from other individuals that are
willing to take the time. Because it takes time to put
the photos together and load them up
and do all of that. So for me, it is kind of like an
avocation almost. I mean, I really
enjoy doing it. I like the teaching aspect and I am
always willing to help someone else
get up the learning curve as far as the placement of
implants are concerned. But I think
that one, if an individual does not want to get
involved right away placing dental
implants, at least they have to be able to do surgical
extractions. They have to learn how
to section teeth, how to remove teeth without
fracturing the buccal plate. Even
getting involved in following Resnick’s posts
concerning wisdom teeth extraction,
because you have to be able to be extremely
comfortable working laying flaps if
you are going to get involved in implant dentistry,
because every case is not going to be
ideal where you have 10 millimeters of attached
gingiva and you can do a flapless
procedure. It seems like the people that have the
money don’t have the bone, and the
people that have the bone don’t have the money
for the treatment.
Howard Farran: I have not heard that one, that is a good one. And I want
to make a
comment about what you said about the
Dentaltown atmosphere. I feel that the single
largest mistake I made when I started
Dentaltown is I thought, “We are all dentists, we
are all adults. I would find it
insulting to go in there and edit your posts and tell you what
you can say and can’t say.” So I kind
of had the hands-off, Libertarian approach. And
Howard Goldstein had 30,000 posts and
he would just keep beating me up, beating me
up saying, “There are cyber bullies,
there are people that are just mean. And they just
ruin it. There is something wrong
with them. You need to get a report abuse button and
you need to kick this guy out.” And
finally, it took Howard a long time, and finally I said,
“Well, why don’t you sell your
practice and you do it?” And it was a huge commitment
for him, but he loved Dentaltown and
he was so committed to the community. He sold
his practice, he did it full-time. He
set up the report abuse and we are all struggling with
patients and insurance and bacterial
infections and Streptococcus mutans, the last thing
we need to do is eat each other. And
he has really turned the Dentaltown community
into one of a safe place you can go
and share and someone might pat you on the back
and say, “Great case. I might have
done this a little different,” as opposed to, “Dude,
you should never do an implant again.
You are an idiot.” You know, it is not what you
say, it is how you say it. And I have
been a big fan of your posts and a big fan of your
cases. How many implant cases do you
have on there?
Emil Verban: I don’t know, pages.
Howard Farran: Yeah, I mean, it is just amazing. And I want to personally
thank you,
seriously. I mean, you never got paid
a dime to post those cases. You put countless
hours of posting with love and
affection and sharing. And you often don’t get to see the
feedback, because you know I lecture
all around and these introvert dentists, 90% of
the people on Dentaltown have never
posted a single time. They are all lurkers. And
when they come up in a seminar and
tell me it is the greatest website, they name guys
like you by name. That is why when I
started doing these podcasts, I wanted to go with
the names that people are talking
about from here to Poland to New Zealand to
Tanzania. All around the world they
call you guys by your first name and it is amazing
what the Internet has done to the
learning curve of dentistry or take information from a
guy like you and have it in 220
countries in a minute.
Emil Verban: Well, thank you. Thank you. You know, I truly enjoy what I
do, even
though I am 65 and have been doing this
for 38 years. I still want to continue with what
I am doing, because you can never be,
you know, dentistry is trying to create the perfect
imperfection I say. And so you can
never be perfect at what you do. There is always
room for improvement. But this site
allows everyone, at least they can go to the site
and they can compare where they are
and what other people are doing and how they
got their job done, because there are
many ways to do things. There is not just one
way of doing it. So there are many
different approaches and you will come out with the
same end result with using a
different implant or using different membranes, different
grafting material. So there is a wide
variety of resources that you can use and you will
still come out with the same end
result.
Howard Farran: And the question that everybody wants to know, you are in
Illinois, so
are you, gosh are you a Cubs fan, are
you White Socks? Who are your teams out of
Illinois? I see you are flanked by
two baseball pictures.
Emil Verban: Well, I tell you what, my father played professional
baseball.
Howard Farran: Really?
Emil Verban: And I live halfway between St. Louis and Chicago. So my
father played
for the St. Louis Cardinals as well
as the Chicago Cubs. So I can go both ways.
Howard Farran: Wow.
Emil Verban: This year I am a Cardinal fan.
Howard Farran: A Cardinal fan?
Emil Verban: Yeah, but I like the underdogs, so the Chicago Cubs, they
are going to
be a team to be reckoned with in the
future. Although I did have a woman in my office
the other day that was 100 years old
and I asked her, I said, “Do you remember the last
time the Cubs won the World Series?”
And she said, “No, I do not remember.”
Howard Farran: Is Chicago the only American town that supports two
baseball teams
in one town?
Emil Verban: New York, you have the Mets and the Yankees.
Howard Farran: Okay. That is amazing.
Emil Verban: And in Los Angeles you have quite a few.
Howard Farran: They say in Chicago that they have two baseball teams and
one is a
baseball team and the other one is an
open bar where people just go there to drink.
Emil Verban: Yeah, that is Wrigley Field.
Howard Farran: Yeah, Wrigley Field, they say that is not really a
baseball stadium, it is
an open bar.
Emil Verban: Yeah, but you have the South siders, so there are the
White Sock fans,
and the North siders and Chicago Cub
fans. But Chicago Cubs fans are probably the
most loyal fans in all of baseball.
Howard Farran: Yeah, and that is in Wrigley?
Emil Verban: That is at Wrigley. If you ever get a change to go to
Wrigley Field, you
should go sometime.
Howard Farran: Okay. And on that note, thank you buddy for all that you
do for
dentistry and for Dentaltown.
Emil Verban: Well Howard, thank you. It was an honor sharing this hour
with you.
And truly if anyone has any
questions, feel free to private message me on Dentaltown
and I will be happy to answer any
questions.
Howard Farran: Alright, that is the spirit buddy. Thank you so much. Bye.
Emil Verban: Sure.
Bye.