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AUDIO - Danny Domingue - HSP #124
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VIDEO - Danny Domingue - HSP #124
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Howard and Danny discuss everything implantology, including whether or not you need a surgical guide.
Dr. Daniel Domingue was born and raised in Lafayette, LA. He graduated from St. Thomas More in 1999 and went on to receive his Bachelor of Science degree from Louisiana State University in Baton Rouge and his DDS degree from the LSU School of Dentistry in New Orleans.
While spending three years in advanced training at Brookdale University Hospital and Medical Center in New York City, he served as Chief Resident of the Dental and Oral Surgery Department. His training included one year in Advanced General Dentistry and two years in Dental Implantology.
During these years, he was awarded the Certificate of Achievement from the American Academy of Implant Dentistry for outstanding leadership in Implant Dentistry, a Fellowship from the International Congress of Oral Implantologists, and an Associate Fellowship of the American Academy of Implant Dentistry. Dr. Domingue was also awarded Diplomate from the American Board of Oral Implantology, the highest award possible for a general dentist practicing implantology. He was also recognized as the youngest recipient of this award in the entire world.
Dr. Domingue was later given a Mastership and Diplomate award from the International Congress of Oral Implantology for his outstanding work in Implant Dentistry. Dr. Domingue is a member of the American Dental Association as well as the Acadiana District Dental Association. He is also an active member of the American Academy of General Dentistry.
After completing his residency program, Dr. Domingue married the love of his life, Megan, in Denver, CO. They decided to move back to Louisiana to settle down, practice dentistry, and raise their family. On August 2nd, 2012, he and Megan were blessed with their first-born baby girl, Elle Ann Domingue.
After practicing for three years in Lake Charles, Dr. Domingue accepted an offer from his uncle, Dr. Smith, to become a partner in his practice. This proved to be a great opportunity for he and his family to move back home as well as to join his uncle’s practice and carry on a tradition established more than 30 years ago.
Dr. Domingue and his wife are excited to be back in Lafayette with family, friends, food, and the rich culture.
http://www.acadianadentistry.com
Interviewer: It is a huge honor today to be talking to my buddy Danny Domain. You have more initials after your name from certifications and post grad training but basically you're an implant maniac aren't you? Is that what you would call yourself?
Danny: Some would say.
Interviewer: Explain all those initials after your name. Tell them your education process on all the training you got on oral surgery and dental implantology and all that kind of stuff.
Danny: I graduated form LSU in 2007. I got into Brookdale hospital general practice residency program. Graduated after a year and they had an optional 2 year implantology fellowship so I stayed for another 2 years. That program was in conjunction with NYU and Dennis [Tornal's 00:01:01] program. We would place implants 2 days a week at the hospital, we'd go to NYU 2 days, and just sit and listen to lecture, and on one day a week we would restore the implants that we had placed and pot op suture removal, take out membranes, things like that.
It was an in hospital residency so we did have call on the weekends. While I was in residency, I joined the AAID, American Academy Implant Dentistry, and the ICOI, the international congress of implant dentistry. I placed a bunch of implants in residency, got to restore a bunch of cool cases. I took the test for the fellowship, mastership, and diplomat ICOI, passed and got those certificates and then I took the test for the AAID, got the fellowship and then the diplomat in the ABOI, which is the American Board of Oral Implantology.
I did all those cases while I was in residency and just submitted it afterwards, took the test.
Interviewer: Basically I want to answer, I'm going to throw some generalized questions at you a and see about them now. Why do you think in Korea and Germany, 3 out of 4 general dentists place an implant every month and in America 95 out of 100 general dentists do not. Do you think that's changing or what do you think about that?
Danny: I think more dentists now really want o start restoring implants. I'm in practice with my uncle, Dr. Smith, who you know. You've been good friends with him forever. He's built up a referral basis with a lot of general dentists. A lot of those general dentists like crown and bridge, they're comfortable with crown and bridge so they want to get the implant back with a custom abutment and they want to take a triple tray impression and seek the final crown and kind of keep it simple.
Guys getting out of school now, a lot of guys want to start taking their own impressions so they can bill out the fee for custom abutment. They want to torque in their own abutments. They want to contour the tissue now. There's more education for general dentists in America now than there was 30-something years ago and they want to build their practice around that. A lot of guys that are coming out of school want to take CE courses, they want to start placing implants. They're starting out new in dentistry they're trying to be the jack of all trades right now and trying to do as much dentistry as they can and then when they get busy enough maybe they'll say,"You know what I don't' want to do molar or endo, I'll refer that out." Or, "I don't want to do implants anymore because I have so much crown and bridge and I really like crown and bridge. Or I want to just do dentures."
I think right now a lot of my friends that are graduating are trying to do everything. Everything from 6-month smiles to Invisalign, and then figure out what they really like and then try to focus their practice on that eventually. Some people really want to get into implants but once they do it kind of makes them nervous or the complications associated with them, that makes them nervous. Some of them like that, they live off of that. They think complications, "This is my chance to learn something cool and I can fix it and if I can fix it ..." and they get more in tune to placing implants.
The fact that Korea is placing more implants, are there implants cheaper? I don't know. I have no idea why internationally they place more implants than the United States.
Interviewer: What do you think are the low hanging fruit lessons that every general dentists who starts placing implants, is going to learn after they've placed 100 that they didn't know before they placed one?
Danny: The biggest thing when you start placing implants is just getting the implant to fork out and making sure it doesn't fail. After you've placed so many implants I think the biggest thing is to start looking at tissue, to see how nice the tissue, to create a nice pillow on the adjacent tissue, get a nice big keratinized, make sure that when you place the implant you're a little bit more lingual, you're grafting the buckle defect and creating a nice crown emergence profile then working on your prosthetics with some custom abutments.
Some people are getting into scanning. People are doing a lot of scanning for custom abutments. I don't see a lot of people doing pre-fab abutments as much anymore. I think the cost for custom abutments has come down a great deal.
Interviewer: First explain what you mean by torque out? I'm always trying to guess questions. We're averaging about 5,000 dentists are going to be listening to this so I'm always trying to guess for questions. What does torque out mean?
Danny: Torque out, for initial stabilization for an implant you have to get the implant to torque in the bone and different implant systems call for different torque values. The system that I place the torque value is about 40 newton cm of force to get the implant to grab ahold of the bone before you can either put on a fixed temporary or put on a helium bone or put on a cover screw before you suture and close the case. You have to get some type of initial fixation of the implant. You can't leave an implanting there spinning. It has to grab ahold of something inside the bone so the bone eventually remodels, grabs ahold of the implant and then you get osteointegration.
Interviewer: What is your criteria on whether you would load that implant immediately? Immediate load versus no way. I'm going to bury it and come back and get it a few months later?
Danny: If the patient .. a good torque value that's the first thing. If an implant comes out really nice it's like, all right we can load this. If it's a single tooth implant and the patient had an open bite, it's a female, she's going to be really good about paying attention and listening to my post op instructions and not use the tooth to chew with for the next three months, then I'll put a fixed temporary on it and just say look, "This tooth is just for smiling. I don't want you to use this tooth. You can't chew with it." A lot of times I see phenomenal results.
It's those patients that forget or some guys just don't follow all the rules all the time and sometimes you have some bone die back. If you catch that early enough you can repair if, fix it, replace the implant. Then usually what I'll do is I'll put them in a different type of provisional. [crosstalk 00:07:45].
Interviewer: You have generalized that women are better listeners to the post op instructions than men?
Danny: I usually tell every woman that.
Interviewer: Yeah I have always seen that and I don't want to get in trouble with Invisalign or anybody but in ortho when you get some 12 year old kid with a booger hanging out of his nose and he hasn't washed his hair in a week and really? They're telling him to wear these trays, really? I just want to glue them on. I want to take every variable in ortho out for a male because they just don't care. A girl, she walked from here to Kathmandu if she thought she'd look prettier. You tell her what to do and she'll do it.
I'm trying to estimate, here's this dentist. They're listening to this, they're driving into work, they've got an hour commute. If you were going to tell them to ... and they thought, "I want to place implants." What would be your first step? How would they learn that? What system would they buy? How do you go from I've never placed an implant to now I picked a course, I picked a system, now I'm going to place one?
Speaker 3: I get that question all the time, or what CE-course can I take or what lecture should I go listen to? What I wanted to tell you, and I listen to some of your podcasts, this is a tremendous feature to have but there's so much free CE out there, when guys that are revolutionary guys that have done so well in their practices that produce millions of dollars a year and their CE is free online. You don't have to travel from Louisiana to Seattle, pay $3,000 for a course. You can just stay at home in your underwear, listen to CE and just hear some world round guy lecture. Dental Town, there's tons of stuff, videos now. These podcasts are tremendous.
I would say if you graduated and you're out, you're practicing, you're busy, I would say start out with trying to find a mentor in your local community that does place implants. Talk to him, ask him questions, see what system they're placing, what they're comfortable with. Go to some really good CE courses in your local vicinity.
The state and local societies usually have some type of CE course. Find out some good CE courses close to you and travel to those local courses and see if it interests you or piques your interest. Then if you want to spend some money and do some good CE, there's tons of courses out there, there's tons of books out there that you can read. I'm not trying to promote our course but we teach a course here twice a year in March and November. We have surgeries in the morning and lecture in the afternoon. Dr. Smith has 30 years of clinical experience and I have 8 years of clinical experience.
A lot of townies come to our course so you could come to this course if you wanted to. There's a lot of, Dental XP has a big symposium. I think you've lectured there right? I want to say you have.
Interviewer: Yeah I think. I've lectured all over. I just want to stop you on what you said. First of all your uncle is probably my number one role model on all things life, dentists, everything. He's just the greatest guy in the world and he's been telling me how smart you are since you were in grammar school. I think it's so impactful, our listeners to realize, how street smart he is. He's talking about, "You can learn this up online, you can learn it free, you can read the [inaudible 00:11:25] book." So many book smart people they're not street smart and they'll go to the missions like seven 3-day weekends and they'll spend a gazillion dollars and they didn't even read the book.
Danny: Never placed an implant. Some of those guys spend all that money and then they get scared and they don't place implants.
Interviewer: You could have bought the book for a hundred bucks and read it like you read it in undergrad studying for a physics test. It's street smart. Then the other thing he said that was so street smart is I don't know a single specialist in Phoenix, there's 3,800 dentists in Phoenix, a single specialist that's they're cool, they want a friend. If you call them up and say, "Hey can I come hang out with you and watch you do a molar root canal?" They're like, "Hell yeah."
Everybody thinks the endodontists isn't going to show you how to do a molar root canal because then you're not going to refer to him. Baloney, you just spent the day with him. Now he's your friend, now he's your buddy. Whenever you have a problem you're going to send it there. It's amazing how street smart all that stuff rolled off.
I want to throw another question at you. At the IDS meeting which is the big European meeting every other year in Cologne. They have it every other year, they just had it in March. There were 145 different implant companies selling titanium implants. How does your amazing mind, and some dentists are saying, "I want to buy an implant system." How do you even look at 145 systems? Are some better than others, do you buy on price? My whole motto with Dental Town is I saw the internet can solve one solution and that is no dentist would ever have to practice solo again.
This dentist was alone in his car, he's driving to work, he's looking at you buddy, he says, "There's 145 implant companies. Which one should I buy?" They don't want to own four systems.
Danny: Right. There's so many different and there's so many clones of those implant systems. I would say do one that's surgically easy to place and easy to restore. Some implant are better than other implants for different reasons. Some implant systems have wider diameter implant plants for immediate molar placement. In residency what we learned was the service technology of the implant system really affects the integration of implants. Surface treatment like laser lock for some implants or the design of the implant like platform stitching. All of those micro-geometry features of an implant greatly affects the way the bone heals around the implant. Those are all important factors to know before you ever purchase your first implant system.
A lot of guys will go out and say, "Well all implants integrate. This implant is $90, I talked to the guy, I'll just buy his implant system because they're cheaper than my friends and I'll go down on my cost a little bit and place a couple for free and help my patients out." That's one way to look at it. I would say do as much research as you can on what system out there has the best surface technology. A lot of implants are tapered, some implants are parallel, some implants have reverse thread patterns, some implants are very aggressive. I would say you really need to spend a lot of time educating yourself on the implant themselves, the technology, before you actually purchase your first implant system. I've probably placed maybe 18 different implant systems before I chose the implant system I was going to place. I know Gerome, my uncle has probably placed more than that, maybe 20, 30 different types of implants before he chose the type of implant system that he's placing now.
Interviewer: Do you and Gerry use the same system?
Danny: No we actually use different systems too.
Interviewer: Will you go through each one that you use and Gerry uses and talk about those too?
Danny: Yeah. I place Biohorizons.
Interviewer: That was the one founded by Carl Misch.
Danny: Yeah. I'm not a Misch disciple. I never even went to one of his courses. It was one of the implant systems that I placed in residency. For many different reasons and a lot of my friends place the implant. First of all it's a very aggressive, reverse buttress thread pattern. You get a good initial stabilization, more than other implant systems. It's got a nice tapered thread pattern which a tapered body you get a better initial stabilization than you do with a parallel mod implant. It also has laser lock which Jack Richie is the godfather of laser lock and we'll talk in detail of how epithelial cells will migrate down laser lock channels compared to implant systems that don't have a very organized array of linear channels.
Interviewer: Is laser lock a name of an implant or is that the name of ...
Danny: Laser lock is actually, it's talking about the first 2mm of the top of the implant. It's very fine laser grooves that are etched on the implant surface, so that the cells of the epithelium can attach to the surface of the implant.
Interviewer: That's the surface treatment of titanium?
Danny: Right.
Interviewer: Biohorizon has this?
Danny: Right.
Interviewer: What other systems have that?
Danny: Pretty much they have the patent on it so I don't think other systems have that.
Interviewer: Then you said reverse buttress. Explain what that means.
Danny: It basically looks like a Christmas tree but it swoops down and cuts in so that as the grooves engage the bone, it locks in and grabs the bone real hard. I think that was one of Misch's original ideas I believe so. Then the restorative platform for the implant is the other thing. It's an internal hexed implant. That's the most used platform prosthetically out of all the implant systems out there in the market right now.
Prosthetics are easy to find, they're less expensive, they're not proprietary to that implant system so you have to buy them form that company and Dr. Smith used to place Zimmer. They're Zimmer compatible and he has tons of restorative parts for Zimmer and he doesn't place those anymore so I get to use all of his old restorative parts if I need to.
Interviewer: Do you buy all of these implants online or do you have a local Biohorizon rep that is a big part of the value of this implant decision?
Danny: We have a local here. One of the girls in our office will just place a bulk order. They give us a discount if we buy a bunch of implants at one time. We use our local rep.
Interviewer: Does the rep add value? Are you a lot of times calling the rep and saying, "What do I do here or there?" Or is that not part of the equation?
Danny: I think some dentists do utilize their sales reps and ask them questions and things like that. To have somebody like that in your cell phone you can just call and ask a question to is invaluable. If you have a local rep in your area that adds value for a lot of dentists.
Interviewer: What does your uncle Gerome Smith, which one did he use?
Danny: Gerome uses [Anyridge 00:19:01] from [Megagen 00:19:02] implants.
Interviewer: Anyridge, that's the fat one right?
Danny: Yeah. Well they have, it goes from a 3-0 body, two piece to a like 8-0 diameter implant. Those things are huge but the body itself is real narrow. I think it's a 4, 4-5 something like that but the threads go out another 2mm on each side for the 8-0. It's a very aggressive implant. It's really nice for the maxilla because it compresses bone as you torque it out. He gets some very high torque value for those implants. He's seen a much higher success rate using those implants as opposed to other implant that he's placed in the past.
He does a lot of aggressive surgeries and he has very few failures. A lot of immediate molar placements, a lot of immediate in the anterior. It's such an aggressive implant in the mandible it's a little bit more difficult because the bone is ... there's more cortical bone, it's much more dense, so you have to use a smaller diameter implant as opposed to the maxilla where you can compress a lot of the bone.
Interviewer: Speaking of Megagen, one of the things I just saw them come out with that I thought was pretty crazily interesting was they had a little grinder for bone grafting. They had this little grinder where you put the tooth in there and you shut the lid and you turn it on and it just turns it to much instantly. It reminds me of the last scene of Fargo when that guy sticks that person in the wood chipper. Did you ever see that movie Fargo?
Danny: No.
Interviewer: You've never seen Fargo? Oh my God. It's still one of my top ten favorite movies of all time and at least half of my friends put Fargo in the top 10. Anyway it's just a great movie, it's in Fargo North Dakota. Anyway he puts it in wood chipper and he's got this piece of firewood and pokes it in there and it looked like a tooth chipper. He said that after it's all pulverized.
Danny: Oh yeah no. I did see that. I've recently, I haven't read the clinical study but I hear about the clinical study showing that actually helps bone remodel. I know what you're talking about yeah.
Interviewer: That leads me into another question, the one thing general dentists all do, most of us, is pull a tooth. Would you recommend getting ... should you bone graft an extraction site or not? Is that overkill? Is that only if you're really, really going to do an implant in a certain amount of time? Does it matter if you're talking mandible bone, maxilla bone? Answer this question. This lady's driving to work and she probably pulls at least 10 teeth a month. To bone graft or not to bone graft. That is your question.
Danny: All right so there's a lot of different variables. Basically if you have four solid walls. You didn't fracture the buckle plate and the walls of the bone have to be anywhere from 1.5 to 2mm in thickness. You don't necessarily have to graft that site. If you're missing a wall, let's say the buckle wall, then it's a very good idea to graft the site to prevent soft tissue invagination into your site.
I don't think it's terrible if you graft every single site in your practice. Sometimes it may not be necessary but I think a lot of guys want to CYA. If they're eventually going to place an implant in that area, they're going to try to put some bone, cover it up, make sure it's perfect, so that when they come back to place an implant the site is a nice big, fat, wide ridge and they're not having to deal with buckle bone, invagination, trying to place an implant and graft over it and then trying to do all these difficult surgical procedures to fix the site.
Interviewer: Go into detail. This person listening to you right now on their iPhone, in their car, driving to work, has never bone grafted an extraction tooth. Tell them how to do it.
Danny: What we do is they take the tooth out. We usually curette the socket and make sure there's no tissue in the socket and sometimes we rinse with micro-sand often. It's just a broad spectrum, anti-microbial rinse. Now you've got this nice healthy bone and a lot of bleeding points and we mix our, we usually use a mixture of cortical cancellous 50/50 small particle mineralized freeze dried bone to allograft.
We mix that graft material with fusion. Fusion which I'm pretty sure you're familiar with and it's been talked about on the message boards forever, basically it's calcium hydroxide with carboxyl methyl cellulose and whenever you mix it with genomycin or any other liquid it forms this doughy consistency and you can mix it like a graft and it's kind of like a carrier. You can kind of just shove it into the socket, place your membrane on top and suture over.
A lot of guys will just place dry particulate graft inside of a socket, you'll just as the blood comes out you're packing bone in and the blood's pouring out and you're packing bone in. This fusion helps form a coagulation in the socket. Once you shove it into the bone, once you shove the bone graft into the socket it doesn't float out.
The blood's not hydraulically pushing that $150 graft material that you just bought. It stabilized the graft material, it's a nice carrier and you actually use less bone whenever you mix it with your freeze dried bone allograft. Then you just place the membrane on top. A lot of times when you use those new membranes from cytoplast the PTFE membranes, they're singlets, you can buy them directly from cytoplast and we suture with a cytoplast suture.
Let that heal for two weeks, take the sutures out, let the membrane stay in for another four weeks, take the membrane out. Usually I have a different shaded epithelial cells. That will keratinize in about another 6 weeks and then we'll take a CT scan at that point, measure the houndsfield units on the CT scan, make sure the bone is ossified enough, and get the patient in 3-4 weeks after that to place an implant.
Interviewer: Danny I cannot tell you, if you would make an online CE course on Dental Town for one hour. In all reality you just said so many things, so many brand names, so many things. The dentist listening in the car is thinking, "I can't do that. That's over my head." That's one of the reasons 95% of dentists won't do this.
I swear to God if you would make a one hour online CE course, just on bone grafting and hopefully that would be the first of many courses you made us over the years, but that would be so invaluable.
I want to ask you another question that I hear on the message boards that I almost see as some type of tribal racism. If a dentist uses mini-implants, these almost like back 1970 smoking pot or something. Everybody's out at the party drinking a beer and having a shot of Jack Daniels and the guy smoking pot behind the tree is the bad guy. It just seems like if someone has a full denture, it seems like the only thing you can talk openly about is if you put in big root forms and do a big $50,000 re-ap.
If you get them in there and you put four minis in the mandible and six minis in the maxilla and make grandma's denture a lot better fitting, you might as well just say, you're gay and you smoke pot. I sense that. On Dental Town we had to separate, under implantology, we had to separate implants from minis just because nobody can post a mini case without some big old guy with all these initials after his name saying, "You should have done..." is it fair to say everything they talk about beating their chest is a $50,000 full mouth Porsche and this guy was just trying to help grandma for $5,000 using her existing dentures.
What do you think about what I just said?
Danny: I think there's a place for mini implants. I place some of them in my practice. I haven't placed a lot of mini implants. There are indications still that you can use a mini-implant. I've used them where the patient was congenitally missing a lateral incisor, the central and the canine were very close in proximity. The patient just got out of ortho, the mid-line was on, the space available for that lateral #7 was the exact same space as the contralateral #10 and you can't put a root form implant in that space. They don't make that small of an implant so you have to go with a mini implant.
Interviewer: That is probably the only indication for a mini implant for a singe tooth replacement. I'm talking about just for the 31 million Americans who wear full mouth dentures and they don't have ... If I came into your office and I'm a 65 year old grandma and say I've been endentulous for 20 years and you are going to rebuild my mouth with implants and fixed bridges. How much would that ball park cost me?
Danny: Let me go back to your first question because I want to answer that first. You're talking about is there still an indication to place mini implants in the mandible and maxilla ...
Interviewer: For fully endentulous people, for full dentures.
Danny: And then put in their existing denture. I don't want to say anything, I don't want to make any assumptions about mini implants or the people that place mini implants. I don't place mini implant in my practice. I've had an indication where the patient didn't have any bone and Misch's argument is, "Well if they don't have any bone why would you put a small implant? Why don't' you build a bone and then place a large diameter implant?" Then the cost goes out of the roof and a lot of patient's can't afford that. A lot of patients don't' have Carl Misch's budget. They don't have that type of finances.
If the guys placing mini implants to help mom and pop get by with their lower denture I don't see anything wrong with that. I do see some extreme cases where people are placing mini implants in these tremendous ridges and then doing full arch rehab on these mini implants.
Interviewer: You mean fixed?
Danny: Yeah fixed.
Interviewer: But no one's recommending that. Wouldn't you say?
Danny: I wouldn't recommend it. Yeah.
Interviewer: I guess what bothers me in this big, great country of ours with 330 million people that for every market that can get a dozen root forms and fix bridges, that's the Cadillac. There's 10 people who can only afford a Chevy or a used car. I just don't see that market segmentation being offered to consumers. I basically see dentists as a car lot that says, "Hey we've got a Cadillac. That's it. You don't want a Cadillac, go home." Then in Louisiana they'd have to sell their $70,000 bass boat, there are people in Louisiana who's bass boat costs more than their car. Would you agree with that?
I also want to ask you another question and I just find this bizarre and I've had a lot of dentists ask me this. The largest dental company in the world is Danaher and it was just kind of weird. They bought a high cost Noble Biocare and a low cost implants direct. I'm just wondering, why would one company own a high cost/ low cost. Is it kind of like GM where they have a Cadillac, a Buick, an Olds, a Pontiac, a Chevy?
Danny: They want to appeal to the masses I guess. Noble Biocare has some very expensive implants, very expensive restorative parts. They're kind of like an elite group of, "We're Noble Biocare, we carry the premium product." Implant direct [Nisnit 00:31:47] came out and he's like, "Look. I can provide you with everything they're providing you for a whole lot cheaper."
He was a genius business wise to create that type of model which I don't' think a lot of people have done that large before. Why did they go and buy up? I guess to appeal to everybody. Everybody from the specialists to the general dentists to the endodontists that wants to place an implant. Strauman just bought out Megagen in Korea.
Interviewer: Megagen just got bought by Strauman?
Danny: In Korea. I think they sold their US division too to some private entities. Now Strauman owns their implant system which is the SLA active surface and they're very proud of that. Their bone level implant and their tissue level implant.
They also bought this Korean company for the Korean market and it's a totally different implant. The thread design, the restorative platform, everything's totally different. I guess that's their way of trying to get into the Korean market.
You've been to Korea. They've got to ave a very strong implant market right? They have tons of [inaudible 00:33:00]. How do they get things to market so fast? How do they develop products so fast and get them to market?
Interviewer: My guess on that is those guys will first own a dental hospital, it'll be like a 10 story building where it's like 3 floors of general, then a floor of endo, perio, pedo, prosso. They already own this massive dental office that's 10 stories high with 100 docs working there. Then they'll start an implant company like Megegen and their own in house doctors can place a thousand of them and restore them and brainstorm.
I don't thing 3M owns a dental office. I don't think Noble Biocare owns a dental office. I think the Koreans are very smart in the fact these big companies are owned by some big dentists that have 100 dentists on the payroll so it's just faster.
I want to ask you about this, you talked about custom abutments. You talked something about scanning implant fixtures to fabricate custom abutments. What's all that mean?
Danny: You know Saroni came out a long time ago with [Serac 00:34:11] where you can scan a tooth and you can make a crown in your office. E-max crowns, things like that. Now what you can do with Saroni and other companies like free shape or Iterro, you can scan a implant to make a custom abutment or even a final crown or even a screw down crown.
Now if a patient comes to our office we don't take a fixture level impression anymore with impregum or any type of polyvinyl impression material. What we do is we take the helium abutment out, we scan the tissue around the implant by forming the adjacent teeth, then we scan the opposing arch. Then we place a implant scanning abutment, we screw it into the implant and then scan that. Take it out then scan the patient's bite. All that takes about chair time by the time the patient sits down, type all the information out, scan the patient, put his temporary back in. It's a 30 minute appointment in our office. I usually just go in the room, tell the patient hi, walk out the room and the dental assistant does most of that procedure. With that digital file it gets emailed out to our lab and that file computer generates a custom abutment based on the tissue emergence profile and then it can create a tooth or a temporary or a screw down crown or you can create a bridge on implants.
What we use is we use three shade. We use their trio system and now we're making custom zirconium abutments, basically we're not doing pre-fab anymore we're doing all custom. We do custom zirconium abutments. As soon as I scan that patient it gets emailed and the lab receives it within 5 minutes.
Interviewer: What lab? Be specific?
Danny: We use DDX in Jersey. You can type in DDX USA and there's a [inaudible 00:36:25] that owns it and his name is Jonathan Kang. I've heard him lecture before. He's a great prosthodontist, he does a lot of ...
Interviewer: K-A-N-G?
Danny: Kang. Yeah.
Interviewer: Can you email him and CC me Howard@dentaltown.com and tell him I'd love to interview him?
Danny: Yeah absolutely.
Interviewer: That would be a great follow up to you.
Danny: Yeah.
Interviewer: Tell him that your next crown should be free since you just set him up an hour long commercial for his lab.
Danny: Okay. Basically his lab tech Andrew gets the file and the computer pretty much does most of the design work, he'll make some modifications if he sees necessary and then he'll email me the work up. On my email at the end of the day I'll go through all of my scans that I did and say, I want the contacts of that crown to be wider because she's always complained about food entrapment or the tissue kind of fell in a little bit I want you to make that abutment real thicker and push the tissue out or I'm referring this back to the dentist and he does a lot of serac crowns so I want wide margins to be 2mm shoulders on that custom abutment.
There's so much you can do in the software and then they just mill out the abutment and they mail it back to me. I get it within a week, week and a half.
Interviewer: That's Jonathan Kang and he's the orthodontist at DDX lab in New Jersey right?
Danny: Right.
Interviewer: Then you said you use three shape what? Three shape trill?
Danny: Trios.
Interviewer: Trios. But the other system was Iterro?
Danny: Iterro has one system too. I think Johnathan Kang actually owns that system.
Interviewer: Uses it or owns it?
Danny: I think he owns one in his office and he scans his implants with it.
Interviewer: You like three shape?
Danny: It's faster. It's a faster system. I did a lot of research when I went into the flap. There's another system called ZFX, I think Zimmer owns part of that system. 3M has a scanner now. Serac they have one now. Out of all the systems out there, out of all the open systems out there I was told that three shape is the largest in most labs. They have the biggest footprint in most labs across the globe.
I still think that's true because a lot of labs I've talked with use their software, have their inbox's. They get the file that day, they get the scan that day. In our office we mostly just use them for implants but you can use them for crowns, you can use them for bridges. It's actually easier to scan if you don't have crowns or bridges.
Interviewer: Are you restoring any or do you only place implants?
Danny: If the patient finds out about me through a friend that I placed implants for they come to my office and they don't have a dentist, they're not seeing anybody currently, I'll place the implant for them and restore the implant for them.
If it's a patient that's a patient from one of my friend's practices and they refer them over here for the implant placement, it's a strict policy that we just place the implant and we refer the patient back with a custom abutment and a temporary.
Interviewer: You just set yourself up for this next trick question. If the implant's angled wrong, the restoring dentist says that the surgeon placed it wrong and the surgeon says that's where the bone was. Who's right? Is this implant in the wrong position because that's where the bone was and that's the only place I can put this implant or you place the implant then restore the top or do you design the top crown down and then put an implant underneath it?
Danny: The most important aspect of placing an implant is to place it properly in the bone. If you don't have the bone then you need to grow the bone. That is a very ... if you're talking about single tooth implant, that's a very easy, very predictable procedure. You just do an on length graft or a veneer graft to try to restore the bone in that area. Then you can place the implant properly. I think placing the implant in an unrestorable site it makes it more difficult for the restorative dentist so I think trying to plan the case and growing the bone and putting the bone where it needs to be. If you can't grow the bone and you can't get the implant in the proper position and the restorative is going to be compromised, then I think you need to start looking at other ways to restore the case like crown and bridge or anything. Just something other than placing the implant in the palate or ...
Interviewer: This girl is driving to work today and she's thinking of this case that maybe this would be a good implant case to refer to you to place implant and she wants to restore it. She's sitting there driving to work thinking, she's fat, she's obese, she smokes, she's got a smokers cough and I always see her at the bar every night after work. What medical implications would you say, "Nah. That person shouldn't have surgery" or can you just put them in that chain smoking, diabetic, alcoholic?
Danny: If the patient's an uncontrolled diabetic there's no reason to place an implant. You really should get the patient controlled medically before you place an implant. If the patient is taking IV bisphosphonates and their CTX value is out of range then its probably contraindicated not to place the implant because you run the risk of osteonecrosis.
I would check the A1C value for diabetic patients if they're not controlled and the CTX values for the patients that are on bisphosphonates and find out what their level are. If they're within normal range there's no reason why you can't put an implant on somebody that may be diabetic but they're well controlled.
Interviewer: What about a heavy smoker and a boozer?
Danny: If I didn't place implants on people that smoked I probably wouldn't be placing implants right now.
Interviewer: You'd be working at Kentucky Fried Chicken at the drive through.
Danny: You can tell people who smoke.
Interviewer: It's kind of a catch 22, the people who lose the most teeth usually have perio, gum disease, smoke, don't brush or floss. It's not like Mrs. Healthy Yoga instructor lady is coming in for implants it's always their cousin big Bertha.
Danny: That's a risk factor. Last week I placed an implant on a guy that had been smoking, he's 45 years old. He's been smoking for 25 years. His wife said he will never stop smoking. I just told him, you run a risk of these implants failing. For him to have these teeth taken out it was a personal issue because he never wanted to have his teeth taken out, because his father had his teeth taken out and he swore he'd never be that guy one day.
He actually stopped. It's been a week so far and he hasn't touched a cigarette in 25 years. That's tremendous. I just think it takes will power and that person, those are rare cases. I don't expect everybody to stop smoking but I will tell them the risks of ...
Interviewer: They'll quit one day. I guarantee you they will quit one day. Sooner rather than later they'll quit.
Then also I know this is an old question but I still hear it. What about placing a 3-unit bridge from an implant to a natural tooth? What would you say to that person. They're missing a bicuspid. You get this question it's a 3-unit bridge and one end's an implant and one end's a tooth.
Danny: Smartest guy to talk about and have this conversation with is a guy named Gary Greenstein. He's a periodontist in New Jersey, I think Eaglewood Cliffs, New Jersey. He's a very bright, well written periodontist and he does a lot with a guy named John Cavillero, John is a prosthodonist, John practices in Brooklyn, New York.
They tag team, they do a lot of research together and they publish a lot of papers together and they've lectured all over the world. We've seen failures whenever you tie implants that don't have a periodontal ligament to natural teeth. Being in this practice Dr. Smith has cases from 35 years ago that originally you could tie implants to natural teeth. I still see some cases that have lasted 20 years.
What are the reasons for those? Why are those cases successful and in some cases just have a terrible failure rate. If I can place two implants and put an implant bridge I prefer that over tying ti to a natural tooth. I've only been in one instance where I couldn't do that. I did tie an implant to a natural tooth.
There's certain rules that you're supposed to follow if you actually do that, and I'm not saying I advocate tying implants to natural teeth, because I've only done one in 8 years. I had no other choice than to do that. Gary will elaborate this in his tremendous fashion. Everybody on Electro-circuit talks about there's a 16% failure rate whenever you tie implants to natural teeth. The fact is is most research papers out there, matter of fact all research papers out there if you actually read them, there is about five papers that show there is a roughly 5-7% failure rate.
There's one paper by Mike Block that shows a 20% failure rate whenever you tie implants to natural teeth. I don't' want to get anybody's panties tied in a know but the difference in those two papers are, Mike Block cements his crowns and those permanent restorations with a temporary cement. All of the other papers that have a higher success rate and lower failure, cemented with a permanent cement. Also come of those papers that had a higher success rate only tied natural teeth to implant in say the anterior segment where the canine, let's just say the canine was an implant and the central incisor was a natural tooth or the lateral was an implant and the central ... that's a different story than tying a first molar to a third molar and trying to make that bridge work.
Also Mike Block used a lot of semi-attachments, I don't really do this in my practice but basically a dove tail design where the implant is permanently cements and then they dove tail to a natural tooth, they start to see the failure rate was like a car jack. The natural tooth would be extruded out of the bone. I've actually seen that on some cases where that's been done. That was a failure of tying implants to natural teeth.
To answer your question I don't do it in private practice but if you do read the research you'll see that there isn't a tremendous failure rate on doing that procedure. Actually the highest failure rate in doing those procedures are recurrent decay around natural teeth or the natural tooth needs an endodontic procedure, or which happened to me in the only case that I actually did, the endo tooth became re-abscessed and had to be retreated and then I had to redo the bridge on the natural tooth to the implant. I was scratching my head saying the implant didn't fail, did I cause the damage to that natural tooth? Would it always have re-abscessed. The failure rate is always within the natural teeth.
Interviewer: If you're saying that that's an amazing point. That the failure rate is always going to be that you tie it to the natural tooth. Then what I want to ask you is why do so many intelligent dentists when a person is missing a tooth file down two adjacent natural teeth and do a three unit bridge instead of a titanium implant. What do you think of that decision?
Danny: A lot of people don't practice in Phoenix Arizona. 90% of the population practices in small rural areas. We have people in south Louisiana that have to drive an hour to come get a dental implant. Why would they want to drive an hour if they just, "Hey I just want that tooth back. Can you just put it in for me? Why do I have to drive an hour, be sedated, get an implant, it's going to cost X amount of dollars. It doesn't make any sense to me, I just want a tooth. Why don't' you just shave down that tooth?" That makes more sense to some parts of the population.
Crown and bridge is still very successful but the 16% of the failure rate of crown and bridges is recurrent decay.
Interviewer: What percent?
Danny: I think it's 16%. Misch talks about it in his book. That's the first time I've ever read it. I think it's like 16% of the failure rate of crown and bridge is recurrent decay. That's a good indication for my why I wouldn't prefer bridge. I don't really do bridges anymore but some of my friends still like crown and bridge, they still enjoy and that's what they love doing in their practice.
Interviewer: I want to ask you another restorative question and I hear this a lot. You have two implants right next to each other and you could restore two single units. I don't want to feign expertise about laws of bridges and things like that that Misch talked about that the stronger geometry if it's one force. If you had two implants, same time, when you restore those would you sink a two piece bridge to connect those or would you make them two singles?
Danny: I get that question a lot too. It depends. Is the patient a bruxor? If so he's probably putting more forces on those implants. Are the implants placed in the mandible or are the implants placed in the maxilla and they're very short implant and you had to place short implants because there wasn't a lot of bone? You couldn't do a sinus lift, the patient didn't want a sinus lift. Are they placed in the mandible right next to the inferior ovular nerve and you couldn't do a vertical augmentation, you were stuck with the bone. They're short implants so you want to fuse the implants to increase the strength.
Is it a 90 years old woman that has an upper opposing maxillary denture and you place a 5-0 x 12 mm implant? Obviously I wouldn't split those implants. Does the patient have good oral hygiene? Are they going to floss? If they're not going to floss then I guarantee you they're not going to water pic underneath that fixed bridge. The reason why they lost that tooth is probably because they didn't floss. Probably they're not brushing their teeth they're not going to floss.
I don't often split implant crowns together in the posterior. Oftentimes patients tell me, "If I'm going to get two implants right next to each other I want to be able to floss between them." Whether they do that at their home or not I don't know but patient's want the ability to floss between the appliance.
Again going back to what I said, if they're short implants, if the bone is very porous bone, a very weak bone, if the patient is a bruxor, he's a big guy, big jaw, grinds all of his teeth, all of his teeth are real short. He's always breaking a tooth off at the gum line, for sure I'm going t want some extra support and maybe splint those two implant crowns. We know that two is stronger than one. The two implants will be stronger together but there's also other research studies that show that if you splint the implant crowns together that doesn't increase the success of the implant, it does strengthen the crowns of the restorative procedure against the opposing teeth.
The answer to that question is sometimes yes I would, sometimes I wouldn't. I would tell you this, I would in that case make a zirconium crown.
I'm doing a lot more of this and I really need to post a case that I did recently on this lady who had rampant decay on all ... she's had thousands and thousands of bridge work done, endo done, tons of restorative and she was very unhappy with her smile. Very pretty woman but just didn't like the way she looked aesthetically. All of her teeth were crap, the bridges were failing. We took out all of her teeth, we put in a bunch of implants and we did a full upper and full lower, monolithic zirconium bridge. We were able to screw retain the entire bridge. The results were just beautiful.
She's a grinder and I'm not going to put a zirconium core with layered E-max on top because that patient is going to be coming back in with chipped porcelain. That's a very expensive restorative case and I'm not going to be putting PFM bridge on it because one of the biggest failures I see in practice is chipping porcelain, prosthetically. The patient's got an implant they can put a lot more force on it so they're going to be chewing a lot more on that one tooth. All of a sudden the porcelain chips off. The patient calls and says, "My crown's broken."
If it's in there proximal you've got to cut the crown off and do the whole crown over for them for free if it's within a certain period of time. I've moved a lot of my restorative procedure from PFM to monolithic zirconium and just staining the zirconium.
There's a new zirconium called cube X I want to say it is ...
Interviewer: Right.
Danny: Next time you talk to John Kang you ask him about it but it's a multi-layered monolithic zirconium.
Interviewer: Who makes that? Is it [inaudible 00:55:06]? It's Cube-X.
Danny: I think it's called Cube-X if I remember correctly. The aesthetics are just tremendous but right now we're only limited to only doing three units. Up to three units. You can do like a 3-unit anterior bridge.
It's a little bit more expensive restorative material because it's brand new, so you can't do a full arch like we did on that one lady. I'll post that case. I've been meaning to do it before I got on this podcast.
Interviewer: I wish you would. I think you are just amazing. I really do. Just amazing.
Danny: That zirconium it's 100 millipaschals of strength. That's super strong. E-max I believe is 300, PFM is what 100 millipaschals. The bite forces that some people can put on their... what was that strongest man? He's a Guiness book of world records, how much did he bite down? It was like 500 millipaschals of bite force. He's a weight lifter.
Interviewer: He must have been a Russian.
Danny: He was Canadian.
Interviewer: He was Canadian. Canadian hockey player, Russian weight lifter, same thing.
Danny: Yeah so I switched a lot of our restorative material to monolithic zirconium.
Interviewer: It's kind of funny being 52 because when I got out of school it was the revolution of going from gold to PFM and I just didn't see it coming the death of PFM. It's just really plummeting. You talk to labs and a lot of labs will tell you that over the last 10 years their PFM market is down 65% all being replaced by zirconium.
Danny: Wow.
Interviewer: Is that what you're really recommending is just zirconium?
Danny: It has great properties and to do it on the three shape I don't really dust the occlusion very much. The crowns just seat in real nice, there's not a lot of occlusion abrasion or adjustment contacts. The three shape we have is so precise it's really nice. Again we're also doing screw retained crowns. I mentioned this earlier but a screw retained crown is basically a monolithic crown and the base of the crown is titanium. That screw into the implant so that's the internal hedge platform. That gets luted to the zirconium core crown. Do you follow me so far?
Interviewer: Yeah.
Danny: There's different types of tie bases and the tie bases are ... every different implant system has a different type of titanium base. It's important for listeners to understand this, the long the titanium base is, the more tension you get. Also if the labs sandblast it with the micro-etcher, you get more retention before you lute it. They can also sandblast the zirconium core before they lute it.
If they have a flat surface to the titanium base, it's easier for the clinician, if they ever come unluted, which I've had it happen to me before, you can easily put it back together and re-lute it in your office with a rely-X type cement. Then if they taper, it's also more retentive and if they have these microgroup channels it becomes more retentive. A lot of the older titanium bases that I used to see, were shorter, polished, not tapered, didn't have a flat side. They were a lot more difficult to lute back on the final crown. Now that we have them like 6mm and 8mm titanium bases we can screw retain a full coverage crown in the anterior, premolar, posterior molar. We're doing a lot of screw retained crowns as well.
I see failures in where the luting cement becomes unluted and you have to cement it back in your office, I see the failures in shorter titanium abutments or abutments that weren't sandblasted or abutments that don't have microgrooves, or abutments that don't have that flat margin where you can easily orient it.
Interviewer: Last question and this is the most controversial question out there right now. You can't get his question right no matter how you answer it you're going to be wrong. You have two massive camps. One camp says, "Oh you should have access to a 3D, CBCT comb beam and you should make a surgical guy." The other camp who tends to be people who've placed thousand of them said, "No." We're talking just single tooth replacement where there's a tooth in front and behind. Remember in [inaudible 01:00:10] bridge, 95, 96 out of every crowns sent to the lab is for one crown and implants are placed 95% of the time one at a time for a single replacing tooth.
The surgeons are saying, "No. You don't get a surgical guide. You're not Stevie Wonder. You need to learn how to be a surgeon. You've got a tooth in front, a tooth behind. You're a doctor, you're a surgeon, you need to learn how to lay a flap, look at the bone, you might need to do something to that bone. If you're just going to snap on a surgical guide and sink a drill through a hole you're not a surgeon." You've got people that are fanatics on both sides. There are oral surgeons, like Jay Resnik, he uses a surgical guide every time. There are oral surgeons who haven't used a surgical guide one time in 10 years and will scold you if ou talk about going down that route saying, "You don't need training wheels. You're not Stevie Wonder, you're not Ray Charles. Learn to lay a damn flap and look at the bone. You've got a tooth in front, behind."
How do you weigh in on that? You're talking to a 30 year old dentist driving to work who's never placed a single implant.
Danny: I think it's fair to say that everybody that gets into implant or wants to get into implant you need to be comfortable with first of all incision design, second of all you need to be comfortable with laying a flap. When it is indicated to make a [inaudible 01:01:28] incision versus a [krestyl 01:01:29] incision. Where is it indicated to make vertical releasing incisions? When should you make those vertical releasing incisions past the mucogendible junction?
You need to be comfortable with making those decisions at the surgical visit and you need to be comfortable with laying a flap period. I think everybody that places an implant in dentistry, I think it's fair to say that if you get into a troubled situation that you need to be comfortable with laying a flap to remove the implant if something happens or to graft the site or do anything. I think that's fair to say.
Getting a comb beam CT scan for every patient, I think it's fair to say, makes it much easier for the implant dentist to place the implant because you know where the bone is. You know the bone, where it is, how much you have, how thick it is, how close you are to the nerve, how close you are to arterial blood supply, where the sinus is. I think it's fair to say that if you have all that knowledge before you walk into a case it becomes much more easy for the implant dentist.
A lot of guys will say, "Well I've been placing implants for years. I just use the Panrx. Use a little 5mm ball and I just take a Panrx and I can figure everything out." That's good but I don't' think they would dispute or argue that having that comb beam ahead of time and viewing the amount of bone that you have before you walk into that case and make an incision, is tremendous knowledge and makes it much more predictable for you before you lay the flap to say, "Well I want to make my flap a little bit more lingual because the bone's a little bit more lingual or I don't have a lot of soft tissue or a lot of keratinized tissue so I'm going to make the incision more lingual and bring that tissue over to the buccal."
I've used surgical stints before. Lab fabricated, I've used surgical stints that are made off a CT scan and a lot of my friends that are just tremendous clinicians swear that every implant should be placed with a surgical guide. That's fine if that's what they're comfortable with in their practice and that's what they want to do in their practice.
I've seen failures in surgical guides that I've made, I've seen failures in surgical guides that other dentists have made where the surgical guide didn't either help them very much, it might have actually hurt them or if the guide wasn't actually placed properly to begin with maybe that was a mistake. I've seen that situation happen before where they couldn't get the guide in properly, it was too tight and they were trying to push down, the patient got uncomfortable so they just said, "I'm just going to go in and start to drill this." They were too nervous to lay the flap and they got into a little situation.
Interviewer: This person listening to you right now in the car and they're pulling up for work and they're saying, "Hurry up Howard, you said it's an hour and it's already an hour and three." If they were going to place their first 10 implants would you say use a surgical guide or not use, for the first 10?
Danny: In my residency I was taught you have to lay a flap and visualize the bone, just to get an appreciation of that's where the bone is clinically. That's just how I was taught and that's how I would teach somebody if they came to our course or they came to ask me questions or emailed me personally. I would say lay a flap on your first 10 cases and visualize the bone and see where the bone is. What I would also say is have a CT scan ahead of time to make sure that there's enough bone before you put that implant in.
If you have any questions you're welcome to email me. My email is danny@geromesmithdds.com or my personal email is domain.danny@gmail.com. I'll email you back and give you some help if I can help you out in any way. You're welcome to come to our course if you want to. Our next one's in November.
I would definitely say for the first 10 cases you have, take a CT scan, read the CT scan, know what you're getting into before you get into it. I think anybody that's been placing for 30 years would tell a new beginner that's the first thing you should do is try to get as much clinical data as you can before you actually see the patient. Then if you're comfortable laying a flap and place an implant and be smart about it. Place the correct size implant, try to get in the center, don't get too close to the adjacent teeth. Things happen in surgery sometimes and you can get close to a side tooth or go too far lingual or too far buccal, but being able to correct that after the surgery and correct your mistakes is very important too and that comes with time.
Interviewer: Well Danny we are out of time, overtime. I just want to tell you I cannot tell you how much I think about you and your uncle and I can't tell you how many times over the years people have told me, "Well you can't place implants in my area. I'm in a poor part of Nebraska." I'm like, "Dude I know a dental office in Lafayette Louisiana that places more implants every month than any office I've ever seen in my entire life." A lot of people, myself, even Sammie Purdue, many people will say that they think of all the offices they've ever seen in their life yours is the most well run, most organized, highest quality, happiest staff. I just can't say enough.
I really hope, I don't want to put a lot of pressure on you, I really start hoping you build some online CE coursework because I can't think of anybody I'd want to learn from more than you.
On that note I've got to go.
Danny: I appreciate it. This has been great. Thanks for the podcasts, thanks for putting all the [inaudible 01:06:58], thanks for going Dental Town. You've been an awesome inspiration for so many different dentists around the world. Aren't you also the most well know dentist throughout the world?
Interviewer: I'm only a legend in my own mind.
Danny: You're the nest. I appreciate it.
Interviewer: All right thanks Danny. Thank you very much. Bye, bye.
Danny: Bye.