Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

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Howard Farran:

It is a huge, huge honor for me today to be podcast interviewing Dr. Samuel Lee who is a DDS and Doctor of Medical Science, a DMSC, from Harvard University. Let me start with your bio, Sam. You are an amazing man. I can't even believe you are only thirty-nine.

Dr. Samuel Lee has earned double doctor degrees in dentistry. He has earned Doctor of Medical Science four to five years full-time doctoral degree from Harvard University, and Doctor of Dental Surgery four years from UCLA School of Dentistry, is a diplomat of American Board of Oral Implantology/Implant Dentistry, and limits his dental practice in implant surgery and orthodontics. After completing his Bachelor's Degree in Microbiology and Molecular Genetics at UCLA, he continued his studies at UCLA's School of Dentistry for his Doctor of Dental Surgery Degree. While attending dental school, he has taught biochemistry for three years.

He loves teaching and enjoys developing new technologies. As a dentist, he practices implant dentistry and orthodontics in a private practice in Buena Park, California for seven years. He and his family moved to Boston area to further his study at the Harvard School of Dental Medicine for a specialty certificate in peridontology and to earn Doctor of Medical Science from Harvard University. Currently he concentrates on research and development dentistry and he runs a private practice in Burlington, Massachusetts.

He has won the first place table clinic presentation award at many prestigious organizations, the 2008 American Academy of Implant Dentistry (AAID), the 2007 American Orthodontics Society (AOS), and the 2007 International Congress Oral Implantologists (ICOI). He is an inventor of the crestal window sinus grafting technique and owns the patent on his sinus instruments. He currently teaches internationally on his sinus techniques and TAD to specialist general dentists and dental schools. He also developed a new method of dental x-ray and he owns the patents related to this technique. He is the president of the International Academy of Dental Implantology and focuses his career on teaching and research. Sam, you are an amazing man. Just an amazing man. My god! Do you ever sleep?

Samuel Lee:

Thank you. Thank you, Howard for kind introduction.

Howard Farran:

What made you so interested in implant dentistry? What got you motivated to go there?

Samuel Lee:

To be honest, when I graduated I wasn't even sure whether dentist was a good career, but I began working for a general dentist who has been placing implants since 1976. His name is Michael Kwon in Los Angeles. While working with him ...

Howard Farran:

How do you spell it? Michael Kwon?

Samuel Lee:

Michael Kwon. K-W-O-N.

Howard Farran:

Michael Kwon in California?

Samuel Lee:

In California, Los Angeles, yes.

Howard Farran:

Okay.

Samuel Lee:

In that practice I learned how to do sinus lift implant, third molar surgery, and really I pushed my limit in terms of learning dentistry. The best way to learn is hands on training and I was at the right location at the right time. Ever since then, I've been doing a lot of sinus lift and I came up with the new technique of lifting sinus. It's called crestal window technique and that technique put me on the stage in many international meetings. On average we do about fifty seminars a year just teaching our sinus technique.

Howard Farran:

Wow, that is amazing! What was not working with the way you were doing sinus lifts that made you invent a whole new way to do it?

Samuel Lee:

First of all, we can divide the techniques into two techniques. Lateral window versus crestal approach. Summers osteotome technique, which uses mallet, is a good technique. However, it is a blind technique. I thought why not combine the advantage and disadvantage of both techniques, and come up with a hybrid technique. I named this technique crestal window technique and I'll be more than happy to show you today on my presentation how to do this technique.

Howard Farran:

Do you want to start there? Just go for it.

Samuel Lee:

Sure, let me pull up my screen. Are you able to see the screen?

Howard Farran:

Yes, we can see it. Maxillary sinus grafting with a beautiful, beautiful woman there.

Samuel Lee:

Yes. Historically, we have two techniques available: lateral window technique versus crestal or [augular 00:05:00] approach. As I mentioned before, lateral window technique is somewhat more invasive and after the surgery it is very common to see a lot of bruise, swelling, and pain after lateral window. In contrast, crestal approach is preferred and it was first started by Dr. Summers using a mallet. This is a better approach because patient is able to function better without much swelling and pain. However, one of the biggest disadvantage of Summers' approach is that it is a blind technique and lateral approach, people don't like to do lateral approach because of this intraosseous anastomosis, a small arterial that runs on the lateral window, and this can be a nerve-wracking experience. Therefore, many people do not prefer to do a lateral window technique.

As I mentioned earlier, crestal approach, any crestal approach out there whether it is using hydraulic lift, or balloon, or Summers' ostetome technique, it is a blind technique just like driving with your eyes closed. Certainly, I don't drive with my eyes closed and I don't think anybody does. Then I want to challenge those surgeons who are utilizing blind technique because you are not sure whether you have perforation or not. I do not recommend blind technique.

One of the biggest limitation is that you need to have minimum of five millimeters of bone height when trying to do crestal approach and that is the limitation. What if you have less than five millimeters, because we are adding bone as material to lift the sinus, we end up with a dome shaped graft and if you don't lift enough because of less blood supply and less support to your implant, the long-term result is not as good when compared to lateral window. If we are doing lateral window, it is very important to lift the window all the way to the palatal side, as you can see in my drawing.

As a young dentist, after learning all these awesome procedures, I thought why not combine these two techniques together and come up with a hyrid technique called crestal window technique. You are looking through occlusal view from the oral cavity and as you can see, you have nice [inaudible 00:07:57] membrane visibility and it is like opening a lateral window, except we are opening window through the crest. Therefore, I named this technique crestal window technique. This is the only crestal approach that is not a blind technique. All the sinus technique out there is a blind technique, once again, so you don't know whether you have perforation or not.

In fact, when you are doing crestal approach, you can have three scenarios. You can have very thin sinus membrane, as you can see on your left. The color will be transparent, it's dark because sinus is dark. The middle picture is an example of a thick sinus membrane because the color is white, it's not transparent, you cannot see through the sinus. On the right side is example of unhealthy sinus. It looks like [granulational 00:09:00] tissue and it's thicker than three millimeter in thickness.

Now, if you have very thick sinus, whether you do a blind technique, or a water technique, or balloon technique, the result will be phenomenal. You will always have a nice dome shape graft after the lift and you will be very satisfied. In contrast, when you have very thin sinus, such as on the left, you will think that blind technique doesn't work all the time because a patient will present with a very thin membrane, and it's very fragile, and easy to tear the membrane. When you are using non-blind technique, we are able to identify what type of membrane patient is presented and you can utilize appropriate technique.

For example, if I have a very thin sinus, then I would like to use small instruments that I developed to be able to lift the sinus and I want to verify that membrane is not torn before putting bone graft or before putting any foreign material to the sterile sinus. In contrast, when I have a thick sinus membrane, it's very easy. It's very predictable, so I don't even bother to lift the sinus. I just [pack 00:10:25] bone, and insert the implant, let the implant push the sinus membrane towards the sinus.

Now, most important aspect is identifying unhealthy sinus. Typically on the CT scan, this sinus shows up thicker than three millimeter and it is very important to remove all the granulational tissue and perhaps it's not a good idea to lift the sinus at this stage. It's better to abort the procedure and come back until the sinus becomes healthier. If you do proceed with sinus lift in unhealthy sinus membrane, then patient will end up with lots of swelling, and a headache on their frontal sinus, even [inaudible 00:11:14] sinus will be all clogged up when you see the CT scan, and absolutely bilateral sinus will be completely blocked because you're putting foreign material to the sinus and that will block the natural ostium.

Sinus needs to drain. If it doesn't drain, then you will have complication. In fact, it is okay to perforate the sinus. Perforation is not a big deal, but if you perforate the sinus, and the graft material goes into the sinus, and blocks the natural ostium, that's when you have problem. This patient was seen by a colleague and patient couldn't open his eyes. When I went to my colleagues practice I had to do [inaudible 00:12:04] procedure to relieve the pressure in sinus and as you can see in this video, we are draining all the mucus out of sinus because previously blind technique has been performed and he unfortunately blocked the ostium, and patient was not able to sleep for more than one week. It's not a good idea to do a blind technique and we have to be very careful not to block the natural ostium.

I think CT scan is mandatory prior to doing any sinus lift and for things that I look out prior to doing sinus lift is making sure there is no [water 00:12:53] fluid level, which is a sign of acute sinus infection and also I want to make sure the ostium is open. If ostium is open, patient will do fine. Even if you perforate the sinus and the bone graft goes into the sinus, if the ostium is big enough, it will drain and it will come out through a nostril. Even if you don't perforate the sinus and everything goes well, if the ostium is blocked and the sinus membrane is not healthy, patient will develop symptom.

This patency of ostium is by far the most critical aspect and thickness of membrane should be evaluated. As I mentioned earlier, thicker the membrane is not a good sign. It's a sign of chronic sinusitis and I recommend to abort the procedure. Also, the location of this infraorbital artery, it is a good indicator for choosing which techniques to use. Howard, am I boring you too much?

Howard Farran:

No, this is just amazing and you're explaining it so well, so even if they're just listening to sound only on iTunes they're still picking this up. This is outstanding, just keep going. I could listen to you all day long.

Samuel Lee:

Wonderful, thank you. Let me talk to you a little bit about some clinical cases, some common complications that I've seen. For example, this case was done by my good friend and as you can see, patient developed sinusitis one week after a blind technique. You can see the graft material all over the sinus and the sinus is completely [already 00:14:45] opaque with some kind of fluid. This is when we go back, and we remove the implant, and we suction out all the granulational tissue, and mucus, and so on.

I asked my colleague to look at the preoperative CT scan. On your right, you can see that on preoperative CT scan, prior to doing a sinus lift, ostium is blocked. There is no opening to [inaudible 00:15:13] and ostium is completely blocked. Also, you see that sinus membrane is very, very thick and as I mentioned before, sinus is all about the natural ostium. If ostium is open, you will have a great result. In this case, blind technique was performed, and thickness of membrane was not visualized, and it lead to complication.

This is an example of a CT scan that shows that this patient does not have a healthy sinus and any kind of sinus lift should be contraindicated. This is example of a healthy sinus on your left and unhealthy sinus on your right. You want to see a big opening, as you can see in this picture in my mouse. I don't know if you can see my mouse cursor, but this is an example of a very nice sinus opening. Another important factor to note is presence of mucocele or a polyp. It is very commonly seen, especially in north eastern part of our country where the temperature is very cold. I see a lot of mucocele and polyp inside of patients' sinus.

In this case, patient had a very, very large mucocele, as you can see in my outline with the white drawing and the doctor did not take a CT scan, did not notice the mucocele. How do you know when you have a mucocele when you are doing surgery? When you are trying to lift the sinus, you can feel a lot of resistance. It almost feels like a balloon filled with fluid. When you push it, the membrane comes back and when patients breathe, the membrane does not move up and down. That's a good example of mucocele.

We have to make sure the mucocele is at least twenty-two millimeter away from [osteomuatal 00:17:20] complex ostium. If it's closer than twenty-two millimeter, then study shows that there is a lot of complication. This is example of a polyp inside a sinus. As a dentist, I think doing a sinus lift we have to be very careful because if patient develops a symptom after a sinus lift, medical legally you have to be able to defend yourself. If patient has polyp or mucocele, you want to identify, inform the patient, and also contraindication should be discussed, and risk and benefit should be discussed prior to performing because last thing you want to have is you do a sinus lift, patient develops symptom, they go to ENT, ENT said, "I see this polyp around your dental implant." You don't want to be blamed, especially not in United States where we have more lawyers than dentists.

This is during my teaching program. I'm teaching a doctor how to extract mucocele. We typically when we have a mucocele, what we like to do is we want to aspirate the mucocele, we want to shrink it so that it's less than twenty-two millimeter away from osteomuatal complex. Now, I used to go in there and remove the whole mucocele, but I find that they return anyway, so now I just shrink them and you will see a yellow liquid come out from the sinus.

Howard Farran:

What is a mucocele ...

Samuel Lee:

This is an example of a small arterial when performing lateral window. This actually, you can pretty much ignore this type of bleeding because it will stop spontaneously, especially if you use cold saline because body tends to [vasoconstrict 00:19:26] when we have a cold temperature. However, sometimes the artery is so big that it will shoot out all the way to you, so you have to be very careful wearing eye protection, and you have to be very careful not to have blood come and invade your personal parts.

As you can see, sometimes the bleeding is very severe from the lateral window and that is one of the reason why I prefer to do crestal window rather than lateral window technique. This type of bleeding we can use [electrocartery 00:20:15] to stop the bleeding and a lot of times we see this type of bleeding shooting all the way to outside of the mouth as you can see in this video taken with iPhone.

Membrane perforation is one of very common complication. However, as I mentioned before, it is not a really bad complication. As long as patient has a good ostium, this can be managed with collagen membrane in some future. We develop nice instruments to be able to elevate the sinus membrane without perforation. This was a case where one of my [before 00:21:03] attempted sinus lift for the first time. Unfortunately, there was a perforation, so I rescued the case by using a better instrument. We will attack it with collagen membrane, but before we attack the collagen membrane, we want to suture the membrane. That way the collagen membrane, it's not dislodged into the sinus.

Membrane going into the sinus cavity, it's a very, very worst thing that can happen because for sure this membrane will block the natural ostium and you will have a complication. You want to prevent the membrane going into the sinus. How do I achieve that is I suture the sinus membrane with one of the walls so that we have a netting effect. Then I introduce collagen membrane. Certainly you can use the [tacks 00:22:00], bone tacks to hold the membrane from moving into the sinus, but I don't like to re-enter the surgical site to remove the tacks, so I just use the suturing technique to hold the membrane and we will continue to elevate.

Another common complication that I see all the time is people do fine technique, and the membrane is torn, and implant is introduced into the sinus. I have to go there and remove the implant from inside of sinus, so we have to make sure we have good stability and also if the perforation is big enough, it's better to avoid putting implant into the sinus. As I mentioned before, many people recommend the lateral window when we have less than five millimeter and we recommend crestal window when we have more than five millimeter of bone, but unfortunately this recommendation seems to make sense.

However, it is incorrect and this is a two-dimensional recommendation. I would like to present to you a better classification by three-dimensional classification where the width of the bone is more important than the height of the bone. Remember, the sinus is three-dimensional, so don't rely just on two-dimensional x-ray to choose which technique to do. If patient has wide bone and about seven or six millimeter of height, there's no reason to do sinus lift. We can utilize wide and short implant, and it's going to be easier for you and easier for the patient. Now, when patient present with wide width, but only one or two millimeter of bone height, I recommend to do my technique called crestal window technique even though it has less than five millimeter. When the bone is wide, we can make window through the crest and it does not become a blind technique. We can see everything. In fact, in extraction site after extracting a molar, you always have crest, too, because always the width is more than sixteen millimeter [inaudible 00:24:31] lingual.

When you have extraction site, don't do socket graft. Do the sinus lift first and then place wide implant at the same time. You can minimize number of surgeries to our patients. Class III would be conventional [inaudible 00:24:50] case, but instead of using mallet or hammer to your patient, try to use innovative [burrs 00:24:58]. Nowadays, there's a lot of companies out there, but this particular burr is one I invented in 2006. It's in the market, it's in United States and all over the world. I have a little stopper and I have a burr that does not cut the [inaudible 00:25:14] membrane.

Can we eliminate lateral window completely? Unfortunately answer is no. When we have a very narrow reach, but very, very [inaudible 00:25:27] sinus we have to do lateral window because we cannot do crestal window due to the fact that the crestal window will be too small and in a sense become a blind technique because I do not like to do blind technique in my patients.

This is a mini study that I did in my patients and I asked the patients how much pain do you have first day, third day, and the seventh day. Obviously you can see that all three different techniques, short implants, crestal window technique, or blind technique, it's not very painful. However, lateral window technique is very invasive procedure postoperatively. If we have some time, I do want to show you some cases, especially pertaining to class II, my crestal window technique.

Crestal window technique, as I mentioned before, is best for extraction site. Here I just extracted two molars, and I am using small [inaudible 00:26:33] instrument and [cobra 00:26:34] instrument to elevate the membrane. On your right, you can see that this is not a blind technique and we utilize wide implant to seal the socket. By utilizing healing abutment you get primary closure all the time. Instead of doing three surgeries, socket grafting, sinus procedure, and implant [inaudible 00:26:55] procedure, we combine all these three surgeries into one and patient is very happy. We can restore this case in less than six months.

Can we do crestal window technique on a [heel 00:27:11] ridge? The answer is yes. Let me show you one more time how this technique is not a blind technique. You can see certainly from [occulsal 00:27:24] surface of a mirror that this membrane can be visualized and you know it did not get a perforation. You know this membrane is healthy because it's moving as patient is breathing. This is the best technique to utilize. In fact, there is no flap. You don't even need to make an incision and just simple sutures to close this case.

Now, when patients come with a very wide ridge, in this case patient had only one or two millimeter of initial bone height and most people would think, "I have to do lateral window." However, doing a lateral window in a patient with very, very wide ridge is very difficult to perform because it's very difficult to go all the way to the palatal wall. It makes more sense to make window through the crest, as we can see, here I made four crestal window and I am lifting through this [osteotemy 00:28:27] [inaudible 00:28:29]. Touching palatal wall is much easier through this approach compared to a lateral window technique.

Once again, to do a lateral window technique you have to open a bigger flap because you have to go all the way to your cheek bone. Retraction is difficult, visibility is difficult. Now, when you are doing a crestal window technique, it's like doing [inaudible 00:28:56]. It's the easiest procedure that you will do. Compared to lateral window, you have a very difficult time visualizing, and seeing, and approach is very, very difficult. I recommend crestal window technique, which is not a blind technique and relatively easy to do. There's no artery that you have to worry about because the artery is sixteen millimeter on the [vocal 00:29:26] side from the crest because we're lifting the sinus from the crest, we don't have to worry about the artery. Take your time, lift the sinus, and place implant at the same time, but you have to choose the right implant design.

You have to choose the implant that is wider at the crest versus the body of implant because we don't want to dislodge this implant into the sinus cavity. Eighteen, nineteen implant has been placed, simple suture has been done, and the patient was very happy. Now the question is how can we temporize this full-mouth case when we are doing a full-mouth sinus case like this.

How I temporize this case is I will utilize in order to prevent this type of accident because when patients wear a denture, it will push the implant into the sinus and we don't want that to happen, so I recommend to place an implant on the palate. Here I placed three palatal implants and I relined the denture so the patient can wear prosthesis. This prosthesis is not touching on the occulsal surface, so my implants are fine. On the lower is opposing denture, so I will immediately [load 00:30:48] the lower with the permanent crown and the other has been temporized with the denture, and the [inaudible 00:30:56] are cut off, but the most important thing if after nineteen implants the patient is able to wear something so that he can go through his daily life.

We developed a special implant called palatal implant as well. Thanks to these palatal implants, none of the permanent implant, as you can see in this panoramic x-ray, all permanent implants survive, even with only one millimeter of sinus floor. I recommend using this palatal implants and right now we are doing clinical studies. We're almost done to introduce this palatal implants into USA market. Unfortunately, I have to tell you that in America, as an American, I have to tell you that we are behind. When we go to Europe or Asia they are much advanced compared to us because our FDA approval process is very slow, plus we have too many lawyers and a lot of doctors are very scared to try new things. Our biomedical science has been very slow in development.

These implants are available in Europe, but unfortunately not in America yet. Hopefully next year we'll have these implants available and we can make the patient very happy, as you can see. These palatal implants are wonderful because it gives a lot of solutions to patients who are diabetic [inaudible 00:32:33]. This patient is uncontrolled diabetic, she came to see us. Unfortunately, she was not a good candidate. [inaudible 00:32:43] bilateral sinus and implant, so I chose alternative, which is palate implant and patient is very happy because her denture is very stable and she does not have to use the glue anymore. This is how she takes it out and we just put four locators on the palate because everybody have bone on the palate. We may not have enough bone on the crest, but everybody have bone on the palate.

This is another patient in my office in San Diego. Patient is ninety-seven-year-old, and he wanted to have bilateral sinus lift and implant. Unfortunately I told him it's going to take more than two year. He told me he doesn't have two year, so we chose the alternative, which is to use palatal implants to stabilize his prosthesis. Then patient has nerve very close. This is the mental nerve and this is the [interogular 00:33:42] nerve. We can avoid cutting interogular nerve by putting three palatal implants on the mandibular.

I named this implant palatal implant, but certainly you can use it on the mandible as well. Only problem with this many implants, I call this palatal implants once again, this super [inaudible 00:34:05] implants. Only problem is that they are so stable, patient did not finish with the permanent implants that I placed. Sometimes giving very good temporaries, it's not very good as we may end up using a permanent case. Howard, are you doing okay there?

Howard Farran:

I'm doing fantastic. This is so amazing, Sam.

Samuel Lee:

Howard, I want to show you a couple other research and development that we do if you may permit me.

Howard Farran:

Please.

Samuel Lee:

My goal here is to find out how much morbidity there is in specific procedure. We do a lot of clinical studies in my institute and the best way to do clinical study is split mouth design. In this case, patient present with a very narrow ridge bilaterally in posterior mandible. Here I chose to do GBR using titanium mesh and ridge splitting on the other side. I asked the patient how much pain do you have after this procedure, right side versus left side, and I compared them. Also, I measure the swelling, how much swelling does this patient have one day, three day, and seven day afterwords. Howard, how much pain do you think there is when we compare it? Which one is more painful when we compare ridge splitting versus GBR procedure?

Howard Farran:

Tell me.

Samuel Lee:

In fact, I did not know which one is more invasive. That's why I conduct this study and I thought GBR is less invasive because ridge splitting involves cutting the bone and spreading the bone apart, which sounds very painful, but after the study I found that actually ridge splitting induces less swelling and less pain for the patient. Split mouth design is the only clinical studies we can do to find out without too much variable because everybody have different pain level, everybody responds differently to inflammation, so split mouth design is very, very valuable. I was able to do a lot of split mouth design in my seminars where I take ten students only to China, to Mexico, Costa Rica, and Chile. We do this about ten times a year, ten students per session for five days, and we teach them how to do implants. At the same time, we do three implants in various university in China, in Mexico, in Costa Rica, and in Chile.

I want to show you a little video about our course and our next course is in China, March 30th to April 3rd. Here we teach lateral window technique, [inaudible 00:37:18], gum grafting, implant placement, and bone graft technique, crestal sinus as I mentioned, [inaudible 00:37:28], ridge shifting, and because I'm a pariodontist, of course gum drafting as well. Here, you get to place your own implant and the facility is amazing. As you can see in this video, we have CT scan, lasers, we have the latest technology including [inaudible 00:37:48], guided surgery, and [sterile 00:37:52] surgical technique as you can see.

Speaker 3:

Highly recommended, lots of fun, lots of sight-seeing. It's a new experience, I recommend it for everyone.

Dr. Barbara:

Hi, I'm Dr. Barbara [Weniker 00:38:10] from Albuquerque, New Mexico. This is my third lab surgeon course, but by far the best lab surgeon course I've taken. We're able to do many different types of procedures, both simple implants all the way up to [connecting 00:38:22] tissue grafts, and chin blocks, and sinus lifts. You can also assist or observe, take photos and videos so you can learn on your own. I am definitely coming back for another round of lab surgeon.

Speaker 5:

This has been one of the most exciting adventures in dentistry in my whole life here in China and this group of students was unbelievable. It was a real diverse group from all over, from all levels of experience, and I don't think any of them had a spare minute. It was a wonderful experience ...

Speaker 6:

Hi, my name's JP. I come from San Jose, California. This is my first time. This is the best hands on course ever. This is my first, this won't be my last. I placed a bunch of implants, bone grafting, CT grafts. Everything chin block up. You're going to do everything you have seen in the videos. Come here ...

Speaker 7:

Hi, I'm [inaudible 00:39:20]. This is my second time taking Samuel Lee's course. Mexico the first time and now in China today. I highly recommend it if you want to do any implant dentistry at all. Every time you take this course your confidence and your abilities will soar. I can't say nothing bad, I'd take it again.

Cornelius:

How are you doing? My name's Cornelius and I'm from New York City. I've been placing implants for about six, seven years. I found out Sam Lee and I did a [inaudible 00:39:47] a couple years ago. [inaudible 00:39:50] such a great guy, good lecturer. I decided to hit up all his programs, went to [inaudible 00:39:56] program, did Peru, now I'm in China. In China you can see the surgical suite and he has absolutely phenomenal great assistants. We do everything from simple implants, ridge splitting, block grafting, bone grafting, a lot of soft tissue, a lot of sinus lift. Definitely recommend Sam Lee's program. [inaudible 00:40:15] China if you guys can come.

Samuel Lee:

This is the program that I would invite our Dental Town colleagues. Learning how to do implant, it's like learning how to swim. Can we learn how to swim by watching videos or reading book? Answer is no. No matter how much book reading or lectures that you attend, unless you start to do surgeries hands on on a live patient, you will never learn how to do it. Your confidence will never achieve then. We recommend to join our live surgical course. It's a very small class. We only accept ten students per session. That way we have quality control.

Some doctors ask me, "How many implants can I place in your program?" I tell them they're not going to place many implants. Why, because we're all about quality. Even if you place one implant, I want you to do a perfect implant placement rather than putting thirty, forty implants. Anybody can throw in thirty or forty implant if you are not going to do a perfect implant. In fact, Howard, I can tell you I placed more than ten thousand implants now in my short career, but every implant I place, it takes me a long time because I want to put that implant exactly on central [inaudible 00:41:43], exactly where the prosthetic goes and it is a very, very challenging procedure. Howard, may I change the subject a little bit and then show you one of exciting research I'm doing in my office?

Howard Farran:

Sam, can I just add one thing, one recommendation to you?

Samuel Lee:

Sure.

Howard Farran:

If there are people who don't want to leave the country, there's a homeless shelter in Phoenix and they only work on vets. They got a permit from the Arizona State Board of Dental Examiners that have a licensed dentist from America goes there from another state, they have a temporary license, so you should be doing a course at the CASS. Who's my buddy at CASS? Let me just real quick ... Yeah, Chris [Volcheck 00:42:46], but I wish you would talk to Chris Volcheck because I just want these dentists to learn and get it done, but sometimes people are afraid to go to a foreign country. It just puts it out of reach of some people and Phoenix, Arizona, they love Phoenix. You could talk to Chris Volcheck because he's got a state of the art nine chair facility and you have all the legal protections of going to another country. He's got the Attorney General, the State Board, everybody gives you your paperwork so you're all legally good. How does that sound to you?

Samuel Lee:

Wow, that's a wonderful, wonderful opportunity. California also passed a law where if it's for non-profit, dentists are allowed to perform surgeries in California, so we've been preparing a free clinic in California, in San Diego, to be able to perform implant surgeries for under-served communities. Now, our academy have two missions. Of course first mission is to educate dentists, and develop better techniques and materials for implant dentistry. Second goal is to provide free dentistry to under-served communities, so we'll be very interested in expanding our services to Arizona, but one thing that my lawyer and other doctors recommended is to keep the less invasive, much slam-dunk cases in United States because unfortunately we do have a lot of lawyers and people sue you for anything.

For example, one of my doctors who share a story, she is a OB-Gyn in New York and she does cancer therapies. She saved a patient's life and the patient was so happy that his surgery went so well he basically told the doctor, "Doctor, thank you so much for saving my life, but I have to sue you because I need the money." Unfortunately our legal system is not very favorable to us. I recommend doing simple cases in United States, and more challenging and advanced courses should be done overseas where my doctors don't have any legal responsibilities after the course.

Howard Farran:

Sam, how do these listeners get more information because you've got two websites. You have ce4dentist.com and you have samleedental.com. Explain what those two different websites are and which one do they go to to get more information about your courses.

Samuel Lee:

Sure, at ce4dentist.com we have several videos and we have scheduled all the events. Ce4dentist.com stands for continued education for dentists, so that's where all the dentists should go for continued education information. Now, samleedental.com is my personal website where we are doing some fundraising to develop the world smallest x-ray. I would like to discuss world smallest x-ray a little bit if I may.

When I was at Harvard, one of the requirement was to do a research and I wanted to do something that impacts our community very much. This is our facility in San Diego and I'm holding the world smallest dental x-ray. I thought instead of using regular x-ray as you can see, by decreasing the distance, if we can decrease the distance ten-fold, we can decrease the radiation hundred-fold because it's reversely proportional to the second power as you can see in my diagram.

If I can make the x-ray very small to the point that I put it inside the mouth, then we can reduce the radiation by more than hundred-fold. That was my hypothesis. However, by doing various tests and experiments in a cadaver, we were surprised to find out that this technology can reduce radiation up to five thousand times. It's much easier to use because you're not shooting outside the mouth, you are actually putting right against the tooth and you are able to get image. Your assistant will never miss an image because it's pointed right on the tooth that you want to diagnose and it's portable.

You only require four watts, so it doesn't have to be plugged in. You can use just a battery power and you can carry it in your pocket throughout your office, but you only need one x-ray in your office. It's very cost effective. Only one x-ray will do all the tricks. This will replace most CT scans because this is the only technology that can give you 3D image using this technology. We just got this patent approved in November of 2015 and of course, this thesis work that I've done at Harvard, I graduated with honors from my thesis committee. We just got a twenty million dollar grant from the government to develop this x-ray into a market.

It's a very exciting x-ray and I just wanted to give our [townies 00:48:52] a heads up of what kind of technology we're bringing into a market. This is example of a cadaver study that we did. We made an incision in the thyroid, so we put the sensor in the thyroid, and we measure the radiation in different location compared to regular x-ray, which give five [uGy 00:49:10]. This technology is almost undetectable. It's about five hundred times less in this experiment and I'll be more than happy to post more detail in Dental Town in the future.

Another study that we are doing in our institute is finding a stem cell in the PRF. PRF right now is very hot in terms of using it as a growth factor, but we do not want to end at osteoinductive phase. We want to go into osteogenic phase and we have this technique where we aspirate the stem cell from the [tuberosity 00:49:55] instead of going to the arm, instead of going in the [crest 00:49:59], we go right on the tuberosity. We are very comfortable in this location and we can draw lots of stem cell for our experiment. This is another project that we are working on to be able to bring a better osteogenic potential and we found lots of CD34 and 45 cells in this tuberosity blood. Quite exciting technology that we will have pretty soon to our colleagues.

Howard Farran:

You are an amazing man. I mean, you're a unicorn. You are just a freak. I can't believe you do all this stuff.

Samuel Lee:

Thank you, Howard. I will take that as a compliment.

Howard Farran:

Oh, my god, it's a compliment. I've met so many dentists, everywhere from A to Z and you're the top of the list, buddy. I mean, you have so many amazing, genius projects going on.

Samuel Lee:

Well, it's because dentistry's fun. I have to tell you, dentistry is my hobby and I can tell you everybody who I met through my educational program, they are such a dedicated people towards our patient. Otherwise, you will not spend money and time for continuing education. Those of you who are dedicated to your patient will log into Dental Town, will come into continued education, invest your money and time, and I have never seen anybody that are really a bad person who are dentists. That's why it makes my job very, very interesting and very, very fun to do. I think we are very blessed to have such a great profession, which is considered to be a hobby. I would like to get more involvement with the Dental Town, I would like to post more lecture series and I would like to get more involved with the Dental Town in the future.

Howard Farran:

I wish you would put a course up on Dental Town because you have so many courses on ce4dentist.com I think if you put a course or two on Dental Town it would be great marketing and advertising for your website, ce4dentist.com.

Samuel Lee:

Absolutely, absolutely. I'll be more than honored to do that. Howard, do you think I can show you one case?

Howard Farran:

Absolutely, keep going. I'm not going to stop you for anything.

Samuel Lee:

Okay. Let me present this sinus lift case that I did in my office in Boston. A patient came into my practice, but unfortunately many specialists do not believe in bone grafting yet. As you can see, patient presented with pneumatized sinus and very, very knife edge ridge. Here, we cannot place an implant. We need to have at least eight to ten millimeter of bone in width in order to place an implant, but here patient present with one millimeter of thickness, so how can we place an implant when patient has been denied by many, many specialists that she has seen?

When she came to my office we did the lateral window and lateral window is relatively easy procedure to do. In fact, it's a very exciting procedure because you can see the membrane move up and down. It's not [inaudible 00:53:27] technique and I enjoy doing lateral window very much, but [building 00:53:33] bone is more exciting. Here I took [FCVA 00:53:36] with the titanium reinforced membrane and we build bone with just a cadaver bone, no going into [inaudible 00:53:45], or hip, or in the tibia. You don't need to do that. You just take a bottle, you just put a whole bunch of FCVA, and with the right suturing technique and tension-free closure, we can build bone in any dimension we want.

Here, after eight months, I removed the membrane. Boom, we have more than twelve millimeter of bone [inaudible 00:54:08] compared to pre-operative case. We can build bone in any dimension we want. Now, building height is limited in terms of building height, but building the width is just ninety-nine percent successful. This is in my private office. Here, you can see that pre- and post-operative CT scan we can build bone so that we can place implant with enough bone in width. The [osteotemy 00:54:41] has been placed and we always try to put the implant in tripod position.

Patient wanted to do implant on the lower mandibular ridge. Here you see very clean keratinized tissue, which means the ridge is also very, very nice edge. Making incision is very difficult in these type of cases because the ridge is so thin, putting the blade right at the crest is very challenging. Here we opened the flap and the bone is just like a knife. It is so thin that it is impossible to place implant at the same time. We have to be very careful not to cut the [mental 00:55:20] nerve because once you touch the mental nerve, as I mentioned, we have too many lawyers in United States. We have to be very careful not to have numbness.

Now, decortication is very important on the mandibular, especially because it's mostly cortical bone. Tension-free flap management is very important, especially the lingual side. Here I'm using bioss collagen and titanium reinforced membrane. Only location I did not add titanium reinforced membrane is where the mental nerve is. Internal matrix suture that we teach in our course is very, very crucial in achieving tension-free closure and primary closure is a must. I don't believe in the open membrane technique. We should always try to do tension-free primary closure.

This is three months later, six months later, nine months later you can see that the ridge is much, much wider than before. Only area that is thin is around the mental nerve. This is time after removal and you can see nice amount of ridge augmentation that has been done when you compare with the before picture. It was less than a millimeter, but now we have more than sixteen millimeter of [inaudible 00:56:42] lingual ridge.

It can be a little bit confusing where to place the implant because the ridge is so wide, so using the surgical guide is very, very crucial because the ridge is very wide, the case becomes very tricky. You can place the implant too [vocally 00:56:59] and the case becomes a cross-bite, so I recommend to use a surgical guide so you can orient very nicely when we have too much bone.

This is before and after. You can see that the width of the bone we can grow very, very nicely, but building height is very challenging because of the [occlude 00:57:28] pressure, it's very challenging to build bone vertically. Only time we can build bone is when you have a defect like this. When we have the mental and the distal wall, then we can build the vertical defect. However, like in this case, patient had a flat ridge and the interocculsal space was already limited. Therefore, building height is not indicated. Plus, building height is clinically very technically sensitive as well.

Here, instead of building height, we decided to do nerve re-positioning, so we made a small window on the mandible and we just retract the [inaudible 00:58:13] nerve very, very lightly so that we can place implants longer than ten millimeters because this patient is very young. She's only in her fifties and we don't want her to have a short implant. Short implant by far is a good alternative, however, [inaudible 00:58:34] publish very nice randomized [contra-trial 00:58:39]. However, the longest that they have is five years, so what happens after five years? We don't have a good long-term study, so we wanted to put very long implant with the informed consent and we decided to do minimally invasive [interaugular 00:58:59] nerve [laterization 00:59:01].

This is after implant placement, and sinus lift, and nerve laterization. I just wanted to conclude today's podcast by mentioning that doctors are forever students. We should always seek to find a better technique and don't be so much trapped in the dogma because dogma is always changing with the new technology. I recommend you guys to join our institute, especially the hands on training that we do. As I mentioned before, we cannot learn how to do surgeries by listening to the lecture or by watching video because when I hear, I forget. When I see, I remember, but when I do, I understand. Thank you very much, Howard, for inviting me to this wonderful opportunity.

Howard Farran:

Sam, you are so amazing. Can I ask one question?

Samuel Lee:

Sure.

Howard Farran:

I'm starting to hear rumblings more and more from ENT's, rhinologists that a lot of sinus issues going on are actually failed upper root canals. Have you seen anything like that in that the tooth had a root canal, it's asymptomatic, the person's having all kinds of sinus issues for years, and that it's literally [odontogenic 01:00:34] tooth origin? Do you hear any of that?

Samuel Lee:

I see that all the time. In fact, sinus is connected to our upper molars. Therefore, if there's any [peri-apical 01:00:49] lesion, patient will have thicker [inaudible 01:00:54] membrane. Always we work together with ENT to rule out whether the sinus symptom are coming from the molars or from actual the sinus itself, so it's very common that I refer to endodontists for root canal treatment prior to doing any kind of sinus surgery. Especially when I detect very, very thickened [inaudible 01:01:22] membrane.

Howard Farran:

Yes, I think that's becoming more and more common to realize now, that these sinus issues could be odontogenic origin. Sam, I just say, seriously dude, I tip my hat to you. A double doctor starting all these companies, that x-ray technology you're talking about, it's just world class. You're a visionary, you're just an amazing man. I would give anything for you to put any of your courses on Dental Town just because I want to market and advertise this amazing man, Sam Lee, so that everybody knows you're a household name because everybody needs to be listening to you.

Samuel Lee:

Thank you, Howard. Thank you, Howard, for a wonderful opportunity and like I said, all the dentists, we are all wonderful people and dedicating to continue education is the best thing for our patients.

Howard Farran:

You live on two corners of America, then. The nice, sunny Southwest San Diego and the upper, bitter cold Boston. Do you try to spend all your winters in San Diego and your summers in Boston?

Samuel Lee:

Unfortunately I travel to New England every month to see patients. I practice in New England one week out of month and I practice three weeks in San Diego, but recently with the grant that we got from New York state, we're planning another move to New York state.

Howard Farran:

Okay, well don't freeze to death because the world needs you around for a long, long time.

Samuel Lee:

Thank you, thank you, Howard.

Howard Farran:

All right.