Dr. Marc Nevins is the Executive Chairman of Little Implant Co. and inventor of The Marc Nevins® dental implant system.
VIDEO - DUwHF #1149 - Marc Nevins
AUDIO - DUwHF #1149 - Marc Nevins
He is in private practice of Periodontology and Dental Implants in Boston, MA. Dr. Nevins is a Diplomate of the American Board of Periodontology, Associate Professor of Oral Medicine, Infection and Immunity at Harvard School of Dental Medicine and serves as Editor-in-Chief of the International Journal of Periodontics and Restorative Dentistry. Dr. Nevins has research interests in tissue engineering and osseointegration.
Howard: It is just a huge honor for me today to be podcast interviewing Dr. Marc L. Nevins DMD, MMSc he's the executive chairman of Little Implant Company and inventor of the MarC Nevins dental implant system. He is in private practice at Periodontology and dental implants in Boston Massachusetts. He's a diplomat of the American Board of Periodontology, associate professor of oral medicine infection and immunity at Harvard School of Dental Medicine and serves as editor-in-chief of the International Journal of periodontics and restorative dentistry. It is just beyond a huge honor to have you come on my show today I want to start off Dr. Nevins is, these kids listening to you they're gonna walk out a school four hundred thousand dollars in debt and guess how many dental implants they place in school
Marc: Probably none I hope that some of them had a chance to at least restore some in school. I mean it depends on which University in which schools are at though probably.
Howard: Well if I meet someone who place a dental implant in dental school I will run the Boston Marathon dressed as a tooth fairy. How do you go from coming out of dental school and just read about it in textbooks or online to placing your first implant?
Marc: I think that the most important thing is the education program and I think for most people who have not had the experience of at least restoring implants that they need to begin at the beginning, which is an education program which is restorative driven focusing on the end point of what the restoration is going to be and then planning the surgical placement based on that and it's going to give them fundamentals to choose them which cases they should be starting with and which cases they might want to put in the referral basket so that they can build on successes we want to build on successful outcomes and build confidence that way. At Little implant company we have a wide range of educational experiences so students could go to a two-day mini residency program we call it where they'll get basic lecture basic hands-on and be able to observe multiple surgeries with surgical placements and we also have programs with over-the-shoulder teaching in several locations where students, dentists can have over-the-shoulder education and they can do the surgery themselves. So I think you know depending on how much experience someone has had on the restorative side that might guide them as to the best approach starting out on the education side and we try to sort of meet people at whatever whatever level they're at now we try to meet them there and then help them expand their horizons and get the confidence to get the experience and succeed.
Howard: Okay so these hands on your website company is www.littleimplantco.com Why did you name it little implant company where did that name come from?
Marc: Well we're you know we're just we're just a little company you know and you know it's sort of a pun on that because we think that we we have a special product and a special approach and we think that you know over time our little implant company might grow a little bit we have many unique aspects, you know before we get to the product we're talking about education and we have a mentoring program built into our implant company so every time that you receive your implant and you open that box and your implant there's a little card and they're giving you access to a clinical mentor in our...
Howard: Is that your mentor in a box program?
Marc: That is our mentor in a box program.
Howard: Congratulations on that and the name and everything. That was why I called you, you didn't call me. I called you and I thought that mentor in a box I thought I was genius concept, genius marketing.
Marc: Some of our mentors right now including Tony Fact, David Little, Gary M, Pamela Ray, and that mentor in a box program gives you access to them you can email them if you in get communication right back within a day or set up a time to communicate directly even on telephone because if you need to help assessing a case, reviewing a CT scan or just a question about the instrumentation to have someone there who is a clinical expert and be able to build a relationship with them. We really want to take it very seriously how to meet clinicians where they are with their implant experience and help them grow their practices in any way we can. It's not we have a great product but it's not all about products about customer service and it's about being there to give the give professional support that's needed and I think that's unique in the industry.
Howard: It seems like you're more focused I mean I look at your lectures and they seem to be more of Kentucky, Kansas City, San Antonio, is that is that pretty much true is that is that...?
Marc: We have education centers in the in those areas and will expand the geography of that as we move forward in time but those have been working working well right now and we will plan on an expansion of that over time as far as geographic locations and depending on which types of programs it may be that some programs will be in certain places in some larger lectures or surgical demonstrations may be in others but right now those are our main centers yes and we have we have a series of programs including many residences set up in Kansas City in March in May, in Lexington Kentucky in May and coming up in San Antonio in June and then we have some advanced courses coming up real soon. There's one this weekend in San Antonio and then the beginning of March 9th another one in San Antonio and then at the end of March in Kansas City the full array of educational programs is available online but what we have anything from the two-day mini residency to a edentulous course, we have a new extraction socket bone grafting course. So we're trying to help people build the skills in the area the areas that we think will help them expand their practice.
Howard: So first thing I want to get on the way is there's over 400 dental implant companies and the Cologne meeting is the largest dental meeting in the world it's coming up this on this it's every other year it's coming up in March and rumor has it they have like over 250 implant companies having a booth and this young millennial driving to work right now she's like you know I don't have time to go through 20 different systems let alone 400 systems. What do you tell her why why your system why not any of the other 400 systems?
Marc: Yeah I mean I think what's unique you know when we when we talk about the Little Implant Company we are a company that's owned by clinicians and our design team is not a marketing team and I think a lot of dental implant design has been dominated by the marketing side not all of it I mean they've picked up in a lot of clinician designs as well but if you go to Cologne and you walk around that exhibit hall in my eyes a lot of what I see is designed on the marketing side not on the clinical expertise and we've really focused on both the actual implant fixture itself design for the way it will go in the bone and the way the bone will respond to it biologically and we've also focused on our surgical instrumentation design in both of those to make it easier to use easier to place and to be more successful. It's a little bit of a long-winded answer but it's a very important question with implant design if we think about wanting the implant to be stable on the bone but we don't want to damage the bone and if we think about the implant healing process we typically think that the bone to implant stability might get weaker during the early couple weeks of healing before it gets stronger as new bone is laid down. So you have a sort of a battle between bone resorption and new bone growth, if you can reduce the damage in the way the bone is drilled and the damage by the way the implant compresses the bone but you can still have a high stability so that implant is locked in place then you've been more gentle to the bone you can have more bone apposition more bone strengthening and less bone weakening in the early healing period and what we've done is designed an implant it's easy to place because of the tapered design in the thread design it locks in the bone easily at full placement but it doesn't damage the bone. What this does it makes it more predictable healing more predictable integration faster healing and more flexibility when you for more advanced treatments things like immediate loading which we've done a 12-month research project on successfully and more versatility. So without being too lengthy I think we've specifically looked at how our implant behaves from the way it feels to the clinician going into the bone but the way it's going to respond biologically and their's a lot of designs that have a lot of fancy thread pitches and thread designs but if you can't get that into the bone without damaging the bone then it may not be the right choice.
Howard: So you have you have your own competitor because you have your system and also when your instructors is Pamela Ray.
Marc: We have four diameters in the Marc Nevins implant system so we have a 385 a 4.2 a 5.0 and a 6.0 and all those implants have the same connection so it keeps the armamentarium very simple, in addition to that we've designed a Little Implant Company has designed a different 3.85 fixture known as the Pamela Ray and this fixture has a extra taper to it so it tapers down all the way to two point two millimeters. So it's part of our narrower solutions and let's say you had a site with an undercut in the maxillary anterior or a lower interior where the ridge was more narrow they rather than selecting a Marc Nevins the 385 fixture you might select the Pamela Ray, which only comes in that 385 diameter right now which has the extra taper to it so it's part of our whole little implant system implant solution and that's one component of our narrower solution. We will also have a more narrow implant a 3.0 fixture known as the Tony Feck which should be coming out in July next this current year. So we hope to have that available at the beginning of the third quarter as part of our narrower solutions broad product solution.
Howard: Yeah explain this to her, she's in dental school and whenever she sees a pano of an older patient who got implants 20 years ago they are always a straight cylinder why what happened to the straight cylinder design and why do you see now more tapers and conical 's and things like of that sort?
Marc: Again if you think about with a straight cylinder you need to have a fairly limited extension and cutting activity to the thread or that cylinder is gonna lock in place by having a more tapered body the thread itself long as the long as the threads are spread out enough can have more extension and cutting ability what that's going to do is allow the implant to self tap into the bone if it's designed correctly but also when you get that implant into place it's gonna lock in place. If someone's a novice or even experienced implant surgeon and they're using an implant that's a straight fixture it can be that sometimes the implant is to loose in the bone and sometimes it's too tight it's a little challenging to get it just right with a tapered design like we have the process of placing the implant but getting a strong stability is much easier more predictable and again their's other aspects of the design to make sure the bone behaves well but that's a really it's an important question and why things have trended towards tapered fixtures.
Howard: You know when you and I were little an implant drill kit had so many drill bits you couldn't count them and say you know the root canals I mean my god you'd use any different files root canal.
Marc: Listen not when we were little most implant companies today have drill kits with 15 or 20 different types of drills in it.
Howard: So you've seen endo where they try to get it down to where then it's just has to use a couple of files and use that you've done your what you call multi drill technology yeah how can you do in two drill bits were you know when I started out 30 years ago you use half a dozen or more to a dozen?
Marc: So the kits been designed where the multi drills are step drills that are highly engineered very precise cutting and what I found is a lot of I typically drill at 600 rpms and if I'm more than a three millimeter diameter maybe four thirty four fifty and with the multi drills they cut so efficiently I find myself even drilling a little bit slower slower than that and they're designed if you want to go step by step you can go from your two millimeter twist drill, to our number two to multi drill the number three multi drill if you're putting a 4.2 fixture you would then go to the number for multi drill if you prefer to use less drills you can go directly from the number two twist drill right to that number four multi drill from a cutting efficiency the drills are designed to do that, So you have a choice of going step by step or to the to drill concept. I think for myself I tend to use a to drill concept in area where it may be difficult to access like the mandibular second molar region where I want to make it more efficient for the patient and then a lot of other times I might go from the 2 millimeter twist to the second-to-last drill so I can feel the bone dense and then decide how much I want to use the final the final drill but overall whether you're doing step by step or two drill concept the whole kit that we have has only the only six drills there so you're going for a two millimeter twist and then through our multi drills that go number two through six and if you're doing a smaller diameter you know four and five millimeter diameter fixtures you're you know very few drills that you need to use and the whole kit is so nice and simple because all the implants have the same connection you only have one type of delivery device to deliver the implants into place. So it's much less confusing and intimidating than most of the more conventional surgical kits that you've seen.
Howard: and how much is a certain traduction surgical kit?
Marc: The actually have I want to make sure I get the pricing right here right now at this time Little Implant Company has launched specials that they're launching and so they have a special where for 30 implants which normally retailing at 156 dollars right now on the launch they're launching at 30 implants $97 each so a total of $2910 and they're gonna give you your surgical kit and prosthetic kit free with that purchased and that's a limited time offer but that still is running right now as of February 11th.
Howard: So how much is that total?
Marc: Yes $2910 for 30 implants and the surgical kit and the restorative kit there's an adjustable torque wrench included in that restorative kit and the ratchet wrench as well as a straight driver in the surgical. So it's pretty a pretty high value available for the quality of the product that we feel we're providing. The company is very streamlined you know how can you provide high quality at that kind of value well it's a streamlined company you don't have middlemen but we do have a amazing customer service and we have our mentors available to help you.
Howard: So the total kit $2910
Marc: We that includes 30 implants
Marc: Hey for the 30 implants and getting the kit with that
Howard: but here's what I'm telling the kids you know the when you look at something for twenty nine hundred and ten dollars you basically only have to do one or two implant cases yes and you get all your money back. I mean it's like people you don't want to spend money learning Invisalign it's like dude your first Invisalign case would pay for your training back next question...
Marc: If someone wants to get all their money back in their first case we have another option with only five implants for $1995 that includes the surgical and prosthetic kit and five implants. So they're in one case they might be able to get all their investment back.
Howard: and I know that first implant you know she graduated from school she's working for her mom who's a dentist her mom doesn't place implants are you still recommending the first implant be placed in the first molar or maxillary second bicuspid is that the lowest hanging fruit or not really?
Marc: I think that probably a lower first molar site or maxillary second bicuspid is probably the easiest sites to start with I think the maxillary second bicuspid would be the least the least stressful if they have a site with a relatively otherwise healthy dentition just because they don't have the issue of the inferior alveolar anatomy nerve Anatomy and it might be even less intimidating than a lower molar site and again that just depends on the size of the Ridge and whether they have tomography available in their in their setting to have measurements and things.
Howard: So if you're listening this start looking and having your hygienist, have everybody start looking for a maxillary missing second bicuspid he's telling you that's the lowest hanging fruit. Is she gonna need a CBCT?
Marc: Well yeah that's what I was thinking and I think in a maxillary second by sight you're less likely to need to need a comb beam CT of anywhere in the in the dentition. Myself I've been using 3d tomography since I was in dental school so I was fortunate that I knew I was interested in implant dentistry and started treatment planning implants for me to restore when I was a second end of my second year in dental school. So I actually I actually had the opportunity of restore single teeth three and four unit prosthesis maxillary bar over to enter case all while I was in dental school graduating back in 1994 but once I and then moving on to my residency using again conventional CT scan radiology and then I've been using comb beam CT scan since 2003. So for myself I think there's great value in simulation of surgery for implants so almost all my surgeries I'm gonna simulate on my computer go through that process so by the time I sit down to do the case I've already done it digitally you know I know where I'm gonna be working as far as the implant placement I also use a lot of surgical guides generated from the scans but I've always been I think if you're gonna do everything has to be restoratively based so whether it's analog or digital I have always been trained having a diagnostic workup or wax up and today it's mostly digital and then planning the implant placement based off of that.
Howard: Wow so you went to dental school at Tufts School of Dentistry graduate in 94
Marc: Yes I did
Howard: Then Harvard a nice but Tufts had CBCT's in 94?
Marc: No those work using conventional scans
Howard: Cat scan?
Marc: Yep conventional cat skins I used from when I was in dental school through 2003 and then to that starting in 2003 I actually would have scans done at Harvard for myself using a comb beam scan and then getting those put into a software where I could do planning I did my first guided surgical case in 2003.
Marc: I've been worked I've been working with guided surgery for I'm in my 16th year of doing guided surgical cases and I think from you know maybe 2006 to 2012 as the systems became more commercialized in the ease of use let me increase the amount of that I did I would use it and I think I use it more and more each year you would say well you have a lot of experience you don't need to use guided surgery but I just think it's a great tool in increases the predictability so I'm a big fan of I want as much information as I can have so I can have as much control of one of what I'm doing.
Howard: So have you placed a hundred implants how many of them would have a surgical guide?
Marc: I would say the let's say 20 20 of them are immediate implants 20 out of 20 are probably not gonna have a surgical guide maybe there's one central incisor that the tooth is sitting towards the buccal plate and it's so there's an undercut it's extremely offset so maybe one out of that twenty might for immediate extraction but most of them I'm gonna simulate it on the computer and just I'll know where I have to intersect the extraction socket into what angle to get that placement and then you know maybe there's another 10% that have an Anatomy like that second single second bicuspid with a huge ridge or big jaw lower molar that doesn't require it and probably the other 70% are gonna have guides that are generated from the CT scan through stereolithic methods and 3d printing.
Howard: Okay one of my biggest complaints on this show is that we don't mention brands so when you say a CBCT which one are they want to know which one you're using.
Marc: I'm using a Care Stream in my practice and right now in 9300 and then will be later this year we'll be putting in a new 9600 and I've had great experience with that.
Howard: and that that's the same one I use but it's just coincidence Care Stream didn't give us any money, their's no money changing hands on this stuff. What if this what if this young dental student has this fantasy in her head that was CBCT and surgical guides she's never gonna have to see blood and bone and lay a flap and I mean I've heard him say you know with a surgical guide a CBCT, Stevie Wonder could place implants. Do you do you only think you can be an implantologist and now the bloody surgeon?
Marc: I think you I don't think you need to be invasive but I think you need to have have some very simple basic surgical skills and you want to be comfortable lifting the tissue and seeing the bone so you can understand exactly what that bone ridge looks like. I think the most challenging place or a place that can make the most mistakes is in the maxillary arch and in the maxillary arch it often looks like the the ridge is nice and flat in the tissue it looks flat but on the palo side it may a go off at 45 or 50 degrees and you want to be centered on that ridge and there's no way to really see that without making a flap and if you have a if you have a flat ridge that's ten millimeters wide yeah you don't need to make a flap but i don't see that very often i can think of maybe three cases we did in the last 90 days with single tooth sites where I did not make a flap I'm almost always making the small flap so I can see the bone. If I have a site again as as a specialist a lot of the single tooth sites I see where sites that have a lot of bone damage prior to me seeing the patient fractured teeth depended on endodontic infections, on those cases where I've done rich preservation grafting I want to see the bone and make sure that that bone is nice and solid on the surface I what I explained is that the most important for maintenance and health of that implant is going to be the part of the bone near the platform of the fixture and so I think having learning some learning some basic surgical skills is important and I think with guided surgery you need to first know the basics because what if that guide breaks in the middle of the surgery what if what if the guide doesn't fit you know you need to be able to know how to abort from using the guide in support you support yourself with the surgery. If you have a narrow Ridge and you're drilling through the guide you can't feel whether half the drill is a bone or all the drill is and bone so you could create a time where you're drilling on the side of the bone not in the bone and that could be a challenge. You know you want the tubes on those guides close to the bone so this is a little chance to leverage off to the side but I think that that would be a whole different education program focusing on a guided surgery I don't want to drift too far too far into that but you know getting a little off course.
Howard: I want to ask you some more on quiz questions if you placed 100 immediate implants, immediate after surgical extraction how many of those 100 would also be immediately loaded?
Marc: For myself in my practice I would say you know fairly few because I'm pretty conservative with that. You know if if you start looking at how much bone is holding the fixture it's not that I don't look at the option I always look at the option of what's going to be the fastest course of treatment for the patient and most of the time it tends to be can I get an immediate implant here or do I not have enough threads that are gonna be holding the bone to put the immediate implants in if I have a short root in a large ridge and we can get a very nice primary stability very predictably and there wasn't much infection in that area before we started yeah that's gonna be a good candidate for immediate placement immediately load but what I find in my practice is most the immediate loads for single teeth I to do more more more stage more often than not just the type of teeth that I end up seeing, on the other hand it's the larger cases where we're doing the full arch case where we're extracting teeth often those cases require some Ridge reduction so you're not really using so much of the bone where the socket is you're using the basal bone where you have nice strong healthy bone in those cases you have more of the implants touching the bone so more stability in those cases are great for immediate load where we're making the transition from teeth that are failing and in one procedure taking out the teeth and placing the fixtures and then converting to a full arch prosthesis so higher volume of that I'd say in my own practice then the single teeth immediate load. Getting back to the Marc Nevins dental implant system we had the opportunity to do a 12-month immediate load study and we did eight patients and twenty-nine implants and we had one case where the patient had no bone through the maxillary anterior we only used two implants in the posterior on the left side and the other teeth holding the partial were mobile is a poor case selection you know in that case the partial rocked on to the prosthesis and those two implants failed but the other 27 implants that we placed were all successful with very good bone levels we had a mean of only 0.6 millimeters of bone loss from the platform at the 12-month analysis in those cases included three and four tooth back maxillary anterior segments to fully edentulous mandibles, posterior sextant with three implants where there had been recent extractions four sites where we did do immediate extractions immediate placement and immediate load. So it was a pretty arduous task that we're asking on the implants in this study in very nice results on that we've submitted that to be published in the International Journal of periodontal on the revision of dentistry so that we can hopefully get that accepted and published later later this year
Howard: and your dad Myron started that magazine right.
Marc: Yep in 1981 together with Gerald Cramer and we added that together that we've done for quite some time now he may be the longest journal medical journal editor in history having done that for 38 years pretty pretty impressive and then we co-chair the international symposium on Periodontics and restorative dentistry which will be in Boston this June 9th to 16th. The symposium sponsored by quintessence in the journal and that's you know a great meeting to learn more about dental implants and aesthetics and periodontics has a great range over 60 speakers from all over the world and usually we expect about 2,000 people in Boston for that great time to be here in June.
Howard: So when your dad started that magazine the big thing was hydroxyapatite coating what ever happened to that I was that was the big rage and I asked is because some of these kids see these ancient implants that we place during the Flintstone error whatever happened to hydroxyapatite coating?
Marc: Yeah I mean if you look at our implants today we use a sandblasted acid etch surface we have a proprietary technique that we use to you know increase the way that works on the surface area with the bone healing as well as special cleaning processes but that surface is stable it's not gonna break down over time, hydroxyapatite coatings are very nice that it draws the bone initially but hydroxyapatite in most instances is then resorbable and the problem is once that starts to resorb you may get some negative changes as far as the way the bone is adapting to the implant depending on what the surfaces underneath and how that's affected by the resorption process and some of those hydroxyapatite crystals are gonna resorb during the first year some of them are designed that will take much slower they might take three to seven years to resorb but once they resorb you patient-specific you may see some issues with that so we want a more stable surface to the implant today and you know there have been even today you can find some h.a services but I would recommend a more stable implant surface like a sandblasted acid edge type pure titanium that we have.
Howard: Well you know I'm following up on that hydroxyapatite coating a lot of lot of kids are scared about implants because after five to ten years they see you know maybe a third or half of these having peri-implantitis, do you think removing the hydroxyapatite coating and going to these different services reduce that a little bit or a lot or what is as a harvard-trained board periodontist, what are we looking at with peri-implantitis?
Marc: You know I think that the first component is to make sure that we have enough quantity of healthy bone as well as healthy the gingival tissue at the site of where we're placing the implant and good diagnostics good basic surgical skills learning basic approaches to rich preservation and as well as soft tissue management surgically these all have an effect so if you have a choice of using a tissue punch but you know you're gonna lose the attached gingiva that would then be there around the implant well if you make a small mini flap and make that incision in a way that you can move gingiva around that implant we now have a lot of papers over the past 15 years that really support the clinical benefit of having that attached gingiva around the implant and I think a lot of peri-implantitis is due to the condition at the time of surgery and the condition as a result of how the bone and tissue healed around that implant originally that leaves it susceptible. In addition to that having a an implant design and an implant surface technology that's going to stand the test over time such as the Marc Nevins Implant System is going to be very important. So we have seen a the years so implant specific types of problems I think in addition to that going back to the question about implant designs you know there are certain designs that biologically are more challenging and when you take things like micro threading at the top of the fixture in my experience their's a certain percentage of the population of patients that just doesn't hold bone well on that micro threading and so those patients even after one or two years are gonna be starting with lower bone levels so it's a multifactorial disease if you want to call peri-implantitis a disease and it's related to surgical factors, it's related to implant design factors and then there are biological aspects. If you decide that you're gonna finish with a second bicuspid and that implants gonna have a crown to root ratio that's twice the crown compared to the implant size and the patient has second molar occlusion in the opposite arch you might over occlude that implant and put pressure on it we might get a closer related bone loss on the other hand we can also have plaque induced inflammation and bone loss around implants so there's a lot of different factors in addition to that there's been a lot of publications on cement being then tinnitus for inflammation and bacterial infiltration so we want to make sure that if we're cementing implant restorations that we're designing our abutment so that cements not going to be getting too far sub gingival we may have a vent in the crown to also let the excess cement get out it's a great question a very very important area and there's a lot of factors that have an impact on it.
Howard: I think what you said was so genius because when you talk to periodontist about peri-implantitis a lot of them go right back to the the prevention and think a lot of it has to do with you place is correct with nice attached gingiva all the way around it that is the majority of the problem and when you replace these implants and they're not in attached gingiva then you can open up a whole host of problems. I want to pin your feet down to a very controversial question LANAP, LAPAP. The reason it's a serious question because on Dentaltown most half the people just go there and really like the daily newspaper today's act two topics whatever but when it ever gets to be $100,000 decision i see their searches they'll go in search LANAP peri-implantitis LAPAP because it's like a hundred and thirty five thousand dollars to get up to speed on that. So it's a yes or no question do you think the my homies listen to you should invest a hundred and thirty five grand and a laser to help with the treatment of peri-implantitis?
Marc: I think that...
Howard: Or do you want to plead the fifth?
Marc: Well I think what I'm gonna say is that the research supporting LANAP to treat periodontal disease has definitive proof of principle for periodontal regeneration and that is a study that I've published as well as study that Ray Tuck has published but in our paper that we published we showed definitively on a diseased root surface with the calculus notch and measurements to where that notch was before we root planed periodontal regeneration with new cement and periodontal ligament in new alveolar bone on previously diseased root services. If you came to my parent practice this afternoon in present with periodontal disease that I think should be treated surgically I'm gonna make a treatment plan to treat your dentition with LANAP that is going to be my first course of treatment in my practice to treat your dentition with periodontal disease and I'm gonna be remarkably successful with that treatment almost all the time if I have a tooth that is a hopeless prognosis most of the time I'm going to prescribe extraction of that tooth for the reasons why I've described as a hopeless prognosis not a guarded prognosis but I've also treated a lot of teeth that patients have refused to extract with guarder hopeless prognosis very successfully with LANAP. I've been doing LANAP since 2009 so I'm starting however many years and then I guess my 11th year with that and have had a lot of success with it I think when you switch over to the implant topic and you talk about do you want to purchase a laser specifically to treat peri-implantitis we run into two problems the first problem is we just stated that peri-implantitis is it extremely multifactorial disease and we need to figure out the etiology in each specific case and then we need to make an assessment, is this a case that I should be removing the implant is it a case that I should be treating non surgically or is it a case that I should be treating surgically and then we have to make a decision is it a case for surgical treatment with bone grafting or a case that can be managed minimally invasively with a laser based treatment my problem is that I don't have enough data to show me the predictability for treating peri-implantitis with any approach I have lots of approaches which work but it's such a multifactorial disease that if you said to me, Marc you have to now limit your practice to just treating peri-implantitis and you can't remove the implants I would be afraid to take responsibility for that treatment because I can't predict which cases it's gonna work in which it won't. I could show you many cases where I've used laser treatment around implants and had improved or stabilized very nice results but the predictability that it's going to be much less than I am with treating periodontal disease around teeth and a lot of that relates to the multifactorial aspect of the disease. So it's a long long winded question but LANAP is my first course of surgical care for treating periodontal disease in my practice and I hope that gives you some insight into the question.
Howard: I want to ask you another controversial question, bone grafting after placement the patient you know money's the answer what's the question I'm in pain I want this tooth pulled I don't know when I'm gonna replace it with an implant or a bridge or a partial or a flipper whatever. Some people say that the bone grafting really only makes sense if they come back and get the implant within one calendar year true or false?
Marc: I think it's false I think the only I think if you bone graft an extraction socket the only way that you're gonna lose that bone is if you have a removable prosthesis that's putting pressure on it. So I think if you don't bone graft it we know from the research that within six weeks you're gonna lose 40% of the volume let alone by the time you get to 12 weeks how much you might lose in most cases. So I'm a big proponent of interceptive grafting at the time of extraction and grafting.
Howard: You call it interceptive grafting?
Marc: Well it's rich preservation or extraction socket grafting, my point is if you come back to that site six months later or a year later you know how you now have to do surgical procedure as opposed to a very simple socket graft if you don't graph that site and you decide a year later you want an implant and now your Ridge is three millimeters wide instead of eight millimeters wide you have to come in and do a ridge augmentation procedure on the other hand at the day of extraction most of the time I can manage that with a flat bus approach for myself I'm using bone allograft mineralized allograft from base bone which is a product that little implant company sells and most the time in my socket grafting mixing that with recombinant human platelet-derived growth factor which is a recombinantly or biotech engineered growth factor it's marketed Gem 21s and sold now by Lynch biologics and I can just take I can take it any tooth socket no matter how much bone loss if it's a fracture whatever's going on and manage that with a flapless of approach just packing the allograph soaked in the growth factor into that socket so that's a procedure that someone without a lot of surgical experience can learn to do very easily whereas a ridge augmentation is a much more surgical experience required process and it's much more invasive for the patient. So I'm a big proponent of doing preservation grafting procedures at the time of extraction it makes things easier it keeps the options for implants open for that patient a lot of patients don't know what it's gonna be like missing that tooth before it's extracted they're gonna come back two months later and say wow I really want an implant when can I have that and now if we've lost the bone it puts us in a compromised position so I think we have to take the time to educate the patients before we do the extraction and we have to explain to them it's gonna be more invasive, take more time, cost significantly more to go in and do an augmentation procedure as opposed to just doing a preservation procedure and getting in there at the time of the extraction.
Howard: Okay so again walk her through I mean where's she gonna learn to bone graft or ridge preservation after she extracted a tooth and where she learned that and what did you say that you sell for that? You have the course too?
Marc: March 9th in San Antonio next month we have a course on surgical principles of a traumatic tooth removal immediate implants and bone grafting and then we have another course with the same topic on April 26 and 27 so we have two courses coming up in the next two months focused just on that topic teaching a traumatic tooth removal we don't want to damage the gum tissue we don't want to damage the bone. What I explained to the patient is I want to I want the site to look like I made the tooth just disappear when I finished extracting the tooth there's usually almost no bleeding the gum tissue looks perfect like it did when the patient walked in and I haven't damaged the bone and that's what we want them to learn and then as I said little implant company cells base bone bone allograft which is a free tribe bone allograft it uses a very unique treatment with a high concentration co2 as part of the process so the bone is basically free of any bacteria or viruses without having to be exposed to extremely high doses of radiation which helps maintain the biologic potential of the bone and it's also been very specifically designed by dental surgeons to have a handling characteristic as well as a size and shape of the bone particulate that's going to be optimal for bone healing.
Howard: and define allograft
Marc: Allograft is cadaverous human sourced bone which then goes through a alcohol dehydration process in our case this also then goes through a treatment with a high concentrated co2 in between those processes it's free of any bacteria or viruses and is extremely safe to use freeze dry bone allograft it dates back to use in dentistry to about 1976-1977 in the United States, it has been around for quite some time. You also could use xenografts like a bovine bone particulate if you prefer that I would prefer not to an alloplastic material myself all I think your my results are our best in my prank my hands with allograft and xenograft and specifically for soft grafting I like the allograft when you go to a xenograft you have a high heat processing and that's gonna mean that the the bone might be a little more micro dense meaning it needs more blood supplied if you have a flapless healing an extraction socket you're obviously going to have a little bit of compromise to a blood supply compared to a submerged surgical site.
Howard: So is your first so basically on an allograft where you're going friend be like me donating bone to you would but wouldn't your first choice to be you donating bone from your own body to another sort is that your first pick and then it.
Marc: No not today you know the only time that I use autogenous bone grafting at all today in my practice is for severe vertical root augmentations and their I'm using it combined with growth factor in a xenograft or an allograft and for extraction socket grafting you could have a all the bucket if you come in tomorrow to my practice and you had a fractured lower molar and you were busy the past month with your with your podcast you didn't have time to get it extracted even though you noticed something was going on you have a hundred percent of the buccal plate missing and you have a little half centimeter cyst apl to the tooth I'm gonna treat that with a flapless approach I'm gonna section the tooth remove it a traumatically perhaps with piezo surgery debride and be granulate the defect and then I'm gonna take the base bone and allograft I'll soak that with some the gem 21s liquid growth factor pack that into the defect put a little collagen membrane on the surface with a little medical grade glue and I'm gonna get all the healing I need for my implant without ever opening the gum without advancing the gum to cover without you having swelling and you know really highly simplified and then I come back at four months later in place my Marc Nevins Implant, I'll have solid bone.
Howard: Okay now I want to move above the bone and tissue and all that kind of stuff. You talk about how you have a one prosthetic platform, what do you mean by a one prosthetic platform?
Marc: So what we mean is whether you whichever diameter fixture you're using the connection is going to be the same so there's a 3.5 millimeter internal hexagon on the at the top service implant in the abutment will fit into that you can place the same abutment into our 385 implant that you can our 6.0 implant so it makes it very simple it also means the healing caps you might choose a slim or a regular or wide depending how you want to shape the tissue but the connection is the same. We have digital scan bodies if you prefer to take a digital impression registration and then we obviously have conventional impression copings for either closed tray or open tray and we have a full array of restorative components whether you want prefabricated abutments in atomic shaped prefabricated abutments or whether you want to make a customized abutments we have tie bases if you want to have a zirconia abutment cemented to a tie based a titanium base to that full array of prosthetic solutions. We also have multi-unit abutments which is what we're mostly using for our those immediate loads edentulous cases that we talked about which work very well so a full array our material.
Howard: and where our how where do you make you make your own surgical guides, do you send them to a lab what what's the deal there?
Marc: Most of my surgical guides are made by depending whichever software I'm using for the three 3d simulation analysis so for example if I was using a materialized simplant that's going to be then shipped directly from them once I plan the case. There are some systems that allow you to have your own 3d printer in your office I haven't done 3d printing of my own guides.
Howard: Do you have a specific name or website of one place where she can get her surgical guides made, do you have any recommendations?
Marc: Yeah I mean I think it's for someone who has is just getting started I think the good options include 3DVX.
Marc: Yep Simplant and there's a new company that's just entering the marketplace which is really easy to use you can plant it on your phones and an iPad which is 3d MA which which will be available later this year and so there's different approaches there are some softwares you need to you need to have a full license and other ones you can do case-by-case and you know each company has different options for that.
Howard: Do you still use piezo surgery?
Marc: I do I use it every day
Howard: She might not even know what it is what is piezo surgery and why do you still use it?
Marc: It's an ultrasonic technology in the original piezosurgery from Mecktron actually works on a dual wave piezo ultrasonic frequency and the reason for a dual wave is if you are using the instrument to cut the bone and the pressure interrupted one of the waves if you'd only had one wave you might burn the bone by having a dual wave working parallel you can put pressure to cut the bone and it's going to cut in a smooth fashion and my most typical use for it is I use a scale or tip on it and use that to go down into the PDL so that broken tooth we were taking out I would section it into a mesial root and a distal root it was a lower molar and then I would use my piezo ultrasonic scaler tip to go down the PDL space and make it so I can very easily remove that root I like to say that a pair of pliers is my favorite force up because I can use the piezo surgery often times and then just lift the root right out of place not always that quite that easy but it's really a helpful armamentarium,
Howard: Some people are don't want to implant surgery because they don't know if they're really into drawing blood and spinning platelets and...
Marc: No no I don't I I don't do any of that, the growth factors that I use today are biotech engineered so it comes in a little half milliliter vial and the the potency if you take platelet gel it's a whole series of growth factors and those growth factors work synergistically and I started using those in about the year 2000 and what I found was the potency of that platelet gel wasn't quite enough to change the paradigm of the types of procedures I was doing like when we talked about that flapless extraction socket even with a lot of bone loss. It wasn't until I had a bio technology growth factor that I could purchase off the shelf where the concentration the PDGF was a thousand times what I could get in platelet gel that I saw a healing pattern that changed the way I was able to practice. So I don't do any blood drawing and spinning down in my own practice I know it's very popular today but I think you have to really look deep into the science and to weigh out how much clinical benefit there is to the patient with the biology the healing with that.
Howard: Well you know who was not a big fan of drawing blood and doing all that?
Howard: Karl Misch
Howard: I did a podcast with Karl before he passed on and he thought it was unnecessary to draw blood and all that kind of stuff and it was the most controversial thing he said on that that interview I don't know if it's because I don't know why but it seems like many many humans like to make everything more complicated than they have to. It's a very bizarre mind just to keep it simple stupid they just always want to make a mountain of them all I don't see how it would be a practice builder telling your patient oh yeah and we're also gonna have to draw blood.
Marc: Yeah I you know for people who are doing sedation there already setting up an IV line but I did find when we were doing that many years ago now that it did create quite more anxiety than you would expect for the patients yeah.
Howard: Yeah I want to embarrassingly tell you how I fell into implants got my diplomat in the International Congress of Oral Implantology. So I had learned right out of the gate that whenever you went to a dental course the dentist so really were happy and had successful practices and we're making money and everything great about them, they always were had their FAGD or their MAGD so I said okay I'm just gonna copy that and then in getting my AGD I looked at the deals I had to take all these classes on implant dentistry so I told the guy in Arizona well I don't want to take those because I don't do implants I want to do those with more fillings and he said well you have to end of story and I was so mad so I looked and say to find a curriculum or I could just take one course and get that whole damn FAGD out of the way and it was Karl Misch's 7 three-day weekend course in Pittsburgh and I'm telling you this guy's got I mean come on guys you don't have to hustle he's got a 2-day mini residency for 4 grand coming up in March 22nd in Lexington, Kentucky and then March 28th in Kansas City, Kansas that's where I went to dentist go that's the most rocky hot town and then San Antonio that's the boardwalk dude you I mean the boardwalk has got to be one of the coolest places Wow then he's got another one and then he's got him again repeating him in all those cities but my gosh you look at that course in it 2500 bucks dude you're gonna place two implants and get your money back and you got it just the journey of one stop.
Marc: Yeah and the mini residencies, they can they're basically getting the surgical instrumentation in the first five implants as part of the tuition so you know our goal as I said is to give people the support they need to get the experience and build from where they are and provide the mentoring we feel that I know that that we have a system that's much simpler much easier to use and we've had a very good response so far with the people have had experience with it and really excited about the growth to come this year and getting in the hands of more clinicians and getting the process to grow so we're excited about it.
Howard: and the world seems to be getting crazier as I get older and older I don't think of it I don't think people were this crazy when I was in a high school but Tucson right now you can't even get a hotel room in Tucson AZ, I'm in Phoenix 90 miles down the street an hour and a half because they're having a oh my god what is a crystal convention and it's all these crystals and they heal all these things and one of the big things now is people come in and they want metal free do you think?
Marc: We can we have a big argument as to whether as to what metal free means so what's your solution for metal free is that zirconia could we could argue whether zirconia is really it's white but is it a metal. I mean so I don't see any biologic reason to go to anything other than titanium for myself if you're my patient and you want a zirconium implant then I'll let you refer yourself to someone who wants to place those but I will stay with titanium myself.
Howard: Okay so true or false do you think patients are happy that some patients are having allergies to medical grade titanium.
Marc: No I think I do not I think if you go back 10 years ago you had some companies that were using some alloys that had more additives in it and there could theoretically have been patient that had reaction to some of those additive and something like nickel for example over the past I'd say between five and eight years almost all companies have gone two types of titanium alloy that are much more pure and I think in today's marketplace with a reputable company it's extremely extremely unlikely that you would come across something that would have an allergic reaction.
Howard: Well I'm in Ahwatukee, it's actually Phoenix but everybody calls it Ahwatukee and me and my drinking buddies we always refer those crazy patients to the same dentist but anyway.
Marc: Well yeah I mean I would go back to you know even 10, 15 years ago did a couple of dentists that practice quote unquote a holistic dentistry they still supported dental implants so if it was okay then it seems to me it's okay now.
Howard: Well you just walked into a trap to work is up then I'm gonna have the biggest threat on dental town is Netflix has a movie called Root Cause.
Marc: Yeah and I haven't seen it though so I don't know if I should I probably will have no comment I've heard about it it sounds very alarming.
Howard: It's very huge and I'll sum up the entire hour long movie in five minutes there's no other surgeons in medicine that leave a dead organ in your body this tooth is dead they're leaving a dead tooth in your body and that starts the whole cascade to badness and rottenness and I mean you just you know no one leaves that no one leaves a dead appendix in your body or a dead kidney or you know anyway it's so bizarre but they did find four dentists to go onto the movie and talk about it and if you haven't seen the movie you need to see the movie because your patient sees the movie like some people always say yeah why do you post some of the stuff that you do on Dentaltown you know maybe it's negative towards dentistry and like the one I'm getting the most complaints about today you see how I said that the most complaints today I get complaints a lot and I'll just tell you why I do this I posted this article yesterday that's hugely searched late on the internet that says Mark was told he needed twelve hundred dollars worth of dental fillings he needed six dental fillings he went to another dentist and the other dentist said he didn't need any fillings and people are said asking me why do you post this negative stuff because your patients are reading it I know you're a dentists I didn't know you're so sensitive you live in a bubble but so again you you I don't know if you're old enough to remember the Reader's Digest article are you old enough to remember that when Reader's Digest came out with that?
Howard: Okay so it was a long time I just got out of school and Reader's Digest there was no internet The Reader's Digest was on everybody's nightstand and their most prestigious journalist William Ecenbarger who won several awards he says how dentists rip us off and what William Ecenbarger did is he took his FMX and study models to 30 different dentists and by god he got 30 different opinions. What does that mean to you when you're patients if they went to is it that way with periodontist if a patient went to 30 different periodontist how many transplants do you think you'd get?
Marc: At least 29
Howard: So dentistry I mean it's 2019 there's a lot of art there's a lot of science but it's you know just it just is what it is. So I'm gonna ask you some more do you have time I can't believe we already oh my god oh my god we went way over but another question reached she's gonna be looking for a missing maxillary second bicuspid you said that was the lowest hanging fruit, she can look at that but yes he's a lot of she sees a lot of edentulous she sees a lot of people coming in for a denture and the patient wants a realign do you make a new what do you what could I do to help a denture.
Marc: I think another you know a great area for a huge patient benefit is a simple overdenture with two implants and lower interior and fantastic solution, sophisticated Freeman is obviously to do a fixed case on implants and I think you know probably doing your first case being a fixed case with for four or five implants is going to need a little more assistance than they over denture or a single tooth site just to start with but we do have for those with more experience we are offering courses focused on the edentulous case to give people the confidence and training for those types of cases as well but no I mean implant dentistry continues to really be the most powerful thing I think in dentistry today and it's just amazingly rewarding part of practice the patient appreciation of what we're doing for them is incredible and yeah we want to make it easier for people to get more experience and to grow successfully with it.
Howard: and I just want to tell you young kids who are so worried about your student loan debt I've seen in my 31 years I've seen a lot of dentists come out of school and buy an $800,000 office and then didn't realize that they they couldn't diagnose some treatment plan they couldn't they couldn't do the molar endo the guy was doing and they're referring that out and and they took an eight hundred thousand dollar-a-year practice and ran it down to six hundred but bought it for the full 800 whereas on the other side the biggest return on investment practice I've ever seen where somebody buys a practice for three hundred thousand and within one or two years it's doing three million a year as they go down to the poorest part of town and buy the old denture world clinic than some small building in the poorest part of town where all the retirees and trailers are and all that kind of stuff and they never did implant and they bring in an implant arm and turret and they start off for an upgrade here's the denture we advertise the whole denture for you know 250 but here's a nicer denture for five hundred with more nicer prettier teeth and then here's a denture on two implants and then here's a denture all on four and they start up selling ten twenty percent of these people that were coming in for just a realign like they've been doing for 20, 30, 40 years in these places and Florida and South Carolina and poor flyover state America and the next thing you know this dentist is placing a hundred implants a month, So you know um so I'm just gonna ask you in America the country you were born in for every person that pays twenty five thousand dollars for an all on for how many Americans buy an all on none?
Marc: Probably a lot right
Howard: Probably what a hundred to one
Marc: Yeah I would think so.
Howard: So that's the market instead of trying to learn how to do an all on for for somebody that comes to your practice I mean you know how many people come in my office that can pay $25,000 an arch and give me 50 grand for two all on fours okay for every one of them I'll get a hundred that have a denture and they're coming in because it's loose and it needs a realign you've had a weight change.
Marc: or the overdenture, it's life changing just getting them those two implants and it overdenture it really is.
Howard: Last question because you've been so nice with your time it's when you get a doctor on from Harvard you don't want to let them off too fast but back to restorative do you recommend cementing or screwing?
Marc: Well I think in in cases where it's amenable and it's fiscally affordable that it's nice to be able to have a screw retained restoration and not having any cement and then the other times where it just might be more affordable to use a prefab abutment and do more of a crown and bridge styles cemented restoration, so you can do both just want to make sure you're not leaving any cements subgingival to create a problem so.
Howard: and my second last of the last question the Chinese placed an implant with nothing other than a robot are you in fear of losing your job anytime soon?
Marc: I'm really not, Im okay.
Howard: What did you think of that feed and do you and how long do you think it'll be before the bread and butter implant is placed by a robot?
Marc: Well I think it gets back to your question about blood and whether you need to do surgery and if for myself I still think there's value in being able to open the gum and see the surface of the bone and know exactly where I'm working then probably were you know. It's a nice example of what can be done with technology but I don't see that making it into our everyday everyday over than over the next few years anytime too soon.
Howard: Well hey my last question is I'm begging you we put up 400 online CE courses on Dentaltown, they're all ABA approved AGD approved they're coming up on a million views it would be amazing privilege and credibility if you ever took the time to put an online CE course on Dentaltown or write an article on this. I think it's something that would be amazing would you have we up for that?
Marc: Well I'd be more than happy to do that and you and I could follow up with that and we'll see what see how fast we can get it done.
Howard: Okay and then last again at least to follow up with you you're the head honcho but if you well I think it'd be fun to follow up with your other guys Tony Feck, Gary David, Pamela Ray if any of them hear this podcast I want to come on and share even more yeah and then what you did send them my way.
Marc: That'd be great I think our clinical director is David little and I'd love to see if we could get him on with you sometime in the next month so I will put him in touch with you.
Howard: and tell them all even fly down and visit him because I have five grandchildren and four of them live-in Beeville, Texas which is only an hour so I've been flying in Antonio a lot love the Riverwalk love David Little and thank you so much for coming on my show today and spending an hour with my homies I really appreciate it.
Marc: It's a pleasure