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"Don't be afraid of going short...I ask people all the time, 'Why are you afraid of short implants--that you put a patient through an unnecessary bone graft just so you can get a longer one in? You don't need it. Stay far away from the nerve."
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AUDIO - Bill Schaeffer - HSP #126
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VIDEO - Bill Schaeffer - HSP #126
Successful implant surgeon Bill Schaeffer tells how he got to where he is, and why he decided to also get a medical degree.
Implant Surgeon, co-founder of www.theimplantcentre.com
Bill is exceptionally qualified for his role as one of the implant surgeons at The Implant Centre. Having trained in the UK, Bill is both a dentist and a medical doctor. He is also a qualified surgeon and a registered Specialist Oral Surgeon. As if this wasn’t enough, he also has both a Fellowship and Membership from the Royal College of Surgeons of England.
His extensive background in Oral Surgery provided him with the perfect starting point for learning the finer points of implant surgery when he placed his first implant back in 1996. Since then he has gone on to become one of the most experienced implantologists in the UK and has pioneered techniques now used by implantologists throughout the World.
Bill says “using techniques adapted from other branches of surgery, it’s been possible to minimise the amount of surgery that our patients need to go through for their implant treatments and that’s great for our patients.”
Bill’s extensive experience has allowed him to achieve an impressive success rate of over 99% for implants. As he himself admits “I am obsessive about auditing the implants that I place. Without this you simply cannot tell with certainty what works and what doesn’t and it is the only way to continuously improve what you do.”
Bill recently served on the Executive Committee of the Association of Dental Implantology. The ADI is the largest implant organisation in the UK, and is dedicated to improving the standards of implant dentistry in the UK. To further this aim, Bill became the Director of Education for the ADI in 2009 and in this role, he has developed and improved the ways that dentists new to implants can get the training they need to become safe and competent clinicians. A necessary part of this was for Bill to train a Faculty of experienced implantologists to help in teaching the next generation of implant dentists – “Training the Trainers”.
As a result of all of this, it is not surprising that Bill is also an experienced lecturer and he is regularly invited to speak on the very latest aspects of dental implants all over the World.
In his spare time he like to skydive, ski, snowboard and mountain bike and he’s now learning how to windsurf.
Howard: It is the hugest honor to me to be podcast interviewing today the most famous oral surgeon I know. Bill Schaeffer, from the United Kingdom. Really, dude, on Dentaltown you're a legend. I've got two thousand posts, you're an oral surgeon, you're a medical doctor. Your implant cases are mind blowing and, I don't want to throw you under a bus, but some of it's very controversial because you're known for doing some shorter implants. You've really been educating me and all my friends that you don't have to have a mile long little nail. You can have a much shorter, wider, fatter implant and get the same result and you're such a gentleman too. I don't know how you do it because some people will say, "You can't do an eight millimeter implant," and you're like, "Okay, you may be right. I could be wrong, but unfortunately I've done a gazillion of them and they all work."
First off, thanks for doing this podcast today. I want to ask you, first of all, since eighty percent of our viewers are Americans, what is the implant market like in the United Kingdom? Is it growing? Is it flat?
Dr. Schaeffer: For me, it's fantastic because the implant market in the U. K. is incredibly small which means that there's only one way for it to go. It can't get worse. In terms of most of Europe, we're right at the bottom of implant per capita per population, but that means that we can take a big share of it. It's great and more and more people are doing it. In the U. K., the health service, which is a large portion of dentistry, is being screwed for money more and more and more. There's less money available so more patients are realizing that you do get what you pay for. Great for me.
Howard: Let's talk about that because a lot of American's, they think the dental industry is controlled by insurance, but when you go lecture in countries like India, China, and Brazil where they don't have dental insurance you realize you can have dentistry without insurance. The [inaudible 00:02:14] is it growing, contracting, flat? Where was it ten years ago? Where do you think it'll be ten years from now?
Dr. Schaeffer: I think it will be very different in ten years. In the U. K. pretty much all healthcare, the majority of healthcare, is paid for by taxation. There's [inaudible 00:02:35] insurance. Insurance tends to be for the wealthier part of the population. People have become used to not having to pay for their healthcare, because it's paid for by taxes. They don't have to put their money in there. They don't have to get their wallet out when they have dentistry.
Now, that's not quite true. You pay a small amount so it's partly funded by the government and partly funded by the patient. The problem is it's kind of a race to the bottom. The government are paying the less and less so the dentist are doing less and less. There's lots of supervised neglect. There are still lots of dentists doing their best under the NHS, but more and more dentists are saying, "Enough, we can't do it like this. I can't provide good dental care like this, I'm going to go private."
Now, implants aren't available on the NHS, so I don't have to deal with the NHS. I only do private work.
Howard: So, I have heard numbers saying that when I got out of school in '87, twenty-eight years ago, that there were about fourteen thousand dentists in the U. K. all practicing under the NHS and now twenty-eight years later probably five thousand of them have dropped out and just do private insurance and cash and only maybe nine thousand still do NHS entirely. Is that about right or is that completely off base?
Dr. Schaeffer: I'm not an NHS dentist so I don't know the figure. I can tell you that there are about twenty-two thousand dentists who practice regularly in the U. K. I would have expected the majority of those to do some NHS. Some dentists will only do NHS, but most will do a mixture. More and more dentists are saying, "I cannot work within the system. I can't do the best for the patients, so I'll only take patients privately."
Dr. Schaeffer: More and more patients are realizing you get what you pay for.
Howard: Okay. Tell us your journey because, in the United States, we hear that Korea has twenty thousand dentists and fifteen thousand of them will place an implant every month. We hear that in Germany three out of four German dentists will place an implant every month. In America probably ninety-five percent of the general dentists have never placed on implant in their life.
Walk us through your journey. What happened to you when you got out of dental school? How did you get interested in implants and how did your journey get you to be an implantologist full time?
Dr. Schaeffer: All my way through dental school I never pictured myself being a general dentist. When I qualified as a dentist from dental school I then went and started working in hospitals doing max-fac, maxillofacial surgery. Did more and more, got as far as I could go without doing medicine and then went and did medicine. For me, that was just the logical progression. There wasn't any question about it. That's what I was going to do. I wanted to be a maxillofacial consultant.
When I got through my medical degree, things had changed a lot in the health service. The funding had been cut a lot. Staff were overworked. Resources tightened and tightened and tightened because hospital based treatment is all funded by the government, the NHS. We've been going through some tough times.
I got my surgeons qualification and looked around at all the consultants that I wanted to be like and they were having a miserable time. Now, fortunately I paid my way through a medical degree by doing a mixture of working in hospitals doing max-fac and doing oral surgery and dental practice. One of the dental practices started me off putting implants in and I thought, "You know what? I could carry on doing this as a business."
I went to the bank, gave them some figures. I didn't realize that was business plan. I didn't know what a business plan was. I gave some figures that seemed to make sense. The bank thought so too. They lent me some money and I started going around to different dental practice. At that time I didn't know anybody who did that. I made this up. It grew and grew and grew. Very quickly I stopped having the time to work in hospitals and I was just going around to different people putting implants in.
One of my very good friends, Guy Barwell, came into business with me and started doing the same. Quickly it got to the point where we had too many patients to go and see them. What we needed was to set up our own place where they'd come and see it.
We set up an office site in 2006. We set up our second site four years ago now. Now, we place one percent of all the implants placed in the United Kingdom.
Howard: Because you are that elite, and like I said, I'm not blowing smoke up. I'm not trying to flatter you. I consider you ... [crosstalk 00:07:46]. I can't think of a more elite implantologist. I really can't. I don't know who it'd be. Especially now that Branemark passed away. I want to go right to the controversial four thousand pound elephant in the room that people are trying to avoid in the conversation.
First, you are known on this controversial deal, you're putting in much shorter, wider, fatter implants. Will you talk about that? Tell us what your thoughts are on that and why you're doing a lot of shorter implants instead of longer, narrower implants.
Dr. Schaeffer: Okay, I don't go wide. In the main implant system I use we stock two widths. Three and a half millimeters and four and a half millimeters. We don't stock anything wider. I have no problems with people putting wide implants in or narrow implants, but I only have a choice of two. We don't stock anything wider. They make them wider, but I don't see the reason to use them.
For me, I have two widths and I have a choice of lengths. I used to do what every other implantation starts doing and most still do. You look at the available bone and you think, "What's the longest implant I can get in there?" You kind of look at the x-ray and you go, "Can I get a twelve millimeter in there? Oh, no there's not enough so I have to go down to a nine and a half or maybe I'll have to only be able to put an eight."
For me, I know my shortest implant will work so my thought process is can I put a, for my system it's a 6.6 millimeters long. Can I put a 6.6 in? Yes, fine and done. I don't have to think way past that. A 6.6, for me, I know works. We place three of them everyday, just over three of them everyday. If they didn't work we'd know about it.
Howard: Do you think it comes from the old school that we were taught - the crown to root ratio. The root should be twice as long as the crown. Do you think that's the brain activity that's making them go long or are they just thinking, "If six is good twelve is twice as good."
Dr. Schaeffer: Yes, I think a lot of people think that. I think it's a mixture of things. Certainly, short implants on a machined surface don't work well. A third of them will fail. We don't use machine surfaced implants anymore. We use modern rough surfaced implant. Short works just fine with those.
I think there's a legacy from the old school of machined. I think there's a legacy of looking at implants and expecting them to be the same as teeth. To be honest, for me now, the short implants I use, they look normal to me because I'm using them everyday. I can understand how freaky they look to anybody else. They look strange. You've got to get used to it. For me, it looks strange to me when I put a long one in and I put as many long ones as I put short ones.
Howard: What system are you ... You said you're using two systems. What are they?
Dr. Schaeffer: I use Ankylos as my main system and I use Bicon as well. I was brought up on Bicon. Bicon was the implant system that I started with and I have a lot of love for the system. I think it [inaudible 00:11:17] there were lots of reasons why we chose to use Ankylos as our main system. Really it's all about getting [inaudible 00:11:30] dentists to restore the implants we placed. We thought it would be easier with Ankylos.
Howard: Who makes Ankylos and where is that made?
Dr. Schaeffer: Ankylos is by a company called Dentsply.
Howard: Okay, that's Dentsply's system. Who makes Bicon?
Dr. Schaeffer: Bicon?
Howard: But I mean where are they out of?
Dr. Schaeffer: They're in Boston.
Howard: They're in Boston?
Dr. Schaeffer: Bicon stands for Boston Implant Consortium.
Howard: Bicon stands for what? Boston Implant Consortium?
Dr. Schaeffer: The Boston Implant Consortium.
Howard: All right. Talk again about the services. Ankylos and Bicon have the same type of service. You're saying it's not a machine smoothed surface. You're just looking for a rough surface? Is there a specific type of rough surface?
Dr. Schaeffer: Who cares? It's all marketing. These days everybody's got a medium rough surface that works. We've been through all the mistakes that were made making them too rough or not making them rough enough. Blasting them with this or that. It doesn't matter. It's all marketing hype. These days, all medium rough surfaces on implants.
Howard: You and I are old enough to remember back in the day when they use to put a HA coating and then the coating was coming off.
Dr. Schaeffer: Yes.
Howard: Do you do any HA coating anymore. What are your thoughts on that?
Dr. Schaeffer: Part of the problem you have with HA coated was the implant manufacturers used to recommend that they were used [inaudible 00:13:10] poor quality bowed. They have the same sized implant, machined implant, and they sprayed an HA coating on it which made the implant wider. Not massively wider, but a bit wider. The coating was often quite crystalline so when you screwed an implant in with an HA coating it would often shear off because it wasn't bonded very well on to the implant. That created problems.
I've placed over a thousand HA coated Bicon implants, but they're push-fit. You don't screw them in so there's no shearing off of the HA coating. It works absolutely brilliantly. It works differently. It's a different coating, it's a thin coating, not a thick coating. It's amorphis, not crystalline. It's a push-fit, not a screw type implant. Most people quite rightly don't use HA because you don't need to anymore. You've got grit blasted [inaudible 00:14:06] surfaces that work just fine.
Howard: Okay, I want to ask you just a couple more interesting questions. One of the biggest controversies in America between the surgeons, like oral surgeons who have placed several thousand implants, and general dentists, that are starting implants, the older surgeons are always telling me, kind of angrily, that they're not a fan of surgical guides. We're talking about single tooth replacement which ninety-five percent of all crowns in america are made one crown at a time. Ninety-five percent of all implants placed are one implant at a time. We're just talking about a single tooth, that you need to be surgeon. You need to sit there and be able to lay back the tissue, a full flap, look at the bone. You've got a tooth in front and a tooth behind. You've got the buckle angle. Come on, dude, be a real surgeon. Do it.
They don't like. A CBCT, 3D x-ray machine, making a surgical guide. They think that's training wheels. You're never going to learn to be a great surgeon with the surgical guide. My controversial question to you is if this dentist ... five thousand of them are driving to work right now listening to you on iTunes, listening to the audio. If they were going to place, they've never placed an implant, never get to learn how to place an implant, would you recommend them going down a road of a 3D x-ray and making a surgical guide to help them place it right or would you say, "No, come on. You need to learn how to lay a flap and be a surgeon."
How would you answer that question?
Dr. Schaeffer: I'll answer it the same as if a surgeon asked me how they should place their first implant. Get a 3D scan. Make a surgical guide. A surgeon might be very good at raising flaps and stitching afterwards, but there's a new skill that they've got to learn. When you place your first implant, you've got to learn how to get over the visual clues that are throwing you off in the wrong direction and there are many.
When you, in America and us for us in the U. K., for me and my business, the major of implants we place are single implants. You would think that it's really hard to screw it up when you're just putting it between two teeth. It's incredibly easy to screw up. I've screwed up plenty [inaudible 00:16:30] placement that I should have known better about. Now, I would completely agree that with experience comes the ability to be able to place them better and mess up less often, but to begin with you've got to, you've really go to, have a surgical guide and have a CT scan. If you're not you're just going blind.
You need all the help you can get when you're starting out. If you're hugely experienced then you can cut some of the corners safely, but you've got to know which corners to cut. Everybody should start with 3D CT scans and surgical guides. Even the best maxillofacial surgeon.
Howard: Okay, well let's talk about that. When you walk into the Cologne meeting in Germany last March there were a hundred and forty-five implant companies that had a booth selling implants and that's overwhelming too. My motto with Dentaltown is I'm trying to create a community so no one has to practice alone. What would you say to a person who say, "I want to get into this and there's a hundred and forty-five companies selling implants and, back to the CBCT, there's a dozen CBCT's."
You told us you went with Bicon and Ankylos. Ankylos was your go to system. What CBCT and surgical guide system did you choose?
Dr. Schaeffer: We've got two cone beam CT scanners, one at each of our centers. They're both made my a South Korean company called Ewoo, or Ewoo Vartch.
Howard: I hear that all over the world. Spell it. Ewoo.
Dr. Schaeffer: Ewoo is spelt as it sounds. Echo, what's W in phonetic alphabet? I don't know. William, Oscar, Oscar. So E-W- double O. Then the second word is Vatech. V-A-T-E-C-H.
Howard: Those are two different companies, both South Korean?
Dr. Schaeffer: It's all one word. It's all one company.
Howard: Oh, Ewoo Vatech?
Dr. Schaeffer: Yes.
Howard: Yes, I hear great things about that because I hear the quality's great and the price is low.
Dr. Schaeffer: You can't complain about that. We've had no problems. We bought the first Ewoo Vatech machine in the U. K.
Howard: What year was that?
Dr. Schaeffer: We bought it without having it ... that was 2006. We hadn't seen any Ewoo Vatech machines so we kind of bought it off spec and we almost wondered if we had been conned in an internet scam, but fortunately the machine did turn up and it did work and it's been great. It works so well we bought a second one from the same company.
Howard: So you have two of those?
Dr. Schaeffer: Yes.
Howard: Okay, talk to us about your surgical guide technique. Do you make your surgical guides? Do you send the CBCT file through Dicom to a lab and then fabricate it? Tell us how you make a surgical guide?
Dr. Schaeffer: I no longer use computer generate surgical guides. When they first came out I embraced them. I thought they would be the future of implantology. I was a charter member of the SIMPLANT academy, member of the Chi academy, SIMPLANT pro user. I did a lot. I came to realize that it wasn't fool proof. It just provided a way of making different mistakes. I think it is fantastic for beginners. However, you still got to be very aware of the mistakes that can still be created even when you use one of these guides.
It's much better when you're just doing single tooth replacements because you can really lock it on those adjacent teeth, but if you're doing full arch, full mouth [inaudible 00:20:32] there's a but more give in them. Now, for me, I haven't done a guided case using computer guides for about four or five years now and I was a huge fan of them before that time. Now I have my on laboratory so we make our own guides. They're not computer generated guides. I use a cone bean CT scan. I use a guide showing where the tooth is, but, then again, I've been doing this a bit. I've made enough mistakes to learn how to avoid them in the future.
I don't recommend that anybody copies what I do and, again, you need a bit of experience to be able to do it, but for me, I don't use any guides when I'm doing a single tooth replacement. I don't use guides when I'm doing, usually, a couple of teeth. I will often use something that will center me in the gap. There are a number of different guides that will facilitate that, but they're not stereolithographic guides made from a CT scan.
Howard: Okay, so you're not ...
Dr. Schaeffer: For me, it's [inaudible 00:21:47] implants so I don't have to get really really close to the nerve. I'm putting in a short implant. Part of the reason people use cone beam CT scans is because they want to put that eleven millimeter implant in.
Howard: So you're saying you don't use CT guides for surgical single tooth implants, but you use a lab made guide?
Dr. Schaeffer: I don't use a lab made guide unless I'm probably doing a four unit case. I don't use it for anything else, but I'm not suggesting that anybody else should be a reckless and cavalier as I am.
Howard: So, earlier you said that you think, if you were talking to another surgeon placing their first implant, that they should use a surgical guide, but now you're saying that you, yourself, do not use it for one or two implants. You only use it for like four or more.
Dr. Schaeffer: Howard, I said if they were doing their first case, or their first few cases I would absolutely recommend they use certainly a guide and certainly a CT scan. Whether it's a computer generated guide or not, I have feelings for and against that, or whether it's just a lab made guide made from a waxed up tooth position. Again, there are pros and cons to all of these.
Howard: Do you have your own single lab person making your surgical guides?
Dr. Schaeffer: We have a number of lab [inaudible 00:23:21].
Howard: But, do you send it out to a lab or do you have that lab inside your implant center? Or do you send it out to a lab to make your surgical ...
Dr. Schaeffer: No, we've got a laboratory inside our implant center.
Howard: Do you have one master person that does all these guides for you?
Dr. Schaeffer: No. We've got a lot of people that do them.
Howard: Man, I would ...
Dr. Schaeffer: Making the guides is ... Sorry, carry on.
Howard: Do you think you could get your lab tech to make a one hour online CE course for Dentaltown on how they do it?
Dr. Schaeffer: Making a guide, yes. I can post something on it. It's incredibly easy. All I want to know is, let's say it's an upper anterior, I need to know where the labial tooth position is, where the labial surface of the teeth is. That's all I need to know. Everything we do is screw retained. We just don't do cement retained. I've got to get my implants coming out through the occlusal surface of premolars and molars and through the [inaudible 00:24:29] of canines and incisors. That's my one remake. If I'm doing bridges, I've got to get the implants parallel.
Again, you can't do that without a bit of experience, but that's all we do. We don't do them any other way. When people say implants are hard to restore, they're absolutely hard to restore if you don't get them in the right place. If you get them in the right place, they're easy.
Howard: Bill, I'm telling you, I know these dentists. I watch them talk all day long on Dentaltown at least four or five hours a day from nine to eight and if you put up a one hour course on how to make a surgical guide, it might seem like nothing to you, but it would just be hugely helpful. There are so many dentists who need to see somebody make a real surgical guide and be talking about.
Dr. Schaeffer: I'll have a chat with my lab team. They're the ones that do it. I don't do it. I just use them.
Howard: Yes. That would be so awesome. I want to go on to other things. Some people are drawing blood and spinning it and centrifuging it and coming up with PRF, platelet rich fibrin. Do you think that's something they should get into or do you think that's something ... What do you think about that?
Dr. Schaeffer: I first saw [inaudible 00:25:43] who invented platelet rich fiber, PRF, a decade ago, 2005, in Italy. I was so impressed with his lecture that I immediately bought the centrifuge and bought his kit and started using it. I've been using it for a decade. I know it worked, but it's just a tool. It's not magic. People want to think that it's something that will let them be sloppy. It's just a tool. It helps things heal more quickly. If you put it in a socket it won't magically regenerate all the bone, but it will help the socket heal more quickly. If you put it in a sinus that's a very different situation. You can put anything in a sinus, you can put nothing in a sinus and if you put implants in it will grow bone around the implants. All that PRF does is make that bone grow more quickly.
Now, I simply just don't do lateral sinus graphs anymore. I do maybe two or three a year. I used to do a lot. Now, what I do is I do internal lifts, osteotome lifts for want of a better word. I use Albert and Sheldon's great crystal lift kit from BSB. I think it's fantastic, idiot proof, and I use platelet rich fibrin. That's what I use. I don't use anything else. I'm making tiny incisions, I'm making small holes in the bone. I'm an oral surgeon. I'm a doubly qualified oral surgeon. I teach bone grafting and, yet, the less big grafting I do, the happier my patients are.
Howard: I'd love to get that course out of you. [inaudible 00:27:38] I would so love to get that course out of you. Can I just put you to work all weekend and just make another one? That would be amazing to watch that. I remember, we're old enough remember, it was Tatum down there in St. Petersburg, Florida that was teaching the lateral sinus lifts and you would start with a boiled egg and all that stuff. Now, that's gone.
Dr. Schaeffer: Tatum taught me. He taught me how to do sinus grafts.
Howard: I guess he's moved. He left America. Someone told me he's now in France or Italy. He moved to Europe.
Dr. Schaeffer: Yes. I think he met a French woman.
Howard: Is that right? I'd move to France for the perfect woman.
Dr. Schaeffer: I think so, yes. He's just [inaudible 00:28:21].
Howard: Yes. That is amazing. Another thing I want to ask you about, I America, I don't know if this happens in the U. K., but there's some big corporate four on the floor implant centers where their coming in some of these big cities where they do a lot of advertising. Same day implants. You come in there and they place four on the floor. What do you think about that whole concept? Have you heard about that in the states?
Dr. Schaeffer: Yes. Absolutely. If you're not involved with them, and I'm not, it's very easy to dismiss them as caviler or reckless or [inaudible 00:29:07]. I must admit that for some of these centers they've got one treatment. If you're only missing three or four teeth, for them, realistically, it's easier for them, they're more set up to it to take out teeth then put [inaudible 00:29:27] placing just a few implants and doing perio and doing endo and so forth. They are very well set up. They have very good training. They have very good laboratories.
Howard: Which one? Which one?
Dr. Schaeffer: Well they have their own laboratories they use. They have technicians. It's difficult when they're doing the numbers that they're doing and doing them very successfully to dismiss them. They started coming into the U. K. and, truly, for me, all they're doing is marketing implants. If a patient hears about them and lives near me, they'll come and see me.
Howard: What are they called in the U. K.?
Dr. Schaeffer: I'll think of it in a moment. It'll come to me in a moment. I'll think of it.
Howard: What implant company owns that four on the floor?
Dr. Schaeffer: Noble Biocare. I'm not sure if Noble Biocare owns the company or whether the company just uses Noble Biocare implants. I'll think of them in a moment.
Howard: Okay, back to ... I want to switch gears from a single tooth to full endentulous. I always like to talk about the controversial things, especially when I got lead guys like you. On Dentaltown, we had to separate implants from mini-implants because there's just too much conversations.
It seems to me this, this is the way I'm seeing it. Tell me if I'm right or wrong. It seems like in most countries, the thirty-one million Americans who have zero teeth, if they go to an oral surgeon or a periodontist, they're only going to recommend a Mercedes Benz, a Porsche, an Audi, some fifty thousand dollar full mouth rehab. Six implants, upper, lower. If they don't have the bone they're going to do a lot of bone grafting. It's going to be twelve units to fix, upper and lower, and it's going to be able fifty grand. Someone just says, "I don't have fifty grand." I know dentists that don't have fifty grand. If they say, "I don't have fifty grand," and you say, "Okay, well I've got a five grand option. I'm going to use 3M's intext and I'm going to put four minis on the low, in front of the middle foramens, and six minis on the uppers, in front of the sinuses, and I'm going to use your existing denture and that's going to give you a great service."
It seems to me that if you post a case like that, or you say you'd do that, big boys who place thousands of only root forms, they don't place minis. You're a lesser primate if you're placing minis and real men place full rootform implants. I want to ask you this. What do you think of that assessment? I get that feeling a lot. I've had a lot of people who place five hundred minis a year and we're only talking full endentulous. It's usually a grandma. It's usually a sixty-five to eighty-five year old woman who probably only has a twenty-five, forty pound bite force. She's not like a big guy like you that probably bites a hundred fifty pounds. I know you're in the United Kingdom so you don't even know what a pound is. It's probably a kilogram over there now. You're more advanced than us. What do you think about minis?
Dr. Schaeffer: I think there are many right ways of treating any patient. You go out and there are a whole range of cars you could buy from the Mercedes Benz down to the Scotalauda. Why shouldn't there be different treatments for implants. For me, you see me post on Dentaltown. I get, all the while, that can't possibly work being told that. I get told that what you're doing cannot possibly work.
Howard: And you're such a gentleman about it, such a gentleman about it.
Dr. Schaeffer: I place minis. [crosstalk 00:33:24] It's true. They work. Now, I don't put fixed restorations on my mini implants.
Howard: Right. We're only talking full endentulous.
Dr. Schaeffer: Yes, and I know people do in full endentulous, but lots of minis [inaudible 00:33:51] fixed restorations on them. You know what? They work for them. I personally don't do that, but I use them in the mandible for holding dentures. They work great for that.
Howard: What would your technique for full edentulous that can't afford full root form and fixed bridge ... What is your mini treatment plan? Your lower priced mini implant treatment plan for a full edentulous lady?
Dr. Schaeffer: I put four minis in and we use their ... We rarely are able to use their denture because usually their denture is pretty crummy. Usually, it's fully extended. Usually the OBD's wrong. It it rare that we're able to use their dentures so normally we make them a new set of dentures and put four minis in and o-ring housings to clip them on. The downside of that is that that takes quite a lot of maintenance. More maintenance than a fixed does. You've got to change those o-rings regularly. You've got to realign and remake the denture as they continue to get resorbed [inaudible 00:35:05]. Otherwise, as the mandible resorbs posteriorly, you end up with the denture high and dry on the minis. But [inaudible 00:35:12] provided the patients are aware of that up front, it works great. It works fantastically.
Howard: How often would you have to change the o-rings and how often would you have to realign it?
Dr. Schaeffer: Change the o-rings, usually, a minimum of every six months. It's very quick to do, but there's a cost implication to the patient for that. It depends on how recently the teeth were taking out for how quickly you need a realign. If the dentures really moving around you need to have a realign or a remake. It's all about how quickly the mandible's resorbing.
Howard: Do you mostly do four minis on the lower for a new lower denture or also placing equal amount of six in the maxillary.
Dr. Schaeffer: [inaudible 00:36:02] implant any minis in the maxillar.
Howard: You don't?
Dr. Schaeffer: No, for me, we've struggled to make tissue supported upper dentures work on implants. They work great if they're implant supported. There's lot of ways of doing that, but tissue supported, we struggle. We just can't make them work predictably. They come lose. We find that they don't work in our hands as well as we would like them too. In the mandible, you're just putting four in the front. They work fine.
Howard: What is your technique to avoid placing one in the mental foramen? How do you stay in front of the mental foramen? What is your technique? That's everyone's scare of four minis in front of the mental foramen is that the anterior loop of the mental foramen.
Dr. Schaeffer: Well, with minis, you don't have to get too close to the mental nerves. It depends on whether you're raising a flap or doing flapless. If you're raising a flap you just take a look at where the nerve is. If you're doing it flapless, and most implants are flapless, then I make two little marks and put some temporary filling material in the denture, two little dents, put them in the denture, get the patient to bite together having a CT scan. I get an idea of where the mark is on the denture, where the mark is in relation to the gum, and where that mark is in relation to the mental nerves. It's just a guide, but basically you want to stay further away from the nerve than get too close to it if you can help it.
Howard: So you basically do not do mini implants in the maxillary denture. That's a fair assessment?
Dr. Schaeffer: Yes.
Howard: Just trying to get a market segmentation price, if one of your options was four mini implants in the lower and a new denture, about what would that cost verses ... What would be the Mercedes dream plan? Would that be six implants and a twelve unit fixed bridge?
Dr. Schaeffer: When I do a full arch it doesn't matter. They don't get paid per implant. If they've got loads of bones and I can put implants in, I put six in. If they've got hardly any bone and can squeeze four implants, they get four implants. It's the same cost. For me, it's a full arch, or for the patient, it's a full arch. It's a full set of fixed teeth. When we're doing it, these days, I immediately load everything and I do them in a technique called the [inaudible 00:38:48]. There's a lot going on for that.
If we're doing four minis in the lower and they get one denture that clips on, that's three thousand pounds. If I'm doing a full arch, fixed bridge, with sedation, extraction, osteoplasty, implants, intra-oral welding, immediate load, and then the more permanent bridge later on, that's eighteen thousand pounds.
Howard: So, it's six to one.
Dr. Schaeffer: There's a big difference in product.
Howard: So it's six to one. It's six times more expensive. Eighteen pounds to three. Just for our American viewers, what's the pound trading to the U. S. dollar these days?
Dr. Schaeffer: I have no idea.
Howard: Okay. Do you have any middle of the road treatment? Do you have a six, nine, or ten thousand dollar middle treatment or is it basically two cars? Either a three thousand mini or an eighteen ... You what?
Dr. Schaeffer: [inaudible 00:39:52] that's a removable implant supported bridge. Again, it's kind of metric, but it's much more [inaudible 00:40:03] denture that clips on securely to the implant. It works great, but it's bigger than a fixed bridge. You have to take it out to clean it. It's bulkier, but it's solid, strong. They can eat whatever the like with it. Relatively maintenance free.
Howard: Then I'm going to throw out some rarer questions. You still see people wondering, sometimes people will want to do a three and a bridge and one tooth is a natural tooth and the other abutment is an implant. Good idea? Bad idea? A three unit bridge, one end implant, one end tooth.
Dr. Schaeffer: That's never something that we like or enjoy doing. We do very very little of it. For me, I would much much rather put one implant and cantilever a unit off of it and we do that all the time. For me, that makes much more sense than trying to connect it with the tooth.
Howard: I want to switch gears. First of all, I'm answering these questions and I'm probably not smart enough to even be asking you the questions. Is there anything that you would like to share with people placing implants, instead of the beginner, but the people who have done a thousand implants. What do you think you know that a guy that's placed, you know, a hundred doesn't know? What do you think are some elite tips that you might be able to share right now to the listeners out there that say, "Come on, I'm an advanced implant guy. Tell me something I don't know."
Dr. Schaeffer: I don't know what they don't know. The tips that I can suggest are it's always human error. It's never the equipment. When there's a mistake we all hate to blame ourselves, but it's almost always our fault. Assume that you are human and you are trying hard to make mistakes because they'll happen even if you don't want them to. Look for it. Try and do things. Try and adopt a behavior that acknowledges that human error is a fact of life. Try and trap those mistakes before they happen. For implants, a really simple way of avoiding many of the mistakes is, when you drill your first pilot hole, stop. Take an x-ray. You will be amazed at where your drill actually is compared with where you thought it was. It allows you to stop or to change tact. That's a very simple way of avoiding an embarrassing placement. Let's face it. It's always embarrassing when you screw up, but we're human. We're going to screw up. You've must got to try and have a system that acknowledges that and traps human mistakes whenever you can.
Howard: That's why it's so important that, when you turn fifty, you get a colonoscopy. Usually the colonoscopy surgeon, they find your head there.
Dr. Schaeffer: I'm fifty next year.
Howard: Yes, I got my first one at fifty. I'm fifty-two and that's what the colonoscopy doctor said, he said, "By the way, you have no polyps, but I did find your head." Any other tips? I feel like I've got an elite guy on there and I know there's a lot of oral surgeons and periodontists that placed lots of implants on there. Do you think there's any other tips for those guys that have placed a thousand?
Dr. Schaeffer: Yes, don't be afraid of going short. Again, I get asked all the time, "Why are you so afraid of doing bone grafts so that you can get a longer implant in?" What I now say to people, I say, "Why are you so afraid of short implants that you put a patient through an unnecessary bone graft just so you can get a longer one in?" You don't need it. Stay a long way away from the nerve. If you could get a twelve millimeter implant in, but you're going to get close to the nerve, put an eight millimeter implant in and stay miles away from the nerve. The longer one isn't better. They won't be safe. Keep your blood pressure down. You know at our age, Howard, our blood pressure becomes important to us. If I'm doing stuff that gets me really close to a nerve when I don't need to then I'm unnecessarily raising my blood pressure. I'm unnecessarily putting that patient at risk.
Howard: You know, I'm not worried about high blood pressure or getting old because I heard old age doesn't last very long. You know what this kind of reminds me of?
Dr. Schaeffer: You cut off. There you are.
Howard: Did you hear my joke?
Dr. Schaeffer: Yes. I did. I did.
Howard: It kind of reminds me when I got out of school in '87, the only way to properly do a root canal was the first appointment, clean it all out, medicate it, and then wait two or three weeks to make sure it's okay. Then, obtry on the second appointment. Back in '87 if you said, "Well I'm going to do the whole root canal in one appointment," they just thought, 'well you're just a bad guy. You're just cutting corners.'
There's always that human nature thing where the hardest path is always the best path and I get that. I think one of the best pieces of advice I always give my kids is that when you come to a fork in the road ... You're trying to get to the top of the mountain. When you come to the fork in the road, one choice is going to be an uphill, hard path that scares you. The other one is going to be down hill and easy. If you always take the up hill, hardest path every decision ... You come to a fork in the road, which one scares you? That's the right move.
I think dentists are just super achievers. They become doctors so they just think, "Oh, my God. I'll get that implant one micron from the nerve." When you tell them just to relax and put in an eight, it's counter intuitive. It's counter intuitive to a super achiever doctor. Any other things that you might think an elite guy, a tip for an elite one?
Dr. Schaeffer: Yes. I've never regretted not placing an implant. I've regretted placing lots of implants. I've regretted taking patients on, but I've never regretted turning a patient a down because they're not my problem anymore. Just be aware the fact that all of your problems come from treatment planning and case selection. They will. They will all come from that. Knowing what you are able to achieve for these patients and knowing what you're not. When we're beginners, we let the patient dictate lots of stuff for us. We say to them when we're beginners, "You're going to need to leave this implant to integrate for three months," and they say, "Well, I'm getting married in two months. It's got to all be finished by then. Can't you do it? Can't you just shorten it?" We go, "All right then," and we go against our better judgement. Listen to that little voice in your head that's telling you what is right. Case selection is everything. Treatment planning is everything. You don't have to treat everyone that comes through your door.
Howard: Yes, and I want to give an advice to dentists. I think this is really good advice. I think, since dentists got A's in calculus and physics and geometry, and trig and all that stuff, you know what I think the problem is with the little voice in their head - the little birdie on their shoulder? Since they're so damn smart, they're always debating with the birdie on their shoulder. They're always arguing with the voice and as you get older you realize, 'You know what? Quit arguing with the little birdie on your shoulder. When he starts screaming, just stop. Just stop."
I know you're smart, but don't argue with birdie. When the birdie's saying stop, just stop. You brought up another controversial subject. Immediate load or not? What does your implant have to torque out to before you'll immediate load. When should you not immediate load? What would be a bad torque out where you would say, "No, we're going to bury this thing for three months and come back and load it later."
Dr. Schaeffer: It's slightly different for me. I do own a torque wrench that I can measure when the torque is, but I never use it. It's never open. For me, again, I've been doing it a little bit. For Ankylos, if you put them in too hard then you break the carrier. I don't want so much torque that I break the carrier. That's just a pain. If the torque is too low, you have to hold the carrier to unscrew it, because otherwise you unscrew the implant. For me, when I'm doing an immediate load, if I'm splinting implants together I don't care what the torque is. I just don't care. If I'm not splinting them together, I want to try and get at the upper end of those two limits. I don't want it so high that I break the carrier and I don't want it so lose that I unscrew the implant when I tear the crown off the carrier.
For immediate loading you want a decent amount, but I don't have a number for you because I never measured the numbers. For me, the one thing that I look at is I do almost everything one stage so I put a healing cap on straight away at the time of surgery. I don't bury many implants. If I can take the carrier off without unscrewing the implant, that's fine for me to put a healing cap [inaudible 00:50:11]. That's the only kind of measure I use. If I have to hold the carrier to unscrew it, then, for me, I need to bury that implant.
Howard: I want to ask you another thing. You're a specialist. You're a oral surgeon. You're a dentist, an oral surgeon, a medical doctor. The market has two skill sets. You've got general dentists placing implants with a fraction of the training that you do. What do you think about specialists verses general dentists placing implants?
Dr. Schaeffer: Look, there's lots of things that general dentists do that I would be absolutely dreadful at. I haven't prepped a tooth. I haven't done a filling since dental school. We have different skill sets, but that doesn't mean a general dentist can't place implants. Equally, it doesn't mean that a maxillofacial surgeon can't excavate a pulp when it's called for. As long as you know where your skill set lies, some of my best mentors have been general dentists who are just legends at implants. Their skill set has grown over the years until they are way better than I will ever be. Why should I, then, start suggesting that general dentists shouldn't do implants?
All you should do is know what your limits are. I know that I would be useless [inaudible 00:51:43]. I haven't done it for twenty-five years. I know that I can do certain things with implants that some people might not be able to. As long as you know where your own limits are, just stay within your own abilities. Now, that doesn't mean that, if your own abilities don't include something that you want to do, that you shouldn't get training and do it. Get the training and do it. If you want to learn how to do sinus grafts, go on a sinus graft course. If you want to learn how to immediately load, go on a course that's immediately loading or grafting or whatever it is that you want to learn. GDPs can do courses and learn just as well as oral surgeons can.
Howard: Have you ever been to Los Vegas?
Dr. Schaeffer: I've never been. No, I've never been.
Howard: Why don't you come to Los Vegas some year, any year? We have a Townie meeting there. We have it every year, thirteen years in a row. It's always in April. It's always like the last weekend in April. Do you think you'd ever fly to Los Vegas and come give a course on implants?
Dr. Schaeffer: I'd like to. I already have to explain to my wife why I spend so much time on Dentaltown, much less take a holiday out there as well. I'll have to get it past my wife.
Howard: Well, run it by her. That would be amazing. That would be fun. I've only got you ... I'm almost done. I'm at fifty-three minutes. I've only got seven minutes. I want to switch gears completely away from implants and go to the business of implants. You have an implant center. What have you learned over the years about running the business of an implant center? Marketing, advertising? How do you get paitnets? Are of yours mostly coming from general dentist referring an implant to their buddy, Bill, to place it or are you doing any direct consumer business advertising? Trying to get them off the street like all on four does? What are you doing? What's your business model in marketing?
Dr. Schaeffer: We do everything. We market at every possible avenue that we can. For us, I'm sure you know that there are specialists who will take your referrals who will think that they are very very clever people, and they are clever. They're specialist. They're very good at what they do and, therefore, if they place an implant, they think that the only person who's really capable of restoring that implant is themselves. If you let an outside dentist restore it they could mess it up. They will never have a big business.
When we started with our first center, we had two surgeons and one restorative dentist. We were placing twice as many implants as we could restore ourselves. We had to encourage and train and support our referring dentist to restore the implants we place. We had to make it as easy as possible and you know what? They had fun doing it. It was profitable for them. They liked it so they sent us more patients. They told their colleagues. They sent their patients. If you want people to refer to you, you've got to help those refers to restore the implants that you place. You've got to make it easy for them. That's what we did.
In terms of marketing, we market to those dentists. We train them. We provide CPD days for them. We provide equipment support, mentoring. They can come to us. We can go to them. For the patients, we market online, offline. We do a lot of different stuff. Again, we're lucky. We've reached a size that makes it much easier for us to do that. We've got a good marketing team. They know what they're doing. It works, but you've got to have a mix.
Howard: Who runs your marketing team?
Dr. Schaeffer: We've got an individual group. He's fantastic. He's got a big background in marketing. We got legal specialist. We've got [inaudible 00:56:03].
Howard: Wow. See, there's another course right there. You could have your marketing people give a course on marketing. Patient flow equals cash flow. There's nothing better for a business than getting a fresh supply of customers.
Dr. Schaeffer: Our biggest source is still from dentists and the dentists send them to us because we're not going to steal their patients. We can't take them on as our own patients. They're not going to send them to us for an implant and we're going to send them back with one implant, three crowns, four root treatments, and a full perio workup done. We're going to send them back with what they asked for which is the implant. You've got to just relinquish that idea that the only one who's capable and skilled enough to restore your implants is yourself. Dentists are brilliant. Train them, teach them, support them. They're fantastic.
Howard: Okay, Bill, I've only got you for three minutes so for the close I want you to answer two questions. This dentists is three minutes away from their office. Then, they're going to pull up and get out of the car and you've inspired and motivated and they say, "Okay, I'm going to commit. Someday I'm going to place an implant."
I want you to answer these two questions. At the IDS meeting in Cologne, Germany, there were one hundred and forty-five different companies selling implants. The second part is which one should I buy and, number two, what would you recommend I sign up for training? Answer those two questions. What implant system should I buy and how should I get trained?
Dr. Schaeffer: The big secret is that every implant system works if you know how to use it, but, when you're starting out, you have no idea how to use it. Find out who's near by you that can discuss cases, talk you through cases, and give you the support and help that you're going to need when you're starting out, and choose the same implant system that they use. They'll know the tips and tricks to get you out of trouble that you're going to face. Once you know how to do it, once you're experienced, you can use whatever implant system you want. Start by using the same one that they do. Second thing with how do you get training, if you choose that system, personally, I'd say the system is going to want to support you. They're going to want you to put implants in. They're going to want you to succeed. They're going to have training. Then, go to everything that you can find. Look on Dentaltown. I've learned so much from Dentaltown. So much.
Just absorb yourself, immerse yourself in learning about it. You never know enough that you can't learn more.
Howard: You've been on Dentaltown a long time. You've been a member since 2003. What would you say to a someone listening to this podcast on iTunes that's never logged onto Dentaltown?
Dr. Schaeffer: Just log on and see what's there. You've got to have a thick skin on Dentaltown because they'll be lots of people that will have a [inaudible 00:59:22] knock you down. That's fine. That's the same as [inaudible 00:59:24]. You'll learn a lot and don't just be a leakier. Don't just hide. Post things. Post your mistakes. Post your successes. Post whatever you like, but get on there and see what other people are doing. Dentistry can be very insulated. You're working in your own office. It's very easy to not realize what else is going on around you. That's it. Just get on there.
Howard: That's why I started it in '98 just so that no dentist would ever have to practice solo again. I just want to say something about if someone ever said something and it made you feel bad, remember, we have a report abuse button with a dozen volunteer dentists and we read that posts and if we think, "No, you're kind of being a jerk," we tell that person. We either delete the post or we edit it or we say, "Be nice." A lot of people say, "I have freedom of speech," because they think they're talking to the government and the U. S. sonstitution. No, freedom of speech is between you and your government. Dentaltown is private property. I'm the only owner. It's a party in my house and two people can passionately disagree as long as they're having a beer and friendly about it.
The minute you're not friendly and you're being a jerk, you're going to be shown the door. Someone is shown the door more than you'd ever know. They are escorted out regularly. You've just got to be nice. We're getting beat up by insurance companies and patients. There needs to be a refugee where we can all go and have guys like you on there that share so willingly. Dude, you posted over two thousand times. It's just amazing that you do that. I also think you're very street smart because most people, they say, "If you want to learn implant systems, you've got to fly across the country, or to another country and pay ten thousand and go through some course," but that's what book smart people do.
Street smart people say, "What's the fastest, cheapest, easiest way to learn that?" That's either going to be the online Dentaltown or the guy across the street from you or in the same building. Dentists are so scared. You know how many times, Bill, in America, you'll go into a medical [inaudible 01:01:39] and there's eight dentists in there and you say, "Dude, when was the last time you went to lunch or breakfast or dinner or out for a beer with the other seven dentists in here?" Ninety-five percent of the time they say, "Never once in my life."
I'm like, "Are you completely insane?" They'll buy a hundered and fifty thousand dollar CBCT machine not knowing that their dentist or periodontist or oral surgeon, you could send any patient over there, you could drive the patient there and they'd let you take it. They'd want to meet you. Every human wants a friend, a dog, a cat. Everybody wants a buddy and the street smart people find a buddy like you up the street and you mentor them. [inaudible 01:02:20] you're using an implant system. Use that one. Look for an implant system where there's a human in your backyard that uses it or a wrap or a CE course or support or online support.
We are out of time and I just want to sit there and say Dude I think you are the coolest dude. I love your posts. I've been a big fan of yours since 2003. You educate me and you make me think that all British people are proper like Canadian because when people argue with you, you always start so polite and so proper where I just would have said, "Hey, you're an idiot." Blah, blah, blah. You share so much. You're so great. Your cases are breathtaking. I've shared a lot of them in social media. I just want to thank you, not only for all that you do for dentistry in the U. K and implantology, but for all that you do for Dentaltown. Bill Schaeffer, thank you so much for sharing an hour with me.
Dr. Schaeffer: Howard, thank you for setting up Dentaltown in the first place. You've made me a better dentist. Take care.
Howard: Sometime I want to have fish and chips with you in London. Is that what city you're in? You're in Sussex. Where's that from London?
Dr. Schaeffer: Right then. I'm just down the road from Brighton. Next time you're in the U. K. I will be mortally offended if you don't get in touch and I'll take you out for fish and chips. [crosstalk 01:03:38] Brighton, they're fresh caught. We're on the coast.
Howard: You know, I've got four boys and the only thing they still remember and talk about London is, not only the big eye, you know the big Ferris wheel, it's like a twenty story Ferris wheel, but the fish and chips. They still talk about the fish and chips. If you're in America, you've never had fish and chips till you've got them in London. You think you've had fish and chips, but you haven't till you've got them in London.
Well, Bill, I will see you in London someday. Ask your wife if I could buy you and her a plane ticket to Vegas and meet you in person there. Thanks again. Thank you so much. Bye-bye.
Dr. Schaeffer: You're on. A real pleasure.