Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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183 Baby Steps To Implant Surgery with Vance Costello : Dentistry Uncensored with Howard Farran

183 Baby Steps To Implant Surgery with Vance Costello : Dentistry Uncensored with Howard Farran

10/8/2015 12:00:00 PM   |   Comments: 0   |   Views: 601

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AUDIO - HSP #183 - Vance Costello

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VIDEO - HSP #183 - Vance Costello


After graduation from Kilbourne High School and NLU, Dr. Costello received his doctorate from LSU School of Dentistry in 2005. Dr. Costello decided not to specialize after dental school even though he finished first in his class. Instead, he elected to focus his practice on implant surgery and restorations. He is a member of American Academy of Implant Dentistry, Academy of General Dentistry, American Dental Association and Northeast Louisiana Dental Association. He completed the MCG/AAID Comprehensive Training Course in Implant Dentistry in 2009. In 2011, he became one of four Louisiana dentists to be awarded board certification and Associate Fellowship in Implant Dentistry by the AAID. He is also one of the few general dentists in Northeast Louisiana who is certified in IV Sedation.

Now Dr. Costello shares his passion of implant dentistry with others by teaching implant surgery. He has taught nationally and internationally with IMPLANT KNOW HOW and AIE.

Dr. Costello and his wife, Carla, have two sons, Connor and Ethan. Dr. Costello enjoys taking his boys fishing and hunting and hanging out with his family.


Howard Farran: It is a huge honor today to be interviewing a dental implant rock star, Vance Costello. Looking at your cases, first I think we've got to address any relation to the musician? 

Vance Costello : No, not that I know of. I haven't checked that deep yet.

Howard Farran: You haven't checked that deep? Do you play any instruments? Do you sing? Do you dance? Who's the musician, Elvis Costello? 

Vance Costello : I can play the radio. That's about it. 

Howard Farran: It's amazing how many implant legends are from Louisiana. You got to think of Jerome Smith. What is it about Louisiana where people just have less fear of placing implants? 

Vance Costello : Well, I don't know. Jerome was my mentor. 

Howard Farran: Really? I did not know that. 

Vance Costello : Yeah, I've heard about y'all's fishing trip and all this kind of good stuff. 

Howard Farran: I'm not sure if it was a fishing trip or a drinking trip. The Louisiana boys make this yellow concoction. I think they just pour all these. It's yellow. Do you know what I'm talking about? 

Vance Costello : Oh, yeah. 

Howard Farran: Oh my god! It's liquid kerosene. Those fishing trips. I'll never forget waking up one day out there in bayou after red bass fishing. What do you call it red fish? 

Vance Costello : Red fish. 

Howard Farran: Red fish. I took 4 of my boys. I woke up and 2 of them were sitting on an alligator that was alive. About 12 feet long that had gotten lost in the ocean. Totally bloated. Came to shore. Was so bloated and sick. My boys were sitting on him. 

Vance Costello : Oh, yeah. Well, we do alligator hunt. That is a season here. 

Howard Farran: My first question to you, the million dollar question, you can take the whole hour to answer if you want. When you go to Korea, 15,000 out of their 20,000 dentists place an implant every month. When you go to Germany, 3 out of 4 dentists place an implant. When you go to Brazil, a lot of their dentists don't even know what a bridge is. They just place implants. 

Vance Costello : Exactly. 

Howard Farran: Then, you come to America. Just won't place an implant. Yet, they'll pull a tooth. How can you pull a first molar? How do you have the skill to take out a first molar, but you don't have the skill to replace it with a titanium screw? What's up with that? 

Vance Costello : I don't know. Everybody's so scared about it. I do some live surgery courses. I just got done doing one in New Orleans this weekend. Where the doctors come here in Louisian and they place implants on old patients. I do it with Dr. Darrell Burg. Also, did one out in Tijuana in California with Ike Tall. Did one with him. 

A lot of these doctors are just scared to do it, and they would rather place a bridge there. One is much quicker to do a bridge. They have to look down the road at what's going to happen when these patients get older or they can't clean. That bridge is gonna fail when they get a dry mouth. I'm talking to them, but they're just afraid. In dental school, they only chose the top 2 students of my class to do an implant class. I graduated in 2005. I was one of them. My friend that I studied with was one of the students. All we got to do, basically, was check implants that were already placed. We got to hook up some locator dentures. They told us "Just send these off to the specialists. Don't worry about this."

Howard Farran: When specialists tell me, in their arrogant tone, "Well, if you want to do ortho, go to ortho school." My response is these schools are paid by the taxpayers of the whole state. When dentists complain about how much tuition and student loan debt they have, I like to remind them that their tuition didn't even cover 25% of their costs of their school. The taxpayers did. Half of America lives in a 117 metropolitans where you have all the specialties. The other half of America lives in 19,022 towns, most of which don't have a single 1 of these 9 specialties recognized by the American Dental Association. These dental schools have to realize. If they're paid for by rural tax dollars, they have got to send girls back to that village that know how to do a little bit of all that stuff. 

In all the specialties, like in endo, the dentists do all the easy ones. They send the hard ones to the endodontics. An oral surgery, we pull all easy teeth. We send all the impacted teeth and the whizzies to the oral surgeons. The orthodontists don't want to say they'll do all the class 2s and class 3s. General dentists should learn simple ortho for all the easy ones. In implantology, I'm not even sure what specialty is even in charge of implantology. The periodontists are all implantologists. Do you even know a periodontist that's not placing implants? 

Vance Costello : Not in my town. We don't have many, but no.

Howard Farran: The prosthodontists are placing them, the periodontists are placing them, the oral surgeons ... Everybody's placing them, except for everyone listening to this podcast. 

Vance Costello : Exactly.

Howard Farran: Let's start with square one. We didn't learn this in school. My ortho training was about complex facial genetic maladies. It was all theory, zero practical, anything you could do. Implants, in all seriousness, I'm so old when I got out of school in '87, the one oral surgeon that was placing, it was subperiosteals back then, it was ramus frangs. Everybody called that oral surgeon "The Butcher" and they all talked about him. When I opened up in '87, the guy across the street from me was doing subperiosteals and ramus frangs. Everybody made fun of him, that he was a butcher. Some dentists actually had their licenses taken away, because the first time one of their implant cases failed, the board would take their license away.

Now, here it is 28 years later and we're fighting that ancient bias that these guys are butchers. My viewers listen to you for an hour. They're on their way to work. They've never placed an implant. You're telling them to go to the second floor where they're placing implants like a big boy, like you. What's the first step? What's the second step? How do you go from never placing an implant to doing what you do? How do you start? Walk us though the process.

Vance Costello : When I was in college, my wife and I both went to dental hygiene school. I knew I wanted to dental school, but she wanted to go to hygiene school so I said, hey, I'll go with you. I was the only guy in the class of 24 women. 

Howard Farran: Are you serious? You started out in hygiene school? That is so ... You went there just for your ... You were married at the time, or you were chasing her? 

Vance Costello : I was married. I was already caught.

Howard Farran: Okay. That is so cool. Are you an RDH?

Vance Costello : I am.

Howard Farran: That is so cool. I've got to tell you, I'm sorry to interrupt your story, my dad's brother, Mike, was the first male nurse from Kansas. The only reason he went to nursing school ... Parsons, Kansas, where mom, dad, everybody was raised. Aunt Shirley, he never got aunt Shirley in high school. Found out Shirley signed up for nursing school, so he signed up, too. It was a four year program. She didn't go out with him until third year, and he married her before graduation. People say, why did you go to nursing? He just just points to aunt Shirley.

Vance Costello : There you go, there's your answer. I thought it would be a good stepping stone. I didn't know what I didn't know back then, but it was good to get that experience, get those hand skills. First day of operative dentistry when you're looking through a mirror on a [inaudible 00:07:48] Your hand's going the wrong way and I already had that skill set. I knew I wanted to do something in the dental field. 

Howard Farran: That's my Mimi, sorry about that. 

Vance Costello : I thought you were cleaning the screen there.

Howard Farran: Mimi, I'm kind of busy right now. I have two cats, I'm one of those weird catwomans that's actually a man with two cats.

Vance Costello : That's okay, that's fine. 

Howard Farran: My Mimi is the only girl I've ever found that I'm able to live with in harmony.

Vance Costello : There you go. 

Howard Farran: She's absolutely perfect, but anyways ...

Vance Costello : I went on to dental school and did hygiene work while I was in dental school. As I was doing this hygiene work, I was seeing these failing bridges and people that had many missing teeth. There had to be something better. I got with Jerome Smith, because I knew he was a good implantologist. Actually, a girl that I went to hygiene school with was his hygienist, so that's how I got in with Jerry. Of course, he's a cool dude. I took a few courses just to get along and learn a few things. Then I would go over to Jerry's and watch him, take in as much as I could. My first case, I had a patient that I knew and he needed some dental work done. Jerry said, let's jump on it, and it was eight implants, four in the sinus. He helped me do all that. 

The main thing I did start out with was to find a good, simple course. Zimmer has them. I think the first one I took was CAMLOG. I did that and then started growing on that, got a mentor. When I wanted to learn a little bit more, I took the maxi course at AID. I went on and got my associate fellowship, baby steps in your comfort zone. That's where I started at.

Howard Farran: What would you recommend this person sign up for first? 

Vance Costello : The first one I did was through Schein. It was a CAMLOG course, just to go and look at some surgeries and see what was going on.

Howard Farran: CAMLOG, that was started by Jerry Niznick, wasn't it? 

Vance Costello : I think so, I believe so. 

Howard Farran: Jerry Niznick, and then he sold that to DENTSPLY.

Vance Costello : That's right. 

Howard Farran: Then when his five year contract, covenant not to compete, he went out and started Implants Direct.

Vance Costello : That's right. 

Howard Farran: Then he sold that to Sybron Kerr.

Vance Costello : That's right. I think he had the internal connection there from Zimmer, or something like that, wasn't it? 

Howard Farran: Yeah.

Vance Costello : That's what it was ... A quick, easy little course to begin with, just to see what I was getting myself into. Again, I didn't learn much in dental school. I started getting with my mentor, Jerry, which I think is very important. There's things you learn from somebody one on one. If you go take these courses, you're pretty much going to see the best cases. Look what I did, this worked the best. They never show you anything that failed, or the problems. The good thing about my mentor, the first thing he showed me were the things that failed. It's hard to get in a comfort zone when you start doing surgeries, especially by yourself. What goes on? What happens? With him, with my mentor, he's showing me if this happens, this is what you do. If this happens, this is what you do. You have a safety net, and when you learn what to do when something goes sideways, which it is, you know how to fix your problems and get yourself out of a bind. 

You have somebody that you can call and do this, because most guys will go and do these weekend courses, learn how to place these implants or put them in, which are fairly easy cases we select for them. Once they have a problem that goes on, they don't have enough KG on the buccal or the implant didn't take, they bail. The don't want to do it anymore, because they don't know how to fix the problems when something goes wrong. I think that's very important to learn, and to have somebody you can call, you can talk to, and learn what to do when there's a problem.

Howard Farran: His, what is it his nephew, Daniel Dominique in his practice?

Vance Costello : Danny, yeah.

Howard Farran: What's that, Danny Dominique? He's already a legend. That guy's amazing. If someone had said to me, who do you think is the greatest dentist who's alive today, that would be a tough call. There are so many greats ...

Vance Costello : Yeah.

Howard Farran: From Gordy on, but God dang, Jerome Smith would have to be right near the top, and what you just said was what all the greatest ones have, and that's humility. 

Vance Costello : Humility.

Howard Farran: Only Jerome Smith could go up there and lecture, and say, I'm going to teach you everything I know from everything that I've seen fail. He shows his own failures, how he's fixed other peoples' failure. He's just a humble guy. He's just good from his head to his toes. He's just ...

Vance Costello : Yeah. 

Howard Farran: A wonderful guy.

Vance Costello : He is. He was talking to me after he showed me a lot and I got going very good, placing implants. Placed a couple hundred of them, and then he said, why don't you come over, I'm starting this course. It's called Black and White. The black and white implant course, and that's the one he gives. He said sit in on it and tell me what you think about it, see what you think. He had these other dentists that were taking it. He was going up there with these slides saying, this one didn't work out, this one screwed up. This is how I fixed this. This is what we did. 

It blew my mind because all the other courses, all I saw were the best cases, pretty x-rays, pretty finishes. Here this guy is, he's a legend. He places hard implants every month. Showing us what went wrong, and I had to step back and think about that. It's true. He told me, if somebody comes to you, if any doctor, surgeon, whatever, is talking to saying, look, I've never had a failure. I never have anything go wrong, you had better run because he's not telling you the truth. That's the main thing. I think you really need to learn what to do when there's a problem. 

Of course, you've got the easy cases. Like I told my friends the other day, he had a pretty root canal. I said, well, that one's going to fail. He said, what do you mean? I said, well, the pretty ones fail. The one that has the silver points going halfway down the root sitting beside it, it's not going to fail, but yours will. 

Howard Farran: You said something at the very beginning. You said it so fast and subtle, I think a lot of these guys didn't hear. You said, when you do these bridges and they get older and dry mouth, it's going to fail. That dry mouth, you just said two words, that dry mouth. Then you talked about the ugly endos don't fail. Biology is what we're talking about, but when you go to dental courses, you'd think that it's being given by a mechanical engineer. What I explain to my patient, I say I can build the nicest wooden barn in the middle of the cornfield that you want me to, and then put all the onus on you to brush twice a day for two minutes and floss before bedtime, and use a tens scraper mouth wash, but you know what's going to happen? You're a human, and you're going to come back six and a half years later, and termites are going to eat this whole damn bridge. 

Vance Costello : That's right.

Howard Farran: If I build an aluminum barn out of titanium and you don't brush it, you don't floss it, you don't do everything you're supposed to, I know my bugs, Streptococcus mutans, can't eat titanium. When those people get dry mouth, the decay goes crazy. In fact, all the dentists that specialize in geriatrics tell me that when you put mom in a nursing home, on average, they lose one permanent tooth per month in the nursing home from overwhelming root surface decay. I go into about a dozen nursing homes, because I've been out here in Ahwatukee for about 20 years. A lot of people retire in Phoenix. My God, when you see those ladies that you put implants on, and they don't even know my name, they have dementia, how can they brush and floss and take care of themselves? They don't even know the name of their own daughter. 

Those implants, and they're eating an apple. They're eating and they're chewing. You just feel like, man, I did the right thing. We've got to think holistically. We've got to think that aluminum titanium implant, at least it's not going to be eaten by bugs. I want to say this, a lot of people say that implants get periodontal disease just as much as normal, human teeth. I think that's a crock. Do you think peri implantitis is just as common as periodontal disease around human teeth?

Vance Costello : When I look at these, of course, with my hygiene background, I'm looking at the KG around it, the connective tissue. The implants that I see that have been done well, just like a composite filling, if you do it well, it's going to be a great restoration. If you don't do it well, you can have problems with it. An implant that has great keratinized gingiva that was done right, I see all these other teeth have these problems fall away, and this nice, single tooth is sitting there. It looks just perfect. The other teeth my have perio, but that implant is doing just fine. What gives on that? What's the deal? 

Howard Farran: I did not know you were a hygienist before, and I did not know ... Did your wife go to dental school, or is she ...

Vance Costello : No, she said, you can do that. Go right on ahead.

Howard Farran: Tell us right now, how would a hygienist, you, who is also a dentist and places implants, how would you recommend a hygienist clean around implants? Some people don't want to put metal on titanium. Some people want to have special non-metal scalers. What are you thoughts on cleaning around implants? 

Vance Costello : I did a CE course at the local hygiene school here a few months ago. I'm talking to them about checking implants. I go around them with a plastic probe and see what's going on. You can only get so much from a two-dimensional x-ray. They stop me right there. They have a specialist come in and teach two different things there. They said, they told us to never probe around an implant. I'm going, well how do you know if you have any bone loss, or what's going on? They told us not to mess with it. We can get this little, fat, plastic scaler and scale around the abutment there, but you really have to get in there and check it out. 

Keep it clean. That's with anything. If you ever got a popcorn kernel around an implant, that's not going to be very happy. You have to go in there and get it cleaned out. I don't mean go in there with a diamond instrument or a sharp scaler and rough it up real bad, but you have to go around and check it out, clean it. They're advocating not even to probe around it, not even check around it. 

Howard Farran: This might be a rocking hot, your first online CE course for Dental Town is RDHDDS, how to clean and properly take care of an implant. I'm amazed at how many dentists and hygienists tell me that you're not supposed to touch an implant with anything metal, a periodontal probe, a scaler, an ultrasonic cleaner. What would you say if a dentist said to you, when you're cleaning, you can scale or ultrasonic or probe a metal titanium implant. What would you say?

Vance Costello : I would tell them they're crazy. If you go back to the studies, we try to get a patient in every six months because the bacteria get organized. They hook end to end to make that swaying motion, that corncob effect, they start swaying. By the time that six months comes around, that's when you come in around the tooth and disrupt that organization, and then it knocks them back to the basic bacteria. If you're not scaling and cleaning around an implant and disrupting that bacterial maturation, what's going to happen? They're going to mature, get into a virulent type of bacteria and there you go, you're going to start having problems if you don't keep it clean. If you can't probe around it, you don't clean around it, what's going to happen? The bacteria are just going to organize.

Howard Farran: It's my job to estimate, or predict, what thousands of dentists and hygienists who are listening to this on iTunes are thinking. The first thing they're going to say is, but Vance, you're going to scratch the implant. That's going to make it worse. What would you say to that? 

Vance Costello : What if you don't? If you don't get in there and clean it, you're danged if you do and danged if you don't. Like I said, you can't go in there with an instrument, say a diamond instrument, something rough. They have hygiene scalers with little rubber tips that if you use the ultrasonic around, with that cavitation, which I think is great. It's something that you can disrupt those bacteria. Lyse those bacterial cells, but not scratch the implant or cause the nidus for the bacteria to hook to, just like barnacles on a boat. You want to keep it slick. 

Howard Farran: I bet a thousand dentists listening to this are wishing you could make a one hour, online CE course on Dental Town that they could sit down for a lunch in, get pizza, hamburgers, and watch you teach them and tell them what a periomaintenance should be around an implant. [crosstalk 00:20:35] You said you already made the lecture for a hygiene school.

Vance Costello : I did. I wouldn't mind doing that, that'd be great.

Howard Farran: We would love it. I would love to have my Sandy and Sarah and Brandy all watch that. That'd be amazing. 

Vance Costello : The way things are are kept with specialists placing and they're telling you don't do this and don't do that, but they're not restoring it. Everybody keeps things compartmentalized. We as dentists do that, we crawl in our cave and work for thirty years. We peek our head out after 30 years, we're kind of introverts, as it was. Things that I see, as when I was a hygienist and I'm a dentist now, is what I see with my patient. I cleaned my implants, and the success rate that I see on those, I seen one today that's been there for almost ten years, and it looks just like the day ... 

Howard Farran: Do you use the same scalers you'd use on actual teeth, or do you use different scalers? 

Vance Costello : I try to use the scaler. Like I said, the ultrasonic with the little rubber coating on there, like to use that. 

Howard Farran: Who makes that? Give them a brand or a website. 

Vance Costello : I think Hu-Friedy makes one of them. 

Howard Farran: Hu-Friedy, what a great company. That's a hundred year old company. 

Vance Costello : That's an old company. I do get around there, and I do probe and check. We have some better implant scalers now that are more protective. I have to look and see what name it is. Just pick up an old, stand-by implant scaler. The fat, plastic one. You can't get that ...

Howard Farran: No.

Vance Costello : You can clean underneath the pontic of a bridge, that's about all you can do. You can't really get around an implant and clean it. They're worried about you breaking that biologic seal, but if you can't get around there and clean that out, you're not doing any good for the implant there.

Howard Farran: You're teaching hands-on courses yourself? 

Vance Costello : Dr. Darrell Bourg, he and I took the AID course back in 2007 together, and then we took an IV Sedation course at UAB, University of Alabama, and we've been friends ever since. He has it down at his place in New Orleans. I go down there every quarter and help him manage the advanced cases, the sinus grafts, the ridge splits, things like that, when we're putting implants in. He actually has an oral surgeon that works in his office, too.

Howard Farran: And he gives that every three months? 

Vance Costello : I think it's about every three months. We just did, but I did one with Isaac Tawil, I think you know him.

Howard Farran: Yeah, we lectured together at the Megagen Symposium in Manhattan. 

Vance Costello : That's right.

Howard Farran: God, that was fun.

Vance Costello : That's right.

Howard Farran: With Gordon Christensen and John Kois. It was a blast. 

Vance Costello : I went down with him to San Diego and Tiujuana.

Howard Farran: Now, they go down there, they go to Mexico, because you don't have to have a license?

Vance Costello : That's right.

Howard Farran: If you want to do a hands-on and you went to a different state, you can't do it because that state's not going to let you do it. You guys have one right across the San Diego border. Tell about that facility, who owns that? Is that Darrell Bourg?

Vance Costello : No, Darrell is in New Orleans. 

Howard Farran: Right, who owns the Tijuana one?

Vance Costello : The dentist, I forget her name, I met her a couple of times while we were down there. We have her facility to use, and she has a bunch of patients there that need implants. They get the done for free. That's the deal. When you're a US license dentist in a state, you have to have that state's license to operate in that state. Darrell's course in New Orleans, you have to have a Louisiana license. We are working on something with the state and the United States where dentists from around the United States can come and do it here in a constitutional fashion.

Howard Farran: You know what we just figured out here in Arizona, there's a homeless shelter just for American Vets, and Kris Volcheck's been working there for 20 years. 

Vance Costello : That's what I'm talking about. 

Howard Farran: You're talking about that one? Yeah, I told Kris, just go to the Arizona State Board of Dental Examiners and tell them, can a licensed dentist in good standing come to Arizona and practice dentistry if it's in a homeless shelter for American Vets, doing free dentistry for American ... How do you say no to that? 

Vance Costello : Exactly.

Howard Farran: They said, you're right, and they gave permission. I'm just like, badaboom, badaboom, badaboom. This is going to be fun.

Vance Costello : Yeah.

Howard Farran: Tijuana would be damn fun, too. I don't know.

Vance Costello : It was fun. It was tough, I think we put in 200 implants.

Howard Farran: Is it safe down there? 

Vance Costello : Yeah, I was kind of scared. My wife was afraid I was going to get my head cut off, but you know ...

Howard Farran: That last president, in Mexico, the president only gets one term. They said the one who just finished a six year term, and they said 60,000 Mexicans were killed in the drug war during his six year term. 10,000 a year. I have to tell you, me and my buddy, Craig [Sagan 00:26:00] We always go to Cabo once a year for years, go down there deep sea fishing. Me and Craig just love deep sea fishing out there, like I do with Jerome Smith in the bayou. After doing this every year for four years, we were spooked. 

Vance Costello : Right.

Howard Farran: You know why were spooked? 

Vance Costello : Why is that?

Howard Farran: We got robbed. 

Vance Costello : No.

Howard Farran: Guess who robbed us? 

Vance Costello : American citizens? 

Howard Farran: No, the police. 

Vance Costello : Yeah, yeah, yeah.

Howard Farran: We were walking back from the fishery to our resort, and the police pulled up behind us. The sirens, whole nine yards, frisked us, patted us down, took our wallets, took our cash, and got in the police car and drove off. We thought, wow, when the police rob you ...

Vance Costello : That's bad.

Howard Farran: You're probably not safe, but is Tijuana safe? 

Vance Costello : It's safe, I went there, and I've never been to Mexico on the border. Went there, and we were right by an Applebee's, across from a Costco. There's American citizens walking because on every corner, you see a dentist or a plastic surgeon, or orthodontist. Tons of Americans come there for work, or the pharmacies, so heck, it was just tons of Americans there. I kind of felt relieved once I got there. Of course, we had a guy that worked for Megagen. He was from Mexico. He took us around, they shuttled us back and forth. I never once felt like I was in harm's way.

Howard Farran: You already knew what we were doing with this Arizona homeless vets, the CASS Institute with Kris Volcheck. Does that mean you're a Megagen implant placer?

Vance Costello : Oh yes, placed hundreds and hundreds of them. 

Howard Farran: I did no know that was your brand. Why is that your brand, because the dentists out there ... My whole motto from the very beginning is that we can use technology like the internet, podcasts ...

Vance Costello : Right.

Howard Farran: No dentist ever has to practice alone again. Bottom line, when you walk into a dental convention, there's almost 300 different implant companies selling ...

Vance Costello : It's crazy.

Howard Farran: Why did you pick one versus all the others? 

Vance Costello : The way the implant looks after it's restored in the mouth, the gum tissue around it. The way the implant's made to maintain that crystal balm, because it's got the platform switching.

Howard Farran: Explain platform switching. Someone might not have understood that.

Vance Costello : Well, you have biological width. You have to be two millimeters or so from where the crown margin is to the balm level. That's more of a vertical biologic width. You also have a horizontal biologic width where the implant ends on the side and the abutment begins. From where the implant on the circumference ends to the where the abutment is screwed into the implant, it's a stair step there. You have your bacterial connection where the bacteria will stay on that connection from the abutment to the implant. It's a way from the bone, so you don't have those toxins affecting the bone on the outside of the implant, on the edges where the screws are. 

Most implants, Zimmer, and a bunch of other ones, the abutment sits exactly flush with the sides of the implant. When they drive the implant to the bone margin and then you screw your abutment straight to that bone margin where the bacteria is going to get in that seam, then the bone is going to die away to the first thread, two millimeters away, a millimeter or so. The bone is always going to try to get away from that attachment, that connection of the abutment to the implant. The negatives are set in, and also the way the thread system is, it threads a little lower so it maintains that bone on the buccal, especially the buccal, but buccal and lingual aspect.

Howard Farran: You know why I think Megagen is so popular? The founder dentist actually has a corporate dentistry empire in Korea. 

Vance Costello : He does. 

Howard Farran: He has like a thousand dentists working for them. They couldn't get the implants modified as they wanted, so they started making their own. What's interesting about Megagen is when they make a change in their implant, they have a thousand dentists all placing implants all the time.

Vance Costello : Right.

Howard Farran: They can do a 5,000 implant study. They can get them all done ...

Vance Costello : Right.

Howard Farran: The first month this comes out, so they all know in six months or a year what's going on. He has, probably, the most rapid R&D program set up.

Vance Costello : He does.

Howard Farran: For profit in his clinics, it's amazing. That main dental office, a ten story building in downtown Seoul, Korea, and every floor is one of the specialties. He's just an amazing dude.

Vance Costello : It's amazing, that office

Howard Farran: Amazing. Dentists are wondering, you're talking about platform switching. Are you cementing or screwing down? There's a lot of people who think that one of the biggest problems with implant dentistry and peri implantitis is excess cement.

Vance Costello : I do cement retain and I do screw retain. In my office, we have a milling unit. It's an origin. It mills zirconia crowns, titanium abutments, zirconia-titanium hybrid abutments.

Howard Farran: It's a CADCAM?

Vance Costello : We build those. Yes, it's a CADCAM. 

Howard Farran: What's the name of the CADCAM?

Vance Costello : It's a Proteus 5X, made by Origin.

Howard Farran: Proteus 5X, made by Origin?

Vance Costello : Origin, yeah.

Howard Farran: Spell it.

Vance Costello : As in origin, O-R-I-G-I-N.

Howard Farran: What's the website of that? 

Vance Costello : It's made by B&D Dental.

Howard Farran: B&D Dental? 

Vance Costello : Yeah, they're out of Utah.

Howard Farran: Wow, do you know the owner of that? 

Vance Costello : They're Korean.

Howard Farran: Okay, they're just buying it from Korean.

Vance Costello : Yeah, it's Korean owned. They're American citizens, but they have this machine. When I have a crown made or an abutment made, I like doing lab work myself, so I bought the machine.

Howard Farran: How much was it?

Vance Costello : It was about $100,000 with everything.

Howard Farran: My listeners, I know these homies, basically the number one selling brand would be, obviously, Sirona, which just got bought by DENTSPLY. Probably the largest merger in dental history. The second biggest brand would probably be E4D, which just got bought by Plan Mecca out of Helsinki, Finland. Why did you go with the Korean model? 

Vance Costello : This one, it mills out solid zirconia crowns. It mills out titanium, titanium bars, brown house units. It mills out the titanium abutments. It mills out the zirconia hybrid abutments. With a CEREC or an E4D, you're just milling out one crown at a time. We mill out our abutments also. What I was getting to, when I do mill out these abutments or have an abutment made, with that implant, I can raise my cement line up to the gum level. If you use a stock abutment and it's lower on one side, down below the gum line, and you cement that crown down, you're going to get cement down beside that abutment. If you raise your cement line up, your margin around the level of the gum line, it's scalloped perfectly with the gum, you don't get that cement in there. Like I said, I do both cement retained and screw retained.

Howard Farran: What makes you do one versus the other? 

Vance Costello : With screw retained, if you some height limitations, say the crown is going to be a little shorter, you have to use a screw retained. Cement retained is going to be a little bit of a taller crown because you have to make the abutment and then make the crown to go on top of that. Cement retained is one that is a little taller, screw retained can actually be a shorter crown. If it's a case, if you're doing a round house case, I would prefer a screw retained, so I can retrieve it later, get it out and clean it or if anything goes wrong, we can retrieve that. With the cement retainer, it would be impossible to get that off. If I'm looking at something that I want to take off to clean, I'll make a screw retained. If it's a single crown, everything's good, good teeth beside it, I'll make it cement retained. 

Howard Farran: When you place these, are you using a CBCT, a 3D x-ray, and do you do that 3D for diagnosis and treatment, or do you also make surgical guides? 

Vance Costello : I have three offices, and in two of them I have a CAT scan, I use a Kodak CAT scan.

Howard Farran: The CAT scan, the Carestream?

Vance Costello : Huh? 

Howard Farran: The Kodak Carestream? 

Vance Costello : That's right. That's what I use, the Kodak Carestream. What we do, I use it a lot for pre-placement diagnosis and treatment planning. After we place an implant, we take a CAT scan of the implant after it's place, to look at the placement, the bone on the buccal, lingual, every dimension. I think it's also good, it gives you a safety net there, I guess. If you're having specialists question you on what you're doing, you show them this CAT scan before and after. I had a board member here tell me in Louisiana, if something goes wrong with a general dentist placing an implant, the first thing I'm going to ask for is their pre-op CT scan and their post-op CT scan. If they don't have that, that's an X against them right off the bat. 

Howard Farran: That was one of the biggest complaints to Congress about all the healthcare legislation. They're not addressing the legal malpractice. Most experts believe that probably 75% of all x-rays are taken to cover your ass from lawyers.

Vance Costello : That's it. 

Howard Farran: CYA from lawyers. We probably spend 30% of the American healthcare cost just on administrating insurance, and then a whole bunch of diagnostic tests just covering your ass. That's a reality. 

Vance Costello : I don't know what the last time was I charged for a CAT scan x-ray. I do them for free. I don't even charge for them 

Howard Farran: One of my complaints about implant surgery continued education, it's the same things with cosmetic dentistry. You go to an AACD course, it's always about veneers. It's always tint up or veneers and things like that, when veneers aren't even 1% of the industry. 

Vance Costello : No, no, they're [inaudible 00:36:21]

Howard Farran: 96 out of 100 crowns are placed one at a time, and 96 out of 100 implants are placed one at a time. When you go to an implant lecture surgery, it's always this big all on four.

Vance Costello : Right.

Howard Farran: It's multiple sinus lifts and nerve repositioning. It's all this crazy implant warrior stuff. My listeners want to know how to place a single implant. The most common missing tooth is a molar. For that molar, do you use a surgical guide, or since you have a tooth in front, the second bicuspid, and a tooth behind, the second molar, and you're sitting at the 12 o'clock position looking down on that, do you need a surgical guide? Is it better, worse? Is it being anal? Talk about that.

Vance Costello : Early on in my learning curve, I did use a surgical guide. Most of them model based I would make myself to get that position. I want it to be as centered as I could. If you're going behind a tooth, you're always leaning toward the distal. That's one things we correct on a lot of our doctor students. When they go behind, distal to a tooth, they're leaning that hand piece, and they're going in distally inclined. Early on, I used a model-based stint. As I got going and placed a good many implants, I was doing them freehanded, and I do most of them freehanded unless I have something like a lateral. Anterior lateral is very, very close, so I'll get a stint for that. I would say the majority of mine are freehanded. 

Howard Farran: Can you go over how you make, when you make a model based surgical guide, you're not using any information from a CBCT?

Vance Costello : No, back then I didn't have one. I would get the model and be looking straight down on the space and I would take a high speed or a lab drill and drill a burr in there, directly where I wanted it, everything straight. I had these tubes that would slide over my burr, and then make a stint out of acrylic or triad, or whatever. When I would carry that to the mouth, after it was cleaned of course, put it in there and I would make my first pilot hole drill right straight through into the jaw before I would even lay a flap. I could make that hole, and then when I laid a flap, I had a hole there, a landmark. A lot of times, you'll flap that tissue and then you're lost on where everything is. That gives you a landmark. 

A lot of times when you do that, you'll notice, I'm a little buccal here because the tissue fooled you. All you've got to do is move a little bit lingual, start your osteotomy and take an x-ray. Take x-rays as you go along. When you increase drill size, you take another x-ray. That will keep you straight. As I go along, I don't use that much anymore because I've done it so much, it's muscle memory placing the implants. I do most of them freehanded and watch my steps as I go. 

Howard Farran: I have my diplomat in the international congress of implantology, I have my fellowship [inaudible 00:39:33] I think one thing that you said, and I hope the young ones get it, is how when you lay a flap, your surgical guides, sometimes you can still be lost. Before you laid a flap, you placed that on and you punched a hole right through the tissue, before you lose any landmarks or have bleeding. A lot of times, when you lay a flap, you don't even know if the surgical guide is down all the way, and all this stuff. 

Vance Costello : Right.

Howard Farran: That was a hell of a pearl there. I want you to give your best Vince Lombardi speech to this dentist listening. She's driving to work. She's never placed an implant. What should she do? She's got to get her head in the right place. We both were in the American Academy of Implant Dentistry, would you recommend she join that? I think what you specifically said was, find a mentor first. How does she find a mentor? Does she call a periodontist or oral surgeon? She's probably thinking, the periodontist wants all the implants. She don't want to teach me anything. How does ... Were you just luck that you lived near Jerome Smith and met him out drinking while you were telling your wives you're out fishing, and just fell in? How does she find a mentor if she's not out getting drunk with Jerome Smith in the middle of the gulf catching, what it is, red fish?

Vance Costello : Red fish, yeah, red fish.

Howard Farran: God dang, those are good to eat.

Vance Costello : [inaudible 00:40:59]

Howard Farran: You're saying, find a mentor. How does she find a mentor? Talk about those baby steps. 

Vance Costello : At your local dental meeting. You're in town, you know a general dentist that does placing implants, or has placed a lot of them. The AID has a mentoring program, but most people will stick local, because it's good to have somebody in the same town with you so you can call up, you can run over there. At your local meetings, you can talk to them. A specialist, most of them, will just tell you, send them over here and we'll take care of that. Don't do that. I always questioned Jerry, why are you teaching me to place implants? I'm right down the road from you. I'm going to be taking up some of your business. I sent him a bunch of cases before that, and I started doing my own. 

He goes, look, if I teach you, you're going to be these easier cases. Then the really hard cases, you're going to send to me. That's what happened until I got on my feet. With the dentist that's going down the road listening to this and wanting to know how to find an mentor, they know somebody in their town. Local association or their friends that know somebody, just word of mouth networking, somebody that you can get along and talk to. That's what I did. Most of the dentists I talk to now, they met me at the courses where I'd teach them, and they call me up all the time. I'll run over and help them. I'm helping one this Friday. That's how she met me, that course. 

Howard Farran: That's what every intelligent, smart person always says. You never think in fear and scarcity. You always think in hope and growth and abundance. I remember when America got bombed at Pearl Harbor, everybody was scared to death. They thought San Francisco, L.A, Seattle, and Portland was next. Roosevelt said, living in fear is not an option.

Vance Costello : Right.

Howard Farran: We're not going to live in fear. We're going to send these guys. When you think in hope and growth and abundancy, I notice the orthodontists who would work with the locals that were doing their own ortho. Ortho's usually never last more than four or five years in a general dentist's office. They get really busy and they stop doing it. 

Vance Costello : Right.

Howard Farran: Who do they send all their ortho to?

Vance Costello : Exactly. 

Howard Farran: The guy who had the door open. Who's the guy who always has the door open? It's the person who likes people.

Vance Costello : That's right. 

Howard Farran: They like friends. Most all the specialists that will anybody come in their office, they just like friends. They like people. They like people to go hang out with. They like people to go to the bar and watch NFL football with. They just like people. Just look for that. Look for that person who exudes, I want a friend, I want more than one friend. I like people. Hell yeah you can watch anything. If you're going to be a dentist from age 25 to 65, in 40 years, there's enough for everyone. I would tell that young dentist out there that just graduated school to just start calling them. See who calls you back. See if one the phone, you have chemistry. 

Then just be able to have uncomfortable conversations, like look, I know you placed implants for a living, but I want to place implants for a living and you know more than me. I want to know what you do, but I'm sure in the long run, we don't know each other today, and maybe someday, I'll have referred you hundreds of implants because I'll find out what I like, I'll find out what I don't like. 

Vance Costello : Yeah, yeah. That's what we did, and that's what I did with my local orthodontist. Of course, they're the two biggest orthodontists in town, and I do adult ortho. Nothing bite-related or anything like that. It's kind of apprehensive to tell them, because we both deer hunt together, too. I was telling one of them, I do adult ortho, I hope that isn't a problem. He said, take the adults, they're a pain in the butt. They want the braces off as soon as they get them on. He said, if you need anything, need a special wire, bracket, call me up and I'll send one over to you. 

Howard Farran: You know what you said, the ones working with you are the two busiest orthodontists.

Vance Costello : The two most expensive, and the busiest.

Howard Farran: What are they doing? They're thinking in hope, growth, abundancy.

Vance Costello : That's it. 

Howard Farran: They're helping the locals. That mindset is everything. I want you to start talking to my listeners, the mindset of getting them from fear and scarcity and I can't place an implant, I've never placed and implant. Talk to them for a few minutes on, get your mind in the right place. You're going to place an implant. Ten years from now, you're going to have placed a hundred implants. What do they need to start thinking?

Vance Costello : I guess if they're scared, they've got to get some knowledge underneath their belt, the basic knowledge of implant dentistry. I don't know what they're teaching now, I've been out for ten years, but I assume it's not much they're teaching in dental school right now. 

Howard Farran: Not much implants or ortho.

Vance Costello : You can get basic from, I hate to say it, but a weekend course where they go over the basics of it. After you get a mentor, talk to somebody, have someone to talk to, the first on I placed was in the second mandibular premolar area. It was a congenitally missing tooth. I had 20 mm to the nerve. It's a big, fat ridge. Went in there and did what I was supposed to do, placed it, they both come out perfect. I felt pretty good about that. I just did those easier cases. I had so much safety net, I didn't have a drill big enough for me to drill down and hit anything that had a name. That's what I tell my guys. 

Howard Farran: Socrates said humans have two emotions, greed and fear. 

Vance Costello : Right.

Howard Farran: Describe the low hanging fruit, easy single implant cases. Greed, I can do this, and then fear, what I definitely don't want to start with.

Vance Costello : The first molar area, mandibular first molar, like we said, there's a lot of those missing out there. You look at one that has ... We had one this weekend. It was 16 mm wide, 20 mm to the nerve down there. It was a no-brainer.

Howard Farran: Was it a cro-magnon or a Neaderthal or Peking man or Java man? 

Vance Costello : Actually we got through placing the eight implants on him. He went down the hall to the oral surgeon, and he chiseled off a bunch of mandibular tori off of him, too. This had guy had three surgeries done. It was just a big, big jaw. The first molar, the upper bicuspid up there, big, wide, one that's way away from the sinus. You start getting that feel for how the bone feels, how it feels when you go through it. Some of them will freak out when they break through that first quarter of a plate and it drops real fast. They'll think they've done something wrong. That's what you do, start off with those easy cases. 

Stay away from anteriors. Anteriors, they'll bite you with smiles on. I'll always get my patients to smile at me real big before we start so we can see if I can see the bottom part of their nose when they smile, or if I can barely see their teeth. Pick those cases like that, the areas that are generally safe. Mandibular first molars, there's a lot of those missing. If you go on back to the second molar area back there, it will get a little more narrow and the nerve starts to curl up. That's something for a little later. Like I said, the anteriors, that's something for a little later. You have to have some more implants under your belt, some more education. 

After that, you get into moving the sinus out of the way. Once you figure out how to move the sinus, that opens your door to a lot more implant cases, when you can do that. I think what a lot of people get in trouble with, they get out of dental school and what's the average debt that a student has now at dental school? 

Howard Farran: $250,000. 

Vance Costello : Yeah.

Howard Farran: I'm trying to get the number, what is the average cost of the first divorce. I know it's over a million. 

Vance Costello : Yeah. 

Howard Farran: I still think my divorce was 47 times more expensive than my student loan debt, so I don't want to listen to student loan debt. That's an amateur financial problem.

Vance Costello : That's an amateur financial problem. They get out, to them, it's not amateur. To them, they want to try and place every implant they can, and that's where you get into trouble, when the money starts driving the issue. I can put this implant in and make this much money. 

Howard Farran: That's why a dentist should want to be financially successful, because financially successful dentists aren't desperate. 

Vance Costello : No.

Howard Farran: I've only ever done what ... I've never traded time for money. I've always played. I've always enjoyed. Whenever it wasn't fun anymore, I quit doing it, referred it out, got an associate. I've been playing for 28 years. I still don't think I've worked a day in my life, and other people who don't know me think, god, that guy works hard. Really? I don't think I've ever worked a day in my life. I grew up working for my dad. Who doesn't want to spend the whole day with their dad? He was the coolest guy I ever met in my life. You want to be successful so you don't have to do anything for money. 

Vance Costello : That's right. [crosstalk 00:50:02]

Howard Farran: You do something for money, you get depressed, you can get in over your head. Do it because you love it. Do it because it's fun. 

Vance Costello : I had a friend the other day, he was like, oh, I'm dreading Monday. I'm like, why is that? Well, I've got this big case, we've got this, this, and that, I hope that goes in and hope this fits. I'm like, then you're doing it wrong if you're that worried about it. Something is missing in your steps. You don't have those steps correct, where you know it's going to be fine. 

Howard Farran: When you're picking an implant company, I know a lot of my friends ... Tom Mattern, he's my best friend, dentist, in my zip code. We went to Creighton together. He uses Megagen, but I think a big part of it is that he's in love with the rep, Joel Gonzales.

Vance Costello : Ah, Joel. 

Howard Farran: Oh, you know Joel?

Vance Costello : Oh yeah.

Howard Farran: If this person, if she's looking for a mentor, so she's calling oral surgeons, periodontists, you know, will you mentor me. Do you think a rep is a big part of it, too, because you can buy implants online. You can buy implants online from a dozen different countries for a lower price. It seems to me people like Tarun, Tarun Agarwhal, a great friend and mentor of mine, he used Noble Biocare for the same reason. He only uses it because he's in love with the rep there. It seems like everybody who is getting it done has a really close relationship with a rep, and their rep is fixing them up with mentors. The rep might say, this is a big issue, you need to talk to so and so. Let's go have lunch with so and so, or here's his number, here's his cell phone number. What do you think about the rep's involvement in choosing your implant company?

Vance Costello : I would say half of the people who seek me out as a mentor were sent from the rep. They feel confident talking to that rep. Of course, the rep's trying to sell them something, but they hook them up. Like I said, it's word of mouth. I place ANKYLOS for a good many years. It had that same connection like the Megagen did. The female dentist I'm helping this Friday, that's how she got in contact with me was through the rep. I think it was DENTSPLY had that, or Freedent, whatever. That's how we got hooked up. Most of them now are when I teach a course and then I get in contact with them like that. The reps have a lot of skin in the game. 

Howard Farran: People ask me what supply company I buy my supplies from. I've actually bought them from three companies, but you know why I've changed companies ever single time? 

Vance Costello : The rep? 

Howard Farran: Because my assistant, Jan's been with me 28 years and she's been following this one rep, who she absolutely adores. 

Vance Costello : Yep. 

Howard Farran: When she changes companies, Jan doesn't care who back-fills the orders. She has the relationship with Valerie, and she just loves her. 

Vance Costello : That's right.

Howard Farran: If Valerie switched to ACME dental supplies, that's who she'd go with. It's that value-added relationship to say well, your buddy Tom uses this, and Al uses this. In fact, Myacin the other day, wanted to look at a different sterilization setup. She gave him three names that she would take him to their office. She said, we don't even need to call, we'll just walk in and you can see how he sets up everything. 

Vance Costello : Right.

Howard Farran: It's that relationship, and when you have that relationship, it just gets done. Too many anal dentists who studied calculus, trig, and geometry say, well I can save $9.14 if I buy on a website.

Vance Costello : Right.

Howard Farran: You know, in Kathmandu. You're the same guy who's not placing any implants. 

Vance Costello : Exactly. They do save a little money to go on line, or something like that, but I can get on my cell phone. I text Scott, who is my rep, and say I have a problem with this. He'll run on by, fix it for me. I don't have to pay for a service call. How much would that be? We're buddies, we hunt together and all that kind of good stuff, too. I know I can call him, he's going to be there, he's going to take care of me. That's why he's successful, too, that's the way he is. He's someone you can approach.

Howard Farran: Would you recommend joining the American Academy of Implant Dentistry?

Vance Costello : When I joined it, I guess I joined it out of fear when I first started doing it. The oral surgeon that we had in town, he didn't even want periodontists to place implants. He still doesn't.

Howard Farran: When Branemark started, he only allowed oral surgeons. 

Vance Costello : He actually taught me anatomy and pathology in hygiene school, this guy did. I went on to dental school and did my whole things. I have got to have some credentials behind my name, something that shows that I know something about this. The AID bonafide credentially. I went in there and took the test, took the oral test and became associate fellow and moved up from there. One day, me and this oral surgeon were on a plane ride coming back from the AID. I saw him, we were getting our luggage, hey, what's going on. He's like hey, I heard you're placing some implants. I said yeah. How many have you placed? About 1,500. That many? He just questioned me over and over again. He said, why do you think you can do that? What's your education? I stepped him through the whole thing, how many I placed and my credentials, and he said okay, that sounds good to me. He shook my hand and moved on. 

Howard Farran: Did you tell him you graduated first in your class in dental school? 

Vance Costello : No, I didn't tell him that.

Howard Farran: It's funny, because I'm sorry, didn't specialists do their first root canal one day? 

Vance Costello : They did their first root canal one day, that's right. 

Howard Farran: The ones that seem like are the most cocky in Arizona, they're high and mighty, I know the name of the endodontist that does that endodontist's retreats. 

Vance Costello : Right.

Howard Farran: Just shut up and be humble. Same thing with a kid screaming on an airplane and people get all upset. I don't know if it's because I raised four boys, but I always turn to them and say, how old were you when you were born? 

Vance Costello : Yeah, I feel sorry for the person, you know. The funny thing was, one of my best friends who is an endodontist, and he was taking the live implant surgery course this past weekend, placing implants. He's been placing some implants as an endodontist. He gets in there, the tooth's cracked or whatever, and he's learning how to ...

Howard Farran: I tell you, I've had more ... I can't count the number of dentists who, we were earlier talking about how desperate people to desperate things. If you send a failed root canal to an endodontist and the only way he can feed his family is to do a retreat or an apicoectomy, but he knows that's going to be in the trash in a year, is he just going to do a retreat, and think I did the best I could. Baloney. You know that tooth should have been extracted and placed an implant, but you don't have a 3D x-ray machine. You don't know how to do it. You just say, oh, I did the best I could. Do you have a warranty on it, that if it's extracted in a year, you'll give half the money back? 

I tell you what, I trust an endodontist a thousand times more if they can also feed their family by placing an implant. I think that's the future. I don't think the future is apicoectomies and retrofills. I don't think it's microscopes, all this fancy dancy stuff. It comes to a point where you pull that damn tooth and place titanium. Do you agree, or is that too aggressive? 

Vance Costello : I agree. When I really started seeing the light, I'd do a root canal and something not work out. I'd be like, what is going on? Of course, whatever that patient spent on that root canal or that crown, I'd put toward an implant. I do that, or if anything goes wrong, I always put that money toward and implant.

Howard Farran: If you did it or the endodontis did it? 

Vance Costello : If I did it. 

Howard Farran: You're saying if you do a root canal or build up a crown that fails, you just credit that to the implant? 

Vance Costello : Every time, yeah. 

Howard Farran: That is so damn cool. I like you even more now. 

Vance Costello : Well the thing is ...

Howard Farran: I'm falling in love with you.

Vance Costello : The thing is, you look up, you've got ten of their family members coming to you know. What's going on? It's the best referral, too. I didn't mean for it be that way.

Howard Farran: I know. I've done that for 20 years. If I do it and it fails, it's all just rolled over and credited into how we're going to fix this damn thing. Here's the catch-22, the endodontist that doesn't have the CBCT, he just says, I tried a retreat, it didn't work.

Vance Costello : He has more money, too. 

Howard Farran: The ones that have a CBCT know that it shouldn't be an implant, but since they have a CBCT, they place the implants. The one that doesn't have the CBCT is Stevie Wonder in there, just doing the best he can with no refund policy.

Vance Costello : Right.

Howard Farran: It's almost a checklist. I can the endodontist, do you have a CBCT, or do you have access to one? Do you use some of these on failed root canals? Do you see if this is even worth a retreat? Do you have a refund policy? If you do the retreat, and it's in the trash in a year, what percent of that is credited toward the implant that you're going to place? If all those answers are no, and you're in a big city with a bunch of endodontists, go reward that young guy.

Vance Costello : That's right.

Howard Farran: That young endodontist who bought a $150,000 CBCT. He takes 3D pictures of these failed root canals and says, no, this thing cracked. I'll give you some hints on it. A three-rooted maxillary molar, there's no give.

Vance Costello : Right.

Howard Farran: If you drop a porcelain plate, it just shatters. A one root canine has a lot of give. A lower molar in the middle with two roots, but a lot of these failed three rooted teeth, they're all broke and fractured, and then downstairs on a molar, two roots doesn't have much give. It only can really rock buccal-lingual, not medial-distal. It's the canine, the one rooted teeth that are like a fence post that have a lot of give, maybe a retreat will work.

Vance Costello : That's right, he and I were talking about it this weekend. He's like, used to, I'd do an apico, but now, I just tell them it needs to come out, we need to do an implant on there, whether somebody else does it or he does it, whatever he feels comfortable doing. I admire that. Like you said, a patient come back the other day, and the endodontist said, yeah, I can do it, but it might last about a year. She was like, well, I want an implant. He sent her back. 

Howard Farran: My personal deal, I've thought about this a lot, the average man in america lives to be almost 75 and the average woman is 80. I warranty it five years. 

Vance Costello : Right.

Howard Farran: If what you're doing can't last five years, then what are you doing? 

Vance Costello : Right, that's what mine is, five years.

Howard Farran: The patient's going to live to be 80. If they're going to live to 80, and you're working on a 40 year old, and you're not even going to give them 5 years, you know it's not going to give them 5 years, you did the wrong diagnose and treatment. You've got to diagnose aggressively, where you can sit back and say, that thing will last five years, or I'll give you your money back, credit it toward the next procedure. 

Vance Costello : That's right. You hit on a note a while ago, saying you don't work, you have fun doing what you do. You enjoy your work. If you start looking at your schedule and seeing a person you did a root canal on three years ago, a problem with that tooth. They write down what's wrong. You get that sinking feeling, something's not right. I don't get that, because I know, hey, I'm going to take care of it, don't worry about it. It's all good. 

Howard Farran: You know what the non-implant dentists don't do? The non-implant dentists ... An anterior tooth snaps at the gum line. Why does it snap? They're older, it's dry and brittle. The only thing they know how to do is do a root canal, try to get a 2 mm ferrule, do some big post build up thing, put a crown on, and within 5 years, every single time, they walk into your office and it's in their hand. The only reason you did that treatment is because you didn't know how to pull it and do an implant. Talk about that exact case, say someone comes into you, they're as old as me. They're 53, the lateral maxillary incisor number 7 had a root canal build up in PFM, snaps at the gum line. Talk us though that. What would you do? Would you pull that, place implants then? Go through that exact scenario.

Vance Costello : I had one this past week, came in, same thing. Of course, with the Megagen, you get real good initial stability. GO in there, told the patient, look, I can't put a post in this. It's going to fracture. I'd have to make a long crown on it to even get enough to hand on to it, I explain it to them. Have digital x-ray, so you can just bring it up on the x-ray and you can see it there. They get it. They can understand that, most of the time. I said, we need an implant here, show them a couple of pictures. They said yeah. We went ahead and placed the implant that day. I had a couple of other dentists work with me so they could take the slack up. We try to do same day dentistry if we can because they're there and they want it done. We put the implant in. 

We have something called a fuse abutment that Megagen makes that if they overload that for some reason, the abutment snaps off. You won't overload your implant, it will be an immediate temporary that day on that case. Sometimes, I'll go in there and place it and bond, make a little suck down, or bond the teeth next to the other teeth and put a little provisional in there, but I just won't ... I used to put posts in there, but like you said, they just come right back in a few years later and it's in there hand. There you go again. You're going to save yourself money by doing the right way the first time. 

Howard Farran: Vance, do you put RDHDDS after your name, or do you just go DDS?

Vance Costello : Just DDS. 

Howard Farran: I think you should have the RDHDDS and then build DentalTown. Start building some courses on that. I'd love to have a RDHDDS that everyone can watch how to do a cleaning around, all the things you can think about. I wish you'd start building some courses. Everyone I know that knows you says you're just an all-American boy, you're their idol, you're just good from your head to your toes, and you're just crushing it. I am into triple overtime. I'm supposed to cut these off at one hour, we're at an hour and four minutes. I just want to tell you, dude, seriously, I'm a big fan of your posts on DentalTown. I'm a big fan of you. Thank you so much for spending an hour with me, and someday we're going to either meet the CASS facility in Ariozona on the vets, or Tijuana, or your office, or drinking with Jerome Smith and Danny out red bass fishing, or red fishing.

Vance Costello : Okay, sounds good.

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