Dentistry Uncensored with Howard Farran
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You Can Do Surgeries with Ziv Simon : Howard Speaks Podcast #145

You Can Do Surgeries with Ziv Simon : Howard Speaks Podcast #145

9/11/2015 12:00:00 PM   |   Comments: 0   |   Views: 648

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AUDIO - HSP #145 - Ziv Simon

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VIDEO - HSP #145 - Ziv Simon

Ziv Simon, DMD took a non-dentist--someone who doesn't even have a dental degree--and put him through his 7 hour suturing training. After the course, this student got results that were better than some of the dentists. Listen in to learn more.



Dr. Simon maintains a private practice limited to periodontics, dental implants and reconstructive surgery in Beverly Hills, California. He obtained his dental degree from Tel Aviv University. and his periodontal degree from the University of Toronto. He is a Diplomate of the American Board of Periodontology and a Fellow of the Royal College of Dentists of Canada in the specialty of periodontics


Dr. Simon is the president of the Beverly Hills Academy of Dentistry and founder of the Beverly Hills Multidisciplinary Dental Study Group and the Dental Hygiene study club of Beverly Hills. Dr. Simon teaches at the School of Dentistry, University of Southern California. He lectures and publishes on esthetic periodontal surgery, bone grafting and computer-guided implant surgery. Dr. Simon is dedicated to developing and implementing novel surgical techniques and teaching dentists to be successful surgeons. He is the first to publish on Surgical lip repositioning in the dental literature. Dr. Simon is the creator of SurgicalMaster™, a surgical training program for dentists and the zPad™ suturing training system.

Howard: It is a huge honor today to be interviewing the man, Ziv Simon who is really the latest rock star in dentistry. Giving dentists more confidence in how to extract teeth, place implants, I am a huge fan of your cases on dental town. You have a huge Facebook following and you practice in Beverly Hills. My first question to you is to be successful in Beverly Hills, I notice you're a dork, but you're always good looking, gorgeous guys. Could a short, fat, bald guy like me even make it in Beverly Hills or would they just look at me and say, you're not a cosmetic dentist, and walk out?

Ziv : All you need Howard is a tight suit and a little bit of attitude and just do good work and you'll do just fine, okay?

Howard: What's it like in Beverly Hills? Is it as rich and famous and elite as we all think it is?

Ziv : It is sometimes, but really it's a normal world. We are normal people, flesh and blood. The patients are normal, nice. A lot of the patients are coming from outside Beverly Hills. It's just like any other place in the world. It's just we have a special zip code and we feel good about ourselves. You're welcome to visit, you'll see how it is.

Howard: My identity to Beverly Hills would be more like Eddie Murphy's, that's how I would be in Beverly Hills. Did you ever see that movie?

Ziv : Of course.

Howard: I got to tell you something about that and Beverly Hills, I'm kidding you not. When I was lecturing in China, these dentists were telling me about America, and I said, well have you ever been there? They said, "No, but I watched Eddie Murphy, Beverly Hills and I've seen your country." I thought, wow, what marketing those Hollywood movies do and Hollywood is in your neck of the woods. When you go to other countries, it's like Hollywood is the marketing department of America. Most of their thoughts and views about America are all film scenes that they've seen in all those movies.

Ziv : Yes, reality is that we wake up at five o' clock in the morning, there's no glamour at five o' clock. We work hard and we just do the work. Good restaurants and beautiful people, but it's still dentistry at it's best. 

Howard: I want to ask you, the first question, I like to not talk about anything that everyone agrees on, I like to try to find the four thousand pound elephant, the disagreement. 

Ziv : Sure.

Howard: I wrote the most controversial column I've ever written in my Howard [inaudible 00:02:40], I think I've written a monthly column since 1994. Basically what I was trying to put in this column was that when I talk to a lot of older periodontists and oral surgeons who have placed ten thousand, twenty thousand implants. They like the CBCT, they like knowing where your anatomy is. They have told me, a lot in private and some have on podcast, a real surgeon lays a flap, looks at the bone and ninety five out of a hundred are replacing a single tooth. Every time you go to a lecture they're always showing these full mouth rehabs, that's just not the real market. If you talk to a crown bridge lab, ninety five out of a hundred crowns come in one at a time, not ten upper veneers and all this sexy stuff that everybody talks about. 

The most common tooth you're going to replace is a first molar. They're like, dude you got a second bicuspid in front of this hole, a second molar behind it, you got a [inaudible 00:03:37] a lingual wall, if you can't lay a flap like peeling a banana, see that damn bone and bulls eye that thing in the middle, you're not a surgeon. Their worry is that if all your surgeries are guided planes punching through the tissue, that if you ever do have a complication, you're not going to know how to lay a flap and fix it. I'm going to open up with that can of worms and let you sink or swim with that question. 

Ziv : Good, I read your post, I loved it, I responded to it. You know, Howard, a real surgeon, and we're all surgeons, we're all doctors of dental surgery, so every dentist should be able to perform surgery. A real surgeon knows when to lay a flap, when not to lay a flap. A real surgeon places implants in a safe place in the right place, and there's a lot to learn. There's an old dogma where a big surgeon makes a big flap, and that's not true anymore. Now we have a lot of good technology to make procedures more minimal with some training. You don't have to rely on what we were taught even in dental school. It's not anymore a bulls eye Howard. The bulls eye is you decide on it, it's not just in the middle, because it's not always the right place for the implant. 

I can talk about it forever, but in reality now, we have very accurate protocols when you need to lay a flat, when you need to do it punched or flap less. It's just exciting, the opportunities that we have. I don't think you opened a can of worms, I mean this is just reality.

Howard: Then Ziv, let's start with this then. I always say that politicians don't need an original idea because with two hundred and twenty countries, your idea is already being tried somewhere. We could just all learn from everyone else.

Ziv : Sure.

Howard: I learn the most about thinking outside the box by reading hundred year old dental books written by G.B Black, or going to other countries. When I go to other countries like Germany and Korea, three out of four dentists place implants. Then you come to the United States and some say that as far as general dentists, you see numbers between five and ten percent.

Ziv : Sure.

Howard: About seven thousand people are going to listen to this, we got to assume that probably only four hundred of them have placed an implant, five hundred of them. What I want you to do is take baby steps with these people. Most of them are driving to work and they got an hour commute and how do I go from, I've never placed an implant to placing an implant? 

Ziv : Right.

Howard: How do I start that journey?

Ziv : The journey starts by wanting to place an implant. You see, some dentists are afraid of surgery, some are petrified. First of all you have to over come this. You have to want it, you have to see the value and if you don't know the value you can't convey to your patients. That's the first step in really wanting it. Number two is to get educated in implants. I'm not just talking about the protocols and drilling and just learning the parts and pieces. It's to know the anatomy, know your safety zones, know about nerves and spaces and things like that. Then, what I suggest is get comfortable with surgery in general. 

Start extracting teeth. Start doing some periosurgery. Get a little bit into incisions, flap design, know the instruments. Then you've got your basic skills to start an implant procedure. That's what I recommend let's say you're not doing any extractions in your office, you can't move on to placing implants. You've got to get your basic surgical skills, get your fingers wet. That's the first step.

Howard: Could you personally, your course is hands on, take them from A to Z? Do you provide the complete training package to go from never placing one to placing on?

Ziv : Yes, from A to Z.

Howard: A to Z, I love it. 

Ziv : That's how we do it. Yeah, the surgical aspect, absoulutely. My focus in training is to teach safety, teach accuracy, know what you're doing. If you're just blind and you're just drilling a hole, at some point you'll get into trouble, you may get lucky -

Howard: Okay, what is your website for? 

Ziv : That's my private office website, you can learn a little bit more about me. Really the way I do my training is through mentorship and hands on courses. Most dentists that I work with first sign up on my website Then they subscribe to my email list and getting an email and a video every week. Then we start engaging and staring a conversation online, and we take it from there. The dentists that I work with, Howard you won't believe the results that they're getting. They're emailing me excited and when I meet with them they have almost tears in their eyes the things that they're able to do. Sometimes better than a specialist. Sometimes.

Howard: Let's go to specifics. Is this a one program, like a two day, three day? Or is a curriculum like three two day weekends or speak specifics. 

Ziv : At the moment I have courses at USC that teach periosurgery. The full range of periosurgery from soft tissue grafting to crowning thinning to soft tissue management on implants. Then computer guided surgery, it goes over the basics all the way to the demands. Then I have my private mentoring doctors that I work with and I set them up and once they're up and running they really don't need me anymore. We just keep in touch. Of course we have the online training as well. 

Howard: That is amazing. What would you recommend the first step? To get your curriculum at USC then?

Ziv : The first step for implants?

Howard: Yeah.

Ziv : For implants, you USC has a curriculum that I don't run at the moment, but that's a really good program. Get some basic training from your implant company. Get some experience understanding the different burs and sequence of drilling. Get some periosurgery training. We know that periodontists are very qualified in soft tissue management, that's going to help you get better results. Really all of the above Howard.

Howard: You like the USC program?

Ziv : I love it, I teach it. Absolutely. I love it.

Howard: So what is it, is it a one weekend a month for a year -

Ziv : The implant program is a continuum, there are several weekend programs throughout the year. That's a good program to start with, but really any program will give you the basics. The key is what you do with it, and that's where I come into play because my teaching is more real life. I'm a real person and we keep everything simple and safe. That's a really good program to start with. 

Howard: My whole motto in 1998 when I saw the internet came out, I said no dentist should ever have to be alone. This internet could connect all of us. There's only one out of every eighteen hundred and fifty of us in America as a dentist. We could all talk together, and so this dentist is alone and they're going to the dental convention, and there's an implant booth on every corner. There were two hundred and sixty five implant companies at Cologne last year.

Ziv : Yes.

Howard: Is Titanium, is there any difference between a five hundred dollar implant and a hundred dollar implant? What's the criteria for this individual dentist driving to work right now who's never placed an implant, they don't want to own five systems. Specialists have to own five systems because they're referring doctors. This is the spoiled general dentist, what system would you recommend?

Ziv : That's what I recommend, I recommend the system. First of all, titanium is titanium and different implant designs. I would choose a company that offers a range of implants from paper to parallel, platform switching and good restorative options. Number two, that's probably the most important, you want to pick an implant company that is not going to go out of business in the near future because we now have problems of knock offs and go look for the implants and implants placed different parts of the world. Pick a reputable company that has FDA approved product lines. It doesn't have to be a brand name, I'll be honest. I use brand names I'll be honest. I'm a specialist so I use whatever my guys want me to place. 

It does not have to be a brand name. All these implants, I've tried them all, they all work the same, it's about the technique and how you place them and even before, how you plan them first. For the general dentist that's just starting out, don't buy fifty thousand dollars worth of inventory and a million components, you have it siting there and it's a waste of money and confuse your assistants. Start with a basic startup which is like twenty, thirty implants. Basic components and educate yourself about how to plant for implants, how to place implants and just do it. Get started, because it's just going to sit there.

Howard: This person's all alone, can you give them any specific recommendations? [crosstalk 00:13:49]. Can you give any specific implant companies?

Ziv : Well, I can start counting companies, but I use the five major brands.

Howard: Okay, what are the five major brands?

Ziv : The five major brands right now -

Howard: That follow all those [inaudible 00:14:04], won't go out of business, do research.

Ziv : They have a track record of good customer service, so we're looking at Nobel Bio Care, we're looking at [Astro 00:14:12] which is basically dentist supply. We're looking at Stramen, we're looking at Zimmer, Bio Horizons. There's some of the Korean companies that are getting up there. 

Howard: Is Zimmer Bio Horizon or is that two companies?

Ziv : No, Zimmer is different -

Howard: It's Zimmer and Bio Horizon. Bio Horizon is [inaudible 00:14:30]. 

Ziv : You know, he's part of it. It's not his, but he's definitely part of it. 

Howard: But are you saying Zimmer is Bio Horizon? Zimmer Bio Horizon?

Ziv : Zimmer is not. Zimmer is now combined with 3I, Zimmer bought BioMed 3I so if you buy 3I or Zimmer it's the same company. These are the major -

Howard: And Bio Horizons. 

Ziv : And Bio Horizons. These are the major companies -

Howard: So Noble, Astro, Stramen, Zimmer, Bio Horizon, that's five.

Ziv : These are the major companies out there, they have a good track record. That's not to say that all the other companies are no good Howard. I'm not saying the because I don't want to have phone calls after the show, "Why didn't you mention our name?" Really, the reality is the company has to be strong financially, has to have a good backing behind it. Each company buys the other one. You don't want to be stuck with hardware in your patients mouth and the company's out of business. I think that's something we owe our patients.

Howard: You know, I think the reason I'm up to seven thousand views per show is because you will get phone calls after this because I like to be a dental journalist, I like to ask the real questions.

Ziv : That's okay. 

Howard: I got to go back. My job is not to, these questions, it's not that I don't know the answer, but I have to ask the questions that I know these individuals are thinking. You just rattle off three words and I bet you half the audience didn't know what they were. You said, you have to have a system where they're tapered, parallel and platform switching. So you need to go back and explain what's the difference between a tapered, a parallel and what is platform switching.

Ziv : You got it. Howard, now we have so many clinical options for patients. We have immediate loading, we have delayed loading, we have so many restorative options. [inaudible 00:16:20] four and a single central incisors. The reality is that the shape of the implant and the threading, whether it's very light threading or aggressive threading, makes a big impact on the initial stability. If you're using a system that has aggressive threading and a tapered design, generally speaking, these implants will achieve higher initial stability. That's the stability of the implant once you place it in bone. That gives you more options for immediate load, immediate provisionals. That's the shape of the implant. You have to have a company that has all these features. Doing okay so far?

Howard: Yes. 

Ziv : Okay, awesome. Number two, the platform switch, if you think about the old implant design, and old is not necessarily good, okay? We all know that. Think about the platform of the implants and if the restorative components is slightly smaller than the platform of the implant, we call it the platform switch. Okay? It switches from a wider diameter into a smaller diameter. What it does, and by the way, it was never proven in literature, that amazes me. What I'm telling you is not scientifically based, but that's the trend of the market. When you use a platform switch implant, bone levels are much stabler because the micro gap, the small little gap between the restorative component and the implant is farther away from the bone. It's towards the middle of the implant. You're decreasing the inflammation. 

That in turn reduces bone loss. Number two, when you have an implant that has a narrow neck, if you will, you have more room for soft tissue. Soft tissue stability is better, so I personally switched, basically all the systems that I'm using, I'm using the feature of platform switching because first I'm getting better results. That's really the trend of the market right now.

Howard: The platform switch is the [inaudible 00:18:31] is wider than the implant?

Ziv : Actually, a little bit in reverse. In the implant there is a little [inaudible 00:18:42] if you think about the platform of the implant which is the most coronal part of the implant, the platform itself has an inward bevel. Anything that you connect to it, by definition is a little bit smaller than the circumference of the platform. That's called a platform switch. 

Howard: I want to ask you another huge controversial thing. You're a periodontist first and foremost. 

Ziv : Yes I am.

Howard: Humans aren't born with p gingevalis. The baby comes out, it does not have P gingevalis, correct? 

Ziv : It comes germ free, absolutely.

Howard: Yeah, so it picks up this contageous disease somewhere?

Ziv : It does, it does. The P gingevalis is much worse than that.

Howard: Yes, I want to ask you two bizarre questions.

Ziv : Okay.

Howard: Can a dentist really treat a woman ever three months for perio on three month recall for ten years and have never seen her husband? I'll give you a really crude analogy. Could I treat a woman every three months for chlamydia for ten years and never once get her lover in there? Can you be kissing a trash mouth in bed every night while you're getting three month cleanings at your dental office? Or should a dentist say, "No, I'm sorry, I need to see everyone you're trading saliva with."

Ziv : Yes, if your spouse is good looking than yes. This is the story Howard. P gingevalis, AA, you don't call it periopathogens, they're not STD's. They're not STD's, so like you said, a baby is born germ free. As it passes through the birth canal, it starts to acquire bacteria and viruses and fungi. Okay, sounds good. I'm actually having a baby on the way, so I'm thinking about that. The story is, the first inhabitants of the babies oral bacteria usually comes from the mom. Usually comes from the mom that basically kisses the baby and cares for the baby. That's the first encounter with all the periopathogens. Now, these babies, these kids and later on adults can carry these bacteria and develop periodisease. So the the husbands and the spouses, boyfriends, girlfriends. 

The reality is there's something called the immune system, and if your immune system is not susceptible to having periodontist disease developed, you can be you and me can have P gingevalis in our mouth without developing periodisease. There's a balance between the bacteria in the immune system. It's not as simple as transmitting an STD, it's a little bit different. [crosstalk 00:21:36] it's a good way to get the husband in by the way. To get the husband for treatment, but it's not as simple as it sounds. 

Howard: Okay, well this is a several step question trying to get to the final answer. 

Ziv : Okay.

Howard: It's a gram negative facultive anaoram, it can't live in oxygen, correct?

Ziv : [inaudible 00:21:52]. 

Howard: When this baby is [inaudible 00:21:56] and has no teeth, you couldn't transmit it form the mom to the baby because there'd be no place for it to live, is that correct?

Ziv : Correct.

Howard: Then, it's only when the babies first two baby teeth come through that there's be an environment to transmit this disease.

Ziv : Sure.

Howard: Then my question is this, this convaluded question was trying to get to this. I had to do all these additional steps -

Ziv : No worries. 

Howard: My crazy question, most of the people that need your services, they had gum disease and decay and all that stuff. I see dentists pulling out all these teeth and then placing implants, wouldn't it be better to pull all the teeth and let them go edentialists and have no environment, all those gums are gone and then go back and place implants? If you went totally edentiasts to a denture, are you now free from p gengivalis? Then when you place implants after that would you have less peri-implantitis? Was that the world's record for the most questions in a single question?

Ziv : Howard, I love your question, it's right to the point and it's a great questions because in the absence of teeth, by definition there's no periodisease. Okay? Technically, once you extract all of the teeth, the patient has no more gum disease. So far we're clear. 

Howard: But are the bugs gone now? Did they all die -

Ziv : That's a great question. We have to ask a microbiologist. I'm a clinician, but I know a little bit about bugs. The microbiota in the mouth is complex and I think those specific periopathogens are gone. In a significant amount where they won't cause any damage. The reality is once you start creating a [inaudible 00:23:47] between the oral environment through the gum tissue and bone, all of this is going to change. All of this is going to change because we're not living in a bubble. We're going to start acquiring bacteria from the environment. Like you said, the spouse and whoever else. Patients with periodontal disease have the same type of bugs that patients have with perioimplantitis. We see it in the, that's called the mixed [inaudible 00:24:17] for an adult. 

When you have patients that have natural teeth and implants, the bacteria sampled from both is the same. One that has a lot of periopathogens around the teeth will have it around the implants. Interestingly enough, that does not mean that the implants will fail. To add to the complexity. I don't see more failures in periopatients compared to patients that just broke a tooth and had it replaced. There are some things we don't know. Now we're looking more into, which is interesting, not so much the bacteria, but also the viruses. There's more research coming out of USC that shows that viruses play a role in periodontal disease through a complex mechanism where they cause an immune disregulation and basically helping the bacteria create more damage. Bacteria and viruses are pretty good friends in working against us. 

Sometimes antiviral medication is also a good option. Did you know that?

Howard: Yes, and I did a podcast with [inaudible 00:25:24] Christian and they were talking about there's a new study talking about that in decay, streptochoctis [inaudible 00:25:32] is working with candotisis. That's one of the reasons the plaque is, they're working hand in hand together. Isn't that bizarre?

Ziv : It is bizarre. One misconception that a lot of dentists and sometimes patients have, is that the enemy is the bacteria. That's true, the bacteria is enemy number one and the enemy number two is our immune system. The immune system a double edges sword because the damages, the ravages of periodontal disease is not because of the bacteria directly, it's because of the immune system responding to the bacteria causing all this [inaudible 00:26:08] around teeth and implants. It's really complex more than what we think it is, and if a patient thinks give me some antibiotics, lets get rid of the disease or extract all of my teeth it'll go away, not the reality. It's much more complex than what we think it is. 

Howard: Back to those bugs. There's a lot of products in the market that put little chips under the gums and pockets, things like that. 

Ziv : Sure.

Howard: Are you a fan of any of those on patients?

Ziv : I'm a fan of everything that can help. I don't like the abuse, I don't like the using it just to generate an income. Generating income is a good thing in itself, but we're talking about products like Arestin is an example, it's a great product, but I personally use it in very localized perio-defects. If your patient needs two hundred application of [Forestin 00:27:04] every time he comes for a cleaning, it's cost prohibitive. 

Howard: That's a tetracycline right? Arestin?

Ziv : That's a minocyclyn which is in the same family.

Howard: Minocyclin, okay, what do you think about my low cost technique where you just take a tetracycline, the capsules, pull them apart into your dappendish and put just a little bit of water and then just brush that into the area? Just brushing tetracycline from a pill out of the refrigerator, is that not good?

Ziv : I'm not saying it's not good, I'm not familiar. It has to do with the pharmacol kinetics. I'm not so familiar with the Arestin, but they actually compile it into micro spheres that stay in the pocket for about three to four weeks. I'm not sure just the powder of tetracycline can do it. By the way, it's hard to get tetracycline in the United States, as you know.

Howard: My last question is, the other very controversial issue. There's people out there swearing with [Lanap 00:28:09]. They're going down there with a specific laser into these deep pockets. They're killing bugs and getting healing. Are you a Lanap fan?

Ziv : I don't use Lanap, I don't use the laser for that purpose. I've seen some great results Howard. I've seen some research, I've seen some pretty amazing cases with Lanap and I have to say, that's something that I have to educate myself more to give you a good answer. It becomes a religion. Whether you're a Lanap fan or you're a hater, all I'm saying is I need to learn more, I need to know more. Not necessarily research, the fact that something was not proven doesn't mean it doesn't work. 

Howard: Right. The older I get the more humble I get. At fifty two you just realize that we're dealing with imperfect data. They're not going to know half of these answers for a thousand years.

Ziv : Listen, even if they studied Lanap or any type of procedure in dentistry, by the time the research is complete is like three to five years. Then by the time it gets publishes, two, three, four years. What you're reading in an article is data that is almost ten years old. My the time you read the article there's new stuff and you already proved yourself wrong. We're tenacious, we're going to test it on our patients. 

Howard: I want to go back to the very beginning of this interview.

Ziv : Sure. 

Howard: This girl's driving to work. She's never placed implant. You gave her names of a system, but I know a lot of them are talking on Dental Time, they're like, "Help me pick the lowest hanging fruit." What would be the easiest first implant? I don't want to do a number eight -

Ziv : No, don't do it. Don't do it. 

Howard: What should I be more afraid of, hitting the sinus replacing a first molar on the upper or hitting the inthrab nerve on the lower? What's the low hanging fruit knowing that the most common tooth missing is the first molar?

Ziv : Yes, and you hit it just right, that's what I call the money tooth. That's the tooth that is the most treated in dentistry. Starts as a cavity, goes onto a three surface, a crown, a root canal and apical, and ends up with a crack and an extraction. You read about it in my book How To Extract the Money Tooth, hopefully soon. That's the lowest hanging fruit, and it's low because it's lower. Typically, I'm generalizing, typically if you performed a reasonably atramautic extraction and you preserved the site, you placed the bone graft and you have some bone volume and you didn't lose too much of the vertical component. 

Typically it's a safe area to practice, it's away from the aesthetic zone. You have a pretty good leeway of mesiodistal space. [inaudible 00:30:54]. That's where I recommend starting. Get comfortable reflecting a flap, get comfortable positioning your implant, use some type of guidance. It could be a conventional guide, it could be a computer guide, it could be a more sophisticated computer software if you'd like. That's not just for specialists. Start with that. Place, not too many, five to ten implants in the molar position, first molar position. Don't go to the second molar, the second molar is a different animal Howard. The second molar position, the infilvila nerve is at its highest position. It's molingual, you have lingual cavities, so first and second molars are totally different. 

Sometimes you're running into problems with actually not enough restorative space. Not enough room for your drills and your hardware to drill properly. First molar not the second molar. 

Howard: You're trying -

Ziv : I can also give you long answers okay?

Howard: You're trying to describe ... Our goal in this interview is try to get the other nine out of ten general dentists to place their first implant. To pick the lowest hanging fruit, first molar, would you go mandibular or maxillary? 

Ziv : Definitely mandibular. Definitely mandibular. Often ninety five percent of upper first molars, you will have some type of sinus proximity. You're going to be dealing with softer bone, less initial stability, and why start with that? Why make your life complicated? 

Howard: This patient, should it be your mother or mother-in-law?

Ziv : That all depends. I love both. 

Howard: My first, [inaudible 00:32:40] my mother-in-law. 

Ziv : How'd it go?

Howard: It was great, she's so amazing. She was so sweet, she wanted it and she wanted me to have someone to try it on. 

Ziv : She was okay before and after?

Howard: Yeah, and she's still alive. We're talking about a mandibular first molar, what would be the first lowest hanging fruit? Would it be a second mandibular, second premolar? Or is the [crosstalk 00:33:04] -

Ziv : No it's actually going to be a maxillary second pre-molar for a very simple reason. As you move in your implant training, and your skills and your confidence, you want to actually move to the maxilla as soon as you can because it's a type of bone that responds completely different than the mandible, obviously. I don't like to start with a number five or twelve, I don't recommend starting because the canine, the upper canine has a distal angle and it's a classic mistake. A lot of the beginner implantologists don't take it into account and you know what happens, they start to engage the root or they get dangerously close. Start with a number four, number thirteen. You still have enough leeway and basically once you do that, place a couple of lower pre-molars. Be careful of the, obviously the mental nerve, and work your way up to start doing some more aesthetic work. You got a different animal. 

Howard: Okay, and CBCT, any of those that you like? Are they all the same? Do they all work?

Ziv : As far as I'm concerned. They're different Howard. They're different, they have different bells and whistles, they have different levels of quality of image and different images that you can create from them. The reality is all we need is the final product. For me I need the dichom images, or the dichom files. All you need to see is the anatomy, because the anatomy is the life. The anatomy is the most important thing. As long as you can see the anatomy clearly and you can identify nerves, spaces, and outline of bone. Maybe bone quality, you go with. All the CT scanners on the market do it. 

Howard: You're a periodontist, so I want to ask you the truth. I like street smart dentists, I don't like book smart dentists. 

Ziv : Okay. 

Howard: I don't think you need a hundred and fifty thousand dollar x-ray machine. You need access to one. 

Ziv : Sure. 

Howard: Is it rude to call up your periodontist and say, "Can I send my patient over and use yours?" 

Ziv : Sure. 

Howard: What would make it kosher to do that? Success is about how willing you are to have uncomfortable conversations. A lot of people ... Would it be rude? Give them terminology to call up your periodontist and say, "Look, I'm going to get into implants, and I'm going to try mandibular molars nineteen and thirty, maxillary [inaudible 00:35:51] four, thirteen. Ziv, I'll give you all the rest. I don't want to buy a hundred and fifty thousand dollar x-ray machine, you have one." 

Ziv : Assuming, I don't have one, assuming I had one. Assume I had one.

Howard: Okay, so see you're so street smart, why do you not have one? You're the most famous Beverly Hills implantologist, why did you not buy one? Because you're just that street smart?

Ziv : It has nothing to do with street smart. The way I see it and it's nothing wrong with having a scanner in the office. Once you buy a scanner, in about three to four years after that, this scanner becomes obsolete. Are you going to buy a new scanner in four to five years? Are you going to keep upgrading it? I think the answer is no because it's such a big chunk of money. I have seven operatories right here behind me. I prefer to use these operatories for clinical work. If I have a dedicated radiologist, which is just two minutes away, and I can send my patient there, they treat it professionally. The positioning of the patient is perfect, I get the results within an hour. I don't see this as a problem. I'd like my office to be clinically active and not doing imaging. The other thing is, and we're talking about the elephant in the room. 

Once you have a scanner in your office, Howard you got to use it. If you don't use it, why'd you buy it? I think it puts a lot of pressure on the clinician to use it and somebody who is borderline unethical might have some issues with that. I think I don't want to have a monster that I have to have some pressure on me to use it. I have definitely the volume to make it worth my while, but the space -

Howard: Is that the true answer or is it really that you saved up a hundred thousand dollars and your wife went and spent it on Rodeo Drive on purses and shoes?

Ziv : You know, my wife would be happier. I have a beautiful wife that deserves things like that. 

Howard: Ladies and gentlemen, this guy is street smart. You need access to a CBCT. [crosstalk 00:38:07]. 

Ziv : You call your specialist, Howard you asked me about can you call your specialist. Specialists would love that. I think. I would love that. 

Howard: That's what I think because they're trained to start conversations to meet people. That's why they join the dental society, that's why they're always hanging out at study clubs. They're afraid to call you to go to lunch because they're introvert scientists physics geeks just like you are. It's two introvert people afraid of each other. I think they want a relationship.

Ziv : Yeah, do it. Absolutely. 

Howard: Pick up the phone.

Ziv : Call the specialist and let them help you. 

Howard: They get a CBCT, the expert on dichom file. Let's talk about on these first ten implants mandibular molars nineteen, thirty, maxillary second bicuspids four and thirteen. Would you recommend a punch less surgical guide, flap less experience, or would you say no it's time to man up, be a surgeon and lay a flap?

Ziv : Again, laying a flap has nothing to do with being a surgeon. Laying a flap is an option that you have very specific guidelines. If this is your first lower molar implants, what I would do, I would take the time, study the skin, study the location of the nerve, study the dimensions of the ridge, but also see if this ridge is at the right position. Maybe take some models. Call your local specialist, call me, show me your case. That's what I do with a lot of the doctors that I mentor. I always tell them, don't jump the gun, get all the information, give me a call, let's do a Skype one on one. Let me see some of the models, let me warn you about some pitfalls. Let me prepare you for the procedure. Then, part of it is looking at the soft tissue. Many times in the [inaudible 00:39:55] there is not enough attached and [inaudible 00:39:57] tissue. There's not enough good tissue to work with. 

If you punch through this tissue, you're actually creating damage. You're just messing it up. I would say study the case, look if you have enough space, and then ideally order a surgical guide from your lab that will have some type of access so when you drill, you know that you're in the ballpark through what you call a screw access positioning. Take your time. Don't rush through it, don't book half an hour. Book two hours, give yourself ample time to get the patient comfortable. Do it properly, suture and all this other stuff. Then you'll be in good shape, and your patient too. Don't rush.

Howard: What you just said was very profound. If you're going to go do a punch less flap less deal but your hole eats up the whole radius of the attached gingeva and you're leaving buckle lingual margins in the tissue -

Ziv : Yeah, why do it?

Howard: That's just mess up. You just did a big segue to ... You just said suture up. When I think of you, you're elite, you're the whole package. You're charming, you're smart. Your cases are stunning, but you're suturing is kind of at a freak level. You take suturing more serious than anybody I know and you look like ... Really you're like Picasso when you're sewing. Why do you take suturing so serious, and is this a big part of being a surgeon?

Ziv : Yes. Suturing, you touched upon, one of my passions. Suturing has been a problem since I started teaching. I've been teaching forever and every dentist in every course, a lot of the dentists tell me, we have problems with suturing. We know how to do big surgeries, we're comfortable doing implants, we're doing sophisticated cases, it comes to suturing, we have two left hands. It bothered me for so, so many years and I was always emphasizing suturing but really about a year ago, I started a new suturing teaching system called the z pad. I created a physical device, do you want to see it?

Howard: Absolutely.

Ziv : Okay, let me see if I have an example. 

Howard: A lot of people tell you it took longer to suture the surgery afterwards than it did to do the surgery.

Ziv : Yeah, let me show you an example.

Howard: How many times have you heard that?

Ziv : Yeah, that's a great question, we just tested it. This is called a z pad. Okay. You can guess that this is a size and shape of an iPad, but it's a z pad because my name is Ziv. Basically what it is, it's a game. It's a game where doctors that are training in suturing go through different tasks, let's call it basic training and suturing. At the end of the course, at the end of the curriculum, they get it, they know how to suture, they get confidence. They call me and say, you know what, I know how to suture. I point to the test Howard, you won't believe what I did. I took somebody who's not a dentist, he's never touched a hand piece, he doesn't have a dental degree, and I took this guy, nice guy, I put him through the suturing training and I put him together with all the dentists. The course was seven hours. 

After seven hours, he got results on the z pad that are better than some of the dentists. Can you imagine that? This stuff is effective and I'm going to come out with this hopefully in the next few months and we'll change the world around. We'll teach dentist students how to suture properly. You can have a great surgery and at the end of the day, you'll mess it up because you didn't suture properly. I came up with laws of suturing. I came up with tips and tricks and everybody can suture, even you.

Howard: Talk about your new book which is true. You talk about the money tooth.

Ziv : The money tooth.

Howard: Which is the first molar. 

Ziv : Yes sir. The lower molar.

Howard: The lower molar?

Ziv : The lower molar is the money tooth. It's the first one in the mouth. It's the one that has those deep grooves that need to be sealed, that develop carries. Basically it's the one that is missing for a lot of patients, maybe for a lot of dentists as well.

Howard: Talk about your book. When's it coming out?

Ziv : It's almost done, it's going to come out soon. Basically this book is going to describe protocols on how to extract this tooth. If you think as a dentist that extracting a tooth is just grabbing the tooth with forceps and ripping it out, it's not reality. Now we're thinking not about extraction, we're thinking about the next step which is an implant. If you're going to damage all the surrounding, you'll pay for it later on. Your patient will pay for it. What I do in the book, first of all, I describe the money tooth, I explain why I call it the money tooth and why it's important. Then I go through different protocols starting form plan a through plan b, c all the way to e and I explain each step of the way. Basically it's my logic. It's not a picture book, but if you have some trouble with extracting lower molars, I think that would be a good interesting book for you. I look forward to your feedback as well.

Howard: You know what? I try all the time, you post some of the most amazing [crosstalk 00:45:28] videos, I'm always trying to get your content on dental town. Maybe that should be your first online CE course on dental town, and when they pay for the course, they get a copy of your book or something. 

Ziv : Let's talk about it. Let's talk [inaudible 00:45:40]. Absolutely.

Howard: Yeah, we just passed two hundred thousand members, I think the smallest country we have, we have dentists in every country, and we're coming up on four million posts. I'd give anything to get more of your amazing content on there. I want to ask a redundant question. A lot of dentists, they place an implant and it's just one stitch distal to the implant, one stitch mesial to the implant. Is that okay or is that really not enough? Go back and talk about -

Ziv : Sure. 

Howard: Does it all work, or do they need to take suturing a little more serious?

Ziv : That's the thing. Sometimes that's all it takes. That's the beauty of suturing. Suturing is not a dogma. Suturing depends on what the tissue needs. It depends how you need to stabilize the flaps and stabilize the tissue or stabilize the graft. Sometimes that's all it takes to suture one distal one mesial, and that's enough. I don't have any problem with that. Really, the proof is in the pudding Howard. If you finish your surgery and you put just two simple interrupted sutures and it works it's great. Keep doing what you're doing. Don't change the winning formula. I don't have any issue with that. 

Howard: I wanted you to talk about getting rid of some of guilt some of these dentists have. A lot of times a person comes in, they've got a tooth ache, we do the financial arrangement, I'm in Phoenix, Arizona, I'm not in a fancy suburb. In my office, about three out of four people with a tooth ache will say, "Okay I'll go with a root canal and a crown." Which is going to be about twenty five hundred. Then one out of four say, "I ain't got that kind of money, I just want it pulled." When we pull a tooth, we're always wondering, should I be bone grafting that? Some people say if you bone graft that and they don't go back and get an implant in six months you just wasted time and money. Other people are saying no that's not true. Will you talk about when this dentist driving to work right now needs to be thinking when do you bone graft after extraction?

Ziv : Great question. Common question for dentists, common question for patients too. If you're not planning an implant, I'm planning a bridge, on no replacement should I bone graft. When you think about extraction, it's not the extraction, it's thinking what's going to come next. If you're not planning an implant, this particular patient may be able to afford an implant down the road, so by grafting the socket, you'll be able to preserve some of the ridge. You'll get some resorption no matter what, even with grafting. So my personal preference is graft every socket except for third molars of course. Preserve the socket even if you're having a [potic 00:48:27] site. You still want this potic site to have some type of dimensions. You don't want to have a long potic. Grafting is recommended for any extraction socket in my recommendation that's what I do. If the patient object to it, financially then there's nothing you should do about it. You should definitely talk about the benefits. 

Howard: You're a street smart guy, I'm truly your biggest fan. It's either me or Delia Tuttle, I don't know who thinks you walk on water more, me or Delia [crosstalk 00:48:55]. When you talk about bone grafting, some people are centrifuging blood and some people always lay a membrane over it. Is there a simple bone grafting or are you buying human bones? Is there bone putty, are you harvesting it from back where their wisdom tooth is? Can you talk about bone grafting?

Ziv : Yeah, absolutely. That's where we have choices and options and there's so many great things you can do. I tell you what I do, but generally speaking, the type of bone graft is important and we try to use either an allograft material, which is human bone, or zenograft, which comes from an animal. Both are fine, I don't like the plastic materials. The aloplasts which are gaining some popularity lately. The simplest way to do a bone graft is to pack the socket, assuming you have all the walls. You really don't need a membrane. All you need to do is place a piece of collagen plug, or even gel foam on the acrusal part of the socket. I call it compartment grafting. It's pretty involved in my teaching. I talk about how to do these compartments. 

That's simple. Now, you'd like to have some of the patients blood, which I do. Spin it and isolate some high concentration of platelets to make it better. If you have the opportunity, if you have the option and the knowledge do it, I get much better results. What did we do before? We just kept it simple. You can go from very simple bone graft and collagen all the way to harvesting the patients own bone is just going to create more pain for the patient. For a socket it's absolutely not necessary in my opinion. 

Howard: Go specifics, how does this dentist driving to work get ahold of human bone?

Ziv : Okay. 

Howard: Just go down to the cemetery and dig up one of the coffins?

Ziv : Yeah, you can do that too, but you'll get in trouble. What you can do is just open a dental journal. Open whatever your local society dental journal, or open your professional journal. Look in your mail in the office. Every day you'll get a promotion for some type of ... Call your dental supplier. Call Patterson, call Shine. Call the other companies. They have bone. They'll tell you if it's human bone or not. It's obviously FDA approved. Now, you have to look at the particle size. The size of the smaller particles, in my opinion, makes a difference. We like to use a particle size between point twenty five and one to two millimeters. That's going to be the range. You take this bone and it's obviously a one time use, you open it up, you use it up. 

Howard: How much is something like this going to cost? Do you charge the patient for the bone graft?

Ziv : Absolutely.

Howard: What would this dentist driving to work right now charge that? Would it be equivalent to the same cost as the extraction? Half the price of the extraction? Is there any ratio there? 

Ziv : That's a great question. It's a practice management question. How you should create your fees. In my opinion, if you charge just for the material, you're basically losing. You're going to lose income. What you're charging for when you say bone grafting is the process of bone grafting. It's a separate procedure. What you need to factor into it is the cost of the materials meaning the bone graft and if you need a membrane or let's say a collagen plug. You factor it in, but you need to charge a little bit extra to also make some profit and make it worth your while. You wanted to know the ratio, the ration should be, in my opinion, at least two point five. Two and a half times the cost of the bone graft. 

Howard: Of the actual bone graft? Two and a half times?

Ziv : Depending on the complexity. 

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