Today we have an accomplished dentist in Academia who has won numerous awards and speaks in seminars and conferences regularly. He has developed the Crestal Window Technique to perform difficult sinus augmentation and patented instruments for it.
His passion lies in serving the needy in undeveloped countries while helping dentists learn surgical aspects of implantology.
In this interview learn:
The Best way to help the Needy: Addition Dentistry
Benefits of Split Mouth Studies
Sinus Augmentation: Different Techniques & Roadmap
Value of Live Surgeries
Can you discuss your passion for helping the less fortunate while teaching implantology?
Implant dentistry is a wonderful mode of treatment. Prior to implants, we have been doing Subtraction Dentistry. The only option for patients in third world countries were primarily extractions. We take out the teeth and patients are left with nothing to chew on.
Now with implants, we have Addition Dentistry. We are able to restore patient’s esthetics, function, and speech. It’s really a life changing experience.
However, it’s expensive. Full mouth Implant cases can easily cost from $30,000 – $100,000. In countries where people live on less than $3 a day, it’s impossible for them to even dream of this type of treatment.
So in the past, we’ve been going to third world countries mainly doing extractions. But at the end of the day we feel very bad. Yes, we’re helping by ridding infections in their mouth. But at the same time, now they have no more teeth to chew on. So my friend suggested that we make an implant course in third world countries to generously provide implant procedures for the needy. I thought that was a great idea and we got implant companies to sponsor us.
We have been doing this since 2006, starting in Nicaragua, El Salvador, and now in more than 8 countries, doing this wonderful free implant dentistry. Each time we take 10 dentists with us, training them to do implant surgeries and other advanced surgical procedures on live patients.
As you know, the best way to learn is hands on with live patients. By far this has been the most rewarding educational opportunity I have been offering for the last 10 years. So that’s how we began, doing extractions in third world countries, but we realized that wasn’t the best mode of treatment and began placing implants to restore their missing teeth.
So dentists taking your CE will place implants and learn advanced surgeries. After implant placement, who follows up with them and does the restorative portion?
So every country we visit, becomes like a marriage. We are committed to following up with patients every year in each country. Sometimes, we want to stop visiting a specific country because it is too far or we find countries with more need. But because of our responsibility as dentists, we still go back. Next month, we’re going to Chile with 3 doctors instead of 10 because we want to wrap up and finish cases we started years ago. Also, local doctors are crucial in helping to finish the restorative phase.
What are some advanced techniques that you teach?
We do everything. Sinus lifts, bone blocks, GBR, gum grafts, implant placements, guided surgeries.
We place about 200 implants in 4-5 days. It’s a very powerful program because we get to collect a lot of data. Now we are focusing on immediate loading of implants with concurrent bone grafting. We have a lot of power to not only teach other doctors but to learn so much and gather data through Split Mouth Studies. I personally still learn so much every time we visit the needy and serve them.
Can you discuss some of your Split Mouth Studies?
Depending on our implant sponsors, we test different implant materials and different bone grafts. For example, during bilateral sinus lifts with similar defects, we place one type of bone graft on the right side and another type of graft material on the left. Then we compare. Six months later we do a biopsy and do histological studies under a microscope. We also follow up implant cases long term to see exactly which type of graft gave the best amount of bone.
There are so many new products on the market. We get to test them in large numbers in just one weekend. It’s a very powerful and educational event for the attendees as well as for me. As an educator, I want to know which product is the best for my doctors. The only way to know this is to compare different implants and materials on the same patient during a Split Mouth Study.
You must have a lot of experience with numerous implants companies like Hiossen, Nobel, and Strauman. Which brand do you personally like?
Hiossen is a great brand. They take the best attributes and components of different brands and combine them. However, personally I prefer to use AnyRidge from Megagen. It is specially designed for immediate loading. It is nicely threaded. The threads are thin and very long. This allows excellent initial stability. Even if the bone quality is poor, you can still get good torque and great ISQ value. And we get excellent results with immediate loading.
Patients always want teeth immediately. They don’t like to wait 6 months. By using very aggressively threaded implants, we can deliver the final restoration in about 2 months. Sometimes in certain scenarios, immediate loading is possible if the occlusion and bone quality is favorable.
You have developed a new technique for sinus lift augmentation. Can you discuss your Crestal Window Technique?
The easiest Sinus Lift technique is the Lateral Window. It’s the easiest because you have direct vision. You can feel and see the sinus membrane. If the membrane tears, you immediately know.
However, the lateral window involves a large flap and is very painful for the patient. Healing takes several weeks and typically involves swelling, bruising, and pain. For the private practitioner, this may not be the best technique to use for their patients.
Post operative pain and swelling from the traditional lateral window technique
The Crestal Approach has less post operative pain. However it is unpredictable because it is a blind technique. You don’t know if you have a good membrane lift or not.
So I developed a non blind technique, the Crestal Window Technique. It has great predictability and minimizes pain. But you cannot use it for every case. You want to use this with really pneumatized sinus cases. The bone height must only be 1-2mm and the ridge buccal lingually at least 10mm.
You open a window through the crestal bone and lift the membrane through the crest with a special instrument I’ve developed.
Watch Crestal Window in Action
This is the easiest technique, yet not many know of this technique because it’s a fairly new concept and we have been brain washed with dogma.
We’re taught to do the lateral technique when the bone height is less than 5mm and to do the Crestal Approach when we have more than 5mm bone height.
However, it’s actually the exact opposite. When the bone is very minimal with a wide ridge, we’re able to make a window through the crest.
Roadmap for proper Sinus Augmentation
Pneumatized sinus are usually found in patients over 60. Can Crestal Window Technique be used on older patients?
Yes. Baby boomers nowadays are living a long time, I would consider 60 years to be very young. For patients over 75, fixed prosthetics would be a good choice. Bridges are a wonderful treatment option as you can deliver it within a few weeks. However, for anyone younger than 75, I always recommend implants and sinus lifts as needed.
Can dentists learn your Crestal Window Technique easily even if they have limited implant or sinus augmentation experience?
Absolutely. It is the easiest technique ever because, often times it is performed flapless. Again, the best way to learn is to attend the live surgical course for hands on experience.
Learning how to do surgery is like swimming. You cannot learn how to swim by reading textbooks or watching somebody else. You have to jump in the water and start swimming with an expert at your side.
Confucius said it best,
I hear and I forget.
I see and I remember.
I do and I understand.
That’s why live surgical courses are so valuable. We have produced so many great clinicians. After the course, they immediately start placing lots of implants in their practice.
I’ve been told by my docs that they have taken many courses before, but have always been scared of doing implant surgery. After they take the live surgery course, they’re able to place implants the next day.
In worst case scenarios, if the membrane tears, how do you manage and negotiate it?
The most important aspect of the sinus is the ostium. The ostium is a little opening in the superior posterior portion of the sinus. If the Ostium is open, everything will drain out. But if the ostium is blocked and you have a torn membrane, then you have a huge problem because the bone graft has nowhere to go.
If you have a torn membrane and you pack bone, there could be 2 scenarios:
1. If the ostium is open, the patient will say, “Doc, a lot of bone graft came out of my nose.” Which is actually a good thing. The patient is free of infections.
2. If the ostium is blocked, then the patient will develop excess mucous and inflammation from the foreign body within the sinus. The patient will report severe headaches, pressure under the eye, and pressure in the brain. Now you have to go in there and take everything out with a Caldwell Luc procedure.
So it’s not the sinus membrane that is important, it is the sinus ostium. You must check the size of the ostium through a CT scan prior to doing any type of sinus augmentation.
Watch what happens when Ostium becomes blocked
Can you discuss the palatal implants you’ve developed?
Palatal implants are used when you are doing a lot of bone grafting with multiple implants. When the patient wears their denture, it will put pressure on the implants causing movement, which will lead to failure.
As we know, the denture causes a lot of ridge resorption, so you don’t want to put dentures on after doing a bone block or GBR procedure. The only way to keep the surgical site free of unfavorable pressure is to use Micro Implants on the palate. Then have the denture sit on the palatal implants instead of the maxillary ridge.
Palatal Implants can also be used on the mandibular arch to avoid the IAN.
Anything else you would like to add?
We would like to have as many dentists as possible to help our nonprofit organization, Care to Share Smile. Like this weekend, we’re going to Mexico to do free dentistry.
We would appreciate any contributions. We’re trying to set up as many clinics as possible in impoverished countries. So any expired/near expired medicine, old or broken instruments, any equipment not being used in the practice. The 20 year old ugly dental chair, old x-rays, anything. We would love to get those donations over to Mexico.
If you want to take some hands on courses to place implants please join us. We have several interesting courses in our institute. In addition to implant training, we have third molar extraction OS, IV Sedation to get your license, and a one year orthodontic course.
My orthodontic philosophy is different from the traditional method. By utilizing implants, your tooth movement can be immense.
Conventional techniques are very limited. But now with implant dentistry, you can do a lot of amazing tooth movement that was not possible before. By using the implant as an anchor, you can get true unidirectional movement instead of multidirectional. Absolute anchorage instead of 50/50 which you commonly get. When trying to close spaces, which is stronger the molar or bicuspid? Who is going to win? Usually you get 70/30 with large molars.
For every action, there is an opposite reaction. Also, with minor surgery in the gums you can adjust the anchorage value and also have rapid regional phenomenon, which means the tooth moves much much quicker. You can complete complex cases which normally take 2-3 years within 1 year.
We can also do palatal expansions. In dental school we learned that palatal sutures fuse and close at an early age. So palatal expansion is not an option for adults. However with rapid palatal expansion, we can open up the adults maxillary arch and do many many things. You never know what can be done until you try new techniques outside your comfort zone. I like to push my limits all the time and I learn so much by doing so. Nothing is impossible.
Our orthodontic course is one year. We meet every month at my San Diego office. I have a group of orphans we take care of. They drive up from Mexico to see us. We do free orthodontic treatment for these under served children. At the same time we offer education to the dentist. So this is probably the only orthodontic course where the doctors actually get to see the patients on a monthly basis. A very interesting learning model.
Finally, how can other people contact you?
They can contact me at:
International Academy of Dental Implantology
You can watch a detailed presentation on his Crestal Window Sinus Lift Technique here.
Dr. Samuel Lee
Dr. Samuel Lee has earned double doctoral degree in Dentistry. He has earned Doctor of Medical Science (4-5 years full time doctoral degree) from Harvard University, and Doctor of Dental Surgery (4 years) from UCLA School of Dentistry. He is a Diplomate of American Board of Oral Implantology/Implant Dentistry, and limits his dental practice in Implant Surgery and orthodontics.
After completing his bachelor?s degree in Microbiology and Molecular Genetics at UCLA, he continued his studies at UCLA School of Dentistry for his doctor of dental surgery degree. While attending dental school, he has taught Biochemistry for 3 years. He loves teaching and enjoys developing new technologies. As a dentist, he practiced implant dentistry and orthodontics in a private practice in Buena Park, California, for 7 years. He and his family moved to Boston area to further his study at Harvard School of Dental Medicine for his specialty certificate in Periodontology, and to earn Doctor of Medical Science from Harvard University. Currently, he concentrates on research and development in Dentistry. His current practice is in San Diego, Ca and limited to Orthodontics and Implants.
He has won the 1st Place Table Clinic Presentation Award at many prestigious organization: The 2008 American Academy of Implant Dentistry (AAID), the 2007 American Orthodontic Society (AOS), and the 2007 International Congress of Oral Implantologists(ICOI). He is the inventor of “Crestal Window Sinus Grafting Technique,” and own the patent on his sinus instruments. He currently teaches internationally on his sinus techniques and TAD to specialists, general dentist, and dental schools. He also developed new method of dental x-ray, and he owns that patents related to this techniques. He is the president of International Academy of Dental Implantology, and focus his career in teaching and research.
Overcoming Pneumatization of the Maxillary Sinus. Implant Practice. May 2009 Volume 2 Number 2.