Replacement Options for Incisors – Denture? Bridge? Implant? – PS018

Teaser:
No.

So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins. When we lose a central incisor, we have to discuss how was that central incisor lost, and most common cause is trauma. The most important predictor success of a resin bonded bridge is the same as it is for veneers. If you’re not sure what the treatment plan should be, you probably haven’t asked a patient enough questions.

Jaz’s Introduction:
Welcome to this Back to Basics episode on replacing the single central incisor, why the single central incisor is the most important tooth, obviously, but so that we can just go a little bit deeper into this topic rather than talking about replacement options in general, which you’ve already done on the podcast.

There are certain features which are very special when you’re replacing the central incisor and why it is regarded as the most difficult treatment to deliver in terms of patient satisfaction expectations. We’re joined by the Protrusive student, Emma Hutchison, where we’re gonna go into the basic overview of decision making.

When is a denture appropriate? Is it ever appropriate for an incisor? How about bridges and what type, and what are the implant considerations, and actually choosing between these options? I think one of the biggest takeaways you might get from this is communication. There’s a specific way I communicate to patients about this, and that’s what I think you’ll probably take away the most from this episode.

Hello Protruserati. I’m Jaz Gulati and welcome back to the student edition of your favorite dental podcast. I know we call it Protrusive Students, but young practitioners or those returning back to work often find these episodes very valuable. Of course, we’ve got so much more where this came from.

We’ve got all sorts of genres and topics covered in Protrusive Podcast and recently on YouTube. We’ve done the playlist so you can actually pinpoint the different themes of the podcast. On our app, Protrusive Guidance, head over to protrusive.app if you’re interested in that. It’s the community of the nicest and geekiest dentists in the world. We put some extra videos, not on YouTube, on there as well. Let’s now join Emma, and I’ll catch you in the outro.

Main Episode:
Emma Hutchison, the Protrusive Student, welcome back. How are you doing? How is clinics going? Final year, you’ve done your exams, but it’s the actual more clinical exposure. How’s everything going?

[Emma]
Mm-hmm. Yeah, it’s going good. So as I was saying last time, it’s just more, lots more experience this year, which is good. So I’m up in Falkirk in Scotland every second week, just Monday till Friday, nine till five, seeing about four or five patients a day. And then the other second week I’m in Glasgow doing more specialized stuff, watching some consultants in restorative and things. So it’s good. It’s good. Just plodding along quite nicely, which is good.

[Jaz]
Good. And you obviously have been a dental nurse. So once you’re seeing four to five patients a day, you have this extra level of insight that maybe your colleagues don’t have. Like, in the real world it’s 30, 40 patients sometimes, sometimes 12, sometimes one. Like, it’s such a variation.

‘Cause obviously you’ve been an implant nurse as well. So what advice do you want to give to your colleagues who are maybe listening to this and they’re seeing these four to five patients, and you want to prepare them for the real world? What would you say with your very unique perspective?

[Emma]
Yeah, I think when I was working as an implant nurse, I remember speaking to the dentist I was working with and he was saying why he moved to private dentistry initially is just because the real life just isn’t like the gold standards that you’re taught at dental school. In the NHS especially, you’re time restricted.

So I think I do have that in the back of my head. I know that I won’t have the luxury of such long appointments when I graduate. So yeah, I’m just getting myself prepared for the real world. ‘Cause I am gonna do VT or DFT so that I can work in the NHS to start off with and then see where I go from there.

But I do know that in the back of my mind it’s gonna get a lot busier as soon as I start VT practice. So yeah, just that you’re not gonna have the best materials that you do in dental school. I know in Glasgow anyway, we tend to have really quite good materials. Good rubber dam. I know I’ve spoke to you about things like that before, and just that it might not be like that in the real world when I graduate and get out there and start working.

So just to prepare myself for that. I’m aware of it, it’s fine. And I’m just trying to relish the opportunities that I have at the moment and the staff around me that I have as well. I think that’s one thing.

[Jaz]
You’ve gotta be like a leech, Emma. You’ve gotta be like a leech, like a sponge.

[Emma]
And just ask all the questions whilst you have all these specialists and consultants around you and just take note of everything that they’re saying. Especially the way that people communicate with their patients and pick up little things that they’re saying to their patients and make it your own. So I’m trying not to wish away my last year, so that’s good.

[Jaz]
No, enjoy it. Enjoy the comfort and the bubble and the protection you get in school before you enter the big, bad world. Do you think your experience as a nurse and seeing over the shoulder, you’re suctioning, you’re seeing things close up? Having said that though, I always find that maybe the nurses, we think they’ve got a great view, but they often don’t, especially when you are trying to juggle a million things.

‘Cause recently I’ve been using my clinical loupe camera more and more, and so now the nurses who’ve been working for 20, 25 years, they’re like, “Oh, now I got to see what you are seeing.” So maybe it hasn’t been that much of an advantage that you come from a nursing background. What do you think about that? Just be honest.

[Emma]
I think initially, when I got into dental school, first and second year, it helped obviously. Premolars, molars, all the very basic stuff. And then maybe second, third year when I started to see patients, I was pretty much at the same level as everyone else.

Apart from communication. I’ve found the big thing is that patient communication has came quite naturally to me, and I think that’s because of my dental nursing background.

[Jaz]
Because you heard those conversations, right?

[Emma]
Yeah.

[Jaz]
You were present, and you’d seen the dentist explain the risks and guide patients to certain treatment philosophies and whatnot. That’s a really good point.

[Emma]
Yeah, so I think communication. Doing it yourself is a whole different ball game. Getting that manual dexterity is something that you need to work on. But even just communicating with patients, I’ve taken so many tidbits from other dentists and how to explain things to patients.

I’ve worked with a paeds dentist, John McCall. I worked with him for a year, so I say a lot of similar things that he did to children, and I get on really, really well with children. And then when I worked in implantology, that’s maybe transferred over into oral surgery when I’m talking about those sort of things. So definitely in the communication side of things.

[Jaz]
Super. Well, we’re talking about more than just communication. We’re talking about replacement of an incisor tooth, right? Because I thought, okay, we could talk about replacement of missing teeth full stop, but I just feel that’s so broad, right?

Like when you talk about a molar to a premolar to an incisor. So I thought, why don’t we go a little bit deeper and just talk about incisors. Let’s talk about central incisors, maybe some laterals, that kind of stuff. But just generally somewhere at the front of the mouth, you’re missing a tooth, be it trauma or long-term missing, and we’ll get into it.

But we want to discuss the considerations and treatment planning options and the delivery techniques, little details and nuances when it comes to this type of dentistry. So Emma, take it away. What would you like to know in your student lens when it comes to replacing incisors?

[Emma]
Replacing incisors. So I actually had a patient in my outreach center. He had a missing central incisor and had done for quite some time. He had a single tooth denture in there, wasn’t getting on with it at all.

And in student clinic we have the luxury that our patients don’t have to pay anything, and we’ve got quite good labs on our hands and things. So we thought, let’s try an adhesive bridge for this patient. And my clinician at the time said that replacing a single missing central incisor is often considered one of the most difficult things to do in restorative dentistry. So why is it so difficult in your opinion?

[Jaz]
Okay. I’m gonna turn the question back on you. What is your perception? Why do you think it’s actually more difficult? What did you think?

[Emma]
So I think from my perspective, seeing that patient, he had no other missing teeth. All his other teeth were natural, a few composites here and there. So I think just in terms of restoring that central incisor… I’m not too sure how to answer this actually.

[Jaz]
It’s okay, if you’re not sure, I’ll help you out. But I’m just trying to understand from a student’s perspective. Because I remember being a student learning this as well and I was like, wait, why is it so tricky?

What are the special considerations for a central incisor? They say the single central veneer or the single central incisor, full stop. You’re quite right to say it’s difficult, and I only really appreciated it more and more when I actually started to replace central incisors, how difficult it actually is. Do you want me to go for it or have you got more ideas?

[Emma]
Yeah, go for it. Go for it. Go for it.

[Jaz]
Okay. So have you heard of something called central dominance?

[Emma]
No.

[Jaz]
So in the face, the central incisors should be the star of the show, should be in the middle, and the centrals should be like twins, right? Centrals should be like twins. And so when you’re trying to copy the adjacent central, therein lies the problem, right? Because yes, you may be able to copy the shape, but there might be some compromises. But getting the shade right, getting something to look good, okay.

And then also a really important thing is smile line. When I talk about smile line, what is a smile line? What does that mean?

[Emma]
Like how much tooth is at show when your patient’s smiling or where your lip sits?

[Jaz]
That’s important, but yeah, where your lip sits. Because more important than tooth is how much gum actually. Because if you have a very gummy smile, so very high lip line, when you smile like curtains, your lip raises really high and everything’s on display.

Those are by default considered very challenging cases because now not only are you worrying about white aesthetics, the aesthetics of your restoration and the ceramic and whatnot, but now you’re also worrying about pink aesthetics, which is the gums, right? How it’s so critical not only for the shape of the restoration to be matching so closely to the adjacent tooth, the shade characterizations, but now with someone with a high smile line, when they smile, that gum contour is so critical.

And you would’ve seen this in implant dentistry. How much grafting and attention. It absolutely blew me away when I spoke to some of my patients who’ve had… I’m very lucky. There’s a really great dentist that works nearby me called Rob. Okay, I dunno if you’ve heard him. He’s brilliant.

Okay. A lot of dentists will refer to him for the single central incisor. And he’s not cheap. And you know what? He fully justifies his fees. Like you could buy a small car. We’re talking about near five figures for a single central incisor. And when I first heard that, I was like, wow, what’s going on here?

And as I gained more experience and I restored more centrals, I was like, wow, you know what? That fee is totally justified. Because when I see his cases, not only is he paying for the top-end lab work to try and really match the ceramic, really trying to match that tooth, but more often than not, when we lose a central incisor, we have to discuss how was that central incisor lost?

And the most common cause is trauma. And when there’s trauma, there’s often soft tissue loss and hard tissue loss, because the bone, the buccal plate, it’s paper thin. And so what you have with implant is you’re dealing with the scenario where we have less bone in such a critical area. And so there’s soft tissue grafting, bone grafting, and it’s all to do with getting really high-end symmetry and aesthetics. That’s why it costs so much.

So ultimately, central incisors are very tricky because we’re always trying to match to nature usually, or the adjacent tooth in general. And there are soft tissue and hard tissue considerations, and that’s why it’s difficult.

And so the number one thing is, if ever you’re replacing a central incisor, even if it’s a resin bonded bridge, like your patient you described, you have to explain that, hey, what we’re giving you is gonna be a replacement, but you have to really tell me how perfect you want it to be. Because there’s different levels.

Because the way that a restoration reflects light is very different to a tooth. And they need to understand. I used to work with a consultant called Raj Patel, and he would basically wave a tissue in the air to a patient and say, “What color is this tissue?” And they’re like, well, it’s white.

And Raj was known for this kind of communication, right? He’d be slightly, okay, I hope he doesn’t mind me saying this, but slightly sometimes, in terms, patronizing. Like he’d ask a patient, “Do you like flowers?” And the patient goes, “They’re okay.” “I guess, okay, I like flowers.” And then like, “What do flowers need?” And the patient’s like, feeling patronized. “Well, sunlight, growth, water,” that kind of stuff. It’s like, whoa. Your teeth and gums are like flowers, and so his hygiene discussion would come like that. And I saw him do this with like a builder man. I was like, what the hell? Like, what’s going on here?

Yeah. So anyway, back to the tissue. He’s waving this tissue and he’s like, “What color is this tissue?” It’s like, well, it’s a white tissue. Okay. And then he’d put it on his trousers over his lap, right? And so now that tissue was still white, but it looked like, because you see his dark trousers through it, so it’s kind of like grayish now. Do you see what I mean? And the patient’s like, okay, well yeah, I see that it’s still white, but it’s not the same white.

And then he’d try to get the patient to understand that look, we can’t match the adjacent tooth perfectly. He’s very good at that, and I always took that example. So I very carefully choose the patient through that tooth. Does that make sense now?

[Emma]
Yeah. Yeah, that does make sense. And it’s the first thing that people see, and the ones that people are more aesthetically worried about are their central incisors naturally. And I don’t know if this is maybe good for my first case replacing that central incisor. My patient wasn’t—

[Jaz]
Have you done it already? That patient, the denture replacement? How did it go?

[Emma]
It was good. Yeah, so we did a resin bonded bridge, like a Maryland from the other central incisor. But he wasn’t too aesthetically demanding, and for this patient going private wasn’t really an option, just financial wise. And he was just happy to have any sort of replacement other than a denture.

And so to me, like it was nowhere near perfect match, you know? But we’d done the best that we could. His contralateral central was three different shades in one tooth. You’re never gonna get it matched perfectly. And with what we’ve got on the NHS, you pick one shade, and that’s sort of what you’ve got to stick with. And he was happy. And I saw him for a review last week and it’s still in there, which is good. And he’s happy with it. But yeah, it was—

[Jaz]
What did you think? When you look at that central, does the shape match well to the adjacent tooth?

[Emma]
Yeah, I’d say he was happy with the original denture that he had and the shape of that tooth. And he wasn’t wearing that denture because it was actually broken, and I sent that denture away to the lab as well.

[Jaz]
Oh, nice.

[Emma]
I know that they’ve got impressions of the uppers anyway to match to the other, but they might as well just have it to see what this patient’s already happy with, mould-wise. So he was happy with that. I don’t think it’s too bad a result, but yeah, you can definitely tell that it’s not a natural tooth that’s there. But he was happy with it, and I’m happy with it for my first go. But it was tricky. It was tricky.

[Jaz]
It’s always tricky. Now we’ll talk a little bit more about that, but when it comes to replacing that incisor, you did a resin bonded bridge and therefore, a metal wing or—

[Emma]
Yeah, yeah, a metal wing, yeah.

[Jaz]
Okay. Did you find that the central incisor that you were sticking to, the abutment tooth, did it go a bit gray or not?

[Emma]
Not that I noticed, no, but I know that can happen.

[Jaz]
Do you know when that would happen? Which kind of patient is particularly susceptible to that?

[Emma]
Would that be if the tooth has been retreated?

[Jaz]
Not necessarily. It’s more to do with if someone’s got minimal wear and therefore that incisal, translucent zone. Probably this patient. How old is this patient?

[Emma]
He’s in his 60s.

[Jaz]
Okay, so fine. But did he have a bit of wear on the edge? Was it a bit worn?

[Emma]
Yeah, a bit. He’s got a bit of wear, yeah.

[Jaz]
Okay. So sometimes when you don’t have much wear, or generally some people have more translucent teeth, right? As a feature of their teeth. And therefore in that scenario, you have to warn the patient about graying. And so one thing you could do is you can get a cotton roll and take a photo of the tooth as it is, get the retractors in, and then you put a cotton roll behind it and you take a photo.

And then you see how much impact did that cotton roll have on the tooth. Like if the tooth looks different just by putting a cotton roll behind it, then you know that when you put something black there that is going to look… metal there… it’s gonna look a lot different as well, basically.

And so you’ve gotta warn the patient of that. I’ve seen some cases I’ve done before earlier in my career which really grayed up. And then one way to mitigate that is to use opaque cement. Now, before we go deeper into that, just remember the main lesson, the really important lesson: shape with a P is more important than shade with a D. i.e., shape is more important than shade.

So if you absolutely nail the shape, that’s actually more important. It’s going to have a more pleasing outcome than if you get the shape wrong but the shade right. Okay? So shape is super, super important. Always remember that. And everything you do when it comes to anterior aesthetics, shape is always more important when you’re trying to match.

Did you discuss with that patient any other treatment options, or how did he come to you and your sort of mentor or supervisor come to the decision that resin bonded bridges would be the most appropriate? And did you consider any other options?

[Emma]
Yeah, so I think just from hearing other dentists talk about replacing gaps in practice and things, I always go and tell my patients that there’s four options usually. Does that sort of ring true with you? So the first option is to do nothing, because we always have that option for our patients.

The second option was to try a replacement denture for that patient, and he wasn’t really keen to give that a go. He’s had one… I don’t think he even had it for very long, and it had already broken and wasn’t very retentive, X, Y, Z. And then I say the third option is to do something more fixed, so like bridge work. And then the last option would be to go privately and do something like implants. And it just wasn’t in the patient’s financial budget at the moment.

So he was interested more in going for something more fixed. So I discussed with him that we could maybe do a bridge on that tooth, a Maryland bridge with the metal wing. And then I had a chat with him about that, although I didn’t actually mention to him about the metal wing and that possibly shining through.

And I did have a chat with him. He had quite heavily restored teeth. He had composite on the other central incisor and on the lateral. It was—

[Jaz]
Was it a big composite? Was it a large composite?

[Emma]
It wasn’t… I’d say on the lateral there was quite a large composite.

[Jaz]
Okay, but what about the central, your abutment tooth? Did it have a big composite?

[Emma]
It had a distal composite, but it wasn’t massive or anything like that.

[Jaz]
Okay, good. Good. Because having a large restoration in your abutment tooth for a resin bonded bridge usually has more negative outcomes because there’s less surface area of enamel. Did you know that the most important predictor success of a resin bonded bridge is the same as it is for veneers?

So how well your ceramic veneers will bond and resin bonded bridges is the same. Availability of enamel and surface area of enamel. And that is really, really key. That’s the number one factor when seeing if there’s going to be success. So it’s good that fine, it’s a small one. Ideally, unrestored.

Okay. So you talk about all those options, and here’s a communication tip for you and your colleagues and anyone listening. I used to do the same thing. I used to say, okay, there are four things you can do and blah, blah, blah. And sometimes for a lower incisor, right, if you’re missing a lower incisor and there’s crowding, you could say, well actually, how about we relieve the crowding and then have three lower incisors. Look, I got three lower incisors here, not four. Okay.

So you can do something like me and then we can relieve the crowding at the same time. And so sometimes ortho is an option, but obviously wouldn’t be for an upper incisor, right? ‘Cause that would look weird.

So when we give those options, I think it’s much nicer to do it the following way. So Emma, is it important for you to have a front tooth?

[Emma]
Yes.

[Jaz]
How important is it? You’re missing a front tooth and you have a denture and you hate it. How important is it to have a front tooth?

[Emma]
For me, very important, yes.

[Jaz]
Extremely, right? So really doing nothing is not an option.

[Emma]
No.

[Jaz]
Not gonna give you that option because that’ll be inappropriate for what you’re saying here. Okay. Is it important for you that it’s fixed, or do you mind having something removable?

[Emma]
For me, I would ideally like something fixed.

[Jaz]
Okay, that’s fine. Would you like to be able to eat corn on the cob with it, or are you not so fussed and you’re happy to be a little bit careful with what you eat? What do you think?

[Emma]
Yeah, I’d be happy to maybe be a bit more cautious about what I’m eating, yeah.

[Jaz]
Okay. Do you see, just from those questions, I now know that doing nothing is not an option anymore. A denture is really not an option because you said you want something fixed. So that only really leaves a bridge. And then what type of bridge? We know the adjacent tooth is minimally restored, so maybe not a good candidate for a conventional bridge where you have to prep the tooth.

Okay, so fine. We know it’ll be a resin bonded bridge or an implant. And they both are still on the table here. Both are still on the table. Now, if you said to me that, look, it’s really important for you to be able to eat corn on the cob, and really use your incisor a lot, and you like to bite into apples, and that’s really important for you, then I’d say that look, you’re probably best going for an implant.

Okay. And then in terms of budget, like is money no question? You want the best there is? Or are we on budgetary constraints? And we talk about that, and then we’re like, okay, well actually based on what you said, that you wanna be able to eat corn on the cob, in a hypothetical scenario, then really you’ve gotta go for an implant.

But because of your financial constraints, then a good compromise will be a resin bonded bridge. This is blah, blah. You explain what it is. But remember that this is essentially an aesthetic appendage, something glued. It’s for smiling. It’s not for chewing. You cannot bite your nails with it. You cannot bite tools with it. You cannot cut into… you can’t bite a baguette and tear it. It’ll come away. The worst thing that can happen is it comes away, but you know what? It can be glued back. But you just have to be extra cautious.

And when you have that kind of conversation with patients, they get it. And if you choose well, resin bonded bridges enjoy a very, very high success rate. The King et al. study, very famously quoted in Bristol, they had like 700-something RBBs. At four years, 80% were totally fine with no issues. And if they do last four years without debonding, they’ll probably go on to last 10 years and then beyond.

And one thing I can tell you is I used to work with… well my predecessor, who I used to work with now, he has been doing resin bonded bridges for years. So I’ve got patients on my books that have had RBBs for 25, 28, 32 years, never debonded. The odd one debonded 16 years ago once, and then it’s been okay. Do you see what I mean? And so my predecessor, using the cements back in those days, did a fantastic job. Case selection was really good.

And all the Americans out there: resin bonded bridges indeed can be very successful, but the patient must play a role. I know that my lower zirconia resin bonded bridge I have, I cannot have corn on the cob. It would be a stupid thing to do. You are overloading it and you’ll break the bond. And so those are some important considerations.

Now if the patient would like to be able to chew with their front teeth and they’re like, look, I want something fixed. I don’t want to have to worry about it ever coming away. I want something that’ll last the longest term possible. Then you really… you’ve now selected an implant. You’ve self-selected implant.

So an analogy I use, in the podcast episode I did with Michael Frazis—have you listened to that one, Emma?—is it’s like you’re playing Guess Who. If you ask enough questions, right, you only have a few people left. And so really, you’ve only got a few options left. So if you’re not sure what the treatment plan should be, you probably haven’t asked the patient enough questions.

[Emma]
Yeah, yeah. I think that’s interesting how you were talking about almost getting the patient to self-select and guiding them into their own treatment option, which is interesting actually. Because I’m usually just listing off the four options. “Oh, we’ve got four options, do nothing,” and you’re never really gonna do nothing if that patient’s main complaint anyway was that missing central incisor. So that’s interesting.

And I know you were talking about, so if you’re going down replacement options and would you like a fixed versus a removable, what other sort of factors do you consider from a dentist perspective when you’re deciding whether a fixed option is appropriate at all, or whether a removable option is one that you would more recommend?

[Jaz]
Removable has its place. Like, if it’s for a single central, then more often than not removable is not gonna be… it is very much a budget thing, right? Like it is major budget concerns. And look, I can’t afford even the resin bonded bridge, and you gotta go for an acrylic denture flipper.

But there’s also things like poor oral hygiene. They’ve got poor oral hygiene. It’s a double-edged sword actually, because if you’ve got poor oral hygiene, then you don’t wanna give ’em a denture. But equally, if you know they’re gonna be losing other teeth of poor prognosis, then you can actually be adding to the denture as you go along.

And if they’re missing a central, but they’re also missing a premolar on one side and another premolar on the other side, and then you can actually replace all those teeth in one go, then that is a consideration. Sometimes when you get a little bit fancy chrome denture and you have palatal backings and you kind of make like a splint type framework at the same time, as part of a bigger case for tooth wear.

So there’s a lot that can be done, but it’s about understanding the patient’s history, the number of teeth involved. But if we’re talking purely the missing a single tooth only, mm-hmm, which is a front tooth, removable is something that I would struggle to recommend unless it was a budgetary thing. There’d have to be some really good reasons not to.

Now, for example, let’s talk about age, right? So we talk about smile line, but we’ve gotta talk about age because if it’s a growing patient right up till the age of 25, you don’t want to do implants. Okay. So therefore, it is a resin bonded bridge, for example, or it’s a denture until you are old enough to have an implant.

‘Cause it’s still growing. And so that’s a very, very common thing. And what happens is they have these resin bonded bridges, and they’re successful for many years, and then maybe in their forties they end up having an implant. It’s much better to have an implant in your forties than it is in your thirties. And some patients, all they need is just a new resin bonded bridge, and that’s all they need. So age is really important, and their growth status.

[Emma]
Yeah. Yeah. Okay.

[Jaz]
And then one more thing, when you are deciding, not so much fixed–removal, when you’re deciding the type of bridge… if that other central in your patient’s case was already a crown, then you just take off that crown, polish up the prep, and now you have a conventional bridge.

[Emma]
Yeah. And that’s what I was actually gonna ask you next. Because one of my friends had a similar case. There was an adjacent crown, and then there were chats about what would your approach to that conversation be about taking that crown off? Because I know that there’s a lot of dentists who would have hesitation around that, to take that old crown off if there’s nothing wrong with that crown to then put a bridge on it. Does that make sense? Does my question make sense?

[Jaz]
Yeah, totally makes sense. But the question would be, how old is that crown? And if it’s more than about 15 years old, eventually the replacement event’s gonna come anyway, whether you like it or not.

[Emma]
Okay. Yeah.

[Jaz]
And I used to worry about this as well, but having done several cases now… you get your pulpal diagnosis, you get your apical diagnosis. If everything’s sound, you just remove the crown as atraumatically as possible. You just give it a nice prep, give it some love, and you put a bridge on. And I haven’t had any issues doing this.

And I think everyone’s right to be concerned about it because, fair enough, you don’t know what’s inside that crown, underneath that crown. That core could have been really weak. So yes, you’d be silly not to warn your patient of like, okay, we’re kind of going into the unknown. Okay. But I wouldn’t want to do this if the crown’s been a recent crown, last five, ten years. But if it’s an older crown, it makes sense.

But of course you have to warn the patient. You also have to find out, okay, how did this tooth fail? Check the periodontal probing deficit. If it’s like a single isolated pocket and you’re worried, could this tooth already be quite compromised and cracked? Then maybe not. If the tooth already has a big post in it, and maybe mechanically you’re a little bit worried about it, then maybe the implant is the best way to go. And maybe you should be having a denture until you can save up enough money to have an implant, or if the patient can afford it, go for an implant.

[Emma]
Okay. Okay, that makes sense. So if you know there’s a crown on it about 15 years old, but otherwise looks sound, you’re looking to replace the adjacent gap, as long as you’ve communicated that with your patient and all the risks, you would be happy to go ahead, remove that crown and replace.

[Jaz]
Yes, I would, and I have done it on many occasions. And it’s a good option, because you already have a… it’s like the worst thing you could do is crown a virgin tooth to do a conventional bridge. But you’re literally replacing for like… it’s just carrying a pontic next to it. And again, the same thing goes with it, that you gotta warn the patient that, hey, you gotta be careful. This one tooth is now carrying another one. Let’s not stretch it by chewing or incising on your front teeth in a harmful way and overloading that unit.

[Emma]
Okay. And just when you’re talking about overloading of units there, that sort of takes me onto my next question about, especially in the anterior region, is there any situation where you would prefer or recommend a conventional bridge over a resin bonded bridge, or vice versa? Like especially in terms of occlusion and things like that as well.

[Jaz]
Yeah. So really what you’re asking here is, when you are doing resin bonded bridge, you’re relying on the adhesion, and therefore the point of failure is a debond. Whereas you wouldn’t typically get that with a… you feel more secure, you can sleep well at night.

Like, you made that comment a little while ago where you said you saw the patient review and it’s still there. You probably wouldn’t have said that if it was a conventional bridge, right? ‘Cause you know you’ve got the whole 360 degrees, you’re cementing it on. It’d be a much bigger surprise if that came away than a resin bonded bridge.

So I see where you’re going with that. And yeah, if you have a deep overbite, then that is a little bit worrisome because when they’re chewing, right, the time in contact, the time that the lower incisors are thrusting up against that pontic… because the rule of bridges in general is that the pontic is allowed to be lightly in contact in MIP or ICP.

But in any excursion, any chewing movements, you want to minimize rubbing. But with a deep overbite, as soon as you put some food in between, you’re kind of milling. Like even though it might not be touching, there’s still food trying to push that pontic away. And therefore a deep overbite may be a reason.

But then again, would I still prep? Would I still prep a virgin tooth to make it into a cantilever conventional bridge? Probably not. I’m probably gonna say, look, your functional demands are quite high. Would you like ortho? Or would you like to maybe go down implant, which still will have its own issues because we don’t want to overload an implant, but probably it’s less risk.

It also matters about the patient’s occupation because if the patient’s a high-level barrister and is doing lots of public speaking and that kind of stuff, you may say, look, with your bite in consideration, then I may suggest, let’s do an implant here because resin bonded bridge is just glued onto the tooth next door. And with your bite, it’s a lot of demand. It could still work, but there’s a little bit of element of risk in there. And you try and assess the appetite for risk for that patient and your patient’s occupation as well.

The lip line, all those things. Basically because if the lip line’s really low and you don’t see much, then actually you can get away with a lot more. But if it’s really high, not only are you thinking, okay fine, if you’re gonna do something it’s gotta look good everywhere, and therefore not only is it just an implant, it’s a complex implant where you’re doing soft tissue grafting and really trying to get the best out of the aesthetics.

[Emma]
Yeah. Okay. Okay. That makes sense. And I think that relates to my patient because the reason he was struggling with the denture… a bit had chipped off, but he wasn’t wearing it anyway. He’s a musician, he was a singer, and he was actually at a gig and his denture came out. And so that obviously is not good for him.

And he has quite a deep overbite. And I had like a lengthy chat about him and chatted to the clinician, my supervising clinician, about conventional bridge or a resin bonded bridge. But we were like, let’s try it, let’s try it first and see how we go. And it did need a little bit of adjusting, but that’s why I was quite pleased when he came back two weeks later and it’s still there. We adjusted it a little bit further. Happy with where it’s at at the moment. But yeah, there’s just so much to consider, and so much to consider, and yeah, definitely.

[Jaz]
I want to remind you and all the listeners that when you do resin bonded bridge… which you guys know I’m a huge fan of. We have the RBB Masterclass on the Protrusive Guidance app as well. Have you done that yet?

[Emma]
No. I’ve not done the RBB Masterclass yet. No.

[Jaz]
Okay, fine.

[Emma]
I was waiting until I was at a point where I understood everything, ’cause I started working with you when I was in second year. So maybe now’s a good time.

[Jaz]
Now’s a great time to do RBB Masterclass. Yeah, yeah, do it. So I’ve got some clinical videos on there of actually putting bridges on, which you’d like to see. But as part of delivering a resin bonded bridge, it’s totally fine to adjust the pontic palatally to make sure it’s out the occlusion in that scenario. You want to check excursions and protrusive movement to make sure it’s not there.

But again, equally it’s really important the patient understands that it’s glued onto the tooth next door. You must not put anything between the teeth, or you must not chew that baguette. I always use a baguette example, or corn on the cob. And once they understand that, then you’ll get success.

I had a patient who I did a resin bonded bridge for. I get a very good success rate with resin bonded bridge. I believe in them very much. I do think for a lower incisor, for a single missing lower incisor, the standard of care is the lower resin bonded bridge central. I think if you’re trying to force an implant in that delicate and small area… yeah, why? Why is anyone doing that?

I honestly… please, my listeners, if you are routinely advocating an implant for a lower incisor, email me. Give me a justification. I just… honestly, I can’t see. I’m a very open-minded clinician, but in that one scenario, maybe it’s ’cause I’ve been affected by this and I’m missing a lower incisor and therefore I have it. I just cannot fathom how you can try and force and try and get a small implant, all the complexities of that, when you can just have a resin bonded bridge and just be careful with it. Mine’s been going for about seven years now.

So just remember that you have to look at the patient as a whole and their chewing habits. Just going back to that again, basically.

[Emma]
Yeah. That was actually also one of my questions. You sort of just answered. You speak about implants, not a tooth replacement, but… I’m missing… I don’t know if it’s you or if it’s one of the clinicians at uni, it might be yourself, Jaz, that always says an implant is a good substitute for no tooth, but it’s not a substitute for a tooth. Is that you or a clinician? Anyway, I’ve heard that somewhere.

[Jaz]
I’ve said it before, but it’s not mine. Like, it’s from very clever people. I can’t say who. It’s one of those things, definitely said by a lot of people, speakers and writers, and it’s a great thing, right? An implant is not a replacement for a tooth. It’s a replacement for a gap.

And that’s… yeah. Or any restoration you do. And just going back to be it implant, where you’ve gotta manage the occlusion carefully as well, or any form of bridge, especially resin bonded bridge… like, for example, if you’re doing a premolar. I know we’re talking about centrals, but I think the premolar example really drives it home.

If you’re replacing a premolar, maybe you’re using the second premolar as an abutment, right? So palatal and occlusal wrapper of the wing. And then you’re placing a premolar. Why does that pontic of the premolar need to have a palatal cusp? There’s no need. You can literally put a canine to replace a premolar. Because ultimately it’s aesthetics. When the patient smiles, it should look like they have a tooth there. It’s not for chewing.

And so the same kind of goes to some degree with implant, where we try to make the occlusal table, right… the occlusal table narrower, smaller, so it’s taking less load. Now implants are… you can chew on implants, they can go for it. Okay. Whereas you wouldn’t want to do that on a bridge, so they’re different in that regard.

But to make the occlusion really focus on the aesthetics and explain to the patient that this is smaller, that you’re missing half the tooth around the back, because that’s not important. It’s not to chew. And if the patient doesn’t understand that, if they’re not willing to buy into that, then you shouldn’t be doing a resin bonded bridge.

[Emma]
Okay. And so an implant-supported crown, you talk about that being the gold standard in terms of replacing teeth, but it’s not always in certain situations, especially like—

[Jaz]
Yeah, lower incisors it’s definitely not. In my opinion, yeah. But an upper incisor… you’re a good surgeon, then you know, if you wanted to get something that’s gonna really be the most secure, longest lasting, then an implant. It just makes sense.

Would I be happy to have a resin bonded bridge on my central? I probably would. Okay. I probably would. Honestly, I believe in the treatment protocol. But it depends on the occlusion once again.

Like, if you were to do veneers on someone, or if you were to do a central incisor resin bonded bridge, what’s the ideal occlusion to pick? Like, if you wanted to give a lifetime guarantee to a patient, who would you pick? What kind of malocclusion or occlusion would you pick? I’ll give you a clue here.

[Emma]
A class one. Wait, sorry, say that again. For—

[Jaz]
On anterior upper anterior veneers or lower anterior veneers, in fact any aesthetic work anteriorly, who is the best occlusion to work on, which is almost gonna give you a lifetime guarantee? Almost.

[Emma]
A class one.

[Jaz]
Okay. If it’s a severe class two, then the lowers for sure are gonna last forever. The uppers… there’s always a trauma risk.

[Emma]
Okay. Yeah, that’s true.

[Jaz]
An anterior open bite. No contact. Like, you know anterior open bite, right? This is why if you look at your anterior open bite patients, their posteriors are worn. The anteriors, they often have mamelons still. The functional load, the wear on those teeth, are minimal.

So if you wanted to give a lifetime guarantee, the only patient I would ever even dream of doing that for is an AOB, right? Obviously you wouldn’t, but you get the point, right? So that is a really good example.

We teach this in our occlusion courses that we do, where we think about, okay, think of the patient, think of their functional demands as well. Are they what we call a high occlusal risk patient, low occlusal risk patient? And that always plays a part, by understanding that an anterior open bite actually extends your longevity and prognosis for replacing an upper incisor. It’s a level of occlusion that just is more practical and makes sense.

[Emma]
Yeah. That makes sense. That makes sense. And then my last question for you, Jaz, was actually just about a digital workflow and CAD/CAM milling. Is that something that you utilize in your day-to-day?

[Jaz]
I don’t do chairside making. So like, whether you think you’re digital or you’re not, you’re digital. Even if you’re sending impressions, when the lab gets the impression now, they’ll pour it up and then they’ll scan the model, and now it’s all become digital.

So everyone’s digital, right? And so, yes. I like my technician to, because the shape is so important, they’ll send me an Exocad file, show me the digital design of the bridge, for example, or the crown or veneer, whatever we’re doing. And so I get to see that on the web browser. I get to move it around, make it translucent, opaque. I get to suggest some amendments, and then it goes for the milling, and then it gets sent back to me.

So it’s not I’m scanning, obviously. So scanning. But what I’m not doing is milling in-house, in the practice. But your lab is doing all those things, so whether you like it or not, you are digital.

[Emma]
Yeah. Is that a thing, like milling in-house? Is that…

[Jaz]
Yeah. I mean, look at CEREC. People are doing zirconias and Emax and they’ve got a little oven in the practice as well for Emax. I dunno if you’ve ever worked in a practice like that, or have you nursed for a practice like that?

[Emma]
No. No. Never. No.

[Jaz]
I mean, it’s amazing. I’d love to be in a practice like that one day. It’s like a whole… I like the idea of same-day dentistry. Like you come in and then they do it all, which is cool. I’m pretty sure you can do good bridges with it, but I see lots of veneers and anterior crowns that are done with it. And it’s great. There’s whole Facebook groups, “Keep CEREC Kicking” is one. I see their work. I’m like, wow, that’s amazing that you didn’t need a technician for that and you did it yourself. That’s so cool.

[Emma]
Cool. Yeah, I think that’s all the questions that I had today, Jaz.

[Jaz]
Okay. So the only thing I wanna add to that then, I think for completeness, is when you’re doing the shade, give as many photos as possible to a technician. When you’re doing the shade tab photo, put the incisal edge to the incisal edge. Put the cervical of the shade tab to the cervical of the tooth. Don’t be afraid to tell your technician, look, I think the cervical is A3, the middle is A2, and then there’s white effects here. The more detail you give, the more closely they’ll look.

Lots of good photos. You need to make sure that you undersell and over-deliver. So whether you want to use Raj Patel’s tissue technique or whatever, you gotta tell the patient that, look, it’s very difficult to match a central incisor. We’ll never match, will never be perfect. And if the patient’s got a problem with that, they can go somewhere else. Because you run into trouble if the patient’s expecting perfect.

Because sometimes we think… oh my God, this is from my first year in practice. I had this patient who didn’t pay any money towards the bridge ’cause she was exempt. And so I did a bridge for her, and she was happy overall, except she had a high smile line and this resin bonded bridge, the way the pontic sat on the gums, right? It kind of made a dark line.

So replacing a lateral incisor from the canine, and where the pontic touches the gum. At that time I didn’t have the skill or the knowledge to do an ovate pontic. It was good, but you could just about see a dark line where she could get some floss under the bridge. But you could see a bit of a dark line if you really zoom in. And she said, look, she doesn’t like that dark line.

And then I go to my principal trainer, I said, oh, listen, what do I do? Like, the bridge is looking good, we’re happy with it, but that dark line. And the first question he asked me is like, well, okay, how much did she pay for the bridge? I’m like, she didn’t. And he looked at the before, and he’s like, wait a minute, she didn’t pay for the bridge and she has a problem with it?

And actually I think he was wrong. I actually think he was wrong, because it doesn’t matter whether… so first, it doesn’t matter if they’re paying or not. You need to warn about everything. It doesn’t matter if they’re fee-paying or not. I should have explained that, look, the way this pontic is gonna sit against it, you’ll feel it, you’ll see it. Why? Because you have a high smile and you show everything. So if you want the highest level, you see a periodontist, do some soft tissue work and get that kind of stuff done.

But when a patient is paying a fee, whether they’re paying one onion or five onions… okay, onion can be any currency that you want… basically, if they’re paying, just assume that their aesthetic expectations are sky-high. And so your job always is to bring that down to an appropriate level.

I’m not saying always say that it’ll look really bad, honestly, like you’re just gonna look so, so bad. And then when it looks half-decent, be like, hey, what can I say? Don’t tell them a lie, but you need to give them an appropriate… because obviously you wanna do a good job for them, but you can show them and share with them the intricacies and difficulties of doing that.

And then when it comes to decision-making tree and planning for an incisor, just make sure that you ask enough questions so you know exactly what direction you feel confident in recommending that option to a patient. And be it a denture, be it an implant, be it a bridge, we’ve kind of done a little bit of a very brief overview. It’s up to our Protruserati to delve deeper into that, and there’s a really good episode that I would recommend. We do “Dentures versus Bridges.” I did that with Michael Frazis. That’s a good one. We also do one called “Crowns versus Onlays” with Alan Burgin. That’s a really good one. Mm-hmm. We also talk about dentures with Finlay Sutton.

There’s so many other episodes out there. So for students out there, go back in time and listen out there. And speaking of students, we have some student notes. What are the notes that you are adding to the student section of the app?

[Emma]
I think I might even… I’ve not put it together yet, but I think I might even just take some bits here and there for just replacement options. Not even just for a central incisor, but just for gaps in general. Even just like a communication guide for talking to your patients as well. Making sure you’re not missing any risks and benefits and alternatives. And yeah, just for replacement options, I think that would be good to put together.

[Jaz]
Okay. That’ll be available in the Crush Your Exam section of the Protrusive Guidance app. There’s one thing that we didn’t touch on, I just remembered, is when we are replacing with a denture or a bridge… we’re talking central incisors predominantly, but you can actually have weird and wonderful incisors. Like if you’ve got small teeth, you can have small pontics, small dentures.

But with implants, we’ve gotta reconsider the dimensions, the CT scan, how much bone is available. There’s a whole biological element, which you kind of, to a large degree, can skip with dentures and bridges. However, the biological for a high smile line is still important because the way the pontic, the fake tooth, sits against the gum… that’s soft tissue. Aesthetics then come in for someone with a high smile line.

But you need a minimum distance between one tooth and the next tooth, a minimum distance between the roots. So sometimes you look at the gap, the central incisor, and you think, yeah, this is great, I can put an implant here. But when you take a PA, you see that the lateral incisor and central incisor roots converge. And therefore actually you don’t have the space. You need to have some very complex ortho to torque and fix the roots here.

And so there’s so many more nuances. This is why the top dentists that are doing single central incisor implants, they demand a top fee because they deserve it. It’s very, very complex. And, you know, hats off to those clinicians.

[Emma]
Yeah, absolutely. I think if you’re putting all that work in, then yeah. Charge for it. Absolutely. Absolutely.

[Jaz]
Good, good. Amazing. Emma, thanks so much for being the Protrusive Student. Thank you very much. Next time… I don’t know if you’ve thought about next time. We were gonna consider doing medical histories, guys, but honestly it didn’t excite me enough because I’m like, okay, am I the expert on medical histories? I can kind of advise, okay, let’s open the BNF kind of thing. But it’s something that I think is important though.

So please do some self-reading on medical histories. But are there the more clinical topics that you’d like to—

[Emma]
What have we not really covered? Bear with me two seconds, Jaz, ’cause I actually have a list of—

[Jaz]
Okay, cool.

[Emma]
Let’s see. We’ve not really done any basic oral medicine, have we? Or oral surgery. I know that we did an extraction topic, but maybe we could do something similar… oral medicine—

[Jaz]
Oral medicine. I defer to this really lovely Australian dentist, Dr. Phoon. We’ve done some red patches, white patches, done oral cancer with her. And so it would be a blasphemy if I was to start answering questions on his pathology of oral cancer and stuff.

But we can talk about some other clinical themes. But there has to be a… I love it when you have a patient problem. Like when you have… it is so great that you had a recent patient with that bridge. So I want you to start looking out for real-world clinical dilemmas. ‘Cause that’s what the podcast is about: real-world clinical problem-solving. So over the next few weeks, have a look at what clinical dilemmas you’re facing and then let’s decide the topics from there. Okay. I think we’ll make it more tangible for everyone that way.

[Emma]
Okay. We’ll do that then. Perfect. Thank you very much.

[Jaz]
Amazing. And guys, if you’ve got a recommendation to students for what you’d like, or young practitioners… I’m really proud of the series, the previous 17 episodes we have so far. So, so great. It’s really, really good. But if anything else needs a back-to-basics, something for young practitioners that’s not gonna bore me to death, then please do comment and let us know what you’d like. All right. Thanks, Emma.

[Emma]
Perfect. Thank you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. If you are a qualified dentist and you’d like to claim CE credits for this episode or enhanced CPD, you can do it. Head over to Protrusive Guidance or scroll below. If you’re already logged in, answer the quiz and claim your CPD. You deserve it. You listened to the whole thing, and now you get to test your knowledge and your understanding, and we will reward you with a certificate.

We are a PACE-approved education provider. We’ve got over 400 hours of CE on Protrusive Guidance. All the masterclasses, episodes, and the accompanying premium notes that we provide. Transcripts and infographics are second to none.

Now, specifically for students, we have the Crush Your Exam section where Emma uploads her notes, which helped her smash her exams last year. So the one to accompany this episode will be all the replacement options for teeth. Particularly useful for OSCEs and great revision material. Some of the earlier ones that she uploaded were dental materials, for example, which a lot of you found very helpful.

If you wanna fast-track access into that, email student@protrusive.co.uk. Send us your proof that you are indeed a student, and you’ll be allowed into that part of the app.

Otherwise, thank you all for listening and watching so much. If you are on YouTube, make sure you hit the subscribe and like button, and if you’re on Protrusive Guidance, please do comment. I love reading comments and replying to them. Thanks again and catch you same time, same place next week. Bye for now.