Finlay Sutton has made Dentures sexy again. His teaching style is world-famous and it was an absolute thrill to chat to him. Protruserati – this one is going to be clinically IMPACTFUL.
We started by discussing the benefits of using Loom for video communication with patients and lab – it adds a personal touch. Genius!
What do you do when the framework does not fit?!
Finlay will firstly trial the denture on the model. If in doubt, rehearse the path of insertion several times and you can ask your lab.
You can use occlude spray on the denture fit surface
Regarding Immediate Dentures:
Leave your patients in immediate denture (plus relines) for 9-12 months to get maximum shrinkage before upgrading to Chrome. Sometimes you move quicker but need to reline (use ZOE) and then alginate pick up 12 months later.
Should you use high impact acrylic? It seems a sensible idea!
How about metal mesh?
What if your partial denture wearer is a bruxist? We talked about how your partial denture can BECOME a splint.
Precision Attachments and Milled Crowns
Why Finlay has moved away from precision attachments and true ‘milled’ crowns as they are maintenance heavy. It is simpler to have crowns that are shaped appropriately with guide surfaces that will improve the denture.
He does use Stud Attachments, which he uses just twice a year, to resurrect a root-filled retained root to negate the need for a clasp in a high smile line patient. Tell the patient the root may split, AND the tooth in front will need a clasp in the future. Metal backings are amazing for bracing – ‘My dentures are like removable resin bonded bridges’. Hidden away but provide great resistance to rotation and adds rigidity and bracing.
Another gem was the use of dimples in to the crowns palatally and distal guide surfaces – with metal backings. The metal backing would have small balls that would slot in to the dimples.
‘What I hate is patients coming back with problems after they spent lots of money. If it all fell apart in a few years time, which these do, we’re in dickie’s meadow’ – there we are, keep it simple!
You can use Zirconia crowns with rest seats and dimples but ensure, smooth, round, organic shapes. Be careful about making upper palatal too bulky as affects speech – hence why preferences to make these dimples substractive.
If you want to learn more from Finlay, do check out his website for denture courses and learning resources.
If you enjoyed this, you may also like the episode about Complete Dentures with Mark Bishop!
Click below for full episode transcript:Opening Snippet:Welcome Protruserati to Episode 56 with Finley Sutton. Now, we've all had these situations with dentures before, right? You're trying to fit the framework which has just come back from the lab and it doesn't fit. And you have this heart sink moment like oh my god, like, what do I do now? Right? So if you're ever in that situation and you want to know how to fix it, Finlay Sutton, who is a phenomenal dental educator, will answer this question on this podcast for you, as well as so many others, like what do you do in a deep bite And there's no space for the chrome? Or how about milled crowns? And how to incorporate that with your Chrome dentures workflow. So stick with this episode to learn all about that with Finlay Sutton...
Jaz’s Introduction: I know I’ve been teasing you for a while about this episode with a fantastic educator in the field of dentures, which let’s face it, I mean, since I was a student, I’ve always found dentures confusing. I don’t do many at the moment. It’s just the nature of I think demographics has a lot to do with how many dentures you make. At the moment, I’m not making load. But certainly those struggles I’ve had with dentures, they never leave you even throughout student young dentist, dentures are tricky to get your head around. But I’m convinced that in this episode with Finlay Sutton, you will probably learn more about Chrome dentures and partial dentures in this one episode they did at dental school. Sort of make an announcement that there’ll be another way for you guys to listen to podcasts, and get CPD or CE credits because a lot of you doing it, you know, when you’re driving or when you’re multitasking, when you’re running, you’re listening to podcasts, and you like to get the CPD now at the moment, it’s on dentinaltubules.com, which is phenomenal value, and you can get CPD hours, which I’m just amazed at the generosity of Dhru for letting me host this on dentinal tubules completely for free. So thank you so much , Dhru, but some of you wanted an option whereby you didn’t have to log on somewhere to answer questions. And that may be coming soon as well. Thanks for those who voted on the Protrusive Dental community. So I’m gonna keep you in the loop with that. I’m going to tell you about the Protrusive Dental pearl for this episode. And this pearl is from my good buddy, Alan Burgin, Fantastic dentist you may have listened to episode I think was 37 is that is a unusual journey with a young dentist and you know, he is such a caring kind guy, you can just tell right and his dentistry is world class. So I check out the Cornish dentist, I think @the.cornish.dentist, Instagram account, follow Alan, he’s such a cool guy. And he taught me this little tip on suturing. Because we had like a little mini sort of zoom session. And many of you, I think will benefit from this because like, when you’re placing a suture, let’s say you’re placing a vicryl rapide 4-0, and you’re you know closing up a you know, the socket after an extraction, you’re going to be, you’ve been taught that when you’re actually tying the knot that you take you, the way you pull is that your hand moves away from you. And this will get you out of jail most times so if you just follow the rule, if you forget anything, you do your you know, three throws, and then two throws backwards, and then you pull and then your right hand, your dominant hand goes away from you. And most of time, you’ll be fine, right? But actually, sometimes the way you insert the needle or the way you approach it or the type of suture or not you’re doing means that that rule doesn’t always apply. So is there another way to think about it. And Alan taught me that actually where you take the first bite, and then where you come out of so the direction you are going in is the direction that you pull. So let me make that even more tangible for you. If you’re going from buccal to lingual so you just got into the buccal papilla, okay, you’ve taken a bite. And now you’re going to go to lingual papilla, you’ve taken a bite, you’ve gone from buccal to lingual. Therefore when you do your three throws forward, okay. And you’re going to pull that suture, you’re going to make sure that your right hand goes towards the lingual, right? So you pull their your right hand towards the lingual and then you do your reverse throws. And then you come towards the buccal. And you’ll notice how much of a difference it makes that your first pull. Okay? That’s to get the tight suture that you need. Okay? If your first one is rubbish, and it’s a slack and it’s very loose and you haven’t done a very good job, then you can’t make up for it in the second one because the second one’s just to reinforce the first one. So all the hard work happens in that first tightening if you like or a first knot if you like so that’s my pearl for you. Another few things that I learned from the tutoring sessions that Alan went on this course for tutoring right? And he asked these guys on the soft tissue course. Right? “Who knows how to suture?” Right? And everyone was like, “Yeah, come on, man. We’ve been qualified 15, 20 years we know how to suture.” Can everyone put the hand up, Yes, you can suture. So one by one this soft tissue course instructor, this dentist, periodontist where he was. He told everyone to come on the stage one by one. Okay, and place a simple interrupted suture. Okay? So Alan told me this story, and then they place it. And then the instructor would come along, get his little probe and go click, and the suture would come undone. Next person. So the next person comes again, they do their best suture, he’d come along flick, and the suture comes undone. And it went on and on and on until everyone got a little bit embarrassed and said, You know what, I think we can learn a few things about suturing. So the reason I share that today is no matter how much you think you know about suturing sometimes these little micro tips can retake your suturing skills to the next level. So Alan, thanks so much for let me use that for the Protrusive Dental pearl today. Do check out his episode, the young dentist journey, if you haven’t a listen to it already, he’s a top guy. Now I won’t babble on anymore. I’m not gonna waste any more of your time because Finlay Sutton is about to give you a denture masterclass right now.
But I’d like to know, how were you? Because we’ve all been asking for you to come on the show for a long time now. How was a pandemic for you? How are you doing now? It must be super busy. How are things? [Finlay]
Yeah, it was good. Well, obviously, the pandemic wasn’t great was it? You know, in terms of the world and stuff. But it’s actually open up for use of opportunities, really, I really loved doing the this. I’ve funded about 20 webinars during lockdown. And that was absolutely terrific love doing those. And I’ve got really great feedback from them too. And it’s just really, really nice, just being able to just sit there and just, you know, show people what I’m doing. And also just give back a little bit, you know, so it’s without, you know, without charging anything, it was just really, really nice doing that. So that was good. And then also, we’ve got other stuff sorted out with a practice, which I think was really super, for instance, you know, doing video consultations with patients before they come in, which is Ace, which is really, really good, because like now we can’t do consultations without a mask, you know, being sort of basically covered up and it’s really difficult to get that human interaction really solidly. So turn it over zoom is ace. And the other thing I find it really good as another piece of software called loom, L-O-O-M [Jaz]
I know. I’m familiar with loom it’s cool. How do you, How are you using loom? [Finlay]
I’m using it for helping patients to well before they actually come in. So if they’re coming in for some extractions and immediate denture for then I can actually do their consent form. And to show a little picture of me going through a consent form, you know, talking about what to expect, etc. And also, I think, really importantly, afterwards, I can just do a little personalized video for the patient. And they can revisit it from time after time, you know, so as the immediate dentures are settling in, and maybe that discovery, certain problems, maybe a couple of days down, they can watch the video again, ‘oh, Finlay pointed that one out. So it’s, I find that a really useful and I think also they feel like, we’re a bit more, there’s a bit more of a person behind the clinician, a bit more humanity really and that so. So it’s actually is, this count is opportunity. And also lab communication with loom is fantastic. In, you know, my ceramist is not on site. So how you can just do a whole video for him and show him the mouth and person and the shade and exactly what I’m wanting, you know, say rest seats or guide surfaces, etc. So that is terrific. [Jaz]
I’m so glad I hit the record button because this is a real gem that you’re sharing as to I in fact, every episode I have a Protrusive Dental pearl, so I think we’re gonna share this as Fin’s Protrusive Dental pearl which is to use loom because previously I’ve been using loom as staff training. So for example, nurses sometimes come and go, and if you record something once as a training video then nurse can revisit and you can have that one video and sometimes I work in a team, someone who produces my podcast and God forbid he leaves. I’ve got a training manual on loom but I like how you incorporate dentistry. I didn’t think to do that, especially with patients. I mean, wow, the human touch you’ve added with the consent and the lab communication and the little points afterwards. That is really a level above so thank you for opening my eyes to loom in that way. [Finlay]
That’s great. You’re welcome, Jaz. [Jaz]
Listen, Fin, people, the people listening to podcasts have been begging for you to come on the podcast. Since its inception over two years ago now and dentures has been covered once by my ex tutor, Mark Bishop, do you know Mark in Sheffield? [Finlay]
Yeah, I do. In fact, Mark taught me when I was at Sheffield. He was, this is back in like the night late 1980s, early 90s. And they were just a really young, qualified dentist and super keen. And he was my favorite tutor. Terrific. [Jaz]
Oh, he’s gonna love hearing that because Mark is a good friend. And he listens. And he did an episode on complete dentures. And now I’m so excited. And so are the Protruserati. So the people who listened to the podcast called the Protruserati and the other day I posted on Facebook, I said, “Hey, Fin’s coming on the podcast. Finally, what do you want to know?” And so it was it was the Protruserati decided they want to know more about Chrome dentures. And specifically, I’ll give everyone a flavor of the kind of things we’re talking about today, so that it wets their appetite for the rest of the episode, we’re gonna talk about troubleshooting chrome dentures, and common errors and issues that we have, framework issues, not fitting, that sort of stuff. We’re also going to cover a specific scenario with a client Kennedy class four, you know, obviously difficult scenarios in any case, but it’s particularly in a deep bite. I want to hear from you, how you manage that? And that question was sending from Gian-Marco D’Andrea. Gian, hopefully, hope you’re doing well, buddy. Thanks for saying that question in. Milled crowns, people want to know about precision attachments. So it’ll be interesting to know about your experiences with that. And then something I’ve never done before. And I didn’t know what the thing was immediate anterior chrome dentures. So I’ll be very interested to know, you know, how you do those? But before we get into that, there may be a very small number of people listen to this somewhere in the world who don’t know you often. So for those very small number of people, please tell them who you are. And I’m going to say Firstly, that I’m so glad that you’re British. Because Wow. You are really I think the state of the art in dentistry in rural prosthodontics, which is your, the real passion area. And I’ve seen you educate at the BARD a few years ago as well. Your lectures are so engaging and funny and educational, your online content, no one has ever obviously, no one’s ever said I went to a Fin lecture and it was a bit boring wherever, you are just full of so many gems, which is why I’ve been so excited for you to come on. So please introduce yourself, Fin. [Finlay]
Yeah, I’m actually based up in the northwest of England. And guy have a practice based in Garstang, where she just, I’m not, I live in Lancaster, the practice in Garstang, I have a referral practice with my wife, Rachel. And Rachel as a specialist orthodontist. And we started the practice in about 2007. And we’ve grown it since then. So we have a really nice referral base. And we also, we’ve got two other dentists that work in a practice where those we’ve got Sahid, who’s a specialist in periodontics, that’s Sahid Abad. And we’ve also got Robert Jacobs, who’s an endodontist. So there’s four of us specialists in the practice there. Sorry, that’s my dog barking in the background. So that’s what we have currently. Now. I have been really focusing for the past, I would say 20 years of really in removable prosth I used to do a little bit of fixed as well, you know, just fixed and removable. But around about six years ago, I decided to just take the plunge and just do nothing but removable. And but 20 years ago, I actually did a Master’s at Manchester with Fraser McCord, in fixed and removable prosthodontics. So I was six years qualified at this point. I’ve qualified in Sheffield in 93. And been in general practice for six years. So yeah, I’ve qualified from Sheffield. And then I really found that general practice was unpredictable. There was quite a lot of situations where I’d actually be trying to do something that just wouldn’t work for a patient. And I would feel really bad about it. The patients would be upset. And it was just a real issue for me this predictability. So I worked in various different practices, did lots of courses with some great teachers. One person in particular is Michael Weiss, who was really absolutely amazing. And I did his course and those sorts of things, they made me realize that something else, but I didn’t actually know how to get from A to B to do to be really good at prosthodontics. So that’s why I decided to go back and do my Master’s in prosth to Sheffield. So, so what I did was I saved up enough money to actually leave work for a year, I moved back in with my mum and dad’s in Preston. And then I commuted to Manchester, and did my masters. And it was really a great turning point for me, in my career progression. [Jaz]
When no one ever talks about the sacrifices that you had to, you know, move in with your parents again. And usually, that’s what’s involved when you have to do an MClinDent, or a Master’s or a program like that, after, you know, X number of years, it’s a significant investment in time and money. And you know, often you hear about people who are married, and then suddenly they have to, you know, one person has to completely give up their job and move for the training. And so really, these are the things that to cook people talk about, and it’s great that you mentioned the sacrifice, personal sacrifices you have to make, to get to a level that you want to be at. [Finlay]
That’s absolutely true. It is. And I think that’s really important, because I think dentistry is not an easy job, you know, for many reasons, both technically, and managing patients, etc. There’s so many facets to it, it’s a brilliant job, there’s no doubt, but it is difficult. And so I just found that just making that sacrifice is so worth it, I can’t believe how privileged or happy and content, I am at the age of 49. That’s, my age, I feel, really, [Jaz]
Not at all. Don’t believe it. [Finlay]
But I feel really comfortable with, with my the quality of the work that I’m doing now, I still go to work and have to learn, you know, and I still learn so much all the time, it’s just wonderful. But making up sacrifice years ago, like 20 years ago was just so worth it. And so from that point forward of doing the masters, and I loved it, actually, I was not very good at prosthodontics at all, I really was and I was highlighted by Fraser, you know, when I actually started. So he’s pretty forthright about that. But that was something that was, you know, I really needed to know, because I was, I did think I thought I knew a lot. But actually, I really didn’t. And so I had to get my head in the literature, in the papers, and actually start doing it as well. But it was a great thing because it was a protective umbrella in which I could treat patients being supervised. And also the other brilliant thing about this was, the lab was right next door to the clinic, the dental. So I would go through to the lab with my impressions. And that’s where I met a Rowan, who I work with now and have done, you know, ever since so and Rowan works with me in a practice in hostels done since we set it up like 13 years ago, he works full time for me, and just does some amazing work. And I think that’s one of the things that I think if I another real tip for younger dentists, I think is if you really like doing dentures, then what I would do is try and find a technician who has a similar age to yourself, who wants to grow and go on a journey and learn with you. And then over the years, you can both improve together and go on this really fantastic journey. And I think that applies to all aspects of dentistry. Really. [Jaz]
I mean, that’s a great gem right there. But another one I don’t want to go unnoticed is another breath of fresh air that you said is that, look, you mentioned your age, you said you’re 49 and you’re at a point now where you’re feeling comfortable. But whereas a lot of young dentists are fine, we feel like we need to know the answers three, five years after qualifying in, and I think what you highlighted there is that Have some patience, because it may be some many years later, when would you say you reached a point post qualifying that you actually felt, Okay, now I’m approaching my peak in a way if that’s a fair question? [Finlay]
So I To be honest, Jaz, I think since I’ve come back from COVID, I’m loving my dentistry more than ever, and feel that I’m at my peak now and I still haven’t reached my peak. I’m still getting better. And I think potentially, I think particularly with removable prosth, because having a pair of loupes is really sufficient for what we need. I don’t need a microscope to do dentures really well, but with loupes magnification. I think I can go on to I might 70 or 80 [Jaz]
your patients will need you. [Finlay]
I would think I’m not at my peak yet at all, Jaz. Oh, there’s more to come. [Jaz]
Exciting and scary. And for us mere mortals. Actually things that are How could you not be because you know, I subscribe to your newsletter, I see all these amazing sensational cases that you post and it’s just wow. I mean, I just have to say you really do make a you have made removable prosthodontics sexy again. And I think that, you know, you must have heard that millions of times. So that’s great. So we’re going to dive into some of the key questions. So troubleshooting chrome dentures. Okay? So let’s talk about one particular scenario, let’s say and please do add in the context, contextualize everything, take the you know, feel free to take things a few steps backwards, if it will help students to learn a bit more. But in a situation where you get to a chrome framework try in stage and A) Do you always do that? Do sometimes skip it? And tell us about the background? But what if you are at that appointment And the chrome framework doesn’t fit? How do you, What’s the protocol in terms of managing that situation? [Finlay]
So interestingly, Jaz I had my other patient in yesterday, and it was the first chrome that hasn’t fitted for three years. It was a lady yesterday. And you know what, the reason it didn’t fit, it was a lower denture, she’s got lower anterior teeth, so she’s got lower three to three. And then she had this molar, right in the back like a seven. So this is an I put a ring on that molar as part of the framework, so it has a ring rest on it, and it seated beautifully on the anterior teeth, but it didn’t fit on the ring. And so, you know, while when I did the impression, I took the impression out of the mouth, and the that back to the crown on that had a bit of an undercut on it just pulled the impression out of the tray. And I thought I can just push it back in. And fine, and I pushed it back in, and it looks fine. But it wasn’t, and so that molar was in a different position, you know, on the cast compared to the mouth. So. But anyway, that’s the first time in many years. But what I think there’s two aspects to this, there’s two reasons to this. There’s technical faults, and there are clinical faults, really in terms of why things don’t fit. But I think if we go right back to dental school, why I was always taught was, or felt like I didn’t, I wasn’t taught this, but I had this in my mind that whenever you take anything out the box, it should fit in the patient’s mouth, without any adjustment at all, it should just go in and just be perfect. And, but that is not the case with dentures, because the mouth and the cast are always different in some way. But there are ways to adjust a denture to make it fit beautifully, without causing gaps between the tooth and the denture itself. You know, those gaps, if you think about it, you know, if you have an acrylic denture and you’ve adjusted it, and then you’ve got all these horrible gaps between the tooth and the denture. [Jaz]
Premolar, as you remove the collets where it’s been to tight and then suddenly, yeah, this horrible gap. So they haunt me every night. So I mean, if you could share some tangible tips to to make us better with that. Wow, that’d be amazing. [Finlay]
Okay, the collets, the edge, there’s a key where it touches the tooth, that point where you see it on the model, and it’s fitting on the model beautifully with that color to the tooth that the secret is do not touch the top of the collets, it’s where it touches the tooth. Don’t drill up bit, drill underneath it, anywhere on the neath, then you won’t have this gap. And the secret is using occlude spray. [Jaz]
you know, and is there a specific type for that for better for removable prosth? Or is it I believe it’s the green spray, isn’t it? [Finlay]
It’s the green powder and you can get it from ? Express and dental directory no problem. It’s called ‘OCCLUDE’. And it’s a little can with a spray. And I spray it onto all of the surfaces and this is either with a chrome or with an acrylic base denture when we’re coming to fit it. So where it touches tooth spray on that, take that to the mouth and then try in to state it in the best way possible. Beforehand though, Jaz, what we need to do, I always check how the denture fit on an off the Cast. And if I was sure, I don’t speak with Rowan about it. So I would pick up the phone and talk to the technician about to say, look, hey, I don’t know how to get this on and off properly. And though they are so expert because they’re constantly doing it for me when they’re making it. So we’ve got to use that same path of insertion on the model, as in the mouth. So once you’ve got like a feel for it, and a mental picture of how which side goes down first, then you take it to the mouth, and you try to do that in the mouth. With a patient lying back, you can see what you’re doing, patient then wiggle it in just gently until we won’t go any further, but don’t really force it, take it out. And because we’ve put the occlude spray on that powder, wherever it touches the tooth, it will rub off on those bits. And then I take it [Jaz]
Just to clarify, Fin, occlude spray goes on the tooth and not on the framework, not the denture, right? It goes on the tooth, and there’s a denture that picks up the spray. Have I got that right? [Finlay]
It’s the other way around, Jaz, spray onto the fitting surfaces where the denture will fit against the teeth, and do it all doing all of those, use it uniformly there. And then [Jaz]
So what you’re looking for then is show through of the pink or the silver, that is the area that is the problem area. [Finlay]
Absolutely. It is and then you just gently grind that away. Just using [Jaz]
Any specific bur like for Chrome? Is there any specific bur we should be using? [Finlay]
I use, it’s a shamfer crown prep, Diamond bur, a course one. And it’s perfect in it, I use it in a speed increasing handpiece just next to the patient and then just shave that off the but avoid the top of the collets, do not sort of shuts off of the collets. And then, so do that, adjust it, and then spray again, onto all of those fitting surfaces, back into the mouth, and redo it. And just keep redoing that, time after time, until it fully seats down. And it can be sometimes with these complex chromes. And if you think imagine a patient who’s got like tooth-space-tooth-space. Rowans calls them a Christmas tree dentures. So there’s lots of fitting surfaces, that those take a long time to fit. You know, sometimes it can take an hour, a full hour for the chrome to fit absolutely perfectly. [Jaz]
So an hour of this repetition, sequence of occlude spray, you think? [Finlay]
Yes. And it is I know that sounds like a long time. And also your thing is, when you try it in, if you’ve sitting there and I think, gosh, this is a long way off. And it’s not seating anywhere close, don’t lose hope. It sometimes just two or three little touches, and then suddenly it starts to drop in and starts to get closer. [Jaz]
Good. Because I’ve been in that situation before and you start panicking, you’re thinking hey, do I need to, like you know, abandon ship and just take a new impression, because it automatically you think, hey, it’s the impression, that’s our fault. But I’m so glad you’re saying this because as mere mortals, it gives us so much hope. And I think that will hopefully encourage dentists to go about it judiciously, meticulously and in the way that in the protocol that you set out with the occlude and not lose hope, and that it can take up to an hour in those more challenging Christmas tree type situations. So I appreciate I think we all appreciate hearing it from you. [Finlay]
Absolutely. So that’s really good. And what I do is I think it’s all about we’re going to manage the patients as well in this situation. So what I’ll say to the patient is at the beginning of the appointment “Look, I’m going to try this chrome framework in here. Sometimes it takes quite a long time to do this, I might need to keep putting it in and out in and out to adjust it. So there’s nothing wrong with that, that is totally normal, because we’ve got a plaster model which is going to be different than your mouth.” So I just try and put the patient’s mind at rest because if I didn’t say that to them and I have done you know, in the past to be like Is everything okay? Is it fitting all right? You know, so it just lays and manages the expectations straightaway. [Jaz]
Amazing. So a lot of dentists who’s been listen to this thing thinking oh my goodness, I’m it’s not me, it is happening to other people and it’s a great way to do it. I don’t have any occlude spray but that’s the first thing I’m going to be getting now. So before, I’ll be honest with you before, it’s a bit of a lot of guesswork involved, and it is going to be very painful. So I think though that protocol, that’s a real gem right there. Next question is Kennedy class four situations in a deep bite. So you can maybe talk about framework design in generally, good practices in Kennedy class four situations. But then anything specific we can do in these deep bite situations that Gian-Marco has specifically asked about? [Finlay]
Okay, that’s a really great question is there so, you know, the Kennedy class four is where a patient has upper or lower anterior teeth missing. So they’ve got all their posterior teeth are still remaining, but they’ve got this big saddle anterior like, so often, in like class two division two cases, they’ve quite often have a really deep overbite. And sometimes the bite is such that the teeth have overerupted and slid past each other, and they’re actually occluding onto the palate. So, and that can really be a problem for trauma and things. So quite often, I’m presented with these patients where the upper teeth, say, unrestorable, and they need to come out. So once we’ve gone through all the options of different approaches, if we’re going for a denture for that patient, then the immediate denture, well, and on i, this is where I don’t do and this is answering another question about immediate Chrome, partial dentures. I don’t do them, Jaz, but we’ll talk about that later. But in these cases, I like to do an immediate first and acrylic. But often, I’ve got to jack them open at the [ ? ], because there’s no space for acrylic for them. Because if we just fitted it out the intercuspal position, then we’d have no space whatsoever for a claim for it’d be wafer thin. So I do open them up on that. So the front there. But with the passage of time and recession and the sort of resorption and remodeling of the ridge, this space is created for the denture. So and then we can say.. [Jaz]
So you get the posterior settling a sort of like a almost like a dahl effect if you’d like but in a completely different mechanism. So you’re saying that when you jack them open, and you leave them so heavy on their lower anteriors if there’s for example, in a class two div two replacing the upper incisors due to resorption, everything will just settle into place via the acrylic immediate denture. And if Firstly, am I right in saying that? [Finlay]
Yes, absolutely you are. [Jaz]
And then how thick if you get, if you wanted to get a iwanson gauge and measure the thickness of the acrylic that you have opposing the lower incisors in that situation? How thick should it be to A) that you’re not being ridiculous and jacking them up too much but B) you have enough to respect the material? [Finlay]
Absolutely, I think that we really need two millimeters, two millimeters thickness any less than that it’s prone to breaking. However, I do break these rules as well. So for instance, just before a lockdown, I saw a patient for this particular procedure, and she got a really deep says a bite. And we made it probably around about point five of a millimeter thick, this one.. [Jaz]
In acrylic? [Finlay]
In acrylic but I relined it really quickly. As then, literally about a month later, you know, a month later, I did a [ ? ] line from the base, so where we got a little bit of shrinkage a little bit. So it’s like thinking about I know it’s going to break, I’m going to plan to get it realigned quicker to thicken it up. But so, but if I was going to put to malware for that particular patient, it would really just been just too much. But ideally, we need meters. [Jaz]
Two Immediate questions I have Fin, if you don’t mind. Two immediately have on that, which would be A) Can you? Is it a good idea in those cases to ask for high impact acrylic, it’s something I’ve just gotten used to sometimes writing that in the lab sheet but A) Does it actually make any difference? So high impact acrylic and B) How about incorporating a metal mesh inside? Are any of the these two good ideas or pointless lab fees that is not really necessary for intermediate in those situations? [Finlay]
I think the in fact it’s really good question not just about the metal mesh, but I’ll answer the high impact acrylic question first, definitely yes, I do think it’s worth having high impact acrylic, they are more resistance to flexing. That’s the good thing about them that the more, the less rigid, if you will, so just they are more robust than standard acrylics. The metal mesh, is I think it’s a bit weak, I don’t do it. I just think it’s a little bit pointless, but I can’t really give you a really good scientific fact. Just chip and break. And, unless it’s substantial. It’s just not worth it. But that’s, I know that I’m not really answering your question. Particularly. [Jaz]
It’s interesting to know, you know, if you are not routinely using metal mesh, and I really appreciate that, and we can, we can learn from your clinical experiences. So what you’ve talked about already, in terms of that situation we’re to rely on relatively quickly, that’s a great way to manage it. The other way of just allowing things to settle and leaving it high, if you’d like or proud and letting things settle rather than committing yourself to a, you know, treating entire arch with restorations, for example, or I don’t know if you’ve ever had to do any enameloplasty of the opposing incisors just to get them leveled up. And that gives you maybe half a mil more space. Is that something that you ever had to do? [Finlay]
Absolutely, Jaz. That’s Brilliant. That’s great. So for instance, that patient I was just talking about just before locked down. She had one of the canines was like, really high, low on, and was definitely and it was really spiky looking and didn’t look very nice. But it was really close. So I just had a chat with her. I said, Sure, we just send that down, though. It’ll look nicer just doing that and she was perfectly happy and not just created some space for me and helps. Rather than me having to adjust the denture, I could adjust the tooth. It’s just that Yeah, absolutely. So that’s a great little tip, I think the deep overbites is really important. So Gian-Marco, once we can further forward down what the resorptions happened, then I do like to then go on to the I always go on to the definitive denture, which will be a metal based one. So in those circumstances, I normally will restore that patient to their intercuspal position. You know, because we’ve got lots of space now, we’ve got plenty of room to actually fit the denture into the existing bite, so that’s fine. Occasionally, though, and this is like sort of feeding into your I know your passion is occlusion and you love you know, talking about splints, and this type of area and I dentures, partial dentures can be amazing splints too. So for instance, in these deep overbite cases, these classes, Kennedy classes four if they’ve got a really heavily restored posterior dentition, rather than doing it in intercuspal, we can actually put chrome overlays on all of the back teeth, and the whole thing becomes a denture/splint. And it’s protecting the occlusion beautifully, as well. So that sounds.. [Jaz]
That’s amazing. I’ve done one of those and as a dental core trainee in hospital, but you need a very understanding or a particular accepting patient, because some patients are so worried about metal show. So to have all these sort of occlusal tables overlaid with metal, it now he goes in hand with having the relevant consent with that patient and then being okay with that, right? [Finlay]
That is so true. Absolutely. And it only works in certain cases where some patients really hide the lingual sorry, the palatal surfaces of their teeth. So they don’t really show very much of that. So if we can build the palatal surfaces, or and we leave the buccal edges free. So it’s just palatally position quite often, that metalwork is quite hidden, but it is still, that’s still the area, the patient that is going to bite on, so they can be quite cool, but you’re dead right about that. And then I what I think is really, really good with crowns. And this is digressing slightly is prior to making the chrome framework. What I like to do is get a pattern resin framework made, which is just the same shape as the chrome So it’s literally like a mock up of where the metal framework, we can then try that in the patient’s mouth, I can assess the accuracy of my working cast, because if that fits, well, I know that the Chrome is probably going to, that’s number one. Number two, I can check the occlusion, if we’re going to do, if it’s like a splint, I can check that the occlusion is perfect on that acrylic on the Duralay, you know, on the pattern resin. And also, the other really important thing is, patients can have a look in the mirror, and I can show them where it’s bright reds, that’s going to be metal. Are you okay about that? And that’s really good. [Jaz]
That is really brilliant. So but you do that for all chrome cases, you have this appointment where you try in the pattern resin, the Duralay like for example? [Finlay]
Yes, I do. And I will often incorporate that Duralay pattern with, say wax blocks, if I’m going to record the occlusion, or as a try in with teeth on as well. [Jaz]
That’s really clever. That’s really clever. Now, here’s just me thinking out loud. Is that pattern resin? Is it I mean, your technician, Rowan? Would he then use that pattern resin as the lost wax? Is that possible to use that as a lost wax technique to then if you do all the adjustments on that, then the chrome will definitely fit or not? [Finlay]
That’s it’s not technically possible to do it like that. I just use that as a really great sort of guide for the chrome technician to do the waxing up. So yeah, we don’t use that as that. But it’s a good idea. I thought that we originally I thought Rowan, we can do it like that. But no, we can’t. So they can’t do it. [Jaz]
Yeah, cool. Good to know, good to know. We’re digressing a little bit. But Alicia had a patient the other day, a routine patient examination. He’s got a chrome denture with upper teeth. Now he’s parafunctional. And he wears his denture at night because he’s embarrassed to go to bed, you know, with his wife with missing front teeth. So he wears his denture every night and he’s parafunctioning. And I’m worried that he’s going to start chipping, breaking his denture, but also there’s cracks in his posterior teeth, wear facets. Have you ever had to make a splint incorporating a denture? Because that’s pretty much the road with me going down soon. [Finlay]
Absolutely. Yeah, definitely. I do that regularly. So he will be an ideal case for having you know, metal occlusal surfaces if he’s accepting of that. [Jaz]
I mean, keeping his existing denture I mean, and actually making a removable splint to go on top of his removable denture? [Finlay]
Why not? How many teeth is he got? Natural teeth remaining, Jaz? [Jaz]
He is almost similarly to Kennedy Class four, maybe he’s got four anterior teeth. So he’s got plenty of molars and premolars. [Finlay]
Yeah, absolutely. You could do that without a doubt. You can do over the top of the denture. Or you could do a splint with some teeth on [Jaz]
That’s also a good idea to that. Yeah, that’s so then he will be less embarrassed to go to sleep, you know, with his wife. But then also, yeah, there are some teeth that I didn’t even think about that. So there we are learning from you as always. Fantastic. Very good. Thanks for covering that extra bonus question as well. The next one is, I’m going to come to this one last because such a huge topic. And I have so much to learn about this wants to do. But you mentioned you don’t do immediate anterior chrome dentures, nor do I because I always thought that to go for the effort and expense. And you know, all that resorption that’s going to happen for a chrome immediately. It’s not something I do. But one of the questions was, you know, how do you manage a situation. So could you give some general advice about the complexities of doing anterior chrome work in an immediate fashion? [Finlay]
Yeah, the reason that we have lots of different steps in dentistry in light prosthetics, so you do primary and definitive, and then you do a try, you know, your jaw reg, you try in, etc. All of those steps mean that, if there’s a problem, we can always go back one. And so that each step is done correctly. So if you visualize we’ve got a patient there, and I want to do an immediate Chrome, and now the upper four anterior teeth are going to be taken out, and then we’re going to fit an immediate Chrome, I’ve got to make sure that that Chrome fits perfectly when I’ve taken the teeth out. And that the you know, the flange average, all the whole lot is fitting perfectly. So then we often have to have a little bit of metal framework that’s going to come It’ll be over where the teeth came out as often space issues, you know, like over up to teeth, and we want to have more space created. There’s just so many variables that if I get when I strike, if I came to extract the teeth and fit this chrome denture immediately, I’d have so much going on my head, trying to make it work, and adjusting the fit, doing all of my occlude, getting the chrome to fit and make an extract in the teeth, managing the patient, managing all of that everything, [Jaz]
Aesthetics, Phonetics,it’s all about risk. That is exactly why I never thought to do it. But I think to contextualize the question, first contextualize question, I think, with the first part of the already talked about the Kennedy class four situation, I think you’ve alleviated some concerns. So I think the rationale for doing anterior immediate chrome work was for patients who are likely to break the acrylic denture, because their deep bite for example, but I think you’ve covered it very well there that actually you can leave them open a bit, or you can reline on them immediately. So I think you hit two birds in one stone there. [Finlay]
Spot on. You dead right, Jaz with that, because so that’s what I do. And if I feel the patient needs to go to the chrome quicker, then normally, I’d like to leave them for like 9 to 12 months. So we get really, you know, maximum shrinkage there. But in some circumstances, I go quicker, you know, we’ll do the immediate first, and then once literally, like one or two months down the line, we’ll start the Chrome, and we’ll get the chrome done. And then I will reline it at 12 months. So I’ll reline that denture and I can do it really neatly, beautifully. Reline is that saddle. So and I love using zinc oxide eugenol in the saddle area itself. And that just really just flows beautifully into where we’ve got resorption. And then I’ll do a pickup impression over the top in alginate there and then Rowan can just reline that saddle, you know, beautifully. It’s just like spots on so you can eat, theoretically, you could just get on with making your Chrome straightaway after extracting the teeth, you could like a week later, you could start it and I think that’s a more sort of predictable way of doing it really. [Jaz]
That makes a lot of sense of the realining as well. And I was smiling there because that’s something that Mark Bishop drummed into me. He’s a huge lover of things aka zinc oxide eugenol so you can tell that he’s had that influence in you. Maybe that was an influence, maybe it wasn’t but I can tell you from from being taught by Mark, he absolutely loves ZOE. [Finlay]
Yeah, brilliant. [Jaz]
So last big question is a big one, right? Because I had zero experience with this, but it’s something I want to learn more. And I’m so glad I’ve have you on to talk about this. So this is milled crowns. So for example, the other day, I made a fixed prosth case I replaced mobile and upper anterior teeth. But the three is a solid with a fixed, you know, six unit bridge. But if I was to now because he’s got really mobile posterior teeth and I know that he’s gonna need a denture in the future. So be clever once all the healing has happened to make these milled crowns so that a future chrome work can slot into it. But I have no idea. I haven’t got the knowledge or the experience yet to be able to plan that. So any advice you can do about it give us about getting started with milled crowns and some considerations and also precision attachments. So it can maybe explain for the younger dentist, what those are and how much of your day to day work involves precision attachments and milled crowns? [Finlay]
Right, okay. Yeah, so I do use them. I use both milled crowns. I don’t actually call, they’re not true milled crowns, though they’re crowns that have guide surfaces on, they’ve got rest seats are on and they’re nicely shaped to accept the denture. But a true milled crown is where you’ve got this precision milled shelves really with little slots and things in the crowns themselves. Now, I don’t use those because they are quite maintenance heavy. And they are quite prone to failure as well. This is the issue. So I try to keep things as simple as possible and avoid using attachments, if at all possible. The situations that I do use them are and I generally use RHEIN Stud attachments. So What a RHEIN is arrived studies like it, is a little post, a post that will go into the root canal of a tooth. And it has a stud that sticks out of the end of the root canal tooth. And inside the denture is a little fitting, a little bit like a locator attachment for implants. So it just fits over that rhein stud. So if roughly I’ll use about two of those a year, you know, two a year, all I do is dentures. So it’s not very often, but those situations that I use them and you know what, I hate clasps, I hate the worl of them they are, that’s the only thing about partial dentures that really detracts from the aesthetics. Because basically, partial dentures can be way better looking than a bridge, or an implant bridge, because we’ve got all this beautiful flange and we can replace all the pink and the whites. But say if we have a patient that has a canine, and then that this canine, they’re edentulous. But they happen to have a pre molar root, you know, just not a canine. And if they have a high smile line, and this is why looking at the smile line is crucial in prosthodontics got to see how much they show. If they show that canine is really all the way up, a clasp is just going to look away doesn’t matter. You know what color that you know, dental D is okay, it’s a compromise. But it’s still not great. So if we’ve got a root behind that, and we can refill it and put studd in and clip the denture on, then they work really, really well. But I’m always warn the patient, I’m really, really manage their expectations, because nothing lasts forever. That roots will probably split, I’ll say to them “Look, we can do this, we can put the stud in the tooth, or we can clasp the tooth in front. So we can do either or. And I’ll go through the pros and cons. And I’ll talk about the post could split roots at some stage. And at that point, we will need to add a clasp bond to your denture around that canine because you cannot clasps into flanges of existing dentures quite easily. So it’s just making it future proof that’s really important. For attachments to work really well. It’s crucial that everything is braced properly by the other teeth. We don’t want too much talking forces on the attachment because it will cause that attachment to fail quicker. So this is why I love metal backings on the teeth. So then just if you could visualize resin bonded bridges, you know resin bonded bridge with those metal backings. I love those. My dentures are like removable resin bonded bridges. So they’ve got backing after backing after backing, hidden away, down behind the teeth, but they touch the teeth in so many areas. This offers great resistance to rotation, and it guards rigidity and stability. So it’s reducing the forces on that attachment to a minimum to help it last as long as possible. [Jaz]
That’s a I mean, there’s so many benefits that like I said, the bracing, the rigidity, so you know, you’re less likely to get mechanical failure, you can get a degree of occlusal control as well because you have so much material to work with. And I imagine when you’re raising the vertical dimension, to have those backings and to make sure we have coupling of the anterior teeth or whatever. I can definitely see I like your comparison to resin bonded bridge. So you know everyone can visualize, you know, the metal backings or resin bonded bridge but incorporated within the denture. That’s fantastic. But I mean, I know what that question is such a broad question and there’s really impossible to delve deep into it. You’ve mentioned that scenario with the high smile line why that would benefit from it. Are there any other situations where you think okay, maybe I’ll need to pull out these Rhein studs, as you said or think about incorporating retentive features into the crowns. [Finlay]
I think, Jaz, your case you’re talking about. You mentioned about this patient of yours who has upper three to three, and then the posteriors are shot. So and the upper three to three restored with crowns, if those crowns are not in great condition then the ideal for taking off and then replacing with all these lovely retention features in, so what I would do is if you can visualize having a really nice crowns on those teeth, but incorporated into the palatal surfaces, a dimple, a nice big dimple, you know, a big round bur, you will, you know, you get the technicians do it. But if you miss a big round bur dimple up into them, plus the guiding, you’ve got lovely guiding surfaces on the mesial and distal aspects of those crowns, too. So all of those features there will help to retain the crown because you like it backings that sit into these dimples all the way around the back of those teeth there. And I wouldn’t, unless the patient is really wanting to have no clasps, you know, this is really important. If the patient didn’t want any clasp, so and dental D was out of the question, you could put a little slot attachment that sticks out distally from the canines. So that would be incorporated into your crowns. But in those circumstances, what I would do is I would link the teeth together the crowns. So I would have like 123 linked, and then 123 linked with because the rotational forces on that bridge, if it was just on the three itself, it would tend to want to pull it off. But I would really I would I haven’t done anything like this in years, Jaz, so this shows I what I hate is patients coming by with problems after they spent lots of money, you know, they spend my dentures partial denture, something like I’m talking like that, that’d be over 10,000 pounds, we’d be looking at making more than that. So if it all went, you know, if it all fell apart in a few years time, which these do. Then it we’re in a grill. We’re in Dickies Meadow as we call it. So it’s really keeping things simple. So ideally, you’d replace the crowns, no slot attachments, and a just a simple partial that fits in with those lovely backings and a nice clasp that comes around either gold or dental D. [Jaz]
Well, I think what you’ve summarized well is that, hey, everything is possible, these things are possible. And you mentioned very tangible examples of a slot coming out of a canine using my patient x as an example. So I appreciate that. But you also beautifully put that keeping things simple for predictability is so key and that’s the takeaway lesson from that. I guess, A couple of questions to make the if someone is going to try this and make it more tangible as A) obviously they need to speak their technician and make sure they’re on board. B) is those dimples. Maybe you’ll be teaching us suck eggs, but for those younger dentists, those dimples that also needs to be prepped into the tooth, right? [Finlay]
Yes, it was a bit of space for sure. [Jaz]
So I mean, I put this case up a crown prep the other day on Instagram just discuss about material choices and I said hey, guess what material I’ll be using on this preparation and then the giveaway was that I put this very mechanical slot inside the tooth, which is totally inappropriate for ceramic right? And then the answer was gold. It’s a gold crown but it could easily have been a PFM but these things, Am I right in saying that the Zirconia ceramics it’s just not even go there? It has to be metal? [Finlay]
No, I my technician works beautifully with Zirconia And he did a great thing about it he can match up I like using Schottlandee Enigma teeth, Enigmalife Teeth, they are my prosthetic teeth. And they can match up his ceramics to the base line bonds to Zirconia to the Enigmalife Teeth, so and if like he said, You’re absolutely right, ceramics don’t like sharp edges, they like smooth, round, organic shapes. And when we’ve got those, there’s very little problems in terms of fracturing. So seriously, I’ve been using the PBZ for 13 years, and I’ve had very, very few problems with any sorts of veneering [base] line or stuff breaking off. [Jaz]
Just to clarify that these PBZ with For example, a rounded organic slot or rest slot. Yeah. Distally. And also would you be doing these dimples, flowing dimples into the Zirconia framework as well? [Finlay]
Absolutely, definitely. [Jaz]
Brilliant. I definitely learned something because I was too afraid to go down that route. But it brings me great confidence that you’re that using the Zirconias. But I think you have to respect the fact that the burs that use and the way that you shape the prep, it has to be completely different to what we’re doing with metal. [Finlay]
That’s right. Definitely. Yes. So do the thing I, Jaz, it’s really important with these backings as well is that they work really, really well. But they can, particularly for upper anteriors, they can create speech issues. So I like to do the dimples basically subtractive rests in the upper. So we’re keeping that lingual surface, not too bulky. You know, because if you imagine we’ve got a crown down we’ve got the denture you know the metal framework. So we’re keeping that as thin as possible, the backings so it doesn’t interfere with sibilants and speech. In the lower if I was to do a crown in the lower jaw, say lower canine or incisor, I would have an additive rest on it. So the rest would actually stick out. Almost like a climbing wall hook you know those climbing walls, kids love doing that, just like that. So that the denture can then just sit onto the those and I incorporate those into the shape of my crowns and in lower [Jaz]
That is genius. That is genius. So same analogy as in I do orthodontics. So your upper fixed retainer, there’s sometimes not enough room for upper fixed retainer, but you can always do a lower fixed retainer. So the same vein, you can have those dimples coming out of the projecting out of the lingual surface of the lower incisors if I interpret that correctly. And lovely analogy about the climbing Actually, that’s genius. Fit, we’re out of time now. But Wow, this episode is going to go down in protrusive history for sure as being one of the most clinically excellent, just wow, that was so many gems you shared with us there and that’s gonna immediately improve my dental work. And my choice selection, I’m now going to be speaking to my technician about using monolithic Zirconia in a ways that are not so primitive and maybe not having to always go for the metal. So you give me great confidence. You’ve taught me about occlude spray, and so many other factors there and communication gems and loom right at the beginning, where I thankfully, hit the record button, how we can be using video better with patients and with technicians, including the way you use loom. So thank you so much for coming on this podcast, I would love to have you on again one day because I can just speak to forever and ever and ever about this stuff. And I know I’m gonna be bombarded with messages of like, wow, Fin was awesome whatnot, and I’ll be sort of send those to you. But I’m desperate for people, because I’m going to get hundreds of messages saying where can I find out more? So please tell us about where can people learn more from you, Fin, because inevitably they’ll want to. [Finlay]
Oh, god. Thanks, Jaz, very much. If you just go to my website, it’s finlaysutton.co.uk. And it’s all about the education part of it there. So you can have a look at the courses that I run, which I run in the practice which are really good fun, and I love doing them. It’s so practical, I get a patient 10 and the all the delegates can watch me treat a patient and it’s lovely. And we do it for immediates, partial dentures, complete dentures and implant over dentures. But also, I, you know, from talking to you today, I think, if there’s anybody interested in learning resources as well, if you go to my website, and go to the resources section, click on that, scroll down. There’s absolutely loads of really interesting material, like papers that I’ve written, and also designed, helped, and lots of different patients with different denture scenarios. So you can have a look at all these different designs and things there. So lots of stuff to look at there. [Jaz]
I can definitely vouch for that. So I haven’t been on your course. But I got loads of colleagues who have been on your courses, and they’re always always raving about how much they learn and what a powerful learning experience that you provide. And also as someone who’s subscribed to your newsletter and getting those cases through, and you’re right, actually, sometimes I’ve got a specific because I don’t do many dentures much I used to just a different patient base now. But I know that when I’ve got one coming up and I think hey, I bet Fin’s got a scenario that he’s very generously shared, free of charge a lot of time just use that as why as you’ve just given us so much value and quite often I can identify a case You’ve given me so many ideas from Little things like adding, I forgot exactly what the benefit of that was on the upper anterior as you add these cingulum rests, right? [Finlay]
To allow the forces to go down the long axis? [Finlay]
That’s right. It just and they just help. They’re particularly great in free end saddle dentures, they’re just brilliant. Those little composite rests, and work beautifully. Yeah. [Jaz]
I knew exactly what was talking about. But yeah, I mean, I could just learn so much from every one of the cases. So guys, I’ll put the link to Fin’s website on the show notes for this episode. And I just want to say a massive thank you for answering the question that went directly from the Protruserati. Fin, thank you so much for giving us time today. [Finlay]
This always absolutely pleasure. It’s been lovely. Thanks very much, Jaz.
Jaz’s Outro: Thank you so much for listening and watching all the way to the end. If you’d like that hits the subscribe button on YouTube. If you’re watching on YouTube or dentinal tubules. If you’re listening on Apple, please do, think about leaving a review. I’d really appreciate that. That’s how the podcast grows. And I look forward to catching in the next one. The next one’s a little bit of an interference cast and it’s about the six or seven signs haven’t quite decided yet that you are a comprehensive dentist. Thanks so much Protruserati for joining me once again.