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Completely Dentures with Mark Bishop – PDP029

With ‘The Denture Guy’ Mark Bishop who was also my first ever clinical tutor 11 years ago!

Need to Read it? Check out the Full Episode Transcript below!

We discussed:

๐ŸŽค Occlusion with Dentures

๐ŸŽค Identifying red flags

๐ŸŽค At what point do you need to accept that the patient NEEDS to have implants to have success with dentures

๐ŸŽค What’s more important? A technically excellent denture, or a patient with good adaptation

๐ŸŽค Why do patients who wear ‘rubbish’ dentures struggle with ‘good’ dentures

๐ŸŽค Which is the best impression material?

๐ŸŽค Which are the red flags patients for Complete Dentures?

๐ŸŽค How do you handle a patient who tells you how to do your job?

๐ŸŽค Communication Pearls via analogies

๐ŸŽค How can you achieve suction lower dentures?

๐ŸŽค Do all you dentures need to be in Class I ?

๐ŸŽค How can we improve our registration phase of complete dentures?

๐ŸŽค Why most Dentists trip up at the diagnosis stage of Complete Dentures, and how to overcome this

๐ŸŽค The importance of writing a letter to your complete denture patient

The Atwoods classification and the Registration technique have been posted Protrusive Dental Community

Click below for full episode transcript:

Opening Snippet: Hello everyone and welcome to this episode on complete dentures with Dr. Mark Bishop...

Jaz’s Introduction: Dr. Mark Bishop was actually one of my first ever, he was my first ever clinical tutor at dental school. It was in second year, early in second year doing complete dentures. And what this guy doesn’t know about complete dentures is frankly not worth knowing. We share so many great gems, as always, we talk about talking to your edentulous patients, or your dentate patients about expectations, how to manage occlusions in dentures, we talk about which is the best impression material for dentures, how can we get a lower suction denture? Is there a technique? Or is there something else that’s there to it? Another couple of things, we talked about his red flag patients and how to identify them, as well as at what point can you actually say, actually, this patient in front of you will actually benefit massively from implants. And actually, the dentures just won’t cut it. So that’s something I often think about is actually with such a resorb ridge, are they going to get any success with this complete denture I’m about to make? Or do they actually need to have implants as in NEED to have implants. So we will touch on that as well. The Protrusive Dental Pearl I have for you quite fittingly is actually mentioned in the podcast episode, but it’s something that Dr. Mark Bishop taught me about complete dentures. And it’s basically when you have a patient who has complete dentures, and also due to the complete denture, and you’re trying to adjust that bit on the or ease that denture so that it’s not rubbing against the denture anymore, so it’s a bit more comfortable for them. How do you actually know exactly where to adjust, so you’re not adjusting inappropriate areas or adjusting too much. And you only want to adjust the fitting surface where the ulcer is. So what Mark taught me to use, and when I still use this days, the only reason I have Dycal in the practice, I use the base paste of the the white one of Dycal, and I’ve put put it, dry the ulcer, and I put it a little bit around the ulcer area, and then you press the denture on, you actually inserted and you press it on and you remove it, and you’ll have the base paste of the Dycal on the fit surface of the denture. So now you know exactly where to adjust for that patient. So hope you enjoy the episode with Dr. Mark Bishop and I’ll catch you in the outro.

Main Interview: [Jaz]
Right. So usually is Dr. Mark Bishop for you, our relationship I know you’re happy for me to call you Mark. Mark thanks so much for coming on the podcast.

[Mark]
It’s a pleasure.

[Jaz]
You were my first ever clinical tutor in dental school Yeah, cuz

[Mark]
Yeah, cuz for the first thing you do is like complete dentures

[Jaz]
Yeah. And it was a you know, you set the bar really high. And, you know, to then to be taught by other dentists was never quite the same as being been taught by you and I’m be I’m being serious. I’m being honest. And you are an asset to dental, dental school. However, I know you don’t doing much teaching anymore.

[Mark]
Yes, still two days a week. And as you know, I sold my practice in November 2019. So, time for Coronavirus. Although obviously, I didn’t know it at the time, I feel very, very lucky to have been able to step away at that time. I feel really sorry for you guys, who is still having to work at the [coalface] now, it’s very difficult for you. And But no, I carried on doing two days a week. So I’m now a part time dentist, which is quite nice.

[Jaz]
Brilliant. And this episode is gonna be all about complete dentures and how we can make it easier, more predictable, some some tips that we can share with the listeners. So tell us as part of the introduction. How did you get into complete dentures? I know we all sort of dabble per se and now they say more and more that complete dentures has really become almost like its own postgraduate speciality. But how did you get your enjoyment and fulfillment for conformed complete dentures that you do?

[Mark]
Well, I always knew that I didn’t want to work five days a week in practice. So quite quickly after graduate in about 18 months after graduating. I sent a bit of a cheeky letter to Charles Clifford in Sheffield and said do you want any clinical tutors? So I ended up getting there and realize that was something that I got a bit of a loss for. And then I did a Masters which was a general restorative masters. Because you know, I didn’t just teach complete dentures, restorative as well. And I got to know a guy called David Lamb who became a little bit of a mentor for me, and I just really enjoyed it. I love the what’s the nicest way of putting it. You’re not sticking injections into people. See, you’re not potentially causing discomfort. You do full mouth rehabilitations on everyone you treat. And just, you can have kind of have a bit of a nice chat with people. And so I always find it quite a low pressure side of the job. And I never really saw it, which is dentistry. As well I’m not a happy.

[Jaz]
Well, I have to say, I certainly came across that way when you were teaching me both during second year and also we have a few sessions together in like, fourth and fifth year. And I’ve seen since I’ve qualified, you’ve started doing some complete denture courses around the UK.

[Mark]
Yeah. Trying to about three a year now because I understand this. It’s a subject that undergrad, I just don’t I mean, even in Sheffield now, I current teaching you a shared set of dentures in second year, and now we’ve moved to the same model shared set of dentures in third year. And then you go out into general practice. And very often people have done that. That’s all they’ve done. And they go out into a field, which I personally think we make it more difficult than it has to be. But we go very unprepared. And then people suddenly start treating patients realize how difficult it is. And when they need a course to maybe understand, you know, little tips that they can improve what they do on a day to day basis.

[Jaz]
Well, it’s the same as a crown preparations, root canal treatments. Dentists nowadays, we’re qualifying with less and less of the quota for each of these procedures. And complete dentures is no exception. So we’re going to hopefully improve the complete denture removal prosthetic Dentistry of everyone listening. And the first question I have for you Mark is, so you could have a very technically excellent denture, and you have a patient who has a certain ability to adapt. So there’s the quality of the denture on one side, and there’s a patient’s ability to adapt. I think sometimes we call this the neuromuscular adaptation, or about. So how much of the success of complete dentures comes from it being a technically excellent denture? And how much of it, it comes from the ability for the patient to adapt, which is more important.

[Mark]
Okay, good question. We can only work with things that are in our sort of ability to cope with, okay, so that’s the dentist and the patient. So what can we directly affect? We can directly affect the impression technique that we can take. So this good evidence base to say that the quality of the impression will have an effect on the standard of the denture, okay? And the other thing we can affect is a registration stage. So again, there’s good research to say that the registration stage gives good results, if done accurately, there are things that are way out of our control. So whether a patient can adapt or not adapt is out of our control. So really, we’ve got to concentrate on what we can do. Now going back to your question, some patients obviously adapt better than others. But most people we see I would think are having replacement dentures. A small percentage of in the first set of dentures so that people have in replacement dentures, know how to wear dentures. And what happens sometimes, with dentists, we kind of blame them that they’re not adapting to our new dentures, when realistically would have copied the good aspects of their old dentures, they probably wouldn’t have to go through a major re-learning curve.

[Jaz]
Fair enough. One thing that I think you taught me this, I can’t credit anyone else for this is that when someone comes in, who has a technically rubbish denture, and they’re able to get along with it, I get so happy. And if I’m the next dentist, who’s gonna make them a new denture, and they’re already adapted to this rubbish denture, and I know that I can only technically improve this denture, that for me is okay, this is gonna be hopefully a home run.

[Mark]
Okay, so it’s a home with some potential pitfalls. So some of these patients can be people who have worn dentures for 35, 40, 50 years, and they come in with a set of dentures and look like they’ve been through. You have been through a cement mixer or something, they’re all over the place. And then what happens people go, okay, there’s loads and loads of technical faults on these, I’m going to correct them. And what the dentist often does is makes the mistake of turning them back to the ideal denture, so they don’t measure the freeway space of the old set of dentures, and they don’t have an assessment of where that’s out. So let’s say for sake of argument, you get patients who have lost a dramatic amount of face height. They’ve had the dentures for 35, 40 years, you make them a set of dentures, technically you look at and go, Wow, they are brilliant. But you may have changed the freeway space from something like 17, 18, 19 millimeters to three. Now, there’s no way in this world that patients going to adapt to that, they’re going to have to adapt to it through stages. And in situations labor, ie, it’s part of training the patient to say, look, we can’t make you look perfect. But what we can do is maybe make your dentures a little bit bigger. And then in three years, we’ll make you another set, which we can make the dentures a little bit bigger, and gradually turn you back to having a perfect set of dentures. Although I’d like to just take the word Perfect out of that, because I think perfect and dentures and perfect in dentistry doesn’t always go together. You can’t do perfect, you can do the best you can do.

[Jaz]
Yep, brilliant. And I think that’s exactly what you taught in terms of the freeway space actually remember, we actually remember vividly second year clinics and we had the patient a freeway space of 12 I remember you saying we’re not going to go down to three we didn’t go down about six or seven or there abouts and actually remember you teaching that actually very vividly. The next thing want to ask you they want to start with my experience. I did my DCT one post in guys hospital. I don’t know if you know Dr. [Linden Cabo]?

[Mark]
No, not come across him.

[Jaz]
So he teaches the removable prosth at Guy’s hospital, and I did a complete denture clinic with him at hospital there. Lovely chap, very knowledgeable, very passionate like yourself about removable prosthetics. And I remember him having a study group with us. And he sat us all around. And there was about maybe eight or 10 of us DCT1s. And he went around the room asking each one of us which you have a patient in front of you, you’ve got your special tray, okay? Which impression material will you will you use? And he went out in the room and each person said, Oh, yeah, I’ll use alginate. I’ll use zinc oxide eugenol, which I know is a favorite of yours. I said, Oh, I’m going to use them monophase, I’m gonna use medium body silicon, okay. And the mistake we all made is that not one of us asked Dr. Cabo. Well, actually, what does the arch look like? What does the actual arch look like? Because that will determine what kind of material you’re going to go for. So that question leads nicely to, can you give us some guiding principles about which impression materials, when you’re choosing impression material to use, which ones do you tend to suggest? And what changes your decision making?

[Mark]
Okay, so a couple of things. Firstly, there isn’t a perfect impression material, you know, you can look at all the research and you can’t do a double blind clinical trial on impression materials, because you know, the clinician knows what they’re using, it’s impossible to do. So everyone gets their own little thing they like to work with. All impression materials work, okay? But the trouble is, a lot of people use them poorly. So alginates, my favorite. For discussion, so alginate works perfectly well. But alginate, like most materials works at an optimal thickness. So it works at three millimeters. Now, if you use an alginate, for a resorbed lower ridge, it’s useless, it’s impossible to use, because ultimately, you can’t really get three millimeters of space around the edges of that. And to get alginate to use in its best way. So alginate is a very, very good primary impression material. Secondary impression materials I never use alginate have ever for secondary impressions. I use zinc oxide as you say, I really, really like it. And I like monophase silicones. With monophase silicones again, you’ve got to remember that they have an optimal thickness. So if you’re going to use them monophase silicones, ideally try and get a 1.5 millimeter tissue stuck on it. And you need that space at the periphery as well, because if not, you’re going to record in your borders in the tray, which is not particularly useful. For me, the only time I steer clear of my zinc oxide is when there’s an excessive fibrous ridge, because I don’t want to compress that tissue. I want to record it in a static position. Because anything that you compress will want to bounce back into its usual form, which is not ideal under denture. And I avoid people with excessive xerostomia. And I avoided with people who have not just have a little I get a bit itchy after wearing a [plaster] for seven weeks, you know, people who have proper allergies to [plaster], apart from that I stick with it. The other case I sometimes will I do avoid it with these excessive undercuts. Because obviously you’re not going to get it back out of excessive undercuts. So really stick to what you enjoy using just use it correctly.

[Jaz]
Other than the undercuts, is there anything else in the anatomy that might change? You know, you’re moving from one material to a different material based on anatomical considerations?

[Mark]
Well, again, I think we can go back, the more atrophic the ridge is, the more you want your impression tray to simulate the inside of a denture. So the bigger the tray is, the bigger the problem you’re going to get. Because you’re not going to record those muscle movements that you want to record to get the best result. And so No really, I think fibrous ridges avoid zinc oxide. Severe undercuts avoid zinc oxide. And but I think one of the reasons I get good results is because I’m very consistent in my approach. I think a lot of young graduates, instead of thinking, what is it that caused the problem, they think it must be a panacea of an impression material, that’s going to give a perfect result. And it just doesn’t. It’s about practice and getting good at things. You know, so many people start with good intentions, they’re going to use a material, they do it two or three times they’re not getting the results. So one, they blame the material, when actually it’s takes time to practice anything. Nobody picks the guitar up and bangs out, tune straight away.

[Jaz]
Awesome. The next question I have then is moving away from the impression material is more about the looking at the patient in a broader perspective. Can you tell us about which red flags can we watch over in our patients. I know there’s Yeah.

[Mark]
The red flag patient. Okay. So this is where I think most dentists go wrong. The lack of that ability to say, do you know, I think this should be on my skill set. So you get things like endo, and it’s a multi rooted difficult endo on a seven, people wouldn’t think twice about going right, out of my skills, I don’t think I can do that. Or it could be a full mouth rehabilitation, or it could be ortho or something like that. But with dentures, we all have a go or whatever comes through the door. And that’s where the problems start. So I have got some red flags. Okay. So if anyone comes into me and says, I’ve never been happy with my lower denture, I know full well, that the chance of even me who’s done two and a half thousands dentures in this career solving that problem is massively reduced. Okay, so that’s one. Another one where people say, Look, I’ve been to so many dentures, dentist they can never get the appearance right. Again, boom, big flag starts to warn, what they’ve all not been able to do it. And you know, why will I be the one that solves that problem? There are people who want to design their own dentures. So they’ll come in and they’ll go, right, I have a loose denture and you’ll take the denture out, and the palate will be halfway back along the palate. And they’ll go Well, yeah, but I can’t have it any further back than that. And, but I want it to be tight. I’m not having that conversation to go, look, you choose what you want, because you can’t have both. So that’s another one. And

[Jaz]
That’s a tough conversation to have, isn’t it? To you know, for a young dentist to say someone in the, you know, latter stages of life be like, well, hang on a minute, there’s only so much you can do. It’s a difficult conversation, because there’s sometimes these patients almost tell you that they always tell you, oh, I think you need to adjust it over here like, you know, just over there. I think if you do that, that will do the trick or whatever. So I think they can be quite dictating if they see a young dentist and you know,

[Mark]
Yeah, absolutely. They love it. They love it and watch out for certain professions as well. So engineers, teachers, people who used to telling people how to do things. And I know it’s a generic sort of picking on certain professions. But people who have a lot of control in our life like to tell young professionals how to do things. And I have a way around that. Which is, you remember PSI paste, Jaz?

[Jaz]
I bought it for the practice. I mean, I still use it based on your teachings. Yeah.

[Mark]
Perfect. So what I do with that, with engineers and people who are quite strict, is I tell them what I’m going to do before I do it. So I said, Look, what I’m gonna do is I’m going to load up this impression material around the edge of your denture, and we’re going to press really hard. And what it will show you is where it touches your mouth. So anywhere other than the point that tells me, I want to adjust, I want to just say it because it’s not in your best interests. So if you’re getting pain from your denture, it’s not being caused by the inside of your denture. It’s being caused by something else. So it could be the way your teeth come together. Or it could be you know what, you’re very stressed as an individual and you clench your teeth, and it doesn’t matter where you adjust, if that’s the case, it’s still going to be a problem. So, yeah, so that’s I understand. As a young dentist, you need to have skill sets that you can do like go to ways of proving the point to a patient. Never, ever do that in a non scientific and a non technical way. You have to be able to say, look, this is what’s going to happen, I will show you, we’ll look what we get. And then you’ll understand why adjusting that denture is not in your best interest.

[Jaz]
Now, I really like how you explain that to actually show them Oh, these are areas I can adjust. And you give a reason as opposed to No, no, no, I don’t think so. You justify it. And for anyone who’s listening who doesn’t know what PSI paste is, it’s Pressure Spot Indicator, which I don’t know which company makes it

[Mark]
It’s made by a company called Coltene.

[Jaz]
Okay, Coltene. Yeah, sure.

[Mark]
Yeah. So it’s a must. Remember when you use it, and get your nurses to do it as well make sure they understand why one tube is wide and tube is narrow. Okay, you don’t put the same amount in, you put the same length in. But you keep the nozzles to the width. It’s really important. Otherwise, it’s going to set far too quickly. And it’ll be nondiagnostic.

[Jaz]
Did you have any more red flags or should we moved to next question?

[Mark]
Yeah, let’s have a look secret denture wearers. You had any of those, Jaz?

[Jaz]
I think so. Because they said they don’t want to remove their denture at nighttime so that because they don’t want their partner to see that because they don’t want them to. Is it that one? Or is it because in public?

[Mark]
Yeah, people who don’t want to be seen without their dentures. So that’s a red flag, there’s a potential degree of neuroticism attached to that. And it’s quite reasonable, I can understand why people wouldn’t want to be seen without it.

[Jaz]
Oh just thinking it, it’s very reasonable.

[Mark]
But when it becomes the be all and end all that I couldn’t possibly, you know, the types Jaz that you’ve met, I’m sure you’ve met them before, it would literally be the end of their world, if they were seeing without their denture. And people who say their dentures are loose. Have you ever had that where you have an upper denture patient say my denture is loose, you actually try and pull it out and you virtually have to put nail on the chest to get it out. And yet they tell you that a upper denture is loose.

[Jaz]
I haven’t had. That’s my lack of experience compared to you showing and I haven’t had that one. I’ve had it once in hospital where it’s a fantastic, if I may say so myself a really, you know, textbook denture, I made upper a complete fantastic suction, but it was an error I had made in the occlusion that. Okay, yeah.

[Mark]
That’s always the problem. So when somebody says my dentures are loose, and you try it, and you feel good retention, then it’s always occlusion. Okay?

[Jaz]
That was my error in that case. Yeah.

[Mark]
Yeah. And the other ones are, does anyone talk to the patient about use of adhesive? Do you see that, Jaz? Do you ever speak to your patient before you start about the need for denture adhesive?

[Jaz]
I do say, quite a lot of time, people will need a bit of adhesive now and again, so that it allows your denture to stick on, stay on better so that they are already in the mindset that it shouldn’t be a challenging case, and we cannot get adequate retention without the need for adhesive, they already mentally prep for it.

[Mark]
Okay, so again, that’s another red flag for me. So if a patient’s got a horror of using the adhesive and anatomically, you look at them and you go, you know what that lower denture is going to move, it’s far better to tell them at the start that you’re going to need adhesive but guess what, adhesive is not very good on lower dentures. And I explained about gravity and how the adhesive is going to come out and saliva is going to wash it away because in the end, adhesive really helps dentures and even a well fitting denture benefits from adhesive. So they’re the sort of red flags there’s quite a few like that.

[Jaz]
Well, following on from the last one, he said about the use of adhesive for a lower denture, lower dentures being so tricky and traditionally because of the anatomy, very difficult to get good stability and retention. At what point do you look at a ridge and say, You know what, you actually genuinely need a couple of implants maybe as part of implant retained overdenture or an implant supported prosthesis and you think that with any complete denture in the world, you will not be able to satisfy them. What is the cutoff point? I think I believe the classification of ridges, is it the atwood?

[Mark]
Atwood classifications

[Jaz]
So it can you put a classification on it? Is that how you like to teach it? Or what can you teach us to know that what point we should be looking for? You know what, actually, we better send you to an implantologist? You know quotation marks.

[Mark]
Okay, right. So basically, I’ve just been doing a little bit of a study with a friend of mine called [Johnny Dixon] in Sheffield. And what we’re doing is we’re looking at what comes through the door, when we see people in assessment for undergraduate care. So on the lower region, I’ve just flipped [inaudible] Okay, out of 60 patients, I saw 25, out of those 60. Were outward five and six. So that’s flat ridges or depressed ridges. Okay. So that’s the only 50% of every patient that comes through your door is going to have one of those ridges. Okay. So would all those people benefit from implants? Probably. Would they economically all be able to afford it? Definitely not. So we have to find a way of trying to solve those problems to our patients. And, again, lots of studies out there that show that patients definitely would benefit from two implants. But what’s the going rate for lower implant retained denture down there, Jaz, at the moment?

[Jaz]
For two implants and eventually lower denture? Yeah, 7000 pounds probably?

[Mark]
Yeah. So even in the north, you know, we’re looking around the five mark in some people who are reasonably priced. And we asked well, so I got people can afford? Because if you think of the demographics very often, not everybody is in that income bracket, where 5-7000 pounds can fall into their lap. So going back to your question, how would you decide? Well, economically, pretty much most of them would benefit. Economically, if they all had the money, they’d benefit but they don’t. So you have to work your way of taking accurate lower impressions. And you have to educate your patient from the word go that you know what, I show them in the mirror, I show them the upper denture I show them their upper ridge, I show them the amount of surface area I’ve got. And then I show them on the lower. And then what I do is I show them when I push their denture to the right and push their denture to the left, it’s not that the denture’s loose. It’s there’s nothing to stop it moving laterally. And again, it goes back to what I was saying to you early on, it’s all about that educational first meeting you have with your patient. If the patient’s not on board with it, they’re not the patient you can do anything for because if you’re going to fail, no matter how good your dentures are,

[Jaz]
Yeah, I like that tip of actually showing the patient in the mirror as you move it around. And you know, I think it really brings at home for them.

[Mark]
And I also talk about it a bit like a window sill. So I show them the lower ridge and I show them where the anatomy is. And I say just imagine your denture is on a window sill you open all the windows, and there’s a strong wind blowing. Okay, it’s trying to blow it in one direction, and you’re pushing from the other direction trying to push it out. You’re trying to push and the winds pushing back. If one thing overtakes ever slightly the denture is going to and you know, you can’t talk about neutral zones to patients, but if you put analogies like that, that they can visualize it helps them a lot.

[Jaz]
I love a good analogy. I think Raj Patel used to say a good one to patients about when they had lower dentures, and then they were in pain. And what Raj was trying to convey was the fact that actually it was the lower arch which was quite bumpy that was issued. Has bony prominences so it’s a bit like when you go to the toilet, and you sit on the on the toilet seat. And then now when you imagine you have I think like pebbles on your toilet seat and you sit on it, it won’t do so good. Even if you put some toilet roll on it it’ll still hurt like using a conditioner or something of that. So I do love a good analogy. So if you have any

[Mark]
Glad Raj managed to get some toilet humor in there. Very good analogy.

[Jaz]
He always does somehow. So the next question

[Jaz]
The one I like, Jaz on that. The other one I like on that is the camping analogy. So if you go camping, and you can take a thin blanket and put it on the ground and you’re in a paddy field. And you might be able to get comfortable if you just move into one position. But if you move from that position, everything’s going to start hurting. And your mucosa is that blanket. Okay, that might be

[Jaz]
I like that very much. Raj is full of, you know, a myriad of fantastic analogies actually, he’s

[Mark]
He’s a wise man.

[Jaz]
He certainly is. So the next question is in moving on from the the fact that lower ridges that may benefit from implants like we just discussed and the economical issues and that. Well, firstly, the way I explained to patients that look, you will benefit from implants, it’ll be much better to hold it in. And if they look like they can’t afford it, then I say we can try our best and obviously we want to try and do a technically good as job as possible, but least, you know, you’ve set the expectations, actually they’re gonna, it’s going to be loose, they’re going to struggle, and implants would be a good idea. However, a prerequisite of making an implant retained overdenture is still a good denture.

[Mark]
100% and [overlapping conversation] [Jaz]
and hope the implants will do the rest of it. So that’s another thing worth mentioning.

[Mark]
If you can’t make dentures Jaz, put an implant in since it’s not going to solve that patient’s problem. [Jaz] Absolutely, [Mark] it will stop the lower denture moving and that is it, that is the only difference it will give you.

[Jaz]
You still need the fundamentals to get as good [Mark] 100% [Jaz] good coverage. So moving on from fundamentals as you see all these videos and I see some of your video as well. The lower complete dentures with the suction, and it’s just so magical to see that almost, you know, when you have these patients lower complete denture on suction, you know, who would believe it? You’re able to do this, I’ve had one or two patients in my career so far, we’ve been able to achieve that. And it’s a great feeling it really is. [Mark] It’s magical [Jaz] It really, really is. How do we know if how best to put to put it that how do you know if you can achieve it? Is there something like that? Is that a minimum outward classification that you can [inaudible] Can you tell us a bit more about how we can go about even thinking about getting towards that stage?

[Mark]
There’s a big degree at luck. So if a bit all dentists are the same, they tend to post their successes down there and anything that’s not successful, they hide. It’s exactly the same. So you’ve seen some of my dentures that have suction. Not all my lower dentures have suction. So there is a degree of luck in that, there’s no guaranteed way of doing it. Mr. Albay seems to believe that he can do every time and he may be able to. Good luck to him if he can. But without seeing every suction that he makes I’m not going to buy into that straight away. And so realistically, all you can do is do the best impression you can do. And then the most important part is make sure the occlusion’s right, because if those dentures are being discluded every time there is no way that suction is going to stop it from moving, it will break. So there’s no perfect answer, Jaz.

[Jaz]
So you need a bit of luck and good fundamentals,

[Mark]
Good fundamentals, a little bit of luck, if you have a really big ridge very often it’s harder to get that suction because if you’ve got big ridges with undercuts and you have to block those undercuts out, you get air gaps which are underneath which are too big for this sort of atmospheric pressure to work and it doesn’t help. So there’s no real perfect ridge. There’s no real perfect ridge.

[Jaz]
Well, you mentioned a good occlusion on dentures as being important in getting stability. Can you give us a quick summary of what are the main things the principles of a good denture occlusion? Is it always lingualized or a you know the whole bull technique to get a balanced or lingual lines occlusion, is that we need in every case?

[Mark]
I think a lot of it depends on the patient. Okay, so you’ll get a lot of patients who if they are it’s a bit like the dogs and sheep thing isn’t it? Some of us like dogs we incised our food, denture wearers, a sheep they’re ruminants they move their jaw from side to side. So the more parafunctional activity a patient has, the more you occlusion might be right. Okay? You get loads of people who never complain and you know their occlusion is awful on the denture he look at him and go I can’t believe you’re not struggling with this and they get on fine with it. So I think going to occlusion what I would say is that if you get the occlusion right, sometimes you’re going to find this difficult to achieve that the patient wants because in the end, denture teeth come out of a packet looking like 12 year olds teeth, you know, they’ve all got sharp, pointy canines, etc. But when you get to my age naturally with your own natural teeth, you quickly notice that you get wear facets and grooves etc. So everything you’ve learned about dentate occlusion, reverse it round for edentulous occlusion. So canine guidance is a bad thing in dentures. It’s great thing in dentate patients and non working side contact is a bad thing in the dentate patient but in a denture patient, it’s what you want. Okay? And when you protrude, you don’t want disclusion on your back teeth. However trying to get that in denture cases is really difficult to get the back tooth come in into contract, getting contact in protrusion. But they’re desirables. If you aim to get those on bruxist patients, on parafunctional patients, that’s where you’re going to get a degree of better success. I mean, the key thing with dentures is communication. It’s communication. It’s about talking to your patient about what is achievable.

[Jaz]
One, That’s amazing. I like how you talked about the different chewing patterns. So you say, dogs and sheep, I also might say, you know, the whole rats and cows, you can say what you like then that’s a good way to think about it. So to be more careful in the cows, then, you know, be careful with everyone, but your cows are particularly important, or your sheep are particularly important to get that occlusion just right. Because then they can run to more problems. Now, one mistake I used to make or think about is that every patient must look class one, or have a class one incisor relationship.

[Mark]
Here we go. Right. This is going to be an interesting one, Jaz, I’m going to enjoy this one. Go on.

[Jaz]
Okay, good. Good, because that’s the mistake I used to make when I realized Hang on a minute, whether their class 123 is dictated by their skeletal form. So we need to

[Mark]
100%

[Jaz]
go by their skeletal or so then I started to make dentures that were more occludes correct compared to what they probably had before. Their class two div one before then I like to make their dentures a bit more class class two div one, the only issue I want to ask you is that, Would that is A) Am I doing the right thing? And B) is if their class two div one, then you’re not going to get any anterior teeth contact? Is that going to be generally okay?

[Mark]
And do they get anterior tooth contact with other natural teeth?

[Jaz]
No, not at all.

[Mark]
So why do we create that when we make dentures? I mean, it’s a really interesting debate, I’ve heard people who are really quite qualified in the profession, who kind of insist every denture gets made as a class one, it’s nonsense, you know, one of the things I do when a patient comes in, I checked their sort of profile view. And I make an assumption on whether they’re class one, class two, or class three, okay? And by doing that, again, I can have a conversation with a patient and say, your front teeth are probably not going to meet when I make you the right set of dentures for you. And I’ll go on my front teeth meet on these dentures. And then I’ll go but your lower denture moves. And they’ll say, Yeah, but I don’t want my lower denture to move. And I’ll say, well, we need to set you so your front teeth don’t meet, and then it becomes a bit of a circle again, going round. And again, I try and explain to them I say, look, if you’ve got any photos of you, when you’re 12, or 14, and your school photos, I’ll be able to show you what your teeth look like. And, again, it’s having that conversation at the start, not at the end when they’ve got a different pattern of teeth than they thought they were going to get. Now going back to that study I did again, so one of the complete, one of the things myself and Johnny are working on is trying to think of a way that we can allow guys like you to assess your patient before you start to see what degree of difficulty that patient will be. Okay? So what we’re trying to work on,

[Jaz]
like an index?

[Mark]
So. Like an index, so you can work through like a little tick box. So in these 60 patients, significant class two, so what I’m looking for people, I can see a significantly class two. So 12% of patients are significantly class two. So that takes out all those people who had a slight overjet, these are people whose skeletal patterns are massively discrepancies, massive discrepancies there. And in class threes, there are 9%. So instantly, you’ve got 20% of the population, I’ve got quite severe skeletal discrepancies. Now the way I get that round to your patient is I talked about your upper denture is for beauty, and your lower denture is for function. Okay? So we have to put your lower teeth in the correct place over your ridge as close as possible to where your natural teeth would have been. And that’s the way I get around that. And that’s a conversation I have.

[Jaz]
Brilliant and it’s good to ask like you say for the old photos, not only for the occlusal element, but also for designing the teeth setup as well. So leading onto that.

[Mark]
I’ll ask you a question on thatm Jaz.

[Jaz]
Sure

[Mark]
So if you were going to place your canine tooth and your first premolar tooth in relation to the lower ridge, okay? Where would you place them in relation to the lower ridge? Would you place them buccally? Lingually? or on the ridge? Sorry to put you on the spot

[Jaz]
No, fantastic. So you’re talking about your upper denture? Where to where you put your teeth?

[Mark]
No, no.

[Jaz]
we’re talking about lowers

[Mark]
Bacause lower is one that people have problems with. Okay?

[Jaz]
So, in terms of positionally, whether the teeth themselves the long axis of the teeth are on the ridge, buccal or lingual. I think on the ridge. Something I must be honest with you. I don’t I haven’t thought about that much.

[Mark]
Okay, so you’re correct. It’s on the ridge. So the question I say is why? Okay, why on the ridge? So those teeth that you take out, your canines, and the lower premolars, how do we take them out because dentistry all links up. So we’ve talked about orthodontics skeletal patterns. So if you take out a lower canine or a lower premolar, how would you take that tooth out? You rotate it, you don’t lean it buccally, you don’t lean it lingually. It’s a rotational thing because that kind of [inaudible]. So therefore you get similar pattern a bone loss buccal and lingual. Okay? So your canines and your premolars have to be directly over the ridge. And that’s a fundamental of denture making. And I see so many dentures when they come in to me and those teeth are massively buccal to the ridge on why is that because you’ve tried to turn a class two into a class one.

[Jaz]
Well, if you just think about engineering and physics, if they’re buccal to the ridge, there’s causing like a cantilever leaving sort of effect in that area, it’s not going down the you know, the force is not being going, it’s not going down the correct path.

[Mark]
Well, that’s true base more against the balance of muscles really, because the modiolus muscle will push all the modiolus insertion will push those teeth if they place buccally, they’ll go lingually. So your muscles are not imbalanced. And it goes back to the analogy with a windows as I said earlier, you know, that’s you pushing on a day, that’s not very windy.

[Jaz]
On that note about ridges. Is it true that if you have a flat Ridge, your teeth shape should be flatter than if you’ve got like a pointy a bigger ridge than you can afford to have deeper Fauci on their teeth, like actual, like sharper teeth, if you like. Is that is that a

[Mark]
So my question would be Why would you want sharp fossa teeth anyway, on set of dentures, because ultimately, you don’t, you’re not going to help anyone, your occlusion is going to have to be so nailed on perfect in that case. So really, you need to be flattening cusps anyway, on dentures, I’m not saying go back to having flat cusp teeth, but you don’t want anything sharp. And again, it’s one of the common mistakes people makes and it comes in with a 40 year old set of dentures. There’s no curse on those teeth. And then what we do is we give them a new set of teeth with beautiful cusps. And you know what, weirdly, they can’t slide the teeth from side to side anymore because they’re locked into an occlusion

[Jaz]
Laboratories, when they actually take the stock teeth, did they have like a stock teeth, which are pre flattened or worn, like age appropriate measures? Or do they?

[Mark]
You can’t. Certain companies do have those, yeah, so it

[Jaz]
Just makes sense, doesn’t it, Really.

[Mark]
It makes total sense. Yeah, I you know, if you, I’m in my 50s now, you know, I’ve got wear facets on my teeth, and I mentioned it earlier, you know, you wear things down, you get used to things. And all of a sudden, if you, if somebody can’t make those free excursions, when they get their new dentures, they’re going to get, the lower denture is going to move, because there’s nothing to stop it if their teeth are together, they’re trying to slide, the denture’s going to move, they’re going to get more pain, they’re going to get TMJ pain, they’re going to get muscle pain, they’re going to get all sorts of pain.

[Jaz]
Fine. So in the interest of time, I’ve got one last question before you can give any final closing comments. And that question is regarding probably the stage of complete denture, sort of appointments, where which is I found the trickiest and are probably still that one of the most important ones and the trickiest ones I find is the wax jaw registration stage. I remember as a student on the PlayStation playing FIFA with my friend and my flatmate Harmeet and I’m playing I was at two o’clock I’ve got a patient I’ve got wax jaw reg, Can we just quickly revise like what the five things got to record? And actually remember a lot of time let’s have a conversation remember, what the five things to record. So can you give us, the listeners your main things to record and top tips for the wax jaw registration stage?

[Mark]
Okay, so if you want those, the best way of doing it is there’s some Facebook groups around. So I did I’m trying to do a post a month at the moment to help people with their dentures. I think it was a march post on the by dentists for dents- for dentist by dentists, I think and also on the there’s one called food. It used to be called foundation dentist but now it’s called [food]. I expected a real-

[Jaz]
I like food

[Mark]
You like food? What genuinely or just the website,

[Jaz]
both group and generally

[Mark]
The group. Okay. And I did a whole blog, I did a whole thing about it. And the big tip for me is if you know that your lower teeth has to go somewhere in relation to that ridge, and it’s non negotiable. Okay? Why do we need such big wax blocks? We don’t need wax blocks. So I used something called a three pillar technique where are the small anterior pillar And a small pillar in both molar regions. And by doing that, you’re taking a lot of error out of it. Because all you’ve got to do is make sure three things gently touch at the same time, rather than a seven to seven wax block. So I think the best way of answering that is go on to the website, go on to those Facebook groups, and put

[Jaz]
I’ll put those links on them. Yeah, I’ll put those posts on so that they can access those groups. And also

[Jaz]
And they can go directly to them.

[Jaz]
Yeah I’ll add on

[Mark]
Did you see it Jaz? The one did?

[Jaz]
Yeah, I did.I saw it. Yeah, it’s very nice.

[Mark]
So I think that will help people because it’s very visual.

[Jaz]
So everyone, I’ll add that on. So you can read more about those tips about the wax jaw registration. So Mark, any closing comments that you want to pass on to listeners about how to improve their complete dentures? I think we’ve covered quite a few things about anatomy, patient exploitation, psychology, problem solving, actually, problem solving, we need to actually just cover a little bit about in terms of the patient that comes in for review appointments, and they’re having pain problems. You’ve taught me so much I mean, I still, the only reason I have Dycal in the practice is because of you, about for complete dentures and the nurses give me a funny look, every time I asked for a Dycal for dentures. But that’s what you taught me.

[Mark]
You want to know a funny story about CQC and Dycal. So I still use that. I still use that technique, where I use the white from the Dycal just to dry this ulcerated tender area. Dab it on the mucosa, put the denture in, it picks up on the denture, just the denture. It was one thing that we got a slightly negative mark on because the Dycal is out of date. Apparently a little tip for people if you are going to use things that are out of date, make sure you put in a box saying out of date materials and you find

[Jaz]
Okay, that’s a good idea actually in same goes with composites actually if you’re using comps it’s out of date for like shade checking or mock ups.

[Mark]
Yeah. So put everything in a box say, not to be used for the purpose or intended and you can save these out of date materials for now.

[Jaz]
You have saved a lot of people in front of the CQC in that. So Mark, any closing comments?

[Mark]
Closing comments is take longer for your dental checkup on denture patients. Take a very, very good history. If you think you can’t, if you think the dentures are very, very good. And you’re not sure you can work out what’s wrong with them, don’t start making a new set of dentures. If you can’t diagnose what’s wrong with the old dentures, you’ve pretty much no chance of making an improvement. So that would be my finishing thing and be prepared to say to patients, I’m sorry, I think you need a more experienced prosthodontist for this.

[Jaz]
Thank you very much. And then that all those gems were amazing. And I’ll put all the other sort of links to that post on as well. And one thing that we talked about on Facebook, and I can mention it now is just touching on what you just said is the importance of the diagnosis. Now a lot of times the dentist, the diagnosis is going to be edentulous ridges, and the treatment plan will be complete dentures.

[Mark]
Right? Shall I put you out of treatment plan? Give me a minute. Okay, so here it is. I put this up because I thought we might discuss it. So he’s

[Jaz]
It just reminded me now.

[Mark]
It’s an example of a treatment plan. So here we go. I’ve got it post from my course. Course if anyone’s interested www.thedentureguy.uk.

[Jaz]
I’ll put one on my website, the link as well.

[Mark]
Thanks, Jaz. So treatment plan. So this is just an example of somebody that I’ve seen. So I put recommend that the patient sees the GDP for alternative medication. So the reason I’ve done that is a patient’s on lots of service stomach medications. And no matter what I do, if they’re on a load of things that make their mouth dry, they’re going to get more ulcers. Okay? So next thing recommend Biotรจneยฎ for dry mouth. So this is just the treatment plan for this patient make new dentures at an increased OBD. To increase the OBD by four to five millimeters. So before I start, I already know what I want to do and ensure that we pick slightly lighter teeth and a similar mold and send an impression of the old one, of the old denture to the lab with a photo. Okay, extend the lower onto a retromolar pad and increase the retention and stability. Add an appeal labial flange because this was somebody who came in who’d got no flange at the front but they now can have one and correct the centerline. So that’s one of my dream of plans. Not very fulfilled.

[Jaz]
Exactly. Which is just funny when you think about this. I am very very thorough, very, very it’s like almost like create a little tick box for you as a guide for you to actually what you’re doing.

[Mark]
I have to have tick boxes, Jaz, I’m quite simple guy

[Jaz]
I love it. So, Mark

[Mark]
One very quick thing before we go, Jaz, letter writing as well, I write to everybody I ever make dentures for. I write what I’ve said, I’m going to do for them, why I’m going to do it. And if you get a template letter, it’s that easy to do, it takes 15 minutes to adjust the template letter. And if that saves you having to remake a set of dentures at the end, it’s time well spent.

[Jaz]
That’s a very good idea. Just it’s a part of your consent process as well. So absolutely. Mark, thanks so much for sharing all your pearls and wisdoms. It’s always lovely to speak to you again, it reminds me of being a dental student again, back all those years ago. And it’s been a great pleasure, thank you.

[Mark]
And Jaz one thing, keep up the good work. It’s lovely to see somebody who is an ethical guy who wants to do dentistry nicely, giving these podcasts to people, giving people a little bit of hope that it can be done. So just keep on doing it.

[Jaz]
Really appreciate that. Thank you. I’m enjoying it very much. And the plan so far is to keep doing them because it’s great. I’m learning I mean, I learned a few gems from you there. And just with every guest I have on it’s just Yeah, lots of fun.

Jaz’s Outro: Thank you so much for watching and listening all the way to the end. I hope you enjoyed that. Anything that I promise in terms of the Facebook group that Mark mentioned, and the Atwood classification. I’ll put that on in the Protrusive Dental community Facebook group. Otherwise, I’ll catch you next episode. Please, if you enjoyed this content, share it with your friends, share it with your prosthodontic colleagues, share it with your dental students if you know any and also if you can leave me a review on your podcast platform. I’d really appreciate that. Thank you everyone. Goodbye.

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Jaz Gulati
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Episode 36