Ovate Pontics for Bridges – The Complete Guide with Dr Jason Smithson – PDP158

Jaz’s Introduction:
Look, they’re okay pontics, they do the job, but they’re ugly. Ovate pontics are egg shaped or bullet shaped, and they emerge from the soft tissues, and they look really natural.

As well as that, they offer really good cleansability as well. So Ovate Pontic is the best kind of pontic you can aim for. But it’s so difficult to find good content online when it comes to Ovate Pontics, until now.

I got on, once again, Dr. Jason Smithson, who, to me, is the best dentist in the world. He is amazing. I’ve been to so many courses. He’s taught me so much. And it’s just always a pleasure to have him on the podcast. I tried to really extract as much as I could from Jason Smithson during this episode to try and cover a lot of depth, but also a bit more breadth around this topic. What I also did in the editing stages of this episode is I really stacked it with lots of visuals, because sometimes when you talk about topics like this, when it’s not visual, it’s very difficult to follow along.

Now, for all my Protruserati audio listeners, don’t worry, all of it can be followed along by audio, but when a visual is really going to enhance the learning, I’ve put that on the screen. So for those of you who are watching on YouTube or on the app with the premium notes, you’re probably going to gain a bit more.

So I encourage you if you can make the time to do this, like an on demand webinar kind of thing, right? Just study all the visuals that will really compliment what we’re talking about. In this episode, we discussed case selection for ovate pontics and all the nuances, like how deep do you actually go into soft tissues, which kind of soft tissues are suitable.

What if you don’t have enough soft tissue and everything you have to do to actually develop your pontic site. At the end of the episode we also see the return of Am I Naughty If, because I shared with Jason a shortcut way of working with ovate pontics to try and bypass the healing time and I asked him what he thought and the answer is very interesting. So we do Am I Naughty If.

[Jason]
I don’t think it’s a terrible solution and actually it is possibly a very acceptable solution for posterior units.

[Jaz] Protrusive Dental Pearl
I share with Jason how I cheat, and so let’s see what he has to say about that at the end. Before we join the main episode, I will give you my Protrusive Dental Pearl. If you’re new to the podcast, welcome to Protrusive Dental Podcast. It’s great to have you. If you’re a veteran listener, you know that every PDP episode, I will give you a Protrusive Pearl. So this pearl, this piece of advice I’m going to give you is my rule when it comes to adhesive bridges or resin bonded bridges.

I got to a stage where lots of my colleagues are messaging me with advice for Resin Bonded Bridges. Is this tooth suitable to be an abutment for a Resin Bonded Bridge? Can I restore this case with an RBB? So I’ve got lots of these cases, and of course, all these colleagues and friends ask me for advice.

I want them to succeed. I want their Resin Bonded Bridges to last a long time, and they certainly can. Like my predecessor, where I’m working now, he retired, and I’m seeing bridges that he placed 30 years ago. And we know from the literature that Resin Bonded Bridges, when designed well, in the right occlusion, they really can work. But sometimes we get stuck and we need to know, is this case suitable for a resin bonded bridge or is that too ambitious?

So I’ll share with you my rule. When it comes to metal Resin bonded bridges, what I mean by that is the wing, aka the retainer, is made out of metal. And obviously the pontic is usually out of porcelain or acrylic. For the metal RBBs, I advise never accept more than one compromise. So you’re allowed one compromise.

So what I mean by that, what’s the compromise? Okay. This could be an aesthetic compromise. This could be the abutment size. Maybe the abutment is not ideal. It’s a bit too small. Maybe it’s the occlusion. It’s a bit risky occlusion. It’s a bit edge to edge. There’s not enough. Overjet perhaps, or maybe the path of insertion on the bridge is not ideal.

So you’re looking at one sort of compromise, and sometimes we can accept this. When there’s more than one compromise, i. e. you have a small abutment tooth, that really is not going to give you the right surface area to bond, and you also have an occlusion that’s not ideal, then I would suggest that’s not a case for resin bonded bridges, unless you change something about those two factors.

When it comes to Zirconia based Resin Bonded Bridges, I say no compromises, okay? Really, I want everything set up and I want no compromises here. Because the long-term data, whilst it’s really good, I would encourage you all to check out the papers by Matthias Kern, showing the 10 year recall and success rate of Zirconia Resin Bonded Bridges, especially to replace lateral incisors, like 92%.

That’s really impressive. But I just think the track record with metal RBBs in the papers just spans so many more decades. And also it’s a more predictable bond. So Zirconia Resin Bonded Bridges, no compromises. Make sure the occlusion is perfect. Make sure everything is perfect and they’ll do really well. The data is there to prove it. But for metal ones, maybe you can accept one compromise. So that’s my rule for Resin Bonded Bridges as today’s pearl. Let’s now join the episode with Jason Smithson, and I’ll catch you in the outro.

Jason Smithson. Welcome back to the Protrusive Dental podcast there. How are you?

[Jason]
I’m good. Got a couple of months off. Well, off. That means not traveling. So, yeah, I’ve been at home for a couple of months and I’m just in the practice two or three days a week and although I am to spear in Arizona next week, but I consider that off. I go to Arizona four times a year and then I go to the U. S. usually another twice, I was in the US in February for Academy of Restorative Dentistry, which you may know in Chicago. And then the other long hauls are Australia, which are once or twice a year, and then a bit of Far East. So yeah, not getting on the train at 10.30 at night is a bit of I consider that to be a holiday. So that’s good.

[Jaz]
We’re all very accustomed to your photograph at this train station with the shoes on. Yeah, I lost access to my, your shoes are famous. I lost access to my own Facebook account, but funnily enough, can you believe it, right? So, you’re no longer my friend on Facebook, so I’ll have to add you on my new account.

But yeah, I miss seeing your shoes at the train station. That’s like a hallmark thing, so we admire that. So, thanks again for joining us. No shoes required for this one today. We’ll be discussing, we’re both doing this. That’s what we’re talking about.

Ovate pontics it’s a deep dive and a very small area, but there are a lot of questions, especially if you imagine Jason. Young dentists qualifying with very basic skills in fixed prosthodontics all together. And really, as they progress, maybe five, six years later, they come across cases.

Okay, you know what? I’ve seen some cases whereby I could do an ovate pontic. And then we start looking online as you do for tips and advice, and there’s not much out there. So, I’m hoping that this will become a definitive guide to Ovate Pontics, that you can share your years of experience.

Like when I went to your course on VertiPrep, so BOPT technique and vertical preparations, you talked about the E Pontic, which I think might be a part of today, but I know there’s so many amazing cases and I’ve seen your soft tissue cases and stuff. So, everything is brilliant and everyone is really excited to learn from that.

So I guess where to start would be just for the, maybe the dental students, the younger dentist. There are different types of pontics that are generally used for bridges, and what are the main ones that we use currently?

[Jason]
Alright, so I’d start off by defining pontic. A pontic is a prosthetic false tooth, right? So that’s for the dental students. And that could be related to a bridge, which is the obvious. Or it could be related to an implant retained bridge. And actually, I first started doing ovate pontics by default, and I didn’t even realize I was doing it when I did immediate dentures. So there’s also an ability to form an ovate pontic site when you do an immediate denture.

So there’s kind of three applications. Now, historically, there are four main types of pontic design. Historically, we had what was called a hygienic or sanitary pontic. I mean, I’ll be honest with you, I’ve never done one, but it’s basically a rod that joins. Two retainer teeth together, so you’ve got a crown prep on, for example, a lower first premolar and you’ve got a crown prep on a lower first molar and you’re replacing the second premolar and they’re just joined with a little stick of material and that classic-

[Jaz]
Like an occlusal table, right? Is this a big table?

[Jason]
Yeah, yeah. It was originally done in gold. So you got literally what looks like a bridge, not a dental bridge, but an actual bridge. And the idea was that you had a big blow through hole so that the patient could clean it effectively, hence the name Hygienic or Sanitary Pontic.

Now, that works very well for chewing on, but it looks hideous. And secondly, they discovered it actually wasn’t sanitary at all because people got food stuck in between it. You can imagine chewing a sandwich and getting tons of bread stuck in between it. It’s just disgusting. So although it was easy to clean.

When you’re chewing, you basically get the best part of a takeaway meal stuck between your teeth. So, it’s not ideal. So that is really, you might see them in your practice, but it’s really, it’s in the history books now. So that was the first up, that came out in the 50s really. And then we had a pontic, which is called the ridge lap.

And what that means is your dummy tooth, your pontic tooth, laps over the buccal and the palatal of the ridge, hence ridge lap, because it laps over the ridge. And actually, that can be made to look reasonably aesthetic, but because the intaglio surface, in other words, the fit surface of the pontic is concave, it goes over the buccal and over the palatal.

It’s really tricky to clean, so people couldn’t get superfloss underneath it, and what you end up with when you have a ridgelap pontic is that you get inflamed tissue and it’s red or purple and you get bleeding and it’s not that great to look at.

[Jaz]
Is that the same, Jason, as a saddle pontic?

[Jason]
Yes, yes, it would be. That would be another name for it. Now, that should be consigned to the history books. Sadly, I’m actually seeing quite a lot of that recently. It went out of vogue, and now it’s come back in. When I look at cases on Instagram where, particularly, where people are replacing significant hard tissue defects with implants, and they can’t build bone, and they can’t build soft tissue.

They’re oftentimes replacing that with acrylic, and what they’re getting is a ridge like pontic, and it looks great. I won’t name names, but I saw one on Monday from somebody who’s very, very well known. It looks great on Instagram, and you get all the oohs and ahhs and 50, 000 likes. But from a bio point of view, from a tissue point of view, it’s a really, really bad idea.

You might get a happy patient then, but when you go back to it, when you dismantle it long term, it’s going to look horrible. I dismantled one last week and it just was hideous inside, it stinks. So we got the sanitary and we got the ridgelap or the saddle. So the next one on was a modification of the ridgelap.

What they did is they took the palatal bed off. So what you’ve got is something that sits on the existing tissue on the facial or the buccal side, or American language dropped in there. Sorry about that, on the buccal side. But the palatal bit’s been removed. So you’ve got something which sits on the tissue facially, but is more cleansable.

And that’s what I was trained with. So I spent the first and I think it’s fair to say, most people in the UK, and frankly, probably most people worldwide, are trained with that still. And it offers some advantages. The first and obvious advantage is it’s, it doesn’t require any intervention from the dentist.

You just do your crown preps, or your implant placement. And then you take your impression and the technician does all the work and you seat it and it’s done. So it saves time and therefore saves cost for the patient, usually. And the downside is that they don’t look all that great, generally. You can generally see the margin, because the margin is super gingival, you can see the margin where it touches the tissue.

And it can be satisfactory for some patients, but for others not so much. So then, when was that invented? 1980 actually, by a guy called Abrams, came up with the ovate pontic. So the ovate pontic is essentially a pontic where the bit that touches the tissue is ovate. In other words, bullet shaped. So if you can imagine the tip of the pontic where it touches a tissue is a bullet shape and we could talk about the biology of it a little bit later on, maybe, but because it’s bullet shape, in other words, it’s entirely convex, it’s very flossable.

And also it’s supposed to go into the tissue. We can debate this, but on the whole, probably about one to two millimeters, let’s say one to one and a half millimeters into a dimple that you’ve created in the tissue. So that actually your margin, in other words, where the pontic meets the soft tissue, is actually sub gingival.

So it would appear like it’s coming out of the tissue and the advantage of that is that you get massively better aesthetics. And then you do get oohs and ahhs on instagram and also because it’s ovate it’s cleansable. The downsides are you’ve got to condition the site in other words you’ve got to make the tissue that you’re sitting the pontic on have a kind of dimple in it.

(Name unclear) has a lovely expression. He calls it eggs in a nest. It’s kind of like an egg in a nest. It’s got to sit in a nest. So you’ve got to create that. And that can either be created post extraction, in other words, the tooth’s out and you’ve got a ridge to deal with, and there are ways of dealing with that post extraction.

Or it can be dealt with pre and during extraction. In other words, you’ve got a tooth which is compromised, so it’s got to come out, and you extract the tooth, and then you conserve the extra or some degree of the extraction socket. With your temporary, the temporary could either be a temporary acrylic fixed bridge, it could be conventional, or it could be a temporary acrylic adhesive bridge, or it could be a denture, and there are pros and cons for each of those.

So basically we’ve got four different, to a long, long way around your question, but we’ve got four different options for pontic designs. The ridgelap and the hygienic have gone, and nowadays we’ve just basically got the choice of a modified ridgelap or an ovate, and there’s a slight modification to the ovate, which is what you alluded to earlier, which is the epontic. So there we go. So that’s it.

[Jaz]
Excellent. Well, thanks for that. A really nice summary. I think that’s foundational. And I think now we’re on the same page for those listening and watching. I just like to know in your practice now, what percentage cause you do such a lovely aesthetic work, what percentage of the pontics that you do are going to be modified ridge lap and what percentage will be a ovate?

And then does that change anterior to posterior? I mean, just because you can do an ovate, is there ever a good reason to do an ovate posteriorly, perhaps to a cleansability? You let me know.

[Jason]
Yeah. So, the main question is ovate versus modified ridgelap essentially, isn’t it?

[Jaz]
Mmm-mm.

[Jason]
I would say in my practice, I virtually always do ovate or E pontic, right? I very, very rarely do modified ridgelap. However, I would couch that by saying that I work in, I’m not a specialist, but I work in a specialist practice, and the vast majority of my patients are either referred to me or come to me direct because they want a specific prosthetic or aesthetic outcome, so my patient population is skewed.

The only time, so I think there are very few reasons why I wouldn’t want to do, an ovate pontic. The only reasons why I wouldn’t want to do an ovate pontic, and I’d do a modified ridge lap, are the patient isn’t prepared to come back and have the side conditioning, and that, and oftentimes, dentists say, ‘Oh, well, the patient will pay for it.’

Oftentimes, it’s usually time. In my practice, you’ve got a patient who’s not that aesthetically bothered, and they’re just like, I just want to get on with it. I want to get this done in two visits. Not five. That would be one reason. Another reason, maybe there’s some medical reason that would preclude it. For example, I can’t think of a really good one, but perhaps uncontrolled bleeding issues or something like that. Or well actually maybe a patient on bisphosphonates that was-

[Jaz]
I was thinking IV bisphosphate maybe, yeah.

[Jason]
That would be a good reason. I’ve not encountered it in my own practice, but certainly when you modify the site post extraction, you may end up touching bones. So at that might not be a good idea for a patient on bisphosphonates. So just something that, something I should put in my lecture. ’cause it’s just something that occurred to me, but they would be the only reasons really.

[Jaz]
And posteriorly as well, by default if you’re doing a posterior bridge you do an ovate pontic as well, yeah?

[Jason]
Yeah, because like, in the posterior, in my practice, vast majority of the time I’m either doing implants, or Adrian, my implantologist, places the implants, I restore them, but I’m restoring an implant, so I’m going to put provisional on there anyway. So if I’m going to put provisional on there anyway and load the implants, then why would I not use that same provisional to form an ovate pontic, given the actual time to, the extra time to do that is probably less than five minutes.

Or if I’m working on teeth, the vast majority of time in my practice that I’m working on posterior teeth with bridge work, I’m tending to do a vertical margin. And there are a couple of different reasons for that. The first and most common reason is I deal with a lot of older patients who’ve got significantly compromised teeth, and we do vertical margin to deal with those compromised teeth.

And the other reason may be that I’ve got younger patients and I want to be more conservative, so I do a supragingival vertical margin to be more conservative. It’s actually quite unusual for me to do a conventional chamfer margin for a posterior bridge. And again if you’re doing vertical margin, you need the provisional to condition the tissue for, I know this is debatable, but 40 days.

So why would I not do an ovate pontic at the same time? So that’s where I appreciate I’m in a slightly skewed practice, but that’s kind of where I am with that.

[Jaz]
And for those of you listening, you weren’t watching as Jason was saying that I was smiling because when Jason says something that is very, and I’m already doing that in practice, it makes you feel really good.

So that’s fantastic because I’m a big fan of vertical for, as I learned from you as well. So that’s great that we have that and you passed that on to me. So I feel good about myself. Now there might be some ways of me doing ovate, which you might probably disagree with, and I’m totally cool for you to tell me I’m an idiot, Jason.

Okay, we’re going to come on to that later. And at the end, yeah, I know you would. At the end, we’re going to talk about the E pontic, which will be called. Just in the middle bit, there could be another reason, perhaps that you maybe would be a bit more challenging to do an ovate pontic. So particularly that scenario where I’ve considered doing an ovate pontic before, but then I do the bone sounding, which we’ll talk about suitability of that site to receive the bullet shape ovate pontic, there was like, one to two millimeters, it’s just very thin tissue.

And then to actually get an ovate pontic, I’d have to do bone removal or something. So we’ll talk about that. So let’s talk about maybe what is bone sounding and how much is the ideal amount of tissue that you should have to be able to consider an ovate pontic?

[Jason]
Alright. Would you mind if I just rewound and just took a look to the considerations for pre extraction and post extraction because that would lead on to quite sensibly?

[Jaz]
Alright.

[Jason]
So, let’s look at post extraction first. So, you’ve got a patient comes in with a missing tooth. They’ve had the tooth out, I don’t know, several months, maybe even years ago. They’re missing a tooth, the ridge is relatively flat, and you’ve made a decision that you’re going to prep the adjacent teeth and place a bridge.

So if you want to form an ovate pontic, you’ve got to condition the saddle, the site. So what you need from a biological point of view is, you’ve got the bone, and then covering the bone, you’ve got connective tissue, and then covering the connective tissue, you’ve got epithelium, right? Now, as I alluded to earlier on in the presentation or the podcast, the ovate pontic has got to go into the tissue by about a millimeter to be stable, at least.

I wouldn’t make it more than two millimeters, but it’s certainly got to go in, because that makes it difficult to clean. But it’s got to go in at least a millimeter to look decent. So you need a millimeter. You also need a millimeter thickness for the epithelium. You also need a millimeter thickness, at least, for the connective tissue.

And that was described by Gargiulo under biologic width. So, when you bone sound, and we’ll come to that, you need to have at least three millimeters from depth of tissue to allow you your millimeter for your pontic, your millimeter for your epithelium, and your millimeter for your connective tissue. There is another bit of research, I can’t remember the name of it, I think it’s a guy called (unknown) off the top of my head, if I misquoted in my apologies.

And he talks about prosthetic biologic width. So there’s biologic width of connective tissue and epithelium, but their study showed something like two and a half to three, so a little bit thicker. But anyway, what you would do at that point is you would look at the patient, and you would nut them up, because people don’t like to have this done without being anesthetized.

And you would take a periodontal probe, a non-ball-ended periodontal probe, just a regular periodontal probe, and just advance it onto the saddle, onto the tissue, and press down, and it will penetrate initially the epithelium. And then the connective tissue. And then you’ll hit bone. You will feel some resistance as you hit the connective tissue.

It’s not bone at that point. You need to feel the positive “bung”. And then you look at the measurement. Now, if you’ve got 3mm, you’re kind of good to go and it’s going to be all in soft tissue. If you haven’t got 3mm, if you’ve got 2mm or less, what that means is you can still create an ovate pontic sign, but you’re going to need to remove bone.

All right, because you’ve got to have the room to get the pontic in, the soft connective tissue and the epithelium. Now that creates a few problems in so much as you’ve got to be really careful where your gingival margin is. So the way to do that is what you would do is you would do your crown preparations.

Once you’ve done your crown preparations, you would fabricate your temporary. And what I would then do is get your pontic the right shape as you shape your temporary and adjust the occlusion and get everything right from an aesthetic point of view. So your pontic is the correct shape at the gingival margin and the correct lengths.

Then, the next thing I do is I take a really, really thin Sharpie marker, Indelible marker pen, and just draw around the gingival margin with the tabs in place before you cement them.

[Jaz]
At this stage, Jason, at this stage, what you’re dealing with essentially is a modified ridgelap, right? That you’re going to convert to an ovate?

[Jason]
Absolutely exactly, yeah. So, you’ve then got a little U shaped marked on the tissue, which is exactly where you want your ovate pontic to be.

[Jaz]
The gingival zenith we’re talking about, right?

[Jason]
Yeah, that’s a subtlety, and it takes a little bit longer to do it like that, but it means you put the site in the correct position, because often times people just blindly burr, and then they end up with a gingival margin which is lower than it should be, and it just looks terrible. So you mark it with a marker pen, then you take your temporaries off, and some people use a football bur, coarse diamond you want, and some people, including myself, use a round diamond. And what you need to do then is to actually use the burr to sink, to make a divot in the soft tissue.

Now, going back to the bone sounding, if you know for sure that you’ve got 3mm or more of tissue depth, you can just burr a millimeter, maybe a millimeter and a half into that soft tissue. And you would now know that that’s going to heal up. Okay? And you’re going to have a millimeter of connective tissue and a millimeter of epithelium, so you’re good to go.

So that’s the simplest one. Oftentimes you haven’t, and if you haven’t, you’re going to need to burr more because you’re going to need to burr into bone, right? So what you’re going to need to do is to take that burr, into the soft tissue, and burr through the epithelium, through the connective tissue, until you hit bone.

And the next question is, how much bone do I need to remove? And the answer would be, until your burr is sunk three millimeters into the tissue, from the gingival margin. Right? We’ll bleed quite a lot, and once you’ve done that, you know you’ve got your millimeter for your pontic, your millimeter for your connective tissue, and your millimeter for the epithelium.

Sorry to keep repeating that, but I need to go in. We’ll bleed a lot. That’s not a big deal. All you need to do then is, I just use something, some people use electrosurgery, but I think that tends to be a bit painful, and it stinks. I just use astringent or ViscoStat. Clean it up with ViscoStat, it will stop bleeding.

[Jaz]
It might go black though, so let’s reassure everyone that it’s going to go horrible.

[Jason]
It might go black, but that’ll come back. Yeah. Then, what you do is, some people use flowable composite, I use regular composite. You just put a little bit of regular composite on the apical part of your pontic, and sit it into the site that you’ve just created.

Then you light cure it. It will light, it shouldn’t technically, but it will light cure through the tissue. Oh, a little aside, before you put the composite on the temporary bridge, I always put a little bit of Signum from Corsa. It’s a modelling resin, it’s designed to link acrylic to composite. So anyway, you sink this composite into the site you prepared.

I light-cure it. Then you take it out and it will be rough as rats. So then you shape it until it’s convex all the way around. So it’s a dome shape. Now, you’ve then got to make sure it only penetrates a millimeter to a millimeter and a half into the socket. Because if it’s right on the bone crest, it’s not going to heal very well.

So what you do is you replace your bridge after you’ve trimmed it into a dome shape. And then I just take a pencil, a propelling pencil is really good because it stays sharp. And then you mark around your gingival margin onto the bridge with the propelling pencil. Take it out and you’ll have a pencil line.

And then you measure, I would just do, say a millimeter and a half. Measure a millimeter and a half from the pencil line apically. And then trim the pontic to that level. Then you can reseat it on what you’ll have in the site you’ve prepared as a blood clot at the base. Some space. And your pontic. And then you leave it alone.

Now, how long do you need to leave it alone? Well, when you cement it obviously. And then leave it alone. Be very careful with your cement cleanup. A little tip I do, is I place the temporary bridge, then cover the whole thing with Vaseline. So any time I’ve used Vaseline in the dental surgery. Then take the bridge off.

Dry the retainers, put my temporary cement on the internal fit surface the intaglio, seat it. And then because it’s covered in Vaseline, all the temporary cement will peel off dead easy. You doubt all those smears everywhere and you don’t have lots into proximally. Clean it up with super floss, then leave the whole thing alone for six weeks.

And then you can take your final impressions. You need five to seven days for the epithelium to heal. And you need, well, 21 to 28 days for the connective tissue to heal and mature. So if you leave it for six weeks, you’ve got loads of time. The patient is instructed to clean with super floss. And also, I get them to use waterpicks.

That’s really effective. And then six weeks later, you take the whole thing off, take a regular impression, and then they’ll instruct the lab to fit the pontic in the final restoration into the socket you’ve created, but do not scrape the model. There is a bit of a tendency with labs, when they make a bridge, on the stone of the model, or in the CAD, to actually remove a bit of tissue in the pontic sites, so when you seat it at blanches, you don’t want that.

Because obviously if it blanches, you’re going to end up with a, basically what’s called a biologic width invasion. You’re going to get inflamed tissue. So that’s it really on the post extraction, which is what most people will deal with.

[Jaz]
Hey guys, it’s Jaz interfering here with two mega quick announcements. One, if you want this episode summarized in a beautiful infographic with all the decision making and summaries, then head over to protrusive.co.uk/ovate and we will send it to your inbox. So that’s protrusive.co.uk/ovate. For those of you who’ve seen the protrusive infographics before you know, a lot of effort goes into it and they are the best infographics in dentistry. I am pleased to say.

The second announcement is for our live event on Saturday, 30th of September. So it’s Occlusion and Communication Symposium 2023. We’ve got some great speakers. The lineup includes Dr. Kostas Karagiannopoulos, who did the injection molding episode for tooth wear many episodes ago. He’ll be talking about how to transfer the wax up to the mouth and make sure the occlusion is respected.

We’ve also got Dr. Tif Qureshi talking about DAHL technique versus full mouth rehab. When do you choose which one? Then we’ve got the high flying Dr. Rhona Eskander talking about moving away from single tooth dentistry and all the challenges that comes with being a young dentist and you’re trying to push your boundaries and how you overcome any mindset issues. That’s Rhona.

And then we’ve got a live panel, like a fun thing. Me and Mahmoud Ibrahim will host this live panel discussion. We’ll ask some tough questions to these guys as well as open up questions from the audience. And then after lunch, we’ve got Prav Solanki. He’s going to do a 90 minute master class on how to communicate, how to elevate your communication to increase your treatment uptake.

Like there’s one thing to be able to do the dentistry, but if you can’t communicate the value of that dentistry to your patient, then you’re not going to be able to serve your patients the best. So it’s a whole communication session with a keynote speaker, if you like, is Prav Solanki. And then we’ve got Salman Pirmohamed.

He’s been our guest twice before on the podcast, and he’ll show you some. Full protocol cases. Sometimes it’s nice to see the step by step. Before and afters are good, but I’ve told someone to really show the step by step by step when it comes to these bigger cases, tooth wear, and those that involve occlusion and communicating with the lab.

Lastly, we’ve got a drinks reception from 5pm to 6 pm. So we would love for you to join us on Saturday, 30th of September at the Sheraton Skyline Hotel in London Heathrow. The website for that is protrusive.co.uk/occlusion, that’s protrusive.co.uk/occlusion. Now it’s back to Dr. Jason Smithson. I’m trying to still extract as much as I can. He’s so full of knowledge and at the time of recording, I guarantee you I was having so much fun. I hope you guys are too.

Before we get to the extraction one and then immediate management, it’s got a few nuanced questions about the protocol you explained. So firstly, thank you for sharing that because very difficult to find information about this.

And I think that’s going to be incredibly helpful to all the dentists listening and watching. I appreciate you being so giving with that. With that protocol, I think one bit, if I followed correctly, and just for understanding of it is once you’ve got the-

[Jason]
Very technical without pictures, isn’t it?

[Jaz]
I know, I know, which is tricky, but this is why we’re going to elaborate a little bit more. So once you put the composite into the tissues whereby you’ve just drilled the soft tissue away and maybe you draw some bone away and once you’ve controlled the bleeding you put your composite inside so that it’s kind of like a flattish and it’s going into it but at this point I think one thing you didn’t quite make clear which makes sense to me but just to make it super clear, do you want to seat the bridge on as you’re curing, so that the composite then joins onto the pontic of the bridge?

[Jason]
Yeah, so what you would do is you would, once you’ve got your bridge trimmed to your ideal, then when you add the composite, you would roughen the pontic side a little bit, just with a burr, place a little bit of Signum, place a kind of dome of composite. I tend to use like shades A4 and A5 because it looks a bit root-ish.

And then seat the whole thing over the teeth to full seating. Often times you can just get the patient to occlude or press it down. Or in the posterior just get them to occlude on a cotton roll. That fully seats the bridge so the composite is being forced. into the site you’ve created. You will get some excess coming out.

A little nuance is actually to use an instrument called an IPCL, Interproximal Carver Long, which is a really skinny flat plastic. And you can actually sculpt off the excess with that, means you’ve got less trimming, and then lye cure it. Is that clear?

[Jaz]
That’s fantastic. So the bit of actually seating the bridge on at the time of actually having the composite in the tissues. It was a bit to clarify there. And just for clarification.

[Jason]
Another question would be, why would you use composite rather than acrylic?

[Jaz]
Okay, yeah, is it because of the heat?

[Jason]
No, some people don’t. Well, tissues like composite better than acrylic. It’s a more polished surface. And actually, it’s a bit more viscous so it’s easier to control. That’s why I do it.

[Jaz]
Amazing. Yeah, definitely someone would have asked that on YouTube, why not use acrylics. I’m glad you covered that already. And then when you drew the pencil line, when you have the bridge now seated before you cement it, the pencil line is essentially telling us that is the gingival zenith as we see it basically.

And then once you take that off and you send, you then mark 1. 5 millimeters above that line. That’s like your actual ovate part, the pontic, and then beyond that will be the, all the regeneration of the bone and the connective tissue and the epithelium. Is that a fair summary?

[Jason]
It is. So when it’s seated and cemented, what you’ve got in that area is sometimes exposed bone and then blood clot and then your composite pontic. What’s going to happen over time is that blood clot is going to form connective tissue and epithelium and heal from the base. Now, if you don’t trim it correctly, you’re going to basically have your composite on bone and then there’s no room for that blood clot to convert into connective tissue and epithelium. That’s why you’ve got to be super careful with that.

[Jaz]
Brilliant. And so that explains it all really nicely. In this scenario that you explained is whereby, yes, the tooth was extracted a long time ago and then you describe exactly how you modify it and that was all well explained. But this works when you want to migrate your gingival zenith.

Apically, what about if you’re missing lots of tissue and actually you’d want to bring some tissue down, are we then, this is something I know nothing about Jason, but like, are we looking at connected tissue grafts? How stable is that? Is that something that you do with a periodontist or yourself?

[Jason]
Alright. So, bone defects are classified into three classifications called Seibert classification. Okay. So class 1 is a buccolingual defect. So in other words, the ridge is a bit thin, but you haven’t lost height.

[Jaz]
So this is like when someone’s done an extraction and the labial plate broke off, right?

[Jason]
Yeah. Or the patient just lost tissue, hardened the soft tissue. So class 1, buccolingual’s thin, but the height coronoapical is correct. Okay. Class 2 is when the buccolingual is the correct thickness, but you’ve lost height, right? So, you’ve lost coronal height. And class 3 is you’ve lost buccolingual and height. Okay? Ovate pontic without any graft only works well in class 1.

So when you’ve lost width, in other words, buccolingual thickness. If you’ve lost height, it’s more challenging because there’s nothing to play with, right? Now, oftentimes, if you’ve lost buccolingual thickness, often you can get away with just an ovate pontic without any graft. So in a class one, you can do an overweight pontic without any graft a lot of the time.

If you’ve lost a lot of buccolingual thickness, you may need to consider a graft, but in a class 1 defect, you can usually get away with just a soft tissue graft. In other words, you’re grafting connective tissue typically, usually to the buccal, to generate enough width to create your ovate pontic.

For class 2 and class 3, you always need to consider hard tissue and soft tissue graft. So for the purposes of this podcast, I would suggest that that’s referred out, because that’s a specialist job generally. In terms of class one, with a soft tissue graft, we probably haven’t got enough time to talk about this, but it can be done in a number of ways. You can either take the connective tissue as what’s called an allograft.

In other words, it comes out of a pack kit. And I used to do a lot of cases with a product called Alloderm. You can’t buy it in the UK anymore. It just comes out of a packet, you roll it up into a sausage shape, you make a little kind of slash incision on a gingiva, undermine it, and then you put this sausage shape bit of material in, you kind of tie your sausage shape up with resolvable sutures, a bit like tying a pork joint, if you’ve ever seen a pork joint, and you just put that in.

And I used to tend to suture that to the palatal side and then I tended to over bulk it so that when I made my ovate pontic, it got squidged interproximally and I got some papillae out of it. Alloderm is not available now. There are other, allograft materials on the market can still do that.

Nowadays I tend to use a patient. So you can either take that from the palate with a procedure called a subepithelial connective tissue graft, or, and this is what I do quite commonly, I take it from the tuberosity. Oftentimes, if you take, if you can imagine a wedge of tissue from the tuberosity. With the wider bit of the wedge being the epithelium and the more apex, the triangular bit of the wedge deeper into the connective tissue, I just, if they’ve got a really flabby tuberosity, you can just harvest that, trim off the epithelium, then close the tuberosity, couple of sutures, and then you can do the same thing as I used to do with the Alloderm graft in the anterior, just with this thick bit of tissue.

And the advantage is, it’s a little bit more friendly to the patient because it’s actually them. And you haven’t got the hang up of it being, it comes from who knows where. And it’s cheaper for the patient because I can harvest one of those in, I don’t know, 15 minutes. And you haven’t got the cost of the allograft. So that’s how we deal with that, with a graft or whatever.

[Jaz]
I mean, because that is very specious and we could spend a whole five hours talking about that. I think the only question I have here. It’s actually something from the community. I wasn’t safe for later, but someone actually just asked like, how can we learn the soft tissue skills that Jason has? So is there any way that you recommend to learn?

[Jason]
I wouldn’t recommend learning my skills because I’m not the best surgeon. I very rarely post cases of my surgery. I usually post like, before and after, and I never post in between, because my surgery usually ends up looking good at the end, because I understand biology, but I’m not the most refined surgeon, I’ll be very honest with you, I’m a little bit on the agricultural side of surgery.

So I know what I’m doing, but it never looks very pretty. So I think, there are a number of people who teach surgery to a good standard. I think frankly, and no disrespect to English periodontists or UK periodontists, but really, really, you’ve got to go abroad to learn periosurgery and grafting to a high standard. And I learned quite a lot from Zuhr and Hürzeler in Germany, and then there are a number of people in the U. S. who are very skilled in the-

[Jaz]
I just thought I’d pick your brain on that, and it’s good that we know that where you learnt your stuff for a result, and it was nice to hear, Jason, because we see you as, like, this, like, you’re just good at everything, so it’s nice to see you say that, actually.

[Jason]
No, I’m really not. Yeah.

[Jaz]
Yeah, it’s really nice to hear that, so thank you so much for sharing that, it made us all feel good. Jason, let’s talk about that other pathway now, whereby you’ve just taken out a lateral incisor, let’s say, and you want to use that as a way to develop an ovate pontic for there. That protocol is going to be way different. How do you manage it?

[Jason]
A bit different. I mean, the first thing you said was a lateral incisor. And actually, I would just like to get to segue into a lateral incisor in my practice is almost certainly going to be a pontic every single time. I very rarely replace a lateral incisor with an implant.

Because they typically, there’s oftentimes not enough room for the implant. And secondly, they always look rubbish. And they often look a lot better as a pontic, be it an adhesive bridge, a conventional bridge. or an implant retained bridge. So there’s that. Now, how do we manage from extraction? Well, these are the cases that where the temporary has got to stay on for a decent amount of time, three to six months.

So I would first of all get a lab made bridge, temporary bridge. Made before you start or a provisional venture. So you would prep the teeth, assuming we’re doing a conventional bridge. We can talk about adhesive bridges later on, if you want. You’ll prep the teeth. I would tend to prep the teeth to a good standard before I extract the tooth, because otherwise you end up decorating your whole office with blood.

Alrighty. Then, I would extract the tooth. Now, it’s important to extract the tooth. There’s a saying of, there’s a kind of phrase, atraumatic extraction, which I think is kind of an oxymoron, because like, how can you atraumatically extract a tooth? But let’s call it “extract the tooth with the least carnage possible”, preserving as much soft tissue and bone as you can.

So what I typically will do is go around the gingival margin with a scalpel blade, 15C usually, right down to bone, so I’m not going to tear the tissue. And then I’m going to use really, really fine sharp periosteal elevators and just work my way down with a periosteal elevator. Just go all the way around the tooth.

And if you take your time, you can often find as you’re working with wider and wider periosteal elevators, the tooth will just rise out of the socket. And you’ll almost be able to pick it out with your finger, or take, and if you’re having to lean on it with forceps, it’s just really a bad idea because you’re going to end up bending or fracturing the plates, and then you’re stuffed.

Then what you do is pretty much the same as you would do post extraction, but obviously you’ve got your defect created for you by virtue of extracting the tooth in any case. Now, the next question is, how far do you take the composite addition into the extraction socket? My suggestion, there is some nuance to this and we can talk about this later on if you want, but to be safe.

I would take it three millimeters in first of all, three. So what you do is exactly the same thing. Signum onto the base of the pontic bit of composite resin. Take it into the extraction socket. Clean it up with an IPCL. I often sometimes use a number three brush, as well as some modelling resin, just to smooth it.

Light cure it. Mark the position of the gingival margin. Take it out. Trim it back so it’s in three millimetres. Cement it. Then, I would typically leave that alone for about six weeks. And then after six, there’s no good data on this, by the way, after it’s just kind of, this just was worth the years. After six weeks, I would take the thing off and I would shorten it to two millimeters.

And then after 12 weeks, I would take the thing off and shorten it to 1 millimeter. Now, there are some nuances. If the patient, what you need to look at is your relative risk of losing tissue and creating a Seibert class 1, 2, or 3 defect. Now, obviously, if the patient has very little bones surrounding that tooth buccally, for example, they’re a periopatient.

They’ve lost tooth, they’ve lost tissue, bone tissue, as a result of a periodontal disease. Or perhaps there’s a root fracture, and they’ve lost bone as a result of that. Or a perforation, or something like that. When you take the tooth out, you’ve lost a lot of buccal bone. So, your risk of the whole thing collapsing is quite high.

So, in those cases, I might leave it, after my second adjustment, I might leave the whole thing one and a half, two millimetres into the tissue, rather than shortening it to a millimetre, because otherwise the whole thing’s going to collapse in. You’ve got to temper that with a patient’s ability to clean it.

So if they’re a periopatient, and they’ve lost tissue as a result of periodontal disease, and their oral hydrogen is immaculate now, you might want to leave a couple of millimetres in. If it’s not so brilliant, you might want to take it a millimeter and take the risk. It’s difficult, and there’s no hard and fast rules there.

[Jaz]
And in terms of the healing there, Jason, I suppose the biological width just re established itself based on the most apical extent of the ovate pontic, and it just heals around it. And so there’s no preparation needed because the defect is there and just heals around the pontic and the biology sort of sets itself?

[Jason]
Yes, except in patients that are Kois, who K-O-I-S, who originally described bone sounding, which I kind of talked at about earlier on to some degree, actually describes people as being high bone crest, medium bone crest, or low bone crest? What that means is how the bone relates to the cemento enamel junction of the tooth.

People whose bone is close to the cemento enamel junction, in other words, have very short biological widths, are high bone crest, and people whose bone is a long way from the cemento enamel junction are low bone crest, and most of us are somewhere in between. In the patients with high bone crest, you’ve maybe got to consider, because they’re at low risk of losing tissue. Does that make sense?

[Jaz]
Yep, they’ve got plenty of bone, healing capacity, and yeah, more tissue.

[Jason]
And the bone is super high. So those patients, you might only want to tuck it in a millimeter, and you’re at very low risk of losing a ton of tissue. People with low bone crest are at super high risk of losing a tonne of tissue, so they’ve got to be managed slightly differently.

So, there are a lot of, and then you’ve got the medical contraindications, and then you’ve got, in terms of their healing, and then you’ve also got to think about their biotype, the thickness of the tissue itself. Some people have thick biotype, super thick tissue. Some people have thin biotype, really thin tissue, and it’s usually related to the thickness of the connective tissue rather than the epithelium.

And you can get away with quite a lot with people with thick biotype, and you will, sometimes, you can do everything perfectly, and it doesn’t come out quite so well in people with thin biotype, just because their biotype is quite challenging to deal with. So these are all other factors that you’ve got to factor in, but what I’m trying to do over this very short podcast is to just give a feel for a general approach, really.

[Jaz]
Yeah, yeah. It’s impossible to cover every single case, and it’s also case dependent, and so many biological biotype variables. But just on that, like, does the thick or thin biotype, how could that influence how deep the ovate pontic goes? Can that influence whether it goes a millimeter or more towards the two-millimeter mark?

[Jason]
So, now we’re getting into super nuance now. I mean, if you bone sound generally around their mouth and you’re seeing thicknesses of like four millimeters, and you only put three millimeters for your pontic side.

[Jaz]
That could be an issue.

[Jason]
It could be. Do you see where I’m going with that?

[Jaz]
Yeah. Yeah.

[Jason]
All right. So, this is where it gets into really. I hesitate to talk about this broadly on a podcast because what I want to do is for people to go away and do specialist procedures that people have spent five years training to do and probably 20 years learning it and have problems.

[Jaz]
Very valid. And I think, this would be a good point to just finally conclude and say can you tell us about the E pontic and how may perhaps you’ve already describe it? How does the E pontic differ to what you’ve said so far?

[Jason]
Alright, so the E pontic was first described in 2015 by a guy called Korman, an American, as in, if you want to read about it, I think it’s, a Journal of Esthetic and Restorative Dentistry, JERD.

Alright, so, your ovate pontic is a bullet shape, and your E pontic, and it penetrates a millimetre to a millimetre and a half into the tissue. The epontic is completely different. The epontic, rather than being a bullet shape, is, on the facial surface, it is flat. From mesial to distal. And the flat aspect penetrates a millimetre subgingival.

And on the mesial and distal, rather than it being a dome, it’s a right angle. So it’s very square. And then on a palatal surface where an ovate pontic penetrates a millimeter on the palatal of the E pontic, it rests at the level of the gingival margin. So what you’ve got is this straight, flat surface coming up like that.

This being facial and this being palatal, this being a millimeter sub G, this being super flat. Because it’s flat, it’s still cleansable with superfloss. But the concept is that because you’ve got a right angle mesially and distally, it supports the papilla more. So the thoughts are, the general, in Korman’s paper, he describes the fact that he feels that the stability, certainly papilla wise, is much more stable with the epontic rather than with the ovate.

Nobody’s actually done a prospective trial on that comparing one with the other. So we don’t really know. What I would say is, in my practice, if somebody has thick biotype and I create my pontic at the time of extraction, I’m probably going to go ovate because it’s a little bit easier and my relative risk in terms of their biology is quite low.

If I’m doing post extraction and they’ve got thin biotype, and I can’t change the biotype if they’re not prepared to have a graft, either they don’t want it or they’re not prepared to pay for it, so I can’t change their biology, I might go E pontic, because they’ve got a better chance for papillostability.

Again, this is very much based on, on experience and a knowledge of biology. For anybody listening, I think it’s worthwhile reading all those boring papers and boring books about tissue biology, because you can’t do this predictably unless you’ve got a good idea of biology, and that’s really the key and it’s something we skip nowadays. It’s kind of tedious, but yeah.

[Jaz]
But it was great for you to introduce the E pontic. I’ll put some visuals there as well. And I will put the paper in the show notes that you mentioned as well. I think that’d be useful for people to go in. This said, consider this like a introduction to it. I had final two bits left, Jason of the spot. Really good out of interest-

[Jason]
Just out of interest for papers while we’re here. There’s a really good paper, I can’t remember the journal, but it was written last year in 2022 by a guy called Bill Robbins. You may have seen Robbins’ Operative Dentistry textbook. He’s a super nice guy. I met him at the Restorative Dentistry Congress in February. Yeah, Bill Robbins paper on ovate pontic last year was, it was super good, a really good overview.

[Jaz]
Excellent.

[Jason]
I’ll send it to you in a moment.

[Jaz]
Yeah, no, definitely. I’ll attach that to the show notes. So thanks so much. And with full credit to Dr. Robbins, that’s amazing. My final two bits is, Professor Robbins, that’s Professor Robbins to you all.

Okay, fine, good. So that’s amazing. And I’ll add that. So thanks for sharing that. Final two bits is, any tips on lab communication? And the final bit is, I’m going to tell you the dodgy GDP way that I’ve done it, and I had pretty good results, but you can feel free to critique it and tell me where I’m taking the risks. I know where I’m taking the risk, but you can critique me on the things that I could be doing differently. But I’m, yeah, saving time. So, but anyway, any lab tips that you want to give?

[Jason]
Alright, so you got lab tips in terms of the provisional, and lab tips in terms of the final. The provisional, I would ask them to create the ovate pontic in the model.

So that when you make your lab provisional, the gingival margin and the zenith are in the correct position right from the get-go, which is going to save you a lot of trimming and mucking about. So that’s the first thing. They can either do that with a scalpel or my lab just do it with an acrylic bur.

They create the pontic site with the acrylic bur, put it where I want it. I could, I can mark it on the model with a pencil if I want, or we can mark it digitally. And then that’s that done. In terms of the final, there’s not much lab instruction, other than the fact that you don’t want to scrape the model, which we mentioned earlier, which they’re oftentimes really tempted to do.

The other thing is, and I mean most of my bridge work nowadays, is zirconia. Now, if you look at the studies, tissue likes zirconia more than it likes ceramic. So, if you get the lab to create the superstructure, the framework of your zirconia bridge, that fits precisely into your ovate pontic, so that your pontic site, which is sub g, is entirely in zirconia and is not layered or give you a better tissue is more tissue friendly now.

Obviously, you’ve got to hide that. So there is a product, it’s essentially a powder-based tint, which labs use called Miyo, M-I-Y-O. And they can use that tint, the zirconia, so it would appear like it’s a root. And that’s how we deal with, obviously we don’t tint the fit surface, just a bit, maybe half a millimeter out, and then you get the look of ceramic, but with the business end, let’s say in the zirconia, so that will give you a better outcome. And I don’t really think about that because my lab does that now because we’ve been through it, but it’s worth telling them initially when you start working with them.

[Jaz]
Okay. Brilliant. And I didn’t know about this Miyos. That’s great to be given a lot in this podcast episode. Thank you.

[Jason]
Miyos, brilliant. Miyos. Yeah.

[Jaz]
Never heard of it.

[Jason]
We used Miyo on Emax. Now, we don’t really do that many layered Emax. We just stain and glazes it and we stain and glaze zirconia. We don’t layer that. So the lab love it because it’s way quicker, better workflow, and I’ve got a stronger restoration.

[Jaz]
Amazing product. Brilliant. I look, I look into that. I mean, it may be the lab’s already using it, I don’t know, but it’s good to the name of mine, probably not, which is good. Yeah. Yeah. Fine. Well, I’ll speak to my tech technician. So, lastly, here’s how I’ve managed ovate pontics before when I wanted to cheat a little bit and skip the time for all the healing yeah, I know you’re going to hate me for it.

[Jason]
And I hate you already.

[Jaz]
I know you’d never do this but here’s my hack that I managed to do so if I’ve done my bone sounding and let’s say I’ve got five millimeters my bone sounding and I’ve decided that I’m happy to go to a two one point five two millimeter pontic.

What I will do is let’s say for a resin bonded bridge I will send my scan, or usually for me it’s a scan, and I will tell my technician. I’m going to go for an ovate pontic. I want you to actually create the ovate site for me. I want you to go in 1. 5 millimeters and either I’ll check it when they send me a WhatsApp and I’ll have a look to make sure they’ve gone in.

Now, when the bridge comes back, let’s say it’s a resin bonded bridge. It’s not going to fit because there’s tissue in the way. At this point, Jason, I’m going to get my thermacut bur, right, and just do it away until I can passively seat my bridge and there’s no more blanching. Now, I only do this in cases where there’s plenty of decent thickness of tissue and I wouldn’t do it in an overly aesthetic case on a young patient whereby I really want control, like crazy control over it. But that’s how I’ve cheated before. Am I really naughty?

[Jason]
All right. So the technique you’ve just described is actually in Bill Robbins’s paper that I recommended earlier. Right? So, it’s not too naughty. All right? The things I would say about that, I don’t think it’s a terrible solution and actually it is possibly a very acceptable solution for posterior units.

All right? So, there’s that. In the anterior, I would suggest, it’s been my experience, it’s very, very rare to find that kind of patient with that much tissue in the anterior. It’s quite unlikely. So, that’s one point. The second point is, certainly, if you’re doing an adhesive bridge, even with a thermacut bur, you’re going to have some blood, so you’ve got a complication of your bonding.

So that’s true. And the second, and the third complication is that your healing will be unpredictable. Most likely, you will get away with it to what’s called an acceptable level. But you’ve got a reasonable chance of tissue collapse, and you’ve got a reasonable chance of loss of papilla, or your prosthetic didn’t fill in the papilla in any case.

So I would suggest in the anterior, in the unlikely event that you’ve got enough tissue, it wouldn’t be a bad approach if you’ve got a patient. with low to moderate aesthetic demands. I would say suicidal in somebody with high aesthetic demands.

[Jaz]
Absolutely.

[Jason]
I’m not going to be, I’m not going to sit here and be ivory tower snobbish about it because I don’t think it’s a terrible approach. I just think it introduces some risks.

[Jaz]
Oh, yeah, there’s a lot more, it’s less predictable, for sure. And if you want predictability, you have to, there’s no shortcut here. I mean, I propose a shortcut, but then you’re sacrificing predictability for the shortcut. So, yeah. And then you’ve summarized it.

[Jason]
I think posterior units is, it’s not the worst idea. And actually you’re more likely to have the tissue in posterior units.

[Jaz]
Amazing. Jason, you’ve covered all the questions that I had and given so much value here, as you always do, Jason. We appreciate it. You’ve taught me a lot on your course for onlays way back when many years ago, vertical preparations. I’ve never actually attended your resin course, but everyone raves about them. Please tell us, I know you’re doing so much teaching in America here. What are the kind of courses that you’re running nowadays?

[Jason]
In the UK or the US or elsewhere?

[Jaz]
‘Cause we’ve got a 30% of the audience in the US now. So, I think the American dentist would love to know and also the UK dentist. And I encourage the UK dentist to go and do a little CPD tour around the world as well. So acceptable.

[Jason]
So in the US with the exclusion of some podium lectures, I’m, my hands on is pretty much at Spear. So I, I’m resident faculty at Spear Education, which is in Scottsdale, in Arizona, near Phoenix. Nice location.

If you want a sunny holiday, it’s a lovely place. Nice hotels, nice restaurants, good bars. Second to none facility with really good support. We’ve run a three-day hands-on course there. So, it’s three days of probably about 30% lecture, but the vast majority is hands on, and we cover class four, class one, class two, resin veneers, discolored tooth, peg lateral, diastema closure, and worn teeth.

And the interesting thing about that course at SPEAR, which is called Excellence in Composite Restorations, which is unique as far as I’m aware in the world, is that it’s not sponsored by one composite company. So what I’ve done is I’ve chosen four different composite companies. And the reason why I chose those four is really because their composite systems are all completely different.

In terms of application, so you get the chance to try four different approaches to the same thing. And it’s not kind of sales heavy, which I hate. And I’ve also created in that what I call a translation sheet. So there is, say I use, for example, I don’t know, Ivoclar’s enamel which we do on that course.

There’s a little translation sheet so you can look at that and then you can translate it to, for example, Tokuyama or Kuraray or GC or whatever. So you can basically do that class with the four different composites and if you like one of those composites you could buy that or you could translate it to the composite you’ve already got in your own practice and just carry on doing the same thing on Monday.

So that’s that course. The other hands on classes I do. Regularly there’s one in Australia next year with the Australian Dental Association, which I do regularly in Sydney and Brisbane, although we’re doing Melbourne next year.

[Jaz]
I’ve got loads of Aussies who listen to the podcast, so please just send me those links like just nice and easy place on the YouTube and on the blog page and the app just people to click on because it just makes it easier for everyone. But yeah, please do.

[Jason]
In the UK, yeah, I’m just in talks about doing something in England, but currently my main base is in, well, for the foreseeable future, my main base is in Glasgow, and we have a website called restorativeprogramme.co.uk, programme, double M, E, and we have a class which is Resin in September, which is sold out.

Sorry, and we also have a hands-on class in December, which I think there are spaces available on, which is Ceramic. So, in that class, we cover Ceramic Restoration. We basically prep a full upper arch, and we do onlays, we do onlays with margin elevation, we do partial onlays. We do crown preparations on posterior, on anterior teeth.

We do veneer preparations on anterior teeth, three different types of veneers. And we do crowns with vertical margins. And we also do the pontics, which we’ve discussed today. That class is again, fairly unique, I don’t, I wouldn’t say it’s totally unique, but I think it’s relatively unique for the UK in so much as it’s three days, three seven-hour days, entirely hands on.

The lectures are done by webinar, so the lectures are all prerecorded, so you get the lectures, basically you get the lectures when you sign up, most people get them a month or two prior. You watch the lectures, hopefully, and then you turn up and just do hands on and you also get the opportunity to watch the lectures for six months afterwards with online support. So basically, you get three days out of the practice and 46 hours of CPD. So you’re done for the year.

[Jaz]
Wow. Okay. And this is how all courses should be, in my opinion, or a theory bit that you can learn at home. You can. So I respect that you guys do that already. That’s awesome.

[Jason]
Yeah. Cause I was looking at that and I was like, well. If I wanted to take time away from my family and time away from home and time out of the practice and the cost of travel and the cost of a hotel, I don’t want to be sitting in a lecture hall listening to a lecture when I can listen to it online. And also, the fact is, if you listen to it in a lecture, you miss a bit.

You have to go to the bathroom and take a phone call or you missed it. And you’re asking a question while everybody tuts and sighs in the room, it’s already been covered. Whereas if you’ve got it on a webinar and you think, oh, I didn’t quite get that. You just rewind it, watch it. Yeah. Watch it even twice. So we commonly get people watching it. Two or three times. So that, I think that’s the future of education, really. Webinars watched at home and hands on done live. Blended, blended program. Yeah.

Jaz’s Outro:
Amazing. Jason, please do send me those links so I can put them on. And if you got, Professor Robbin’s paper, that’d be amazing as well. I’ll find the 2015 E pontic but if you have it handy, go for it. But if not, I’ll find that. And I’ll stick in the show notes. Thank you so much. Honestly, it was absolutely brilliant.

Well, there we have it guys. Isn’t that the best resource on ovate pontics you’ve ever seen? If it is, I would appreciate a comment or a thumbs up to show some gratitude to Dr. Jason Smithson. I put all his links at the bottom. He’s a great clinician to learn from. I would heavily recommend going on his courses, go to his courses in America. Right. If you’re in Europe, go to America, have a tax-deductible break and learn from Smithson and all the other educators in America. And for those of you on the app, you can answer a few questions, get some CPD. You’ve made it this far. You deserve some CPD. Thanks again for listening all the way to the end, and for those of you who heard the announcement about the event on Saturday 30th of September in Sheraton Skyline Hotel, we’d love to see you there. The website again is protrusive.co.uk/occlusion. Otherwise, I hope you enjoyed this episode. I’ll catch you in the next one.