PDP154 – Post Crowns – Historical Technique or Necessary Solution for Compromised Teeth?

[Jaz]
He’s very pro COMPOSITE FIBER POSTS. So you’ll find out today what his views are on that. But we take a big, broader view of all things to do with posts in terms of when we should be placing a post. What about restorability in general? If you’re thinking about placing a post, then you are also debating, ‘Hmm, is this tooth even savable in the first place?’

We also cover the very foundational concept of the ferrule, which is so, so important when you’re considering if you can rescue a tooth or not. And also in terms of the long term outcomes for post crowns in general. Lastly, if you stick all the way to the end, we talk about this real world factor of communicating fees to your patient, because if your patient needs a root canal retreatment, and a post and a new crown, you’re kind of in the implant money territory, you know? So this is like a tough thing to help our patients decide which is the best scenario for their tooth.

Hello, Protruserati, I’m Jaz Gulati and welcome back to another Protrusive Dental Podcast episode. Every episode I give you a Protrusive Dental Pearl. Today’s Protrusive Dental Pearl before you join the main episode is about bone sounding.

So what is bone sounding? There’s a couple different scenarios we can use it, but let me give you a clear one because I’ve got recording of this that I want to show you on the screen. And a standalone video for this on YouTube just about bone sounding. So essentially, imagine you are missing an upper lateral incisor.

You have your central, you have a canine, but you’re missing the lateral incisor. Now, if you want to do a bridge there and you want to use perhaps the canine and you want to cantilever, let’s say a resin bonded bridge, or maybe if it’s already a crown, you can do a conventional cantilever bridge. For example, and you want the pontic to look as natural as possible.

Maybe this patient’s got a high smile line, right? So what you would want to do is choose an ovate pontic, like an egg shaped pontic that emerges from the gingiva and looks very natural. But to do that, we need to squish, we need to compress that gingiva, the gum overlying the edentulous lateral incisor area.

Now, what you need to establish and find out is, how much wiggle room do you have? How squishy is this gum? If there’s lots of gum structure and you’re very lucky and you can squish it a long way, you can really get your technician to make a lovely ovate pontic and it can look extremely natural. But if it’s very thin amount of gingiva overlying the bone, then how can you possibly create a decent ovate pontic.

You probably can’t, you probably need something like a connective tissue graft there. So this is where bone sounding comes into play. Now, what you do first is numb the patient up. You anesthetize the patient if you like them. Okay, now please, please, please anesthetize the patient. Anesthetize the patient and then you get your perioprobe.

And what you want to do is you want to sink the perioprobe all the way into the gingiva. So when the patient’s numb and you’re actually penetrating the gingiva. All the way until you hit bone. Now, sometimes you feel some resistance and you think that’s bone, but actually that’s not bone. That’s probably connective tissue.

It’s a bit tougher. You actually want to really go for it until you feel a hard bony block. So you can’t go any further. And then you measure how far into the gingiva are you before you got to the bone. So if you’ve got something like five millimeters, wow, happy days, right? You can actually make a nice three millimeter ovate pontic that sinks into the gums and emerges really beautifully and that’s amazing.

But if you’ve only got two millimeters, one millimeter for example, then that’s no good, right? You know you need to think about some grafting or you can’t do a ovate pontic, you have to do another type of pontic like a ridgelap or something.

So bone sounding is useful in decision making, it’s useful in treatment planning, and I just go into this a little bit deeper and I show you an example case in this standalone video that will be clearly on the app, also somewhere on YouTube which will be a lite version. Please do check it out if you want to learn more about bone sounding, but the importance of it hopefully I’ve explained to you, and now if you didn’t know this technique of bone sounding, now you know.

Let’s join our main guest Dr. Dominic Hassall, and I’ll catch you in the outro. Dr. Dominic Hassal, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Dominic]
Very well, thank you very much. Are you all right?

[Jaz]
Fantastic. Thanks for making time for this. I’ve just done the school drop off this morning and now I’m in the zone. You saw me put everything to do not disturb. And this is, I love obviously recording podcast stuff. It’s just an opportunity to switch off from the world and immerse myself and the Protruserati in some good quality education, which I know you are brilliant at delivering. I’ve seen so much of your stuff before as well. So just tell us a little bit about yourself as a clinician and as an educator.

[Dominic]
So really my background is kind of conventional NHS kind of consultant training pathway. So did the kind of full NHS consultant training pathway, worked part time as a restorative consultant for a while, but really wanted to set up my own training centre and really set up a centre where I could treat patients as well.

One of the problems of being predominantly in the hospital is you don’t get to see many patients and you don’t get to do a lot of stuff. And I kind of like doing dentistry because I like doing dentistry, so it’s good to be in my own centre. Kind of doing my own thing really as a restorative specialist.

The great thing with that then is because you’re doing a lot of it, you can pass on that knowledge through the training centre to other dentists as well, which is great and what I love doing. So the mix I have with the two is great, really. Love doing both things, really.

[Jaz]
Great. And things have changed in terms of training pathways that are available now, which one perhaps available when you were making that decision about which pathway you should follow.

So you followed the STR training, restorative route, assumingly at the time that when you became a specialist you were on the register for all the specialties, is that how it worked? For restorative, for perio, endo, prostho?

[Dominic]
Yes, so you could sit the MRD. The membership in restorative dentistry and then nominate a specialty with that, but then when you came out with your full consultant training pathway and you passed all the exams for that you then became a restorative specialist but you could nominate another specialty as well that was of interest to you.

[Jaz]
Now, where I’m going with this question, Dr. Hassall, is if you were to do it now, if 2023 you’re applying for training, would you have gone down the same pathway? Would you perhaps have considered an MClinDent in prosthodontics, or would you have considered something different in terms of to get to the level that you are practicing at now?

[Dominic]
Very much depends what you want to do, but I think there’s much more options now. So, the institute here we run a sort of intermediate certificate, then an advanced certificate, then a diploma and an MSc, and there’s lots of other places do that. And I think if you want to stay predominantly within practice, I think that is a better career route now.

Because it’s kind of, and with myself and other institutes doing the online blended, you don’t have to take as much time away from practice. The trouble with a lot of kind of traditional institutes is, yeah, they’re either full time, which just isn’t doable for a lot of dentists, or they are kind of significantly part time two or three days a week, which again isn’t doable.

And if your ultimate gain, sort of aim is to kind of do what I would say high end private practice, I think you’re better off going down a kind of different training pathway really. And certainly with my institute, everything’s very practically based, very evidence based. So I think there’s a lot more options out there now than just the kind of traditional sort of training pathway and ClinDent. There’s, there’s much more flexible options now for dentists, which is great, I think.

[Jaz]
Agreed. And when I was at that crossroads and I was thinking, ah, should I go into specialist training? I really wanted at one point to be a restorative consultant, just like you, I want to be like that pathway. And then I did the hospital posts.

And I fell out of love with hospital and to be able to go five more years in hospital. I just couldn’t see myself having a fulfillment from that. So I went up the private route and lots of the more contemporary courses that you have, like yourselves, for example, and that has given me so much training, education and experience to be able to practice at a level I’m happy with.

Obviously, I still want to keep going, keep developing. I’m still a young dentist, but there are so many more options now than there were before. So you’re totally right on that. In terms of switching to the main topic today, which is Post Crowns. If we start with the very bare basics, we’re talking to dental students, let’s say, what is a post? Just start off with the general indications and how it comes into restorative dentistry.

[Dominic]
Really, I think the thing to think about with posts that the simple facts of the matter is the post is simply there to retain a call. That’s it’s only role. We’ve got to forget that, I mean, this has gone a long time ago, but there was all this kind of myth that posts reinforce teeth.

Well, posts don’t reinforce teeth. Anything you do to the root canal that is removing what is left of that root dentine is weaking it. So the only thing your post is there to do is to retain a core. Now that can be a core for either a crown, or a bridge, more traditionally. Or it can be there to retain a core for a composite build up as well.

So that is the only role of the post, is where you have very little coronal tooth tissue left. It’s simply there to retain that core. Nothing more, nothing less. And I think, if you get that sort of basic fact in your head, then you can’t go too far wrong.

[Jaz]
And when you were doing your restorative training, and compared to what you teach now, and what you practice now, tell us a little bit about if anything has changed in terms of either how much you’re using posts, or the types of posts you’re using, or the general philosophies and views on posts.

[Dominic]
Yeah, I think from when I did my undergraduate training, things have changed just dramatically. So, now don’t anybody go and do this, but when I was a dental student, we were taught to use paper clips as a temporary post crown. Now, obviously don’t do that anymore because the G-, that’s not going to go down well with your GDC or your defense union.

But no, we were much more aggressive. I mean, some institutes would, we’re actually teaching for you to decoronate the tooth to put the post in.

[Jaz]
Wow.

[Dominic]
When I trained as well, we were doing quite technical procedures like split cast posts on molars. And that has all changed out of recognition.

So I think the first thing that I would say these days is we just basically, we do far less post. So, with posterior teeth, what predominates over post now is the Nayyar core technique. Now, traditionally, the Nayyar core technique is basically opening up the access cavity, opening up the first two to three mms of the canal orifices, and then basically you used to pack amalgam in.

Well, things have moved on from there because we now have bulk-fill, low-shrink, deep-cure composite. So you can actually do the Nayyar technique now with, with bulk-seal composite. So, you don’t really need to do posts on posterior teeth, and all the dangers that come with that, with trying to get the alignment right, trying to make sure you’re not perforating the canal.

So, I haven’t done a post on a molar tooth in I would say decades. Premolar teeth I don’t think I’ve done a post on a premolar.

[Jaz]
Hey guys, it’s Jaz here interfering with a quick kind of testimonial or a positive comment that we received on Occlusion Basics and Beyond. So on our course platform occlusion.online, where we teach occlusion, Mahmoud and I, we ask for this bespoke thing whereby every lesson under every video lesson, we wanted to enable comments. So they didn’t have this before. So me and Mahmoud specifically requested it for this course that we want delegates to be able to comment under lessons. Now, we didn’t know how popular this would be, but we’ve been blown away about how many questions daily we get on the different lessons and discussions and debates.

And it’s been absolutely brilliant. And what Craig shared with us on July 1st 7:17AM is on a video where Mahmoud discusses the envelope of function. He said, ‘this was so well explained. You have a gift for this. I too always try to create some positive overjet with orthodontics, but with what you said made me realize, after you have assessed a patient for braces, you could well completely encroach on this envelope when you consider a maxillary fixed retainer.’

So what Mahmood says that if you’re planning orthodontics, you’ve got to have enough overjet for the envelope function, but also consider about how a fixed retainer will impact this. Could your fixed retainer be encroaching your envelope function? So I want to put this in A) to raise awareness about occlusion.online.

We’re super proud of it. We’d love for you to learn occlusion. If it’s something that you’re struggling with, let us make it tangible for you. And B) as a learning point, envelope a function. Have you got enough overjet? Have you got enough overjet? Once you factored in the position of the fix retainer as well. Let’s join again the main episode.

Before we move away from molars and go to pre molars and anteriors, just because people might be wondering, as you said it, is there a bulk fill composite that you like, that you prefer, like a brand that you use that you like for these purposes? I think often Protruserati are like, ooh, I wonder what Dominic’s using.

[Dominic]
Yeah, I like the 3M, the bulk fill one. I like because it works well with the new kind of universal bonding system that 3M have. It’s a nice handling material. But the other thing I would say as well is what we’ve kind of pioneered at the Teaching Institute is heated composite as well. And heated composite works absolutely fantastic for core build ups.

Because you can get it into the canal orifices. You can then start building up into the pulp chamber. Now you can only go to about 4, 5mm with that. So sometimes you’ve got to go 1, 2, for really heavily destroyed teeth, even 3. But yeah, that’s the material that I like to use. But don’t forget, pretty much every composite out there can be heated and used. You’ve just got to remember, it heated about 20 times, and that’s the limit that It’ll take, really, for heating.

[Jaz]
Are there any concerns about C factor, or is there any layering technique you recommend to minimize that if you’re doing, let’s say you’re building up a molar with a core with the composite dowels extending into the orifice, do you do it like the one sort of corner like a triangle’s or are you happy to connect walls with the modern composites?

[Dominic]
I think with the modern composites, particularly with the new 3M, because with the modern composites, they are much lower shrinkage than the older composites. In addition to that, basically you’ve got to have, because your composites absorb moisture, you’ve got to have a little bit of shrinkage in them for when they absorb the moisture.

So the C factor worries me much, much less than it used to be. Because these materials are much lower shrinkage. They also with the cross linking within the 3M composites, they absorb the stresses better. With the heating and the modern bonding systems, you’ve also got a much better bond and adaptation to the tooth.

So I think C factor, for those of us who have kind of gone to heated composite, worries us much, much less. The only time I would say that the C factor tends to come into play is, bizarrely enough, with the much smaller occlusal composites. That’s the only time the C factor kind of has more of a significant impact. But I think C factor with the modern composites is far less of an issue than it used to be.

[Jaz]
And if you follow the Bioclear protocols, they’re very happy to do that, the bond, and the flowable, and then the heated composite, and as they would also suggest that if you adapt your cavities correctly, then yes, C factor is much less of an issue with the modern composites.

Now you’re moving to, so basically the theme here is molars, you haven’t done a post in decades, and nowadays with the Nayyar core technique with composite. We probably don’t need to talk any more about molars and posts in this episode. You’re going to move on to premolars.

[Dominic]
Yeah. Now premolars, you’re in that kind of transition zone now coming towards the front teeth. Is there still a role for posts in premolars? Yes, I’d say there is to some degree. Is there a role for posts in anterior teeth as well? Yes, there definitely is. Much less of a role, but if you have a tooth that just has no, virtually no coronal tooth structure, then you are literally forced into that decision as to, well, do, first of all, do I extract the tooth?

Or, do I basically then, I wouldn’t say do something heroic, because it’s not heroic, it’s just, it’s going to have a shorter lifespan and it’s going to be less predictable. Doesn’t mean you can’t do it, but yes, I think that really there is still a role for posts. Definitely. Yeah.

[Jaz]
I think it’s all about restorability assessment and I think there are sometimes you look at a tooth and you think okay this one’s for the bin and that’s fairly clear cut and then on the other side this tooth is restorable with a Class IV composite.

We don’t even need to do an endo and it’s extremely restorable. And so when we get to the middle ground, the gray area is that, ooh, is this restorable? Is this not? Shall I use a post? Shall I not? So if we talk about those two things in terms of just quick and dirty guidelines for the dentist, in terms of at what point would you consider, okay, there is enough ferrule here, if you can expand on the ferule, obviously a big part of today’s discussion.

At what point is there enough ferrule to think, okay, let’s add a post on to retain the core and continue, versus, okay, at this point, the patient will be better served with an implant or something.

[Dominic]
Yeah, what I teach to, this is a study they use in America a lot, the undergraduate clinics. There’s an article by Samet and Jotkowitz, and it’s fantastic.

It classifies teeth as A, B, C, D, and F with very good guidelines are what is the prognosis for that tooth. So I teach that a lot within my courses, that article. And basically what you’re looking at with the post, first of all, you’ve got to be able to get a decent root filling in it. Okay, so you’ve got to be able to get a decent root filling in it.

And then it is all down to how much coronal tooth structure that you’ve got. Now, the one thing we know about posts is the importance of the ferrule effect. Now, the ferrule effect essentially means that when you’re going to prep the tooth often for a crown or an onlay, that you can get onto sound tooth tissue.

The benefit of that is that when the tooth absorbs occlusal forces, those occlusal forces then go down into the tooth. They are less concentrated in the core, the post, or the interface. And it’s interesting, there are studies on the ferrule going back decades which show how important it is. Even up to recent times, there’s quite a recent article by Pascal Magne.

And that actually looked at the ferrule being the most important thing in terms of post success. And we haven’t even got on to post materials yet. So the ferrule is absolutely crucial. Now don’t forget, if we can’t get a ferrule, we still have at our disposal surgical crown lengthening. We also have the use of lasers and electrosurge as well. So sometimes you can borrow a little bit of gingivitis-

[Jaz]
Orthodontic extrusion as well?

[Dominic]
Orthodontic extrusion, yeah. Do you know what? It tends to be less popular with patients, but certainly where that is very useful is where I’ve used it a lot in the past is with trauma cases. So you’ve had youngsters who’ve had trauma.

They also need orthodontics as well as part of a malocclusion and then you can do the two together. And certainly, yeah, that’s something I’ve used a lot in the past, is extrusion of the tooth. But don’t, that’s one of the things is how much of a ferrule can I get? Then if you can’t get a ferrule, the prognosis for the tooth is looking far, far poorer.

The other things with treatment planning that I think it’s worth mentioning now is you’ve also got to look at the occlusion. And when you’re doing that post core and that post crown, you really want to start treating it more like an implant and be trying to get a protected occlusion on it. So you want to be taking that final restoration out of the occlusion as much as you can.

So very low slack cuspal inclines. And the prognosis is going to be obviously worse if they are patients who are bruxist. If you can’t take the tooth sort of out of the occlusion almost. Then the prognosis is going to be worse if you see what I mean.

[Jaz]
That makes total sense, by the way, in terms of the first time I saw this was in North East, I was in, dental school in Sheffield, prosthodontist, and I was reviewing one of his patients and there was a canine which he did a post core crown.

It looked lovely. But it was slightly buccally positioned. It looked very natural. It looked like slightly crowded. And I had a look. I wonder why he’s done that. And I spoke to him. He said, ‘Oh, it’s because it’s a very compromised tooth.’ We want to treat it like it is just like you said, like an implant, which is like a novel thing to me at the time.

So that was an interesting use of that. Now, before we move to the next points, one, just touch back on the ferrule, how important is it in your opinion? Cause we don’t know that the full facts on this in terms to have ferrule a hundred percent all the way around, or is there a minimal percentage like, okay, I’ve got good feral, 70%, this will be enough, any guidelines on that?

And then exactly how much vertical ferrule is ideal for you? Obviously the more the merrier, but the papers say 1. 5 to 2 millimeters. Is that what you teach and what you follow?

[Dominic]
Yeah, the papers very much are 1.5 to 2. So I would still go with that. I would say, yeah, ideally you want to have the ferrule all the way around.

Is that always achievable? No. Okay? The other balance is, yes, could I surgically crown lengthen it, could I laser it, or electrosurge it? But then don’t forget if you’re going to do that, the patient is going to accept at some point that the tooth is going to be slightly longer. Now that maybe is, that’s obviously more of an issue in the aesthetic zone.

So if they’re happy to accept a slightly longer tooth, I would go for a longer tooth to achieve the ferrule. But I think that’s very important. Also, if you’re going to be just lasering or electrosurge, which is always a whole kind of just topic in itself, you’ve got to-

[Jaz]
I’m so sorry, Dominic, because it’s really important for the students listening to this, just to make clear for them, by longer tooth you mean at the gingival level, so, it’s going to be a higher gum line.

[Dominic]
Yeah, you’re going to have a higher gum line which for say if the smile line is low and the patient is happy with that and you consented them it’s not a problem.

But say it’s an upper central incisor with a high smile line then that potentially isn’t going to be a starter for them really. They’re not going to go for that.

[Jaz]
And what about the position of the ferrule? So you know I’ve heard some people say that if you’re missing mesial and distal ferrule and maybe it’s half a mil, but you’ve got three or four mils of palatal ferrule, we’re talking about an upper incisor, that is actually looked on more favorably. Would you agree with that sort of mindset?

[Dominic]
Definitely. Yeah. I think really with the way it’s going to absorb the forces. I think, yeah, you can accept if there is a little bit of mesial or distal ferrule missing, but realistically, yeah, you want to have a full palatal and a full buccal ferrule, definitely.

So, ferrule predominates, okay? Yeah, and I think that’s very much, have a discussion with the patient, because I treat all sorts of patients. Some patients, that would be the end of the world for them, that aesthetic compromise. But, if our patient is more kind of functionally driven, then that is less of an issue for them and they’re happy to accept that.

[Jaz]
So that’s restorability is very much hinges on the ferrule availability. And so you want as much as you can. But in terms of that decision, that tipping point of a post, any guidelines on that? Sometimes endodontist, they’re faced with a scenario where they’ve just finished the root canal and they’re looking at that tooth structure and they’re just about to put their core on and they’re thinking, should I stick a fiber post in at this point?

Because we know that endodontist generally are very much against cast post and we’ll come onto that shortly compared to some other dentists. But yeah, where they’re deciding shall I put a post in any guidelines that you could suggest to an endodontist, a young endodontist in terms of stick a post in this scenario, but perhaps you don’t need it in this other scenario. Any guidelines on that?

[Dominic]
It’s tricky. What I tend to do with the course is we have a number of photos of teeth with different amount of, or different lack of coronal structure, and then kind of decide when you would need the post, if you see what I mean. But yeah, I would say much more these days, we’re kind of going much more for the heated composite and the direct Nayyar.

I mean, if the tooth is virtually completely decoronated, but you can get a slight ferrule all the way round. Then I think you’re going to have to go for more of a kind of traditional post, if you see what I mean.

[Jaz]
By cast post? You mean, by traditional you mean cast post, yeah?

[Dominic]
Oh, no. I’ll come on to that in a bit. What I would say is a kind of, an indirect post, basically.

[Jaz]
Okay.

[Dominic]
Yeah. Post materials, I’ll come on to in a second. The more buccal and the more lingual wall there is the less likely I am to go for what I would say an indirect post rather than a direct heated composite post.

[Jaz]
Okay, brilliant. Well, this leads nicely into post materials So let’s say you find a situation where you have a doubt that if you do not place a post here you worry about what is retaining the core and you’re relying too much on the adhesion at that point, and the quality of tooth structure may not be so brilliant. So if you add post in that scenario, it could help to aid you in retaining that core so you can then proceed to placing a crown there.

So in terms of materials, what are your thoughts? Probably changed a lot over the decades in terms of what you were taught because you’ve got lots more new materials as well. What are the sort of decision making in materials that you employ?

[Dominic]
Now, the other thing I would say is, again, I would not have done what would be termed a more traditional cast post in probably 20 years as well. So all the posts I do are composite fiber posts. The brand I use, because it served me well and the drill kit is quite straightforward, is the ParaPost. So it’s a composite post that they do. There’s lots of other brands out there, but that’s the one I use. And I think the next reason is why go composite fiber post?

Because I think the thing with posts, the first thing you’ve got to tell the patient, this is kind of last chance saloon. So when we do this post, you’ve really got to be thinking about in a number of years, where is this tooth heading? Which is going to be extraction, and then it’s going to be either a gap, an implant a denture or a bridge.

Why go with the composite fiber post? There’s a number of advantages to them over cast metal posts. Now don’t forget with cast metal it can either be just a cast base metal or it can be a cast gold post. So if you’re going to go cast post I would always go cast gold post rather than cast metal.

The aesthetics are better with it, there’s less corrosion issues with it. But, essentially, I would go composite fiber. They are a different concept to a cast post, because the modulus of elasticity, or the stiffness of the post, is similar to the dentine. So it will actually move with the tooth slightly.

Now, what are the advantages of it? Well, number one, if you’re going to go for a composite over the top of it, or basically an all ceramic crown over the top of it, you have no cosmetic issues, because you’re not trying to hide the dark grey post underneath. The other fact with them that I like, because as a restorative specialist, all of us are heavily involved in implants as well, the mode of failure of a composite fibre post is better.

Now, when you look at the studies, generally how they fail is they fracture at gum level. The other mode of failure, which I don’t see a lot, is that they actually fully de-bond. Now, the good thing about that is when it fails and it fractures at gum level, you can show the patient, this tooth is now unrestorable, you make them a little partial denture, just a little flipper partial denture, and then they can think about their options.

The mode of failure with cast posts is really troublesome, because what tends to happen with cast posts is they fail, but they’ve split the root. Patient comes in, you’ve got a quick emergency review. You’re like, oh crikey, what are we going to do? They’re going on holiday. You wash it, you clean it, you particle-abrade it all, and you recement it.

The trouble is, in the meantime, there is a crack in the root, you’ve now got bacterial ingress into the bone, and you start losing the bone. And I’ve seen instances where people have kind of nursed along failing posts for six months, twelve months, two or three years. They then decide, right, I’m going to have an implant now.

The implant is a lot more troublesome, because they have no buccal plate. And so they just don’t have the bone for simple implant placement. So the mode of failure with cast posts is much poorer. So I would rather go for a composite fiber post. Does it take less force to break them? Yes, it does. But then when they break, the mode of failure is much, much better, much, much better.

[Jaz]
You mentioned earlier about indirect posts that you would use though, right?

[Dominic]
Oh, yeah. The composite fiber post would be the only one I would use, to be honest now.

[Jaz]
Okay. In my mind, that’s like a direct technique. I mean, indirect being lab work.

[Dominic]
Oh, yeah. Indirect with an impression. No, I wouldn’t do that at all anymore.

[Jaz]
Okay. Got it. Got it.

[Dominic]
I haven’t done it for ages and ages.

[Jaz]
Got it, got it. And then what I touched on earlier for those listening about endodontists, why endodontists worry is because if you’re going to go for a impression and a class technique and an indirect flow with a lab, then you have to put a temporary post and what the endodontists think is that temporary posts are the devil’s work when it comes to micro leakage. You’ve just done a beautiful root canal and now there’s leakage and that’s always been my concern as well.

[Dominic]
Yeah. And I think the other thing with the composite fibre posts, what the studies show as well, Is they don’t need to be that wide, because certainly when I was at dental school you were taught to keep widening the canal to get the biggest post in.

No, you want to go for a relatively narrow post. And with all the current bonding technology we have, it doesn’t need to be extremely long either. Okay, because we were taught to widen out the canals. No, you can go for a fairly narrow post. So once you’ve got rid of the gutter percha, and once you are onto the root dentine, you can pretty much stop.

And then lengthwise, as long as you are going realistically, you’ve obviously got to go below the bone crest into the root. As long as you are doing that, you don’t have to have posts that are 13 millimeters long anymore. Because the risk of perforation is too great with those.

[Jaz]
That’s true. And just to make clear to any dental students, the reason why you want to go beyond the bone is?

[Dominic]
Basically, you’ve got that bracing effect. And you see with implants as well, sometimes implants that lose bone the top of the actual implant itself can break because it hasn’t got that bracing effect from the bone. So you really want to get below that level there. Yeah, definitely.

[Jaz]
Have you seen or used some of the new posts? I haven’t used them myself yet, but the actual fibers that they place and they sort of are building up the posts as they go along by using sort of pieces, strings of fiber, if you like. And then they’re making this, I see the benefits because you’re essentially using a fiber and then you can adapt to the shape of perhaps an oval shaped canal. Have you used that yet? Have you seen it often?

[Dominic] I haven’t used them as yet, but I have seen them. Where I think they have a role is when you have an endodontically treated molar. But you’ve been quite clever, so you haven’t gone for straight line access down the canal, so you have a lot more coronal tissue.

And I think those sort of, what I have seen the endodontists doing, is kind of mixing those fibers with composite. rather than going for cuspal coverage on the tooth, essentially. But if you’re going to use those endodontic techniques, you kind of need to know exactly what you’re doing with it. They’re not the easiest to master.

[Jaz]
Sure. So to summarize, your philosophy on posts is composite fiber posts. When you need one, then that’s what you’d go for. We don’t need to certainly we don’t want to prepare the canal any more than necessary because that’s going to weaken the tooth and that’s definitely something I was taught as well at dental school.

Pascal Magne, he’s quite a biometric group. They’re quite anti posts. I think you are as well, in a way, you don’t want to have to use them unless you really have to. What do you think about that?

[Dominic]
You see, because I’m a restorative specialist and I do everything, I just kind of look at the bigger picture. Pascal Magne he’s very implant led, if you see what I mean. The trouble with some patients is, first of all, there might be contraindications to implants. They might be diabetic. They might have periodontal disease. They might have this, they might not be in the best health for implants.

So if there’s any contraindications to implants, that’s going to affect my decision to try and retain the tooth for longer, essentially. Also, I think the one that we haven’t touched on as well is, is the cost of it as well.

[Jaz]
I was just going to come to that. In the real world conversations, because these are the, if you’re factoring in potential a re-RCT, a post, a new crown, and then you’re not too far off in implant territory, this is where it becomes a financial equation.

I’d love to hear what you think about that, also how you communicate that to patients. Ultimately the patient decides, but we need to lead and guide them as well.

[Dominic]
Yeah, I think that’s the other thing, that when you start adding up the cost of saving the tooth, you want it to have a pretty good predictability.

[Jaz]
That’s it.

[Dominic]
Sometimes it’s very patient led because you have these patients who basically write, yeah, I’ll do anything to save the tooth. So those are easier to treat because, right, yes, we’ll try and save it. You then have the patients who are very much, well, what do you think? What do you think the best option would be?

And sometimes you’ll be like, look, you’re a smoker. You’ve got periodontal disease, you’ve got and I see this on a weekly basis, you’re diabetic as well. I don’t think implants are the best thing for you, okay? I think trying to save the tooth is going to be the very best thing for you, because you’re not a great candidate for implants.

Whereas with other patients, you look at them and they have immaculate oral hygiene, they have no medical considerations, and then when you start weighing up the costs of it, you’re leaning more towards extraction and implant placement often with those patients. But I think the other thing with the sort of Pascal Magne, it’s kind of what we’ve experienced with post crowns, and it’s the mode of failure of cast posts.

That they come and see you as an implantologist and you’re basically right. I’ll take the tooth out, I’ll clean it all up, but then you’re going to have no bone left. And then you’ve got this whole other issue of what are we going to graft it with? Are we going to graft it with an autogenous bone?

Are we going to use a bone substitute? And all the aesthetic considerations that come with that as well. So it’s tricky. But yeah, I’m definitely not anti post. I’m anti cast post. But I think, yeah, I think the cost is saying you’ve really got to factor in as well.

[Jaz]
I’m going to make up a pretend scenario. Just, this is a play with me here. Patient, 34 years old, male. Has an upper left central, which has a shoddy root canal, and now it’s fractured. You’ve got two millimeters of ferrule to play with, 360 degrees. If you treat him, obviously you’ll need a re-RCT, post and a crown. But we can also go for, let’s take it out and go for an implant. He’s otherwise medically fit and well. Are you trying to save the tooth for this gentleman, or, are you suggesting implants as the first choice?

[Dominic]
I would sort of say 50 50. I would say, if he was 20 years young older. Yeah, it’s how long the post is going to last because posts, there’s lots of studies showing on average how long posts last, but when you do a post, it’s going to have a compromised lifespan.

So certainly with an older patient, you’ll be thinking actually this might see you through if you see what I mean. This may be your final restoration. The younger patient, you may be better off doing the post because then you can delay the implant for 10, 15 years if you see what I mean. And there’s no doubt with implants that technology moves on all the time if you see what I mean.

So, with a patient like that, I would be to some degree more inclined to try and save the tooth. But it also depends what is happening around it as well.

[Jaz]
The occlusion, the aesthetics, the gingiva. It’s a very open question, but it’s, without showing you a specific case, but, I think you touch really well on occlusal, the periodontal factors, aesthetic factors, low lip line, high lip line. We covered a lot there. Any final points for those Protruserati listening about posts in general that you’d like to add in there?

[Dominic]
I’m just trying to think. I think we have pretty much covered everything, but yeah, I would kind of shed away, I think, the kind of anti post kind of movement with some endodontists, I think that’s justified to some degree because of old cast posts, but certainly with composite fiber posts, I think when they fail, no, you’re still fine for the implant, which is great. So I don’t think that, I don’t think they compromise the implant site as they used to because when mine fail, you know, and I’ve been doing them for 20 odd years, so I have had them fail, they tend to be fracturing at gum level.

Or, very rarely, they just completely de-bond, but it’s virtually unheard of that they actually kind of split the root and you can stick them back in. So I think in that respect, I think it’s just looking at it and thinking, well, what do you think is going to be the best thing for that patient? The final thing I would say about it as well is because also, the one that we didn’t touch on was using posts as bridge abutments, because that’s the other thing. And certainly what the studies tend to show is that if you can get a ferrule and control the occlusion, that basically a post is a reasonable support for a short span bridge. So basically three units.

But where they start to obviously just break down these longer span bridges. So that’s a question I get asked a lot is, Ooh, I’ve got this post crown three. Can I use that as a bridge support to a six? And I’m very much, no, basically. That’s a poor prognosis.

[Jaz]
Let me throw a curveball in there. What about a cantilever off a post, crown tooth?

[Dominic]
Definitely not. Cantilevers tend to be bad news, full stop. But yeah, you’ll see them occasionally. You’ll have a patient walk in, you take some x rays of them as a new patient, and they will have a cantilever, a cantilever bridge off a post crown.

And they do well, but statistically, posts don’t do well as cantilevers and cantilevers don’t do as well anyway.

[Jaz]
Yeah, I’m not as brave now I mean if I’m going to be doing a cantilever It’s either going to be a resin bonded bridge with lots of enamel or it’s going to be a decent perhaps it’s an old crown that we’re taking off and you see lovely to structure inside that’s probably going to be a scenario where I would but otherwise I totally agree.

I can’t risk doing a cantilever off a post crown tooth, but it’s good you mentioned that. It’s perhaps a short span bridge. It can still be a consideration. I’m very glad you mentioned that. Dominic, where can we learn more in terms of, because you said you do a blended program. So it’s online and in person. Tell us more about where we can learn more from you.

[Dominic]
Yeah. So I have the training institute in Solihull. Which is great, because we’re close to the train station at International Solihull, we’re close to the airport. And yeah, we run our courses in two ways. A number of years ago, we kind of moved away from just the traditional method, where people come once a month, or kind of once every two weeks to do the course.

And what we found was, we basically do sort of high quality, regular recordings of all the material. And so what people can do is they can effectively do half the course online. Now the beauty of that is you can do it when it suits you, on a device that suits you. You don’t need to take time away from clinical practice.

And then you can come and do that hands on component in a kind of five day block. And we do that very much for our Level 1 course. And we do it for our Level 2 course as well. You can still do it in the traditional method if you want to come more often. But we find that the blended format has become hugely popular.

And what I like about the blended format as well, if you’re not quite getting something, you can hit the pause button, you can rewind it, and you can watch it again. And then if people really aren’t getting it, we do an online forum, so they can just basically email you in and get the answer that they need.

And we did that, we kind of did that, oh, many years ago, about eight years ago now. And obviously COVID has kind of accelerated that kind of teaching now. So, it was popular before COVID, but it’s got even more popular now as well.

[Jaz]
What I like about that is the maximizing the hands on. When you’re coming, you’re taking time off from work. You’re not just sitting, listening to lectures, which you could have done online at home. You’re really maximizing the hands on. Is that the kind of way you do it?

[Dominic]
Yeah, we find people are just better because they’re better prepared. You can come in to do the practical, you do a short little recap, and then they’re straight into the practical.

And then you can have, just a really enjoyable time with people just getting on with what is the job of dentistry, which is the kind of, we can do practical exercises in diagnostic and then all the composite exercises. Or the inlay, onlay, resin bridges, conventional bridges as well. So we can do all of that.

Oh, and there was one thing yes, that, where people can come for all this information, if they go to dhti.co.uk, so if they hunt us down on dhti.co.uk, we have all the courses on there. But what we also have is we have what’s called the evidence-based toolkit. So what we have is a kind of wealth of all our materials on there.

Which I like because people can kind of get free CPD on there. But what is nice is that they can kind of see like is the courses that we’re offering the kind of course that they want to do if you see what I mean. Do they like the style? Do they like what we’re doing? And I think we have got running if i’m right, I think we’ve got a 10% discount or a discount on the courses at the moment. So if they use the discount code Jaz10, they can get a discount.

[Jaz]
Wow. My guys love a discount code. So Jaz did all, all about Jaz10.

[Dominic] But yeah, if they head to the website, they can have a good look at the evidence space toolkit, pick out some of the things that they want to have a look. We’ve got practical videos, lecture videos. We’ve got some of my articles on there. So there’s a whole wealth of stuff that they can have a good look at on there.

[Jaz]
Now, when they visit Solihull, is Solihull a good night out?

[Dominic]
Not bad at all. And Birmingham is a great city as well, because he must said when I left Birmingham to go to university at the age of 18, Birmingham was not the best city in the world. But over the last few decades, Birmingham has absolutely transformed as a city. They’ve kept all the best they’ve kept all the best bits and knocked down all the horrible bits and redeveloped it, so it’s great now. And Solihull’s good as well.

[Jaz]
Excellent. Dominic, thank you so much for your time today. I really enjoyed our chat. It was super clinical. I love these kinds of episodes. And we discussed real world scenarios about costings as well, which we said was really important to bear in mind. Very happy with that. Thanks so much for your time.

[Dominic]
No problem. Been an absolute pleasure.

Jaz’s Outro:
Well, there we have it, guys. Dr. Hassall is not a fan of cast posts, unlike Dr. Pasquale Venuti. So it’s nice to hear two different perspectives. You make up your own mind, listen to everyone and do what feels right to you. After all, I want to thank Dominic Hassall for coming on the show.

If you like his education, check out his course. He did mention the Jaz10 code and I’ll put everything in the show notes so you can always learn more. I always like to promote what our guests do because they’re giving up their time to have a lovely conversation with us so we can all benefit. If you want to gain CPD for this chat, then you can answer four questions on the app to get it.

You can even do a two-week free trial, rinse the CPD, and say goodbye. I don’t mind. As long as you’re learning, I’m happy. It’s on protrusive. app. So on your laptop, go to protrusive. app, or you can just download it on Android or iOS. It’s actually cheaper for you to get it on protrusive.app than on iOS, Android, and then you can use your login on iOS and Android as well. Basically, that’s the most cost-effective way to do it. You don’t pay any Apple fees. You don’t pay any Android fees, etc. The entire PDF transcript and the PDF show notes will be uploaded on the premium version of the app as well, alongside the CPD questions.

And as ever, if you enjoy the show, please do consider giving some thumbs up, some stars, wherever you’re listening. I’d really appreciate that. I’ll catch you in the next episode.