Success with Resin Bonded Bridges – PDP132

Jaz’s Introduction:
I’ve got plenty of friends in North America and in Singapore who felt that way. And I just feel like it’s a massive misconception because resin bonded bridges, or sticky bridges or adhesive bridges, call them what you want. They are such a fantastic and UNDERUTILIZED TREATMENT modality to replace missing teeth. Hello, Protruserati. I’m Jaz Gulati. And it’s no secret that I’m a huge fan of these bridges. I’ve published about this technique before and something that I did a lot of in dental hospital. And I took this into private practice. And the funny thing is that when I started to work in the practice that I work in now in Reading the dentist whose list I inherited, who was working there for 30 plus years, he was also a huge fan of resin bonded bridges. So, I’ve had the privilege of looking after and reviewing patients who’ve had their resin bonded bridges, both anterior and posterior in service for 34 years, 32 years loads in the 27, 28 year mark, plenty in the 20 year plus mark. So, he was fantastic at doing them.

It really validated my belief system in resin bonded bridges. But I know what you’re thinking, you’re thinking, ‘Jaz, that’s like N equals 15. How is that even valid in this world of evidence based dentistry?’ Well, let me tell you, the evidence is out there. And we will discuss it today because resin bonded bridges are extremely successful in the right cases. And we’ll discuss what those cases are and what clinical protocols we use to get that kind of success because I’m joined today my buddy Prosthodontist Dr. Salman Pirmohamed, who you may remember from Episode 97, about face bows. If you want to learn more about face bows, when to use them, when not to use them. You can go back and listen to that episode.

The Protrusive Dental Pearl
Now for this one, I’ve got a Protrusive Dental Pearl for you, which is relevant to resin bonded bridges, but also all types of indirect work. The Pearl is to always picture your path of insertion. Now, when I say path of insertion, most people usually think dentures right, we will always talk about path of insertion and a path of removal for your denture. But path of insertion is also relevant to crowns, onlays, and resin bonded bridges or any type of bridge. When you look at your prep, you have to visualize how is a technician going to insert and remove this indirect piece of dentistry. Because sometimes if you’ve got adjacent teeth that are tilted, it can really complicate getting a good path of insertion, in fact, recently had a tricky case where I wasn’t able to achieve a vertical path of insertion for my onlay so meaning, the technician agreed for a buccal path of insertion, it worked really well. It’s not something I do routinely or want to do. But it’s just something that worked out for me.

And it’s really important to just keep that in mind, especially when it comes to resin bonded bridges, which we’re talking about today. Whenever I’m doing a prep for resin bonded bridge, and let me tell you now, let me give you a spoiler is that there’s not much prep involved. But that doesn’t mean no prep. Minimal prep can often mean making guide planes and reducing maximum bulbosity. So we’ll talk about that today. But a little bit of work can go a long way to get a more desirable path of insertion. Let’s join Dr. Salman Pirmohamed now for the main episode on resin bonded bridges, which I hope will change your mind if you’re someone who is a doubter, a non-believer, then I’m hoping that will convert you to thinking a bit more about using resin bonded bridges successfully in general practice for definitive and long term replacements of missing teeth. Salman Pirmohamed, welcome back for the second time to Protrusive Dental Podcast, we had you before on the face bows, you know all about when and why to use a face bows and you did such a great job. And we’ve been geeking out on social media, by the way your posts, dental_story, you got to follow that account is brilliant. So educational, I’m loving it. And you’ve been posting a lot about resin bonded bridges.

Main Episode
So, let’s come on. And let’s help those who are either not warming up to the idea to resin bonded bridges. And we’ll talk a lot about that or who just want to improve their workflow. But for those who didn’t listen to the episode yet, please remind ourselves, tell us where you’re at in your career. The moment Salman tell us how you fell in love, like I did with resin bonded bridges.

[Salman]
Okay, so Jaz just to introduce myself again, because that was quite a while ago, we did a podcast on Facebook. So, my name is someone I’m qualified about six years ago. I’m currently at the Eastman doing my specialist training and prosthodontics and that’s three days a week. So, under the three days a week, very busy practices. Jaz found out this morning from my daily list three days a week in general practice, do you combination restorative and implant work. Resin bonded bridges like the real passion came about from quite a few things actually.

The first thing is Jaz mentioned, I’ve been posting a lots kind of clinical cases on my Instagram page. And the topic I get the most questions about is always resin bonded bridges and mainly from the international crowd. So, I think the UK-based census uses a lot more and maybe NHS hospitals have changed the way we replace missing teeth. But the people abroad they”re like ‘What you’re doing that you must be doing something wrong here. How is this working? How’s the occlusion settling down?’ And that’s why I thought this podcast might be a good idea and I’m happy that Jaz invited me on because I feel quite privileged to be in a crowd of people that he gets on.

[Jaz]
It’d be so good because I see the kinds of cases you do. And you also told me that at Eastman, you you guys are really pushing the bow, you got really pushing it to the extreme limit in terms of what can be possible with resin bonded bridges. So, we’ll talk about that a bit later in terms of okay, how far can you go? But yes, please carry on.

[Salman]
And the second reason is because at Eastman, as part of our specialist training, we have to have a thesis project or dissertation topic, and mine has been on patient satisfaction, it’s going somewhere quite a long title but, ‘Patient Satisfaction for Replacement of Missing Lateral Incisors’, and comparing orthodontic camouflage, dental implants and resin bonded bridges. And what’s odd is that we often recommend patients in different clinical solutions. But a lot of it’s not actually evidence based, a lot of prosthodontics is opinion, a lot of it is expert opinion, we say on what we learn from our teachers and our VT trainers along the years. And I’m finding that from the research that I read, actually, that resin bonded bridges come up with an almost equal or even higher patient satisfaction rate than dental implants.

And then Jaz, to finish the story here with the last reason I got interested in resin bonded bridges, because I started a new private practice about a year ago, and mainly to do some implant work. And I thought we were doing a lot of implants and a high number of them. And these patients are coming in for free implant consultations. And it’s a great way to improve my communication skills. But what happened is they were all working out with two implants for resin bonded bridges and my principal flagged up said, ‘What’s going on? We’re not ordering implants anymore.’ And I just realized that there are some really underutilized treatment modality that can give a massive benefit to our patients. And I’m sure Jaz share the same stories with the ones that he’s done also.

[Jaz]
Hugely underutilized. And that’s the first thing I want to tackle with you today Salman. Because just give you a bit of story when I was practicing in Singapore, if you remember I used to be in Singapore some years. And that’s when I realized that actually, it’s only in the UK and maybe some few select other countries in Europe, that resin bonded bridges are done to a high standard with good longevity and popular that even in the UK. And then when people talk about it on Facebook, they say, ‘It’s not going to work. No, it’s not going to work. You know, it needs a wing and a prayer.’ And all those funny jokes come out and whatnot.

But I realized it to the extreme level when I was in Singapore because not only did the local Singaporean dentists have zero faith in resin bonded bridges, the US dentist that were working as expert dentists in Singapore had zero faith in resin bonded bridges that they thought was like just it’s a very, very temporary solution before you have an implant. That was the only sort of indication for resin bonded bridge. And even then they weren’t convinced by that. And that and so what happened and the third reason why I think it’s underutilized is commercial. Because what happened when I was in Singapore, I was working for a corporate, I’d written my paper by then dental update, so and I was doing a bit public speaking in Singapore, and I said, ‘Hey, guys, you know, we have a monthly corporate study clubs, I’d be more than happy to come in because I realize no one’s doing this.

I’m more than happy to share with you some protocols, so everyone can feel more confident doing resin bonded bridges.’ They always reply to my emails and never reply to that one. Okay, because the most of the lectures were about implants and referring to their in-house specialists for implants, because what’s going to generate more money? Okay? Implants? Now, by the way-

[Salman]
I would argue with that.

[Jaz]
Well, yeah, I would agree with you. But actually, if you do resin bonded bridge as well and charge for them, they give you a good hourly rate, and how many years ago you got to it in terms of how much you spend, that ratio will be good as well. And I know I’m gonna go in that scenario. But as a commercial viewpoint as corporate, does it want to push its dentist to refer to implant or just for multiple implants versus, resin bonded bridge? I think they had a commercial motive not knowing that, okay, resin bonded bridges can work well as well. So, that is some of the things that I found when I was there. How about you, my friend, because you’ve been reached out on social media, international dentists not having faith, why do you think they’re underutilized?

[Salman]
I think with the American dentist a lot, they actually do a lot of resin bonded bridges, but it’s always seen as a temporary solution. So, the implant guys will always show like a big surgery. And then I have a resin bonded bridge in situ. And I say, ‘Yeah, we’ll take it off in three months and then restore the implants.’ And I just think like, well, if you just left it on, how long would it have lasted because it’s been pretty predictable, so far, without proper like bonding protocols and material selection. And I think that’s really funny Jaz with like resin bonded bridges as UK dentists, we’re often made fun of from the rest of the world in terms of our occlusal management, in terms of our restorative case selection.

But I think in this one scenario, there’s a lot that we can teach other people or just share different treatment modalities, because it’s working in this public healthcare system that’s kind of really made this treatment modality so successful. The question of working in a hospital is yes, there’s less risk involved and things fell, there are patients are paying, there are patients for free. But it’s when we really push the boundaries to the extreme where then the more routine cases become so predictable when I do them in private practice over here and charge patients appropriately for what you do because it will give them that quality of life that they want.

[Jaz]
So, Salman just a little history lesson for us how far have resin bonded bridges come over the years in terms of technology, why are they in a better place now, in terms of protocols?

[Salman]
So Jaz, I think enamel bonding has been around for I think 70 or 80 years a long time ago it’d be on a core in a study on acid and acrylic bonding and enamel etching and then resin bonded bridges has started about 50 years ago, initially Rochette bridges, so you’d have this metal retainer, they’d be stuck to a tooth, and you’d have holes within this retainer because everyone could stick figure out how to bond the enamel, but no one could figure out to bond to the metal.

So, they made this because they needed macro mechanical retention with HGSC or composite resin cement, we then went ahead in the University of Maryland figured out an extra chemical etching with the basic figured out that if you get a specific procedure to the metal, then our resin cements or bond really predictably and made our bridges is kind of stuck as a terminology, but actually the correct term is now resin bonded bridges because we don’t do the electrolytic etching the way the University of Maryland did, Kuraray came up with MDP primary, which has changed zirconia bonding and changed metal bonding and that MDP primary is how we figured out how to get really predictable bond strengths, and specifically to non-precious metals, because they’re the ones that get a thick oxide layer, very predictable bonding. And that’s how it started. And now it’s come even further now we’re looking at zirconia resin bonded bridges, but yeah, it’s been a massive evolution in the last 50 years.

[Jaz]
It certainly has now, I got a couple of points there. Maryland bridge, I know is not the appropriate time to use them all. But you know what, with my patients, I do use it. With my clinical community. I use resin bonded bridges, patients identify really well. They don’t like the term, I’ve just trialed it, you know, for has a nice ring to it. ‘Maryland. Oh, why is it called Maryland? Oh, from USA! Oh, okay, this is interesting. I like it.’ Resin bondedbridges sound too jargony. So that’s-

[Salman]
I call it a sticky bridge.

[Jaz]
Sticky bridge is also a good one. So, that’s good. And then as they evolved in terms of how we use it, and I think he’s really great, you mentioned about the MDP being so important, and allowing us to get some confidence. And a lot of the studies that we’ve done in the UK and abroad, but so much good stuff coming out from UK authors, which is why I think it’s done so well like my principal, who was in the same practice for 34 years and who I took over from. So, he was leaving the practice no longer principal as I took over, so all these patients in their 60s and 70s, I’ve taken off the list, they’ve all been seeing Giles for 34 years, loads of them have resin bonded bridges.

And then I’ve seen quite a few which had been there for 32 years, I’ve seen some for 25 years, and maybe at like the 15 year mark once it came away. And that’s it. And that’s just because I’m interested in this, I’d like to ask those patients, but so many of them have lasted so long and patients are really happy. But back to that question I was gonna ask you is to what degree do you think it can actually facilitate or become functional for the patient as in your sticky bridge or resin bonded bridge, do you expect your patient to be able to function on them?

[Salman]
Yes, I have a very, like long consent process for my resin bonded bridges. And as time goes on, even though I feel they’re becoming more predictable, I think we’ve always done the things Jaz of under promise and over deliver, right? And resin bonded bridges are very much like the rest of our treatment modalities. And when I give a patient the treatment options, the resin bonded bridge solution for me is non-invasive solution that has all the benefits of aesthetics. And I promise them really good aesthetics with that ponti, didn’t work for metal retainer are one of the sub optimal aesthetics with the metal retainer. And I’m often going for incisal overlaps when it comes to discussing function-

[Jaz]
And we we will by the way, we weren’t for those listening, we will talk about incisal overlap later is really important. So, we will touch on that in terms of designing your resin bonded in bridge. But yes, please carry on.

[Salman]
For me, when I go to the functional units, I tell the patient this is not a true functional unit. Because if you think about it, you’ve got one fake tooth attached to one real tooth and one real tooth is taking two teeth weights. And so I’ll say, ‘Always be gentle with this tooth, don’t use it like a normal tooth.’ In the back of my mind. I think if they use it like a regular tooth, they probably function just as well as a regular tooth. But I always wanted to be careful. If they’ve got one resin bonded bridge in their mouth and remaining unrestored dentition. I want them to be avoiding this area of the mouth because naturally that will prolong the longevity of what we’re providing. We know that our cements are good in compression, and they’re not so good intention.

And I designed my retainers in such a way that generally that retainer is always gonna be under compressive load. But if the patient is careless with its bites and forking the wrong way, it’s in the wrong direction, that’s when your cements are going to fell. And often if you talk to patients as to how to dispose them when the bridge come off, it’s so easy, just a random chewing motion. It’s usually, ‘Oh, I knocked it or something happened and then it came off and I regret doing that.’ So, they do work in function. But in terms of consenting patients, I say it’s not true functional unit and that’s the best way to look at it. Because the majority of resin bonded bridges have been done for aesthetic reasons, not for functional reasons it is postulated, which I’m sure that, later it’s a very, very different discussion.

[Jaz]
100% agree and so the commonly replacing lateral incisors, you know, using a canine or central so that’s the most common scenario and even lower incisors which I’m really passionate about. I’m so passionate about how we often use resin bonded bridges to replace lateral incisors and one thing I’m really passionate about Salman and I don’t know if you are as well, is I think as a international consensus in dentistry you know how they had the York consensus about the standard of care should be two lower implants for the lower denture of this person right, I think the standard of care for a missing lower incisor where appropriate should be a resin bonded bridge. Okay, Exhibit A. Exhibit A I’ve got my own resin bonded bridge replacing my two lateral incisors. After some orthodontics there’s one a pontic space and I’ve seen, I don’t know if you’ve seen before, some implants in place in a lower incisor region that’s just been absolute nightmare. And so I always think such a narrow space and-

[Salman]
I’ve got better story for you, Jaz.

[Jaz]
Go on, go on.

[Salman]
So, I’ve taken this audio clip from my iTunes podcast from my practice right now, my principal about 15 years ago, his associate was doing an implant training program and my principal with hypodontia, his lower incisor, so we did an implant placed, squeezed in between the two lower incisors. And about eight years later, he began having the complications from it. And so he lost both of the adjacent teeth. And that was three incisors and is mainly because someone tried to squeeze in implant and for an implant need that seven millimeters of interdental root space which there wasn’t in that case. And for me, the solution I know is narrow implants out with these implant companies. But often it’s just easier to look at simpler solution like resin bonded bridge, my principal now has a resin bonded bridge, which ones from the lower right canine to the lower left canine.

And that’s even more these years hitting off another implant solution because he had that bad experience in the past. And I think we also need to look at modes of failure, right? If you try squeezing an implant in what are you going to cause what’s the complications of it, just because the patient pays more initially doesn’t mean things are gonna last, they may last longer but the cost of complications is a lot greater. So, there’s a lot of factors to consider.

[Jaz]
Lower incisor region for sure. 100%. So that’s the main message I gave in. You know, I talked the talk when I walked the walk when it comes to that, but on that topic or function, so part of my consent is I teach my patients about how it works. And I really say like, ‘You know, can you believe that we’ve just stuck a bit of a thin strip of metal to your tooth, like how amazing is that? It’s just stuck onto your tooth. Now can you imagine someone just peeling it away? And then, ‘Oh, yeah, it could peel away.’ So I say, ‘Look, you can do what you want. Just be careful not to bite sellotape on it, not to bite into a baguette and tear the baguette using your fake tooth, you can use the good tooth next door, but you can’t use my fake tooth.’

So anything that requires you to put the food first or a tool on that fake tooth, and you’re going to lever it off. And I think that message really gets through, the whole tearing the baguette, tearing a crisp packet. And I think as long as you avoid that, these sort of freak of nature kind of incidents, you know, getting elbow and stuff, then they enjoy a really good longevity. And patients don’t often think about it during function to avoid or anything like that. It’s more about not doing anything stupid with it. Would you agree with that?

[Salman]
Yeah, no, I fully agree completely. It’s just about advising his patients properly about how to take care of her. So last and the longest time possible, completely.

[Jaz]
So on the topic of lasting as long as possible case selection criteria, because I’m sure dentists message you saying, ‘Is this suitable?’ And I get lots of messages saying, ‘Is this case suitable?’ And thankfully, the ones I get are quite sensible. Actually, though, the ones I get quite sensible, I don’t get too many far fetched ones thinking it’s a bit of a push, occasionally, you get one which is suboptimal? Because let’s talk about what other kinds of features that think that lend themselves to resin bonded bridge. And then what are the features that don’t?

[Salman]
Or what are the red flags, right? Essentially what you avoid?

[Jaz]
Red flags, how can we avoid being too ambitious?

[Salman]
So, let’s go through the positives first. The things that lend themselves towards a good resin bonded bridge, which I think for me like first thing is enamel. It’s just enamel, enamel, enamel. I don’t know if people talk about Dentin bonding now but for me, enamel bonding is what’s always give me predictability for a resin bonded bridges and I’m very open and honest about my failures too, even on my Instagram. I’ve had two resin bonded bridges that failed, and one of them was pushing the limits, and it’s purely because of substrate that I wanted to. I was trying to replace a lower incisor and both the adjacency for post full mouth reconstruction and had quite composite on them. And I thought I can get by composites fresh and it didn’t work. And it’s purely that quantity and quality of enamel. The it is the first main thing you need for predictability of your resin bonded bridge.

[Jaz]
100%. And you can also-

[Salman]
Would you agree?

[Jaz]
Yes, please. I was gonna say one thing that I know we’ll touch on is favorable occlusions and unfavorable occlusion bite but I know you’re gonna come to that as well.

[Salman]
So ideal patient, anterior open bite?

[Jaz]
Huge class 2 div 1, anterior open bites

[Salman]
Class 2 div 1, is like the opposite? Exactly. So I’d say bruxists are for me a warning flag for resin bonded bridges, especially when I tried to maybe go further back in the mouth to replace the missing teeth. So for me it was when the bridge is usually when you’re retaining to be larger than your pontic tooth or more stable. So people often look at either replacing natural incisors of the essentials or the canines. I’m quite happy to do that. Because the mouth we know it acts like a lever the functional forces are heavier at the back of the mouth, like a nutcracker in the lower at the front. So for me resin bonded bridges will last better at the front of the mouth.

More and more people say why don’t you do posterior resin bonded bridges and I have shown a few cases of mine on social media. But for me, they’re really really really case selective. So for me, posterior resin bonded bridge to replace, for example, an upper second premotor or for first molar is, it needs to be the perfect case there needs to be some existing into space. I don’t want to be relying on the DAHL approach too much. Because I know the occlusal forces there will be greater and so I’m worried about bruxists.

[Jaz]
The first ever group function I did was a question someone asked about, ‘Can you do DAHL using the resin bonded bridge technique?’ And yes, obviously we can. But then when I talk about that scenario with the first molar on adult I’m a bit more reluctant in private practice to do that. But in hospital I’m sure you’re seeing loads of the 17 year olds post orthodontic hypodontia probably using the canine as the abutment tooth in DAHL so the only contacts are on the retainers and then everything just settles. Am I right that you guys are still doing that?

[Salman]
In terms of replacing lateral incisors, Jaz?

[Jaz]
Yeah.

[Salman]
Oh, yeah, that’s a routine case for us. I just fitted a resin bonded bridge to place an upper five off an upper six. And we often know that post ortho patients may not end up in the most standardized occlusion. So this-

[Salman]
Split, split, nicely.

[Salman]
I’m very diplomatic, Jaz. So, we were looking at the existing volume of bone to replace the upper second premolar and we did all the implant planning, she’d been consented we took a CB CT, and we found like half a millimeter bone heights and it had been a major sinus lift to make an implant work in that area. And when I took the study casts, back to the lab as we do at the hospital and actually match them on the articulator, I noticed that the patient’s palatal cusps on 6s was fully out of function completely, there’s about a millimeter and a half of opening. And for me, it was just screaming resin bonded bridge, like you can bring the six back into function, you can keep your five pontic almost out of occlusion and very, very light occlusion. And we wrapped the whole winger and entire portion of that first molar. I’ve got photo Jaz if I can figure out to share my screen with that help with this?

[Jaz]
Let’s do that. So, for those guys that are listening right now we’re going to skip. You won’t get obviously see the cases because you’re listening not watching. For those watching on the YouTube or the app, which is going to be access point for general soon, you’ll be able to see the video, but first, we’re gonna skip past the video put components for those listening. Please describe what you see my friend, obviously people are watching but yeah, sure. Tell us about this case. Is that the case that you just described?

[Salman]
Exactly. So, this is the resin bonded bridge case we were planning an implant replacement, replacing the upper second premolar. And you can see when you had these articulate the study casts, the buccal cusps this patient six was actually crossbite. So I put buccal cusps in function. But the palatal cusps was totally out of function. As we managed to make a really thick, bulky looking retainer which had a maximum wraparound, which didn’t include the occlusal scheme at all. So we managed to give her a nice second premolar with a partial occlusal coverage of the six with a wraparound metal retainer. And Jaz, when I tried this retainer, when I tried the resin bonded bridge even without cement, I could barely get off the tooth.

[Jaz]
And that’s a very good point. And that’s all about respecting the path of insertion. If you’ve got a nice path of insertion, that really helps as well with some stability. Also, having an adjacent tooth next door as well, will help into positional stability as well, which is a good thing.

[Salman]
So, that’s one case and two most I have got dahl cases of 60s to where I have had to do them on some patients because some patients are not keen on implant surgery and they say, ‘Is there any other option?’ And I think as part of their consent process, as long as we advise them the risks of different options, we do it. So this is a patient, I fitted a resin bonded bridge in supra-occlusion. So, this is an upper six again replacing upper second premolar. It’s full occlusal coverage and we maximize all the way and you can see the occlusion as propped open and I think Jaz our international audience might be listening wondering, ‘What are these guys talking about?’ But yeah, this patient was asked to be occlusion on the anterior teeth and they came back in about three weeks and to stay with ICP contacts. So, it does work but my case selection is very much younger patients.

[Jaz]
I love the amount of wraparound you have on all on the occlusal surface there. I mean that is textbook from the classic studies that looks really great. And for those wondering what the hell’s a DAHL technique, please check out the episodes with Tif Qureshi, we talk all about the DAHL and there’s some I just want to point out, there’s some great work being done in the UK by Riaz Yar, really looking deeply into each and every dahl case. Monitoring them, getting digital prime scan records at every stage. T scan records before and after. So, watch your space because I think the DAHL technique understanding of how the biomechanics of it works is about to go a notch higher which is really exciting.

[Salman]
Yeah, so I’m not someone who’s going to advocate putting resin bonded bridge at the back of everyone’s mouth. So, firstly the mouth is a lever and if every millimeter we open up at the back, we’re opening three millimeters at the front and so your case selection needs to be really good because if you put a one millimeter thick resin bonded bridge retainer at the back, you’ll open up three times as much at the front but it works the reverse way around if you have a resin bonded bridge anterior in supra-occlusion you’re not waiting for much posterior DAHL to take place and the issue with that is it’s by its nature unpredictable. We don’t actually know what’s happening, which tooth is intruding, which one’s extruding and so you need to really limit your reliance on it as much as possible. So I’ll pick this posterior RBBs for very very similar cases. And I’m like you Jaz, the more I work in private practice the more I think, there was patient just go for an implant is a bit more predictable in specific situations. For anterior teeth, it’s almost my go to approach and I’ve got Sanj, good volume of an enamel.

[Jaz]
I’ll show you a risky one. Can you see this?

[Salman]
Oh my.

[Jaz]
Check this out. The same thing but it’s zirconia man, but this is an very favorable patient like he had a lot of space here. It’s just the way it worked out but this, it’s been going strong for about three years now so far. But yeah, this did sent shivers down my spine as I was doing this. Am I doing the right thing here? So, got some guidance because he is a cantilever resin bonded bridge and oh gosh, we didn’t talk about that actually the importance of cantilever as the standard design of choice and lot this busting this myth that actually you need to go for a fixed-fixed. So just talk about that, Salman.

[Salman]
Jaz, I recently had like a change of not a change of heart, I’d say. So, the evidence that everyone wants to look at is there’s a PA King paper 2015 which was the one done at University of Bristol. They went through like a whole bunch of resin bonded bridges in a hospital setting.

[Jaz]
So, the 800 I think it was.

[Salman]
The good for looking at that paper is they fitted them in all parts of the mouth. And it was done by a variety of people in different levels of specialty training, different registrars as they chose consultants and looking at differences in success rate between those people. But for me Jaz, fixed-fixed and cantilever I think our reports are like a two and a half times increase failure rate for the fixed-fixed resin bonded bridges, 2.34 I think or 2.74. But for me, it’s a bit of cause and effect also, like, so I’ve noticed that people will often sometimes pick a fixed-fixed resin bonded bridge, when they think it may not work in that specific situation. So they’re pushing the boundary, and then they go for the fixed-fixed bridge, and then they get that unilateral debond. And I completely understand that the benefit of having cantilever resin bonded bridges is you know, when it’s the bonded, you know, it’s come off, you know, you have to fix it. With fixed-fixed.

If you get a unilateral debond, you get that secondary caries. And you never figure out that debond in the first place. But I’m sure there’s some cause and effects hypothesis happening here, Jaz. Because there’s some fixed-fixed bridges that are ideal, so lower incisors for me, if the quantity and quality of enamel is equal on either side of the pontic, I may choose a fixed-fixed design in some specific situations, because I’m not worried about a differential rate of debond between those two retainers and the movement of those two teeth is pretty equal. Does that make sense, Jaz?

[Jaz]
100%. And I think I’ll just add to that, and I think what Salman trying to say is that, think of the way, let’s imagine you’re replacing a central and you’re gonna use a lateral and the other central, then yes, the ligaments, the teeth want to move in the same direction. What you want to avoid, let’s think about this scenario you want to avoid is doing a central with a canine which want to go in different ways, right? And that’s when it’s going to lead to more stress in the cement loop on one of those retainer wings. So yes, similar teeth that move in similar directions like lower incisors. I agree. And actually someone I regret not choosing a fixed-fixed on my own lower incisors. I regret it.

[Salman]
Because?

[Jaz]
Because post orthodontic retention, so sometimes you want to do post orthodontic retention. Now a bit of history here, I do have a degree of mobility on my lower incisors, orthodontics in the past is a funny little thing. So for that reason, to give me a some splinting effect. And for more predictable orthodontic retention, which actually a little bit of gaps are opened up, basically. So I wish I could have done that. And I think sometimes for the sake of orthodontic retention, or stability, when you’re dealing with mobile teeth, it can be favorable. So don’t think that oh, just because someone said you can’t do fix fix it’s not for all cases. There are certainly some indications

[Salman]
So, Jaz, I’ve got a few fixed-fixed bridges to show you. This is the first one. And it’s been five years in situ, going from the canine to the first molar.

[Jaz]
And just to clarify that it’s not a crown. It’s kind of like an onlay. It’s an onlay.

[Salman]
Exactly, yeah. So, we actually needed to raise this patient’s occlusion to restore them to place implants in the lower posterior sextants. Place the resin bonded bridge on the upper is a temporary measure with an onlay to open up the bites. And actually, what ended up happening was the resin bonded bridge, the patient was so happy with it, she has refused to have it replaced. So, this has been five years in situ.

[Jaz]
Can I ask about that Salman? Path of insertion, like I’m trying to like imagine bonding that so this four unit, technically four unit, so two abutment teeth, two pontics there. You’re trying to place it on the sixth through a sort of vertical path of insertion, but the canine probably can just ensure there was some vertical path of insertion there. But was that tricky to place?

[Salman]
Not really. No, you know, Jaz, soflex discs are really, really good for getting guide planes accurate. So, we want resin bonded bridges to be minimal prep, but sometimes just smoothing out the mesial aspects of that six with a soflex disc in any areas of undercuts can just really help open up everything. There wasn’t an issue at all. And Jaz, you mentioned about and post orthodontic retention, what we sometimes have to Eastman is when we have resin bonded bridges anteriorly on your metal retainer, you can actually create a little loop for your fixed wire to go through. And that can still connect as part of the fixed retainer, or you can do this, which actually a section from your paper, you recognized that Jaz.

[Jaz]
There we are. So, central is joined together as like double abutted if you’d like. Replacing two lateral incisors. I imagine this patient well, I know this patient had a diastema or unstable sort of risk of opening up the diastema. And this is a really clever way to to get retention as well.

[Salman]
And I’ve got one last one to show you Jaz. This is actually another one of my mouth, I say failure in my eyes, but as a success of the patient’s eyes.

[Jaz]
Great. Well, I want to talk about a failure I had seven months ago. Debonded on someone who’s dentures are replaced with a resin bonded bridge anteriorly, a couple of them central and lateral. And the lateral came away from a canine because he went to the fridge, he had some cold chocolate, and he rested it on his pontic and bit down. And so that was a freak accident because he then realized that oops, I wasn’t supposed to do that on that tooth. And otherwise, that’s yeah, don’t get many failures, but recent one share and that’s how it happened.

[Salman]
And here’s an another one Jaz. So, this is a patient who once again, we were waiting for them to be suitable for implants. They were 17 years old we’re waiting for- So, the whole point I’m sure people are aware with implants, facial growth continues with life. And it’s especially quick up to the age of puberty. So for men, we usually wait till the age of 25, with girls, at the age of about 21 because if you place an implant too early and facial growth continues, you get relative intrusion of the implant, you get much shorter clinical crown and the gum levels don’t equalize. So, resin bonded bridges we often use in NHS hospitals. Even practice outside when we get referred them from orthodontics like this patient was willing to delay the placement of implants and give them a fixed solution. In the meantime, now this patient came in with missing upper laterals and upper canines, and I placed the fixed-fixed resin bonded bridge from the central to the first premolar. And on the other side from the other central to the first premolar.

[Jaz]
Wow, so central, lateral, canine, premolar, that’s four units right?

[Salman]
Four times two, yeah. So, we placed this and you know, it opens up the bite really nicely Jaz. But occlusion settled in about four weeks really quickly. And this patient actually decided to not go ahead with implant treatmemt five years later, so he’s going to wait it out with his bridges, because he’s happy with the function, he’s not gonna have any problems. And he’s not keen to undergo surgery. But my mistake in this case, and you might notice is look at the incisal translucency, Jaz, I lost it. And this is the case where I was beginning to use Panavia and I wasn’t checking on my nurses opening and I use tooth colored Panavia instead of opaque Panavia. That’s resin bonded bridge and much greater loss of enamel translucency and I had this grey, I looked at and I thought oh my god I’m gonna have to clean this all up patient looked at it and said, ‘I’m totally happy with it doesn’t trouble me.’And I said, ‘Let me know if it does.’ And it’s been five years and it’s still fine.

[Jaz]
Ver good. But yeah, great point make sure using the right cement and use an opaque cement like you know mean we both use Panavia opaque well signs of it, which is yeah, which is a fantastic cement for that reason. But you still have to warn even with the opaque cement that okay, there is gonna be a degree of graying and it depends on the degree of translucency of that tooth.

[Salman]
So yeah, so another disadvantage of resin bonded bridge is that. So yeah, lots of incisal of translucency is an issue. It’s often why- We found replacing and lateral incisor my ideal abutment is nearly always a canine. I don’t like centrals for several reasons. The first one is patients will often notice a mismatch between two central incisors because they lose symmetry. Centrals have more incisal translucency. And finally, we said that the DAHL approach is unpredictable, right? It’s very difficult to know which way teeth is moving. And I have a feeling that sometimes when I fit the resin bonded bridge going high on the central, I think there’s some elements of labial shift of that central incisor going on-

[Jaz]
I agree. Some plane.

[Salman]
Exactly. And patients will notice because it doesn’t match up the central.

[Jaz]
That’s a great reason to consider the canine. How about this whole mesial cantilever, distal cantilever? So, when I wrote that paper, I struggled for hours, my biggest time on research was finding good evidence to suggest that other than just expert opinion that the whole distal cantilever versus mesial cantilever actually has a wealth of evidence behind it and I couldn’t find anything, Salman. So, just to clarify for those things. So, mesial cantilever would be like going from a first molar to a second premolar your cantilevering mesially. A distal cantilever would be going from a first pre molar to a second premolar your cantilevering distally. So, any guidelines terms of to you, is it a relative disadvantage for you to go distal cantilever?

[Salman]
So I think for me like firstly, we know that forces are great with the back of the mouth, right? Always. And when we often fits our retainers in supra-occlusion, we want our pontics have been very, very like it. Well I say lots of guidance in very, very light aesthetic occlusion. I think it’s very difficult to get that pontic in the occlusal scheme. If you have a distal cantilever going backwards at the back of the mouth, it’s more challenging to do that. And that will then put your cement in tension which then leads you to a greater risk of debond but that’s just me logically speaking, completely agree there’s not very much evidence and mesial and distal cantilever because at the window when we look at the anterior part of the mouth, right, central laterals, canines, we don’t consider it.

[Jaz]
It’s not so important.

[Salman]
Yeah, I would never consider placing a second premolar off a first premolar. I can’t see a case where I’ve seen that happen because I usually use the first molar and go mesially but the only distal cantilever I do regularly is first premolar off the canine and that’s a regular to do-

[Salman]
Okay. Yeah, so I’ve done a few of those well raising a first premolar from canine. But I have seen a second premolar, I’ve seen quite a few actually of second premolars being replaced by first premolars at Guy’s Hospital when I was there, and it’s always because there was no molar to cantilever off right and the patient wasn’t suitable for implant. So, they essentially did the shortened dental arch principle by using resin bonded bridges to distal cantilever off the first premolar. Now, one thing I remember my consultant saying at one of those clinics is that actually she’s noticed that the first premolar you get a bit of mobility, not periodontal disease, a little bit of occlusal trauma, but it seems to be persistent and not progressing throughout the years.

[Salman]
So, that’s very common complete denture patients. So, upper complete denture patients who are opposing lower four to four. I’ve often seen this sort of cantilevers off first premolars. And that’s the only time I see it because obviously if you’re opposing a complete denture, you’ve taken occlusal considerations into account you’re not expecting that risk of debond. So that’s the common one that I’ve seen.

[Jaz]
And another lesson there you just shared is, if you’re posing and complete denture go crazy. Do it All.

[Salman]
Similar to open bites, yeah, take a risk, it’s fine. But first canine retainer on the canine. Pontic first premolar that seems to work really well, this canines, naturally you get really good amount of enamel. You can implement incisal overlap, you got a good root there. So, another contraindication to resin bonded bridges for me is looking at the abutment tooth selection. So good enamel, we’re looking at bone support, looking at crowns-root ratio, I do take a little bit into accounts. And because I know that I’m going to be putting that tooth in supra-occlusion, when I’m relying on the dahl approach, and it was taking all the load and make sure it can sustain that kind of load, that’s going to take.

[Jaz]
Very good and just last point where we talk about the clinical protocol, seeing some lower incisors with a bit of bit of mobility, I find that as a good feature to have. If he’s got a little bit, I’ll give some example, periodontal disease, and they’ve had some little bit of bone loss. That for me is not a contraindication to resin bonded bridges, as long as the perio is controlled, but actually it can act in our favor. Because what we find is that as the pontic is loaded, instead of the forces now going into the cement, it’s actually going into the PDL of the tooth is a little bit mobile, so it gives a bit and then the cement gets loaded. So, we think it’s got a cushioning effect. Have you found that with these slightly grade one mobile patients that these these are lasting well?

[Salman]
Yeah, Jaz, mobility is not a contraindication. For me, it’s all about the stability of periodontal disease, you’re going back to those papers about like primary and secondary occlusal trauma, they went through my first year of specialist training where there is, they put the teeth in Super occlusion and they found that any mobility you get from that occlusal trauma from that heavy loading is reversible mobility, and there’s no and pocketing is reversible as long as there’s no bleeding and probing. So it’s all about periodontal disease stability. And for me resin bonded bridge is like the ideal solution for perio patients right? Because implants we know about the complications even unstable perio patients, implants wouldn’t have a greater complication rates, peri-implantitis very expensive, very difficult to manage. And for me go to treatment for private patients is a resin bonded bridge wants to stable.

[Jaz]
Brilliant, I’m definitely agreements. So, let’s talk about the clinical protocol. Let’s say you’ve done your design, but you’ve opted for the incisal overlap. So, what what we mean but just describe what you mean by the incisal overlap to someone who may not know this.

[Salman]
The docket is in my head like I just reel through every time I show you the same once you’ve got a docket in your head for your lab. I’m very, very prescriptive about how I design my resume bonded bridges.

[Jaz]
So, talk through the lab prescription, then.

[Salman]
Okay, so let’s say we’re mock example, we’re replacing a lateral incisor off the canine tooth right? So, my lab prescription, let’s say we’re looking at metal porcelain resin bonded bridge. So, we’re not looking at zirconia for now, first thing I do is I say which teeth is the Ponce, which uses the retainer because labs will get it mixed up because communication is not always the best. So, pontic on this tooth, retainers on this tooth and it’s a two unit resin bonded bridge in case they decide to go fixed-fixed suddenly, okay. Retainer design is then I say I want to base metal alloy. So, either cobalt, chromium or nickel chromium. And I want it in minimum thickness of at least 0.7 millimeters.

So, for me thickness is that really important thing I found some labs, they try to fit your resin bonded bridge into the occlusal scheme of the patient because the wider of propping it open and it’s when your metal wing is too thin that you then get that tension, you get the flex and you get the debond. And what you really want is rigidity with your metal wings so that you don’t get that tensile force on your cements.

[Jaz]
Just a little bit on that Salaman, before you continue the prescription I went around to a unnamed lab and I won’t name the lab and I was like they had a whole table of resin bonded bridges. And I started to go around I got my ones engaged to measure these wings okay, and not a single one was more than half a mil, not a single one was more than 0.5 mil and so we had a nice little chat about okay, why it’s important to respect that because that’s what you know, the papers have shown when they followed that protocol they’ve got success so why not copy that.

[Salman]
Jaz, we like the CQC for resin bonded bridges that’s in. So yeah, so retainer thickness and then I say I want maximum coverage all the way to gingival margin and on maximum wraparound wherever possible. And for me personally, I want a little lip over the incisal edge, okay two benefits and maximizing enamel and I’m also creating a bit of resistance form and it’s a seating trigger at the same time for me, so I know I’m going to cement it in the correct position. My pontic design would either be ovate pontic or modified ridge lap pontic. So modified ridge lap is my go to for healed sites

[Jaz]
Can you just because the young dentists listening, so you mentioned the incisor overlaps. I just want to touch on that so yes, cover a third to a half of the actual incisal table, incisal edge or the canine really, really great because it helps you to-

[Salman]
I’ll show you some examples Jaz.

[Jaz]
Seating lugs. Yeah, sure, pull up some photos as we’re talking. It acts as a seating lug or give you some index so sometimes when you go for a resin bonded bridge without a incisal overlap or without a seating lug. You’re sort of sometimes positioning how’s it going? It’s kind of fits in multiple positions. It overcomes that issue easily because it gives you something to grab on to incisal edge. So location wise it helps when the pontic is loaded. Now, the cement is in compression. So, that’s really Good feature as well. So, it’s a great thing to do. And aesthetically, when a patient smiles against the dark oral cavity behind the backdrop, it kind of disappears. But it’s not for every patient. I think it’s fair to say.

[Salman]
You can always trim it back. Right. So, for me sitting and I just trimmed back gradually trim are sufficiently happy trim more, trim more. And usually I get to this kind of balance where I’m happy, and the patients happy with the aesthetics. And so I get both. And I’m not worried-

[Jaz]
Do you tend to trim it the same day as a fit, I tend to do at review appointment.

[Salman]
Yeah. So, I was told to wait two weeks. For me, I’ve not noticed any difference Jaz, so what I’ll do is I usually wait a good 15 minutes that it will set Oxfam really OCD. I literally won’t touch it for a good five minutes. And obviously God , now for the next 10 minutes I’m taking off, use your personal photos, or cleaning up all the excess cements, make sure the patient’s happy. I give them all the positive instructions, and then I start trimming back gradually. But-

[Jaz]
Okay.

[Salman]
Maybe reviews a safer thing to do. I know a resin cements says, you should wait. And but not necessarily increasing the ones. Can you see this photo here Jaz, in this incisal overlap?

[Jaz]
Yes. Perfect.

[Salman]
There you go.

[Jaz]
A great thing to do. And then the next point that you made sorry. So we just talked about the incisal overlap and the importance. And then you switch gears and you’re talking about pontic so for the young dentist listening, can you explain what is a modified ridge lap design? And what is an ovate pontic?

[Salman]
Jaz, last thing sorry. Sandblasting retainer wings is really really useful.

[Jaz]
Let’s talk about that completely separately after because we need to talk about that give it some love.

[Salman]
To hide the metal shine, for incisal overlap.

[Jaz]
Okay, fine. Sorry. Sorry. To hide that. So yeah, that is relevant to hide the shine that the sort of the twinkle that when they smile basically makes it more matte. Yeah, absolutely spot on.

[Salman]
So, we always as undergraduate is four different points of types. But for me to go to is the ovate pontic, or some people might call it a bullet shape pontic. And the second is the modified ridge lap. So the ovate pontic is literally a totally convex profile that sits against the soft tissues is shaped just like a tooth underneath in terms of the bulbosity. And the ovate pontic is my go to when I’ve got like an immediate resin bonded bridge. So, I’ve kind of taken an impression, when I put my resin bonded bridge two weeks later in a patient’s quite like a retained root in situ. And on the day of fits, I extract the tooth, extracted roots, I’ve got a nice little space, I’ve asked the lab to create an ovate pontic with like a two millimeter extension into the socket, I fit it and then a soft tissue is really nicely hug around them and you get a really nice natural emergence profile.

The modified ridge lap is a technique where essentially buccally you following the ovate pontic design, you got a nice convex profile you extending all the way aesthetically to where you want to be. But palatally with the patient doesn’t see you’re cutting back your pontic completely just clear the soft tissues. Theoretically, it’s a more cleansable design, it’s much easier to keep clean with floss, and it’s still got convex profile. But because you’ve got healed Ridge, you can sit a modified ridge lap against it without any issues.

As time goes on and my patients are becoming more aesthetically concerned and finding a way to more and more ovate pontics so, I’m doing a lot more soft tissue shaping and with Essix retainers or dentures to create an ideal emergence profile. And I’m going for an ovate pontic design. And some people used to say, ‘Oh, it’s very difficult to keep clean.’ But as long as it’s convex, for me, it’s very, very easy for patients that don’t have food trapping, and they seem to like it better. Which goes against my undergraduate teaching.

[Jaz]
Yeah, there’s something really quite beautiful about moving that Essix retainer which you’ve got the composite side to mold the soft tissue or the denture or however you want to do it, pick your poison, and then take it out and use that lovely recipient area of the future. pontic just looks so natural in terms of emergence profile. Nowadays, what I’m doing is what I’m doing, not a immediate resin bonded bridge, but just a routine. Let’s switch your dentures for a resin bonded bridge kind of thing. I’m assessing the volume of soft tissue and I’m using a thermacut bur to just heat and remove this sort of architecture of the pontic I want to be and that helps it to go not 100% ovate but like in between ovate and modified ridge lap you have a spectrum goes more towards over it but I agree that you need that convexity for cleansability

[Salman]
Who was even modified ridge lap. Labs really find a struggle to make it, we asked them for a convex, so I always say when convex fitting surface. But actually if you look at healed ridge, we need to empathize with our lab that’s almost impossible sometimes to get good aesthetics and a convex emergence profile. There’s no good saying into the lab and saying achieve this. We have to help them along the way and create a profile that they need. It’s yeah, it’s always working together. That’s what it’s all about.

[Jaz]
Brilliant. And then was there anything else on the lab docket that you have mentioned yet?

[Salman]
Occlusion, so retainer, one chapter, pontic one chapter so I say and then occlusion. So, I say I’m going for conventional dahl approach depends on each patient’sleave the retainer minimum 0.7 millimeter thickness in supraocclusion and the pontic at this stage will be fully out of guidance and maybe lightly in occlusion. It is okay if other teeth are out of occlusion essentially, I’m okay with that. Because I’m going for a full dahl approach in this situation.

[Jaz]
Brilliant. You know what we talked about lower resin bonded bridges. But you know what? They can be really tough. Just like upper central to matching this upper central to another central, or even lower incisors. It can be really tough for ceramists.

[Salman]
Yeah, so resin bonded bridges. So if we’re looking at specifically metal resin bonded bridges, a set of photos helps massively. And the tips of metal are I’m sure you notice Jaz, mirror handle behind that tooth. So holding a mirror handle behind the tooth and then taking your photos will mimic the lack of incisal translucency you’re about to create in that tooth.

[Jaz]
Okay, I didn’t actually know that. Just a tip for me my friend. I love it. Thank you.

[Salman]
So, that’s the first one second thing what I sometimes do if I’ve got really concerned patient, I do a metal frame of trying. So, I’ll get the metal framework from the lab before they cast the porcelain, I’ll put that on the sides. I’ll take a photo and they’ll mimic that metal behind. And they’re gonna be really extreme, which is not necessary Jaz, but this is what you can do. You can paint dycal on the metal framework.

[Salman]
Yes.

[Salman]
Can sees in the mouth. It mimics Panavia opaque, take a photo-

[Salman]
That’s what I do.

[Salman]
That’s what you do then. Yeah. So I had to do, it’s yeah, it works really well. It mimics Panavia opaque right? And then you know.

[Jaz]
It does and just on that topic, photos are really important. And I use the cross polarization filter like e-lab and that gives them a bit more in terms of getting the aesthetics right of the pontic and then seeing the the deeper removing the specular flash as well so yeah, that really helps in shade matching technicians seem to like it. One story about a consultant actually taught me another thing with shade matching is that she will fit a resin bonded bridge from a central replacing lateral and the patient was like, ‘You know what? The shade is not right.’ And at that point they bonded it. So, what she did was that she got a palatal non precious metal veneer with it for the contralateral incisor to make it look duller as well which I thought okay you know can either another way to do it rather than kind of bridge off why don’t you stick something on so that was an interesting one.

[Salman]
Years for that, yeah?

[Jaz]
Well in hospitals Yeah. You can get away with it a lot I think.

[Salman]
Now and then Jaz I always say make sure there’s a good contact point between the pontic and the adjacent natural tooth because I feel like there’s an anterior rotation resin bonded bridges and when the contact point is good, I feel like a better stability.

[Jaz]
Absolutely, having something next door where you floss, you feel a nice contact will give it some some security. That’s a great point. And you know what, it’s good to mention that in the lab docket so they just pay a little bit more attention to okay, this was one of the requirements one of Salman’s requirements, I’m going to tick that off. So, that helps technicians at all.

[Salman]
I think you’re so silly but I’ve noticed like we use the same labs in practice mean other resources and the quality of work I always get back seems to be better and better and better because the lab knows you’re going to be checking this stuff. The lab knows you can’t.

[Jaz]
They know your anal. They know you’ve got your iwanson gauge, measuring the thickness and-

[Salman]
Yeah, they do know. It does make a difference. So yeah, hold yourself to that standard.

[Jaz]
I agree. So let’s briefly talk through the clinical protocol. You’ve got your resin bonded bridge back, you’ve tried to and you’re happy with the shade, what are the little mini steps that you can do to bond including with or without rubberdam? I’d like to know what you currently do.

[Salman]
Okay, so anterior resin bonded bridge, yeah, we’ve tried to own in the patient’s mouth, happy to fit, patients can find the shade. And you can actually get Panavia opaque try and pastes. I’ve got some recently. So, double check with that also.

[Jaz]
And also, just on that point, really important to rehearse your try in and rehearse it, practice how it goes in so that when a really important moment comes that you’re not fiddling around that you know, okay, this is how it goes in.

[Salman]
Yep, exactly. Yeah. So for me, Jaz, no rubber dam for bonding resin bonded bridges. Actually I’ve done it with rubber dam and without I feel like it compromises the way in which I do it. I can’t check complete seats. And for me resin bonded bridges are all of us the proper seating, because you want that cement to be minimum thickness. And if you don’t seat it correctly, that’s when you will get those debonds in these cements.

[Jaz]
I’m the same, no rubberdam. Occasionally, it’s split dam, especially for lower regions. You know, if I’m doing a lot of premolar, for example, split dam has its benefits and keeping the tongue and stuff out of the way. But yeah, mostly, you know, Richard Porter taught me many years ago, rubberdam is either helping you or is hindering you. And it comes to resin bonded bridges, I think it’s hindering you because you’re gonna go all the way up to the gingival margin or just shy of it. And just that’s exactly what rubber dam wants to be in. I’ve done it before, because I’ve done so many now where I put the resin bonded bridges and I’ve pinched the bloody rubber dam into my resin bonded bridge, I’m trying and pull it out. So yeah, I learned the hard way rubber dam can sometimes get in the way.

[Salman]
So my protocol for cementation, I ask my lab to extend the metal wing all the way to the gingival margin. On the cementation what I then do is add a decementation and place retraction cord. And that gives me that extra half millimeter to make sure we expose that bit of two so I can clear up any excess cements. So I don’t take an impression from resin bonded bridges with a retraction cord is known as a nightmare. isolates include the effects of cement on the day of fit, okay, the second thing is I do PTFE tape isolation not on the pontic side but on the retainer side. So, let’s say I’m cementing a resin bonded bridge, retainers on the canine and the pontic is the lateral incisor.

I’ll do a PTFE wrap around the first premolar, let’s make sure don’t block that contact points up then the protocol is for your metal base resin bonde bridges I’m sandblasting with 50 micron Illumina and then applying an MDP Aloe primer so I think the Panavia V5 the new one has got its combined clear for ceramic primer plus has saline and MDP in it.

[Salman]
Yeah.

[Salman]
But that one’s appropriate you put that one on you leave that on the site for a couple of minutes while I work on the teeth. On the teeth, then I’ll apply my etch and then-

[Jaz]
Air abrasion on the teeth?

[Salman]
Oh sorry, Air abrasion first, 27 Micro Illumina, etch, And then apply my bond. Don’t cure your bonding agents. For tooth primer again Panavia is my go to. Panavia V5

[Salman]
Yeah, you don’t need to cure that. Absolutely you wait for the cement.

[Salman]
The only other cement I consider for resin on the bridges that I’m using is RelyX Ultimate, which I’ve used once or twice. And that’s their protocol involves using scotch bond as the bonding agent of choice because this is universal adhesive contains MDP if you are going to do that don’t cure the Scotch bond on the tooth. The manufacturer says that if you want to RelyX Ultimate mixes with the Scotch bond that creates like a self cure setting reaction, which is pretty cool. But to be honest, my go to is Panavia, I’m just used to the handling it works, there’s no reason to change it.

[Jaz]
Another top tip here from Luz McKenzie told me that the Panavia proper protocol is to get it out of the fridge. Firstly, I post about some on my story. And people were, ‘Wait, is it supposed to live in the fridge?’ I’m like, ‘Yes, supposed to be in the fridge.’ So take it out of the fridge about 15 minutes before you need it that allows it to reach a more appropriate temperature, which apparently reduces how many bubbles you’re gonna get. So yes, use whichever cement you want, as long as it has got MDP. And you are familiar and comfortable with the full protocol.

That’s, I think the main message. But yeah, if you don’t know what we use Panavia, and I’ve also used RelyX Ultimate as to I haven’t used anything else. And all I want to for resin bonded bridge if I didn’t have those two, and for some reason I was working in practice, I would actually change the appointment, I wouldn’t fit it, I wouldn’t fit them.

[Salman]
I’ve just I’ve had to order into back some I started a new practice to order in first day as I can’t actually work without this. Panavia for me like there’s different types, right, so there’s Panavia V5, which is a new one, which I’m really enjoying actually works really, really well as we’ll make using Panavia F2.0 Make sure you don’t miss Panavia SA, the Panavia self adhesive version. That’s the only Panavia that’s not suitable for resin bonded bridges.

[Jaz]
I didn’t know that because I’ve never used it. So that’s really good to know, actually. So in case you think you’ve got Panavia or I’ve got Panavia and it has SA version, then as someone says don’t use it for resin bonded bridges. Very good to know that. I think when it comes to cement, you have to be a little bit anal in terms of respect what the literature works well, and what works and people who’ve experienced hands and my principal or my ex principal for 30 plus years has been using Panavia for donkey’s years, basically for at least the last 15 years. So you know, use the cements that have got good proven track record.

[Salman]
You’re already taking a risk with this adhesive dentistry. If you’re going to be popular, you already buy the book in this case. Yeah.

[Jaz]
Absolutely. So you’ve put it in. And I like to really pinch with my finger in the thumb. The abutment tooth and the wing the retainer together and really make sure it’s really well seated. I don’t do anything else. It’s not tidying up just yet. How about you?

[Salman]
Yeah, same thing. So my consultant used to tell me that after cemented a resin bonded bridge, your fingers should be hurting when you take it off. After five minutes. That’s how you know you’ve cemented it properly. And the reason why it incisal overlap helps so much as you know you’ve got full seating, because when that cement goes, it’s very, very difficult. It’s surprisingly difficult to spot whether you sometimes you get like a shift in the bridge, you can’t tell this as overlap. Once it’s seated, I know I’m in the right position, and then I can just hold it over there.

[Jaz]
Absolutely. Oh, one more thing I forgot to mention about cement. I believe I’m very cynical. And I believe that the only reason Kuraray who manufacture Panavia, the only reason they sell 2.0 and all the other ones, is so people still buy them. And should they stop making it because V5 is the newer, better, sexier version, should they stop making it there’s a risk that they’ll stop buying, and they might then switch another cement. So these manufacturers the reason they make older generation still is because people still buy them. And that’s what I think so I think you’re gonna buy for the first time just buy V5. Yeah,

[Salman]
For me, it’s V5. The great thing about it is it comes in different colors, right? So you get like a variety of colors if you buy the full kit, and then you can use it for other bonding protocols. So gold, non precious metals, ceramics, zirconia resin bonded bridges is basically covered in that one kit in V5. By not the hospital will not switch to V5. So yeah, people are using it.

[Jaz]
Whoever’s in charge of ordering it still got the old system and no one’s changed it and no one dares touch it. Right. So, occlusal check. So you obviously you’ve been careful in terms of cleanup, micro brushes, probe, anything, any fancy clever tips when it comes to cleanup?

[Salman]
So, cleanup for me. So, I think V5 has tack cure mode, right? So I just light cure off it. So that helped me do a bit more to clean up before it gets to full sets. But otherwise, I’ll be honest Jaz, I don’t want to take my finger off that retainer wing when I’m cementing, that’s my priority. And so cleanup is a bit of a headache. So I call the patient back two weeks later to do another thorough clean. And that’s when I also scaling on a bridge straight we have to fix-

[Jaz]
Same.

[Salman]
Two weeks later, and I do find excess cement and it does happen on resin bonded bridges because I’m so OCD about just making sure I’ve seated in the right position. And the PTFE will mean that my contact points are fine. I got TePe brushes on the side. I used to brush this for my cementations now to regulate multiple air quotes and enhance civil status. They work really well.

[Jaz]
Yep. And as I’m pinching and holding the resin bonded bridge, my nurse will be using a long handled TePe brush, pink one. So just go inside in between the teeth as I’m still pinching and that helps to get rid of some of the bulk there as well. Only caveat is that if some reason you got up some inflammation is be careful with bleeding basically.

[Salman]
I’ve got about 10 Micro brushes for every fit for resin bonded bridges. So I keep 10 because-

[Jaz]
I think we’re very similar on that.

[Salman]
Each time I pick up cement, I use a fresh one for each time because if you go through one, you actually work through the tissues in Panavia everywhere, and it sticks to everything. So yeah, it’s a fresh Micro Brush each time I use it and you just keep going through them. It might not be the most environmentally friendly thing to do. But yeah, in this case, I’m okay with it.

[Jaz]
In terms of occlusion checks, to what degree are you checking and adjusting as you just fit the resin bonded bridge and it’s fresh?

[Salman]
So this is where I’m becoming a bit more reasonable, I think so. So I know my lab, if I’m going for the DAHL approach has been a really thick retainer at this stage, which is a minimum of point seven millimeter thickness. So when that patient bites together, I’m expecting essentially all my contacts and maybe one at the back, which is possible sometimes to be on that metal link. And I’m definitely not expecting any context on that pontic. So the only adjustment I usually make is that pontic. If there’s any occlusion on there, I can get it into guidance pattern, or make an adjustment to that pontic to get it out of guidance.

[Jaz]
Get it out of any excursion, right? Anything dynamic on that pontic, get rid of it.

[Salman]
Exactly, yeah, even if it looks heavy to me, I lightened it. Like let’s say I want it like almost shim drag, you know, we have implant crowns, pressingly with a resin bonded bridge pontic. And that’s how like some different occlusion. So I don’t like prepping for resin bonded bridges. And I know some people say it’s only point seven millimeters, why not just reduce the tooth a little bit, and you can stop relying on DAHL as much. And I do see that. But it’s very difficult if you prep to then maintain that space until your next visits. So what I sometimes do is if I think a bit of prep is required for this specific situation, I’ll consider the patient at the impressions appointment. There might adjust a little bit of your opposing tooth on the day of fit.

[Jaz]
Yeah, absolutely.

[Salman]
And they know it’s not like if you said too late, it’s an excuse, right? We’ve said before, it’s an explanation, all that stuff. So yeah, you want them at the impressions appointment.

[Jaz]
And very often you look at the opposing tooth and there’s a nice sharp, useless piece of enamel that’s unsupported that just as begging for a soflex disc to it. And that’ll give you you know, 0.3, 0.4 millimeter sometimes.

[Salman]
Or ideally a restoration.

[Jaz]
Ideally restoration. But yeah, I’m not afraid to polish any sharp enamel bits to give him my space. So that’s an often as young dentists was scared, you know, they’re scared to look at the opposing and adjust it. But if you make a calculated decision and communicate it from the beginning, then that is another neat way to gain a bit of space and not have to rely on DAHL so much. So absolutely. That’s brilliant. So we’ve covered with cement as well which brilliant, we covered the clinical protocol. In terms of occlussal-

[Salman]
I forgot to mention.

[Jaz]
Yes, please.

[Salman]
I forgot to mention connector thicknesses.

[Jaz]
Yes.

[Salman]
Connector thickness is really crucial here on the lab prescription, I’ll actually write ensure maximum height connector possible in this space, ensure maximum thickness because once again, with the metal base resin bonded bridges, you’re trying to avoid any flexion of that metal. And for me like connected thickness, making it as like thick as possible makes it rigid means I get less deep ones.

[Jaz]
Now connect to someone like young dentists and now is probably a year Qualified Dental School, I would not have been able to tell you what the connector even is. Right? So when it comes to a bridge connector, resin bonded bridge, can you just highlight exactly what you mean by the connector? Which part of the connector? And what do you mean by the height and also why the width of it is often underappreciated.

[Salman]
So the connector is the bit of metal in a resin bonded bridge that connects the pontic to that metal link. Okay, so that bridge and metal you have between the two. Now we look at it from an apical, coronal dimension and a buccal lingual dimension for the connector. Right? So if you’re looking at case selection for resin bonded bridges, if you’ve got a perio patient move very, very triangular teeth, big black triangles, you know your connector might be limited in the apical-coronal dimension, you may be limited in terms of heights of the connector. And so once again, that might preclude you that might say you don’t do a resin bonded bridge in this case, because your connector will be so thin. And this patient is not going to accept any metal show in that black triangle limits in your connector heights.

[Jaz]
Or you do some proximal adjustment if you can to reduce that black triangle and then increase the height of the connector. Yeah, increase the height of the connector and the apical-coronal direction. So yeah, that can sometimes work to Detriangulized a tooth.

[Salman]
You stole my point, Jaz.

[Jaz]
Sorry.

[Salman]
Yeah, that’s alright, I forgive you. So just yet I know so buccal labial. So adjusting this is sometimes a very convex, like you know, more or less when you’re facing second premolars, you’re very convex, a mesial wall. If you flatten the soflex disc, you get greater connected thickness both buccal palatal and you get better parts of insertion also, to get maximum wraparound. And so all these factors come into my mind. So that’s connected thickness. So aesthetics also is an issue like sometimes to maximize connector heights, you’re going to compromise aesthetics, if you got very triangulated teeth, very short teeth and that’s also a pontic size shape and even makes a difference.

With the U shape your pontic sizes, you get a greater connector heights. And I think this study shows Jaz, there’s like a low beams but connector height is the most important factor. Compared to connector width. So for me, connector height is always what I’m most concerned about. But we look at it in cross section. So I want a minimum of about 90 millimeters squared cross section from metal based resin bonded bridge in terms of connector dimensions.

[Jaz]
It becomes even more important. I think metal is very forgiving. I think with the zirconia, go to the zirconia, you really, really, really have to really maximize as much as you can not only the height, but the width as well. And that may even impact on your aesthetics a bit because of how thick that connector needs to be. So really crucial because the most common modes of failure of zirconia resin bonded bridges is fracture of the framework, which I’ve seen before. I’ve got some photos of it. Anything you want to add to when we start thinking about zirconia. This has finished on the zirconia and how we’re changing our protocols perhaps for zirconia.

[Salman]
Because for metal for your resin bonded bridge, your whole aim is to get rigidity in metal fracturing. With zirconia, it’s a naturally rigid material, you still need to study up to worry about thickness because then you’re worried about fractures rather than rigidity with zirconia. With zirconia once again, like it is new to a lot of people when I make a as zirconia resin bonded bridge, I specify to my lab, what type of zirconia they should be using. So it has to be three wide zirconia and for zicornia resin bonded bridge, because it will be three wides to Konya, they’ll be opaque. So I’m expecting them to be laying porcelain. And if they’re learning porcelain, then you want to ask them to make sure the porcelain is well supported to reduce your risk of fractures.

[Salman]
Yeah, that’s a great point. So if you haven’t listened to already that Ed McLaren episode, I think it was 117. Please check it out. If you wanna learn about 3Y, 4Y, 5Y. So a great point, you want to use this the strongest, technically least aesthetic, but that’s the monolithic product when you layer it with your layering ceramic, then you get that lovely aesthetic. So great point. Is there anything different that you’re doing, even when you’re maybe your preparation design or any other factors that could be different to what we discussed in the previous parts of this episode, comparing metal based resin bonded bridges?

[Salman]
So what’s interesting if you look at the zicornia resin bonded bridges and the evidence, Matthias Kern got like quite a few long distance study, longtime studies looking at successes of zirconia resin bonded bridges. Now the king paper I mentioned earlier, looked at metal base resin bonded bridges and came up with like an almost about 80% success rates, while Matthias Kern comes up with a more than 90% success rate at over 10 years with his zicornia resin bonded bridges but firstly a case selection so the king paper looks at and this is where like I guess specialist training comes within such as you can kind of critically evaluate papers because the Matthias Kern paper and look says specifically anterior based resin bonded bridges with pre existing adequate into occlusal space. And if they didn’t have it then prepare the teeth to reduce the reliance on the DAHL approach should have a very specific preparation protocol. And it was done by I think more experienced clinicians while the NHS hospital base picking paper fits in metal base resin bonded bridges all over the mouth.

All kinds of designs on NHS patients are choosing hypodontia with no preparation at all. And so my go to bridge for predictability for my patients is still metal based resin bonded bridges and zirconia I still feel very hesitant prepping teeth for zirconia resin bonded bridge. Because for me the whole benefits is a non invasive solution to meet this patient’s treatment need because then when that mode of failure happens, it’s not catastrophic. And I’ve got full back option in the future. But I know his paper specifically has his preparation protocol. And I’ll follow certain elements of it. So with zirconia I’ve realized my lab cannot finish it to such a nice knife edge margin. So considering a small Shaeffer prep or finish line for the seating of the bridge, and you can’t have an as nice in incisor overlap in ciconia. Because with metal you can thin it down with a bow you nicely. With the zirconia I don’t want to be adjusting because I’m worried about subsurface cracking.

So I want to make sure that when I fit the zirconia bridge, I want to do minimal adjustment. So I may not go for that full incisal overlap President I’ll be cutting things back. I don’t have to polish it to a knife edge because there’s a cornea doesn’t work in thin section country with what we will tell you it does crack with a splinter. And so you want a nice thick section resin bonded bridge with zirconia that fits and you forget about it and you know it’s fully seated on that date, too. That’s my kind of thought process behind what I do for zirconia.

[Jaz]
Yeah, brilliant, I’d say the same. The only thing I also want to add to that is when you’re looking at your preparation of your abutment now, but most of these all I’m doing is a soflex like we said proximal wall, get a nice guide plane, but I would just you know we know where the metal like let’s say you’re replacing a canine from a first molar.

[Salman]
Interproximal box

[Jaz]
And not even the box actually know the box is there to maybe to give you the connector width and whatnot but it’s more the fact that as the metal transitions up the palatal wall to the actual cusp as well. If that transition is sharp for metal, I might accept it. It’s okay. But for there’s zirconia I’m going to get a yellow or red microfine and just smooth it and make the internal walls as smooth as possible which is better for ceramics basically. That’s the only a difference comes from, I’m just casting that one more eye, okay feel my finger is there any sharp? With metal it doesn’t make a big difference, I mean metal can tolerate that.

[Salman]
Yeah, anyway metal is good like you want as much of those random surface features as possible for metal because you’re getting that back from mechanical retention from this. The ceramic and the smooth flowing probes you see people do for overlays the same thing. I’ve done quite a few zirconia resin bonded bridge now. Metal’s still might go to. I don’t know how is it for you Jaz, the more I do I still feel like when I fit that metal bridge that seat still feels maybe I’m just old school in the way I do it and maybe I need to do more zirconia even when I consent my patients I say that there’s two options. One was a predictable, one will be more aesthetic.

If you don’t mind aesthetics, this is the one to go for. And if they pick zirconia one I’m still learning expectations massively because for me it’s still new, I still don’t have those tenure data studies was the zirconia that made me back that type of resin bonded bridge design. But as I move more into private practice, and I see more and more patients, they’re refusing metal for the first time. And I’m noticing more and more and more I don’t know post COVID? People seem to be looking at their smiles. And soon, they actually saying I’ll never have a metal wing, when beforehand, they’d be quite happy to have one.

[Jaz]
I’m the same. So I say to my patients, do you want beauty? Or do you want longevity? But which is a lie. Because we know the current paper shows that it can work and I believe in zirconia bonding and whatnot. But you know, I do agree at the moment, I’m 50/50. So 2% chance we’re gonna go to zirconia or metal that some years ago, it was like 100% metal, obviously, then it transitioned a bit more zirconia about 50/50. But if I could have it my way and keep my risk lower, then I still bias metal. I agree with you. But maybe we’ll speak again five years and see if that changes.

[Salman]
Any case, where pushing the limits, which you see from my Instagram, I do quite a lot sometimes.

[Jaz]
Anything risky, then definitely don’t risk your material.

[Salman]
Exactly. That’s essential. So I did a perio splint case. You might have seen it Jaz. I had a patient come in this really interesting case. So I can pull up the photo Jaz, if you want.

[Jaz]
Go for it.

[Salman]
So, Jaz, if you look at this, this is an ovate pontic this is what we get with immediate resin bonded bridges. So this is a lateral incisor. And here we go, it is very interesting patient. Can you see that, Jaz?

[Jaz]
Yes, yes.

[Salman]
So this patient was really interesting patient who came to see me in private practice, and said he wanted replacement of his lower left central and lower left lateral incisors. But he’d gone to see five other people for consultations beforehand. He hated the denture he have at the moment. He wanted to fix solution whereas lower right one and lower right two are grade one mobile, but apparently stable, otherwise, he had actually had perio work done, he said it’d be mobile for the last 10 years. And his main criteria was he did not want to lose any natural teeth. Because all the implant dentists he’d seen earlier, had told him in order to do implants for this case, you need to remove the lower right central or lower right lateral incisors and have a two to two implant bridge for this to work. With a long shot of expectations and what he actually wants it and after a while, the patient just wants a fixed solution, and is happy for reduce remakes.

And his main criteria is anything fixed, that can work that also allows me to stabilize lower at one or two, that’d be amazing. And so in this case is perio splints using resin bonded bridges can work really well. And aesthetically yes, metal is a compromise when his patients opened really big and looks in his mouth, you’ll see this metal lingually. But for a patient in his mid 60s and male patients based on fixed teeth, and they will function and he’s actually more comfortable with his resin bonded bridge. Now, this lower right one and lower right two are stable. In his lower left one, two a pontic. So then a six unit resin bonded bridge from the canine to the canine.

[Jaz]
I mean, that’s some lovely ceramic work, you see the mimicking the root dentin, root cementum. That’s really lovely. But if you again, if you you know, obviously, it’s not so important this case, I’m sure it looks good in conversational distance, but look at that the value is a bit higher and stuff like that. Compared to the natural teeth. It’s really difficult to get the shade perfect are obviously in any sort of dentistry, but I always find it. I always look I have yet to do a restaurant and I thought you know what? Absolutely nail the shade is really difficult. You know, like you’re replacing centrals in any case, it’s really tricky.

[Salman]
Yeah, no, exactly. Yeah. And Jaz, like, once again, like the risk of failure, you’re back to where you started. Or worse you lose us. Yeah, it’s I can always fix in house and do something else. And the more implants I do, the more resin bonded bridges I’m doing. That’s what I’m finding. And this is a nice podcast is to say, like, don’t do implants and implants, all these negatives, because they’re amazing treatment solutions. But it’s really nice to have different tricks for each and every patient, and all your consults will you give me a unique solution to each specific patient scenario. And that’s what makes prosth so interesting, right? Because you’re doing problem solving all the time?

[Jaz]
Absolutely. Now, I think we covered a lot of ground there resin bonded bridges. Salman, I think you do some teaching on resin bonded bridges. Tell us more about some courses that you run. So if anyone listening can attend one of those. I’m a big fan of going to live causes like yourselves.

[Salman]
So actually, this is a shout out to Jaz, isn’t it? Because so resin bonded bridges is like a passion of mine because of the thesis I’m doing currently. And yeah, I’ve run a few webinars and you can message me on Instagram, @dental_story to find out more. But really me and Jaz talked about resin bonded bridges, and I said, ‘Jaz, I don’t know if I want to do a podcast because you run a really, really amazing course on resin bonded bridges. And I don’t have any conflicts of interest.’ But actually Jaz is such a welcoming person. He’s invited me to speak on resin bonded bridges as well. So, I’d say message me, message Jaz because he runs an RBB masterclass, which a lot of my colleagues have actually gone on and said it’s an amazing course to go on.

But generally, I think the main thing I want is I just see patients coming in and we’d like perio patients with implants, implant complications, patients who have not been offered this treatment modality and especially if the more international patients I’m seeing it’s such a nice thing to offer patients that will solve so many of their problems. I think we have a duty to offer these patients the options and that’s really the main reason for this podcast and I just feel like something everyone should be aware about. It’s a really good way of making good money in a minimally invasive way.

[Jaz]
Hey, we haven’t talked about money. I mean, if you can just let’s talk about money if you don’t mind revealing this, how much will you charge privately for resin bondedbridge?

[Salman]
So Jaz even in practice privately So, NHS mix practice if a patient came in with one missing tooth or needed an immediate denture, for example, which would be the go to solution, I began practicing the immediate resin bonded bridge because even on a bank three charge for patients which I think 280 pounds, it’s still for me more predictable and more profitable than being an immediate denture because immediate dentures you often have that replacement, the redo and as long as you want patients for me the resin bonded bridges, yes! Your main industry done in about six months and everything heals up and we can do another one at that stage is perfectly fine. So even that is profitable when private practice from using our private laboratories. Chairside time is about half an hour. Yeah, it’s a 15-minute scan impressions and photos for the shade.

[Jaz]
By the way. I’ve discovered today that Salman is like speedy, Dr. Gonzales, Dr. Speedy Gonzales, right. So anything that a man does, you triple it for the time that I need, but carry on.

[Salman]
My main criticism at the hospital is I need to slow down. That’s just how I’ve always worked spending years in NHS practice. He just wants to do these things for these patients, but 15 minutes for impressions, photo scan, and then maybe another 15 minutes. To us My main resin bonded bridge part of the point is a consent discussion. So a good 15 minute chart of photos of showing them what it looks like. If it does come off in the future. They kind of say, ‘You know what, it’s come off exactly what we discussed this to what we discussed, either remake or recement.’ And then the fifth visit as well. 30 minutes but other 45 if there’s any issues, it’s very relaxed appointment. There’s no injections, you can try and everything properly, you can do cement nicely, and you review again for 15 minutes.

A few weeks later. My charge for resin bonded bridges about, depends on I work at three different practices, but usually about I’m charging mine 900 pounds, because my hourly rate for implants have exactly the same. So I have no bias even my crowns and practice such as exactly the same for every single crown I do because I want to select what’s best for my patient, and not any financial really discussion involved. It’s just I think this is what suits you. That’s my recommended option is your other options. What would you prefer? And I don’t mind which one they pick.

[Jaz]
Mine’s from 900 for sure. Odd time I’m doing a very high demanding patient central incisor if I’m going to zirconia you know, up to 1400 Sometimes So the range is there so that the lesson here guys is that don’t think that resin bonded bridges and therefore it’s a cheap thing. You’re still replacing a patient’s tooth, you’re still enabling a patient to smile. Because the common thing I found our colleagues do is under charge and not feel confident charge privately for resin bonded bridges, which is ridiculous. You’re giving a patient a freaking tooth.

[Salman]
I think you have a tendency to under charge when you’re not sure something’s going to work and that’s usually when you get the biggest problems of all. Charged appropriately you had the time for reach. Like you know the best thing is with resin bonded bridges? You know when a patient was well cared for and it doesn’t fit the shades on right and taking temporary off, remake a temporary recement. Resin bonded bridges they come in to try and I call this Fit visit, try and visit so the patient thinks they’re coming fine and then I told them okay, everything’s perfect. You know what we can fix this today and a second other positive on top of that appointments.

While others are trying to come in. You tried to shade, there’s no temporary to worry about. There’s no like excess cement to remove, you try then you’re like you know what colors are perfect. Take a photo, come back in two weeks, there’s no pressure on you whatsoever. And it’s a really satisfying thing to do for patients. No injections like it’s such an easy racking to offer.

[Jaz]
It is a fantastic massively underutilized treatment modality. So, I think those listening in the UK, they all know this stuff, right? Yeah, we went through little details in gems, which I’m sure they picked up. But this is really for you guys in the states, Protruserati in the states. Australia Protruserati should be pretty good with this. They’re pretty hot on this. Scandinavian good. But yeah, US guys? Come on guys. You know, we love you so much from across the pond. But you guys need to appreciate that resin bonded bridges can play a role in your practice. So please do follow @dental_story, check out those cases, check out Salman’s webinar.

[Salman]
I had a patient from Canada came on my webinar a couple of weeks ago.

[Jaz]
A patient from Canada?

[Salman]
So I’ve seen in fact, this one dentist from Canada, came on my webinar a few weeks ago said he’d never provided a resin bonded bridge. Been qualified about 15 years. It’s like, so I run like a two and a half hour webinar on resin bonded bridge is just an A to Z, everything start to finish. And at the end of is providing like definitive. As soon as you provide something, you suddenly see these cases popping up everywhere. And when you have the confidence to provide something, you suddenly start offering it to your patients.

And it’s a duty of consent that we do offer these two modalities. And this is something you need to refer out. I mean, any general dentists can provide a really, really high standard with good luck communication, I think lab communication makes up 90% of it, because we’re not doing much in the chair. But it’s the interaction between you and your lab you need to get right and you can get amazing results.

[Jaz]
Resin bonded bridges are minimal invasive, they are time efficient, patients high satisfaction and if you play your cards right with communication, it works well in long term and I do think you know even by saying that last little bit if you you know communication, blah blah. I’m not saying we get a lot of debonds at all. They are incredibly successful, but as long as they know not do anything stupid, then you get the real success I think because as long as you’ve got a case elections, good occlusion and enamel, your right prescription, you really can’t go wrong unless the patient has a fall or eats cold chocolate from the fridge exactly on your pontic.

[Salman]
And there are two failures Jaz, but one on a bruxist, or replacing a posterior tooth pushing the boundaries. And the other one bonding to existing composite on adjacent teeth, a free place of I think over 200. Now I keep an audit some of these but yeah, of patients who I know of two out of 200 is not bad. I’m sure the rest would come back. If there was debond because I haven’t we’ve practices I said at the same place.

[Jaz]
That is a really powerful in terms of learning. And I think this is why I’m finding with Giles, who I used to working where I said before, so many resin bridges out there in Reading at the moment, and I see them for checkups, and they’re still there and they’re doing great. So patients do not need to worry about it being a short term thing, you need to change your mentality, guys, as long as your case selection is good, because if your case selection is crappy, you’ll get a crappy result. So Salman, thank you so much for making time for this. I really appreciate it always, always great to chat with you and see your funky cases pushing the boundaries and whatnot, of course, talking through more straightforward stuff as well. Really great.

[Salman]
Thank you Jaz, been a pleasure.

[Jaz]
Absolutely.

Jaz’s Outro:
Well, there we have it, guys, thank you so much for listening all the way to the end, always appreciate so much. If you liked what you heard, but you want to learn more, you want see some more cases. You want spend a couple more hours with Salman then check out his webinar on resin bonded bridges happening on the fourth of December, I’ll put the link below. So if you’re on my website or the app, or if you’re on Spotify, you can read the description and find that link to get on the webinar.

It is an absolute bargain. If you missed the webinar, and you’re listening to some point in the future, then you can also check out rbbmasterclass.com. That’s my online course, for resin bonded bridges. I do recommend the live interaction that you get with Salman on his webinar, I think it’s always fantastic to have these things live, where you get to ask questions, and you’re kind of committed to be there and give your full attention.

But if you missed that, and you want to have something that you can access on demand for the rest of your life, then you always got the online course as rbbmasterclass.com. That cost’s 97 pounds. That includes tax and whatnot. It’s roughly around about $110 US, but I’ll teach you how I do these bridges. And I charge about 12 to 13 times more than that for a single resin bonded bridge and how you can feel confident in charging that to your patient because you have faith because ultimately you’re providing patient with a tooth, you’re providing a patient with a replacement for a missing tooth. That’s a big deal.

And that’s why I teach that you should be charging appropriately for resin bonded bridges and definitely not underselling yourself. One last thing is that if you listen all the way to the end, and if you’re listening or watching on Protrusive Premium on the app guys, if you haven’t downloaded the Google Play or the Apple app, download Protrusive App and make a free account but if you want to get CPD and the exclusive content please do subscribe. It’d be great to have you as a Protruserati on there and you can claim CPD now just scroll below and answer four questions. My team will send you a certificate and you always get access to episodes first before anyone else. So, thank you again for being a true Protruserati listening all the way to the end. I’ll catch you same time, same place next week.