Restorability with a Specialist in Restorative Dentistry – PDP009

Jaz’s Introduction: Hello everyone, long time no speak. There was no episode in July because I became a father. I am the father of a very beautiful, gorgeous, healthy baby boy. We haven’t named him yet. So that’s sort of the reason why I was a bit busy and occupied in the month of July and our guest today Aws Alani also recently became a father. So congratulations to him. We’ve got a jam packed episode today with Aws Alani. He’s a restorative specialist. And we’re discussing restore ability, right? Key topic, obviously, in our day to day practices, I sound very nasal, because at the time of recording, I was a bit poorly. So apologies for that. And there’s no outro today, but all the stuff that I that we discuss, any links that are promised, will be on my website, jaz.dental, or on my Facebook page Protrusive Dental podcast, please follow it for little gems and tips that you know from the podcasts and elsewhere I share on the page. So please like that. However, I will give you a Protrusive Dental pearl and the PDP for today is on the theme of restore ability is to use an A once in gauge. This is a good gauge that you know jewelers use. And obviously, we use dentist use to measure the thicknesses of things. These things could be cusps, as you’re looking for about three millimeters of cusp thickness. Or if it’s less than that, then you may consider to overlay that cusp for example, I use it quite a bit to measure the thickness of burs. And also for lab work that comes back, are my crowns thick enough in the occlusal aspect? Are my resin bonded bridges wings, are they thick enough quite commonly, labs to make them thin? Obviously, we know that they need to be at least 0.7 millimeters thick. So it’s good to measure that. It costs less than six pounds on Amazon, I’ll drop a link. So you know, it’s a easy thing to purchase. It’s something that every restorative dentist should have. So I won’t babble on anymore. Enjoy this episode, Aws the sort of things that we discussed on the description of this episode is quite a bit. It’s a very broad topic, restorability. So it sort of was it could have gone in any direction. And but I’m glad it went the way it did. It’s quite fundamental with a few sort of alternative therapies discussed as well. So I look forward to next. I’ve got great episodes lined up already pre recorded. So I’ll release them hopefully this month. Thank you very much. Enjoy.

Main Interview: [Jaz] Okay, right. Aws, thanks so much for agreeing to come on to Protrusive Dental podcasts. Really good to have you. So can you please tell our listeners out there a little bit about yourself?

[Aws]
Yeah, so I’m currently a consultant restorative dentistry at King. And I’m basically full time. I qualified in 2003. From Kings as well

[Jaz]
People from kings, they tend to stay at Kings, don’t they? Stay within the M 25.

[Aws]
Not actually. But I left. Essentially I left London. I’m the London exile. I left London like eight years. I went to Wales for a while. And then I went up to Newcastle. And I came and I went to Canada for a bit and then I came back to London.

[Jaz]
Oh, that’s really cool. So were you practicing in Canada?

[Aws]
I was practicing. Yeah, I mean, it was it’s very interesting from a political aspect of dentistry because their system is much more generous, shall we say when it comes to dentistry. And it’s funded entirely differently. I so I work four days a week, largely managing patients through diagnostic clinics and patients that I see on MDT clinics as well. And I’m from Fridays, I teach on an operative diploma, course lead for an operative diploma, which is basically a combination of seminar based teaching workshops, Phantom head teaching and clinical teaching, chairside teaching in the second year. And that takes up a lot of my time as well, I suppose. And that’s essentially targeted for GDPs who are UK based and going through, you know, things like treatment planning, occlusal factors, you know, managing the endodontically treated tooth and all those sorts of things. So it’s been up and running now for two and a half years. And well, I’m hoping you’re going to be successful is one of those things that I’ve started I’d like to see blossom essentially

[Jaz]
Awesome. And so today we’re talking about restorability. Which is a huge topic, and It’s something that it’s subjective to a degree.

[Aws]
Very subjective.

[Jaz]
Yeah. Well, I’d like to learn is how you teach on deployment, how you also only thinks about restorability and which factors you take into consideration.

[Aws]
When I think subjectivity of, you know, restorability, the upward pressures on dentists now in the UK, from our patients, you know, patients now are less reluctant to lose teeth. However, they are. I think obviously, the downward pressure comes from things like litigation, the GDC, I think we’re becoming more and more squeezed and trying to push the boat out to try and essentially do some heroic dentistry to try and save them.

[Jaz]
The fee is in question. So when you’re in hospital, there’s no fees involved. And you just go by, okay, give me whatever you think is best. Do you think that could be a big factor?

[Aws]
For talking more generically, I mean, regardless of being hospital based, or otherwise, patients are more informed, because through Google and digital age, you know, when I was having a discussion with my DCT, recently, and we were talking about textbooks, and you know, a lot of learning now is accessed through Google. And if you imagine that you may Google something. And your patient has the same ability, the same accessibility that information as you do, because they can Google the same things that may be on the letter or phrases that you may say, during dent, more demanding as a result of that, why can’t you save it? Why can’t you? You know, do a call? Why can’t you all those sorts of aspects make things a bit more difficult, or not difficult, but at least it will affect our decision making, because we have to empower patients with an information and knowledge, you know, the amount of dentine remaining, for example. You know, the endodontic factors, the periodontal factors that may play a role in successfully restoring a tooth. I think for patients, they need to not grasp what they feel is right, they need to grasp what we feel is most beneficial to them, because every patient doesn’t want to lose a tooth. But on balance, we need to look at the restorability of a tooth fairly objectively, in that we have to balance these multiple factors, occlusal factors in providing something’s predictable to the patient, because anything can be restored. I mean, anything can be restored,

[Jaz]
But it doesn’t mean it should be.

[Aws]
Doesn’t mean, it should be and also the length of time that it’s going to be restored also, is something very important. Because patients want to know is this going to last me five years, I’m sure as you say, in private practice, patients would like to hang a number on the amount that they are investing in. And but you get those patients who, you know, again, talking about subjectivity, there are patients who may have had one bout of paradigm ethical periodontitis in their dental lifetimes. And they even though the tooth may be quite restorable, they’re keen on having just a tooth removed because of their experiences. That’s an eminently restorable tooth. You know, it’s got caris, it’s reached the pupl, but it’s eminent restorable. Whereas we have the other patients where you’ve had repeated restorations, you’ve had repeated post core restorations, and they just want to keep that tooth for as long as they can.

[Jaz]
So yeah, where you come from what you’ve experienced, obviously has a big bearing on the patient psyche in psychology and decision making. Yeah, one thing I want to ask based on what you just said, then implants obviously have grown massively over the last, you know, 30 years, let’s say, especially in the last 10, 15 years, but do you think, do you agree with me that perhaps in the last five years that when a debatable tooth comes up, instead of jumping straight to the implant, we’re going back a little bit back into heroic dentistry to try and get some more years out of the implant, out of the tooth, even?

[Aws]
Patients aware that implants aren’t the panacea, they are not the cure for every dental problem. You know, I remember maybe 20 years ago when implants first really became very popular. And the perception of it was that why would you throw the kitchen sink that tooth to try and save it when you can have it removed, maybe have an immediate implant and have it restored within three or four months, then the real you know, the test, the real test of any dental treatment is time and once you have, you know, teeth that develop peri-implantitis we’ve seen this last 20 years or so, the option of maybe replacing the implant or indeed managing the peri-implantitis is quite daunting renascence of more traditional conventional techniques to restore teeth with limited extra coronal tooth tissue such as the post core or such as maybe looking at root canal retreating a tooth and establishing, you know, a good coronal seal, I think to look at a tooth that may be unrestorable or at least questionable restorability and somebody who’s 20 or 25? If you were to engage in providing implant at that age, you know, it’s conceivable over the next, you know, it’s likely that generations are going to become Centurions and reach the age of 100, that implant will have problems over the course of time and indeed will become obsolete. Remember, is the implants, you know, we’ve seen things on social media we’ve got what implant is this and oh, that’s quite dated, I don’t recognize that. And the design looks quite funky from this 80s or 90s. But teeth don’t generally become obsolete, they’re very timeless, our teeth, you know, if you look at a situation where, if we’re looking at the let’s say differences between, you know, teeth, and implants, the key factor and I know we’ll probably get into this a bit more later on, is that teeth have periodontal ligament, they have this gel capsule, that can really do wonderful things in that it can manage occlusal loading, and essentially react to various different factors, whereas implants do not have that ability, they are very basic in that respect. Implants have become very popular, but, they only should be really provided in situations where we have, you know, good oral hygiene, and all of those other factors going for us, or at least we can modify those factors before we engage in that. But I mean, commonly, you know, if we have a patient, who is a young patient, who I feel may not be ready for an implant treatment, and has an apical lesion that I feel that the tooth has questionable restorability, then, you know, the explanation normally, the explanation or the discussion that we have with the patient is that, I mean, you have an apical lesion on this tooth, it’s got questionable restorability, we need to modify things to essentially make things more amenable to an implant in the future for you. And that may take the form of maybe a root canal treatment, and getting some apicall regression of that lesion before we even discuss that and also obviously buys us time. And it gives the patient a bit of a ,it gives you time to assess the patient’s perception of treatment. You know, patients that come in, commonly come in may say they feel implants are the perfect restoration, or, as I said earlier, the solution to all the problems, it’s not always really that way or it’s not always, it doesn’t always pan out like that, unfortunately,

[Jaz]
That’s a very regular conversation, I’m having with my patients when we’re deciding whether to save a tooth or not. And a lot of patients come in who may be external marketing that implants are just a replacement of teeth. Whereas, you know, as we know, implants are not a replacement for teeth. They’re a replacement for a gap. So it reminds me of when I was a fourth year dental student, I was sat with, do you know Raj Patel because Raj Patel is based in Sheffield, restorative consultant.

[Aws]
Oh, yes, yes, I know.

[Jaz]
Very charismatic, funny guy. I won’t say anything. Perhaps. If you’re a student, you know, you can be quite scary sometimes being on consult place with him. But you know, it was a great experience at the time. And I remember going around the circle with students, and we’re trying to sort of discuss what we know about implants. And I said, Why I feel now was the stupidest thing ever. And I said implants last forever. And Raj Patel, God bless. So he shot me down so hard, but I’ll never forget the beating that I had the verbal beating that I had from that day. And that was, you know, that was a perception or fourth year dental student that hang on don’t implants last forever. But that was a fourth year dental student and the public must definitely feel that

[Aws]
I think the implants are they are essentially a metal bolt, where you have a highly of compared to a highly evolved tooth dentine periodontal ligament, and essentially, you know, the romantic in us should, as dentists should be aiming to maintain teeth for as long as possible, not to the point of being ignorant about a tooth not being saveable because, you know, that would we be doing our patients disservice, but wait, you know, looking at an armamentarium, where we can keep teeth for as long as we can. I think, as I said, you know, things are gonna come around full circle, and patients are probably going to perceive that as well, you know, patients where teeth can be saved, we can upskill and gain extra skills in trying to push the boat out for teeth for as long as we can, whilst also informing our patients of those factors as well, which is, I think, is the key now, because, you know, if a patient is informed, if you spend, let’s just say, for example, you’ve got, you’re looking at, we’re looking at Lancome periapical and the distal margin is quite deep, and it’s close to out the alveolar

[Jaz]
Another common scenario that we see in practice, yep.

[Aws]
And you perceive that as a challenge, your time may be better served, as opposed to really sweating over a tooth and trying to get a good margin on the impression or an extra 10 minutes. It may be that you spend the extra 10 minutes explaining to the patient that unfortunately it can be very difficult to get the optimal margin here for these reasons, then the expectation is managed, you know, your outcome under promising and over delivering, there is a, that’s a great little anecdote, really for us in 2019

[Jaz]
Absolutely and no more so than the challenging prognosis case. Absolutely.

[Aws]
So, I think, you know, changing our way in which we approach, you know, informing our patients and managing, you know, heavily broken down tooth, I think will evolve also, in that

[Jaz]
I find it very useful to, you know, draw the biting or draw the periapical that the patient can see, but actually draw it out and say this is the root, this is tooth, can you see that your hole is so close, and it just makes it and that scanned in as part of the note. So, you know, medical legally all very valid, and that’s, you know. So that’s a nice little communication thing that my patients find quite useful. And then they sort of remember that, you know, my tooth is knackered, and then it brings the expectations down. So if you just jump right in and say, where do we draw the line? Can you tell me where you draw the line? Now, for example, one thing I think about the first thing I think about when it comes to restorability, the word is almost synonymous with ferrule. So for me, the first thing I look at is has the tooth, for example, got a ferrule of at least 1.5-2 millimeters, basically, is that your starting point? Obviously, oral hygiene, perio factors, but can you comment on the structural integrity of teeth?

[Aws]
I mean, so there’s been a lot of work on this, as you can imagine. And, you know, we know that a two millimeter ferrule is required, and that we want to brace the tooth together. And essentially, the ferrule will not only allow give you an opportunity to, you know, bond tooth tissue circumferentially, but it also allows the tooth to be loaded, you know, the toth and the cool restoration, we did, you know, together as opposed to maybe wedging, or at least leverage against the tooth. So that the, you know, the ferrule is very important. There’s been work at the Eastman looking at various different factors associated restorability, there’s quite been, quite a few indices,

[Jaz]
Do you use them? Do you use these indices? I just want to know, in your practice?

[Jaz]
I don’t. No, I mean, again, I feel that because it’s so subjective. Because, yeah, I think a lot of these indices, unfortunately, they can’t really factor in patient expectation, but it also is very them to factor in the occlusal factors, for example, you can’t factor in the patient’s oral hygiene, you can’t factor in various different things. Essentially, we need to look at the tooth as a unit to just what tooth tissue is remaining above the gum, because again, volumetrically that can be quite difficult. So for example, you know, [ ] work at the Eastman, a subsequent to a number of really good MSCs Bobby ban lifted a really good MSc in 2000, looked at, you know, the amount of tooth tissue remaining and reconnecting to teeth that required his crown restoration. And the looked at splitting the tooth up into six sextant and measuring the amount of tooth tissue remaining. Volumetrically, if you’re just in and it’s common now, where we have one wall that is virtually intact, and the other wall be at the buccal or the palatal will be it appropriate up, you know, classic premolar buccally palatally, you have a massive amount of tissue on one side, not the other, you know that volume, ideally, would have been better serve, being distributed more evenly amongst the tooth. So it’s, you know, we don’t get those situations in some of those indices where you have a donor, a conventional, it’s quite predictable. The real point where we start to scratch our heads is when we’re missing so much on one side. And we are virtually intact on the other, be it buccal or palatal.

[Jaz]
Let’s make it tangible, let’s say a case I had actually about eight months ago and so.A lower right first molar it has about a half a millimeter of ferrule supragingival so there may be some subgingival tissue as well, buccally, so half a mil buccally about a millimeter mesial and distal, and then lingually we have the entire lingual wall intact, all other factors being favorable, what will be the restoration of choice, imagine let’s say we are going to restore this tooth because we in a certain way, another mouth who may choose not to and a different mountain that we may choose to get, you know, what would you suggest would be a suitable way to restore such tooth? Or do you think that it’s not even worth going there because the factors are so variable and I respect that if that’s the case.

[Aws]
Endodontically treated or not, Jaz?

[Jaz]
Not treated, not endodontic treated,

[Aws]
Not treated, so vital. And I mean, so what we’re looking at more often now actually is the enamel status of the tooth because you know, there’s quite a lot of conjecture about conventional preparations versus adhesive preparations. So you know, if you have, you know, a circumferential enamel ring that may bode well to providing a sort of adhesive restoration that may be quite neat in its design. In that sort of situation, you know, if you were to go, you know, conventional, that sort of situation and you’ve got lack of tissue, buccally, mesially distally, you know, if you prep that lingual wall, you’re not gonna have much left, as far as I know. So in that respect, you know, the onlay now has gone through, you know, an evolution as it were, because, you know, it hasn’t been the onlay on a molar tooth now really has made, there are numerous advantages of having an onlayover conventional restoration, you know, you can visualize the margin, you can, you know, you can control your moisture control, instead of going deep into a cervical region, you know, if the mark is supragingival your bonding and your cementation process is going to be a lot more predictable, they are a lot harder to prepare, than your conventional crown. Because you have to know two onlays of the same essentially, because it’s the margin of a non lay is very much dependent or indeed dictated by what the tooth is giving you to start with. Whereas if you were to, you know, if you were to go through Shillingburg and you were to look at that sort of preparation, every one of those essentially, if you’re doing your job and you were on the money, you every moment that you would prepare, it would look exactly like that book. Whereas, you know, the onlay preparation which conserves tooth tissue, you know, no two preparations are gonna be the same. And, you know, I think that sort of aspect when you, you know, you’ve described that sort of situation that lends itself to an onlay, I mean, I’m a huge fan of golden onlays, so you know, that can be my go to for certain situations, when it comes to teeth that are heavily broken down.

[Jaz]
So certainly, that’s what I one thing I consider, so onlay was definitely on the list. The other way that I asked one of our good colleagues, Mahul Patel, I sent him the WhatsApp photo at the time. And the other alternative we suggested, was a to elective RCT and do the split post technique, a cast, and then to restore it eventually. So that could have been, you know, another way a lot of work involved there. But definitely a very valid way to do it as well. The patient ended up choosing due to the fees, in other words she was having done is a massive composite, and then the day that breaks, he’s having the tooth out.

[Aws]
Again, I mean, if we go back to you know, electively root canal treating, I think what’s important is that we know what factors what advantages the pulp provides us with, you know, a vital pulp provides us with, you know, there is quite a lot of evidence, some of it is quite dated now, to show teeth with pulps are physiologically more able to manage loading, ie the pain threshold is such that there’s less likelihood for them to fracture than maybe a non vital tooth is because they may, you know, the proprioceptive nature of the tooth is able to manage, you know, sudden loading a lot more easier. I think, you know, obviously gaining what you gain by loss of vitality, that sort of situation is you can, you know, a call that you may feel is more predictable, you’re going to be gaining resistance, well not resistance and retention, but you’re gonna be gaining greater depth of contact of your restorations through the pulp chamber now, and you know, she went through the composite. And, you know, she’s probably been well informed by yourself as to what the practice is going to be. I think you know, for yourself, it’ll be interesting to see what happens with that tooth over time. And I’d like you to tell me what happens actually, because it sounds quite interesting to see how it pans out.

[Jaz]
So far, eight months, no issues, but I expect all just the lingual wall will break off eventually. And then she’s gonna have that tooth out. And that was very much I’ve walked through it and she wasn’t keen on spending best, is coming into implant territory. And we had that, you know, full on discussion with a drawing and everything. And that’s what she thought was best planned for her. I completely get that. And then we got to help our patients and be non judgmental.

[Aws]
I mean, you know, why does she have, why did the buccal wall fractured? That’s the other question we must ask ourselves because we can’t make the same mistake twice, if the buccal wall fractured as a result of occlusal factors. And, you know, we don’t look at cuspal coverage as as something that we require in these heavily broken down teeth and we’re making the same mistakes again. I think that’s also quite key is we don’t we tend to look at the tooth in isolation, whereas there aren’t going to be multiple factors that plays a part in why tooth has become unrestorable, or, you know, essentially making it more difficult for us to provide a restoration that’s very predictable.

[Jaz]
You were just talking about now is that all the endodontic studies about root filled molars like to break. I actually tell my patients not from molars that are root filled are extensive, for example, losing a marginal ridge obviously explained it in patient friendly terms, but I say it’s six times more likely to fracture. Now, I’m pretty sure correct me from this as from Ray and Probe 1995 study, but I like to give my patients sort of evidence based. So they know is six times they know you’re an individual, but according to studies, a molar as we know, with a loss of marginal ridge are six times more likely to fracture with a root canal. And that helps them to rationalize, you know, why exactly, we tell them to have something because once the root canal cause other thing is in my tooth fixed yet?

[Aws]
Yeah, I think for patients is, you know, putting, you know, putting value back into investing in a tooth, you know, a molar tooth, you know, well obturated, well restored tooth is very, extremely valuable to us as dentists and it’s communicating to them. So, you know, for our patients, it shouldn’t really be just a root canal treatment, you know, in the package should be restoration also. And you can argue that the quality of the coronal restoration is more important than the actual root canal treatment itself. Literature that’s intimated that the coronal restoration is the most important, one of the most important factors not only for the fact of keeping the bugs out of the root canal system, but essentially protecting what is now a weakened structure.

[Jaz]
With cuspal protection. Yeah.

[Aws]
Cuspal protection because essentially now, the more you know, as you, you know, we’re using loupes more often now. And we’re seeing things we’ve never seen before we looked down a pulp chamber, you know, where maybe 20 years ago, we may have not been using the most elaborate magnification techniques, we’re seeing cracks in teeth, that are inevitably going to affect our diagnosis, prognosis of teeth. You know, the other factor also is that when we’ve had those cases where we don’t know what’s wrong, you know, the root canal treatment has been optimal. And you take this cone beam CT, and you discover a fracture, you know, and that happened to my nurse recently, where she had root canal treatment done by some really expert endodontists. And, essentially, the outcome, and she had a CB CT taken. And I wrote this up as a sort of a, you know, editorial. And subsequently, we only actually found out what the problem was when the tooth was on the end of the forceps, unfortunately, and all the fracture all the way up the palatal roots, which wasn’t really seen on a CBCT. So, again, you know, we’re looking at ceiling but we’re also looking at protecting the reigning tooth tissue and, you know, inevitably, there is a finite amount of tooth tissue that we need to achieve both of those aims.

[Jaz]
I hate cracks, I think, oh, as restorative dentist and you know, GDPs and everyone in dentistry, endodontists you name it, cracks are have a huge bearing on restore ability, because the mere presence of a hairline crack just you know, turn through a restorability right upside down before because next question are asked us about cracks and how you manage them. But I just want to mention one more point about the ferrule which I think I probably learned about three four years ago. And I’d appreciate it I think it’d be good for listeners to hear it is when I look at a ferrule I don’t just look at the height of the wall by look at the ferrule horizontally as well. How much thickness so that sort of ferrule is important as well for bracing and giving strength for your future sort of restoration. If you’ve got something with that less of a horizontal ferrule, then there’s more flex in the dentine. Anything that you what you can add to that?

[Aws]
Yeah, so I mean, if we’re looking at some longitudinal work, so at the Eastman, their survival rate, or the median survival rate, I think it’s median maybe mean, I can’t remember off the top my head or post core restorations approximately 15 years that may have gone up over the years, that may have gone down, I don’t know, you know, because they don’t publish here. This is the last time that I know of, but their outcomes for new posts, ie replacement post is something like five years. And that may be due to you know, I would you could speculate that’s likely to be due to thinness of the denting wall subsequent to re preparation or indeed maybe root canal retreatment you know, we have this sort of movement now endodontic movement with regards to minimal access cavities or ninja access cavities, or, you know, it’s quite amazing to see, but one of the things that we may not appreciate just by being able to root canal treat an MB3 through you know, a pinhole is that you maintain as you said, you maintain that dentine thickness, and that builds resilience in the tooth and manage occlusal loading. And indeed, you know, it makes the tooth more able to manage or at least seal the tooth because your margin is going to be thicker ie you know, the distance that a bacteria or a bug needs to travel through that margin is going to be much longer to give them classes than when did the apex. So I think of the dentine is also very important as I said to you, there is an overt focus on the height of dentine with all the other factors such as the thickness as well.

[Jaz]
Cool, thanks so much. So cracked teeth, you have a lower seven in a patient with the worn dentition, generally intact dentition minimally restored, good oral hygiene. And you’ve been seeing this patient for a number of years, and you’re starting to notice that there’s this little crack on that seven is starting to get stained, the tooth is asymptomatic. These situations, I really don’t know how to advise our patients because I’ve seen a few over time, then they eventually develop symptoms, and others, you know, you can watch and nothing ever happened. So I never really know whether to recommend some sort of media gold, minimal prep cuspal coverage, like, you know, gold hat for these sevens. And something that I’m pretty sure you can say that there’s no right or wrong answer, it’s very difficult. But any anything that you’re any opinion, clinical opinion you’d like to give in these sort of scenarios?

[Aws]
So, I mean, obviously, it depends on the tooth and it depends on the situation. You know, there has been a lot of work on how to manage these sorts of situations, you know, one of my colleagues, Brian Miller, has looked at providing things that are composite onlay, so that, you know, up until that point, that crack has slowly it would have slowly started to propagate. You know, the tipping point will be when one of the cusps undermined so much so that you have a catastrophic failure and the tooth becomes unrestorable. Now, I have to explain that to a patient photography to grant you know, as you say, you’ve seen the patient over maybe three or four month period, if you took a photograph at times zero and then took another photograph, it’s three months or four months, the ability to convince a patient to go through that process of saying, actually, you know what, you have a crack here. And I’ve been watching it carefully for yourself. And it’s now starting to get stained, I feel that we need to manage this prevent this from propagating, you’re more likely to probably get acceptance of that, then if you would just say that, I’ve noticed this, I think we need to put an onlay on there.

[Jaz]
Absolutely. And this is something I’ve done very recently, actually, with a patient with an upper six actually that I noticed the crack and all my new patients will get a full series of photos at work. And I’m not sitting for you know, a couple of recalls or for recalls. Now two years, I saw him and then with his cracked teeth, I like to only for people with crack teeth, I like take subsequent. So follow up photos, because I’ve done no work on them, everything’s good, I wouldn’t take full occlusal series photos for everyone but famous, okay, got cracked, let’s just compare. And it’s so useful to have two years worth of before and after photos of just normal life and chewing without any denture involved, because you actually see a little bit more wear here and there. And you see the crack a little bit wider, perhaps a bit stained. And I think that can be a real good tool in general practice in any practice to sort of diagnose yourself and, and help in decision making.

[Aws]
I mean, I think when we’re looking at crack teeth, this is an our 21st century epidemic, I think, you know, it is something that we’re going to be managing more and more often. And, you know, those MOD amalgams that went in maybe 80s and 90s, during, you know, when, you know, desperately remunerated a lot better, those sorts of teeth will come back, and then they were present with issues. Again, you know, the common other common situation is when you have somebody with a MOD amalgam, and they want to replace for composite for whatever reason, and they come back with an issue after that, you know, pulpal sorts of issues, though, I think, for patients, again, if we’re thinking future thinking or future proofing, you have the constant factor that we can never really modify or really have any say in is whether or not maybe the patient will wear a stabilization splint or a soft bite guard at night to reduce the amount of non axial loading on teeth. Because that’s out of our control, you know, if they’re restless, they might probably less likely to make, to wear the Michigan splint that we might prescribe them. So if we have that constant parafunction, bruxism working on teeth that have cracks in them. And it is a constant and say, for example, that you spoke about, catastrophically fails, and that tooth is extracted. The remaining 27 teeth or 26 teeth, the amount of force applied to those remaining teeth actually be greater per percentage, because the amount of parafunction will remain fairly constant. But you have less teeth to take that load

[Jaz]
There’s a whole. Yeah, a pair of teeth that have now lost in that, you know, as a percentage quite big. Especially if it’s a seven or a six, if it’s a molar then that, I think greatly affects the equation, isn’t it?

[Jaz]
Well, I think that would be the real moment of realization for patients when that sort of explanation goes through and you say to actually, you know, you’ve lost amount of tooth, but you have another 26 teeth, bearing in mind that you have the wear facets on, you know, that I’m very generally positioned, you know, other teeth that are now going to be at greater risk and at that point, Discussing maybe onlay of a teach strategically to protect them, you know, teeth I mean six, sevens, for example, may not be out, you know, maybe come across as quite sensible at that stage.

[Jaz]
Absolutely. Treatment planning wise, I think that’s something a philosophy I follow that sometimes if you are having that sit and wait approach to the patient, but if something bad does happen, as long as the patient have been, you know, in it the whole time, then I’m a bit more aggressive in my recommendations, but I think that is what is actually best for the patient of their crack to emerge in molar than they are going to be cracks in other teeth to lesser degrees, perhaps to reach that failure point and is at that point is a good idea to then be more aggressive, I think.

[Jaz]
And I think, yeah, I think that realization is quite important patients that they need to manage or act upon the cracking, you know, I mean, I work in London, patients are generally quite stress. You know, it’s routine in my practice, that we go through, you know, a visual analog scale of stress for patients. And you know, when you ask the patient, are you stress and they say, yeah, I’m 9 or 10. And you want to translate that into what they present orally, you were looking for facets, looking for cracks in those sorts of situations. So I think, again, as I say, you know, we’re looking at restorability, but we’re also looking at what the forces on the teeth are going to be able to,

[Jaz]
I mean, the forces are so important, I mean, I’m a big fan of looking at. So one thing I do for all my patients, and you know, please tell me, what you think of this is, I feel that the masseters and temporalis muscles, and because that is a I think that’s really well correlated with the patients who have meatier, or more hypertrophic masseter muscles, and I grade them usually as mild, moderate, or severe. And it’s, it’s part of my custom screen, software vectors and the software we use for note taking, that every new patient will get their maseters and temporalis assessed, I’m looking for 10 minutes, but mostly I’m looking for the size of it. And already, for the patients who’ve got the biggest masseters, I’m already suspecting that there’s a parafunctional habit, and but I’d say about 95% of the time, I look in the mouth, and it’s exact sort of mirror of the size of masseters. So those with larger masters I am seeing wear into dentine, significant cracks. And I’m noticing that a lot more, sometimes based on the occlusion as well. For example, if they have got an AOB, and they’re mostly occluding posteriorly, with combined with the parafunction, then or it could be for example, their facial type, are they brachyfacial facial stuff like that deep bite, but that’s something I assess. And it’s supposed to be a sort of correlated to their bite force as well, which obviously reads into what you’ve been describing now in terms of their stress levels. And generally, the forces they’re playing,

[Aws]
I think, again, I mean, going back to restorability, you know, the, you know, the tooth that is heavily restored are indeed questionable restorability in a patient who is a parafunction patient, versus a patient who is not parafunction patient is quite essentially quite different. Also, you know, the fact that the role that occlusion plays, and maybe guidance as well, non working side interferences, all of those factors play a role. And, you know, just to say, in some of these indices, there’s quite a few of them now, I’m not buying in direction, every one in particular, the occlusal factors probably don’t care, very difficult to factor into that sort of situation. Now, for patients also, I mean, teeth evolved to meet or at least be in contact for 15 to 20 minutes a day during chewing cycles. Now, if you say to a patient, that you are overloading the system, and as a result of that overloading of the system, your Something has to give in maybe your TMJ, or it may be your tooth, that also increases patients perception of the issue, ie, it’s not the ownership of the problem, isn’t the dentist needs to put a crown on this tooth for me before it cracks. The ownership of the problem is now shared amongst yourself, being yourself being the dentist, the patient, as well, because they have to realize that, you know, we can’t help. That’s those sorts of huge amount of forces that are put on teeth that have minimal amount tooth tissue remaining. There we are. I mean, again, you know, we’ve come back to occlusion again, because it’s fairly important with restorability. I’m sorry, we’ve diverged.

[Jaz]
No, and this is important, because the crux of predictability is occlusion. I think that last minute of what you said, is going to be my main snippet, my intro snippet, my promotional snippet for this podcast, because I think that’s exactly why I say to my patients, you know, how many minutes a day in, you know, normally there should be together and I love given that information on patients because they really think Oh, I didn’t know that. And it has helped a lot of my patients over the years when they feed back to me that you know what Jaz, you told me that and I’ve been, and you’re right, I have been pressing my teeth in these scenarios and whatnot. And these are the patients so you have more cracks, you have more large restorations and you have more crowns, because their forces and what they’re doing with their teeth is just much more so I think what you said there was absolutely golden in terms of value that listeners will get from this. So I’m conscious of time. So I just want to ask you, I know there’s only so much we can cover, what are your main pearls that you think would benefit listeners and overall, you know, umbrella term of restorability, or it could be a certain aspect of restorability that you would like GDP is to be looking into more when making those decisions, is there anything in particular you want to mention out there?

[Aws]
So, I mean, again, I mean, it goes back to the amount of coronal tooth tissue remaining, but there’s dentine, or at least that amount of coronal dentin remaining, but also the adhesive status of the tooth. You know, it’s weird how, you know, because of the movement that we have in the UK with regards to management tooth surface loss, that we have this enamel ring around an upper anterior and we bond to it, where it has no resistance or retention form, we’re essentially relying on our adhesive component entirely. But as soon as we look at a molar, it doesn’t, we don’t seem to correlate that sort of same situation. I think, you know, what is important is that we have to max out on every stage and minimize, you know, any thing that may compromise each stage. So for example, if we were looking at, you know, our, for going to restore something adhesively, then, you know, we need to just look at maybe utilizing rubber dam, because if we get some contamination, and we’re doing an onlay that may be bonded on a Panavia or something such as Nexus, we don’t want to compromise that sort of situation. And we need to essentially, need to observe every stage and know and realize that we have to ensure, you know, the most optimal situation with these teeth that have what question restorability, you know, if we’ve got a coronal restoration, or if we’ve got, you know, an access cavity that is bounded by tissue, that’s not a situation that we will sweat over. It’s those, as we said earlier, we have tooth tissue or we have a deep margin distally. And, you know, we want to get a good margin as best as we can and the deepest portion, I think, the other factor is, is that if we get, if we nail that distal margin, and we get a good seating of our restoration on that distal margin, because it’s so deep, you know, you could you know, if we’re thinking devil’s advocate, we could say that that margin isn’t cleansable for the patient, and it’s likely to develop decay in the future.

[Jaz]
Then we go on to discuss the partial exodontia technique, which apparently was a technique founded by a chap called, Italian chap called Dr. Paolo Guazzini and probably bastardizing that word, but it’s a, it’s called a partial exodontia techniques, pretty cool. You sort of have an extrude tooth and you make a tooth that was otherwise borderline or unreasonable to restorable one, and that’s what we’re going to discuss now.

[Aws]
Now, I read something quite recently from I think it’s someone in Italy, where instead of maybe orthodontic extrusion, which may last quite a while, and may be quite difficult to achieve aesthetically, anyway, anteriorly, they were doing extractions of the root and then repositioning with a splint, you know, sort of like a trauma splint, but they were purposefully extracting a root. And, you know, creating an environment for the healing

[Jaz]
Partial extraction therapy, right?

[Aws]
Partial? No. So partial extraction therapy, correct me if I’m wrong is when you have the remaining root buccal to an implant. This is purposeful extrusion of the tooth through a forceps, and then creating a new amount of ferrulw extra coronally.

[Jaz]
Yeah, I think there might be a couple of lenses, or certainly I went to a lecture at the BARD, I think it was about just one and a half years ago, and a chap who had some sort of, he’s been taking 14 years where we had to show lots of great cases. So essentially, for those who are unfamiliar with this is you’re using forceps or like Seta, as he described, but you always have to warn the patient actually, if the bit on luxating breaks, and that’s game over. So just come in to the patient to come in with the mentality that this might not work. And you’re only doing patients who trust in the right sort of scenario premolar, for example, and yet, like you said, you just sort of luxating the tooth that are about to come out by a couple of millimeters. But you know, obviously, then you suture it, you know, in a tight way and you splint it, so that the alveolar bone will regenerate then about I think it was about two weeks later, he would root fill that tooth, and then you have instant ferrule basis, if that’s what you’re referring to, right?

[Aws]
Yes. So I mean, again, like I said, like we said earlier, I mean, we’re looking at innovative ways to keep teeth going. And you know, who would have I would have laughed if he ever told me 20 years ago that someone had, you know, suddenly someone has thought of purposeful extraction or luxation to gain ferrule and you know, it’s got traction, which it has, you know, people are talking about here was what people are doing routinely on I don’t know But the

[Jaz]
I don’t know anyone who in the UK is doing it routinely. And if you are, if you listen to this reach out, let us know, share your cases would be good to learn for everyone. But certainly I know Yeah, it was Italian man that actually presented at BARD I do forget his name. But yeah, I think in Europe it might be more popular.

[Jaz]
So then our discussion turned back to implant. Back there again back full circle with implants and their issues, you know, implant that was placed 20, 30 years ago, just with growth and aging, another BARD lecture i’d went to, and again, I forget, I don’t know his name, I’ll probably reference it later. But he said, all these follow up cases of implants, where the screw threads, so the implant threads were exposed, not because of poor technique of placement, these were placed by top dogs in implantology at the time, but actually growth and the forward and downward growth of certain types of long face females or whatever, and how they grow and how they end up their implants end up looking quite ugly over time. And that’s a huge ticking time bomb as well. I think for the future.

[Aws]
I think, you know, time is the test, really for any restoration. And I think, you know, implants a place quite early as well in patients, maxillary growth in adult males continues until the late 20s. So, as I say you there are cases that have come back where you know, teeth may have been extracted, and the patient may have been referred in and the situation is such that the implant is an ankylosed unit, and it has not migrated with the other teeth either side. And it is essentially, you know, the incisal edges is quite far cervically when compared to the adjacent teeth. With regards to the situation with exposed threads, and all that sort of all that other aspect of things, I think, you know, the change in implantology is realizing that once you’ve removed the root, that you lose the bundle bone, and you’re a great, you’re obviously a greater risk of bone resorption. And the buccal,

[Jaz]
Especially for anterior teeth, which got a very paper thin bone.

[Aws]
Yeah, paper thin bone or even, you know, if you’ve got somebody who has, you know, a very thin bio type, you know, in those sorts of situations, you may think twice about extracting a tooth, and providing an implant, when maybe, if we think also more globally, I mean, post core restorations or, you know, innovative ways in restoring teeth. You know, we’ve been doing, that is part of dentistry, that’s been done in dentistry for hundreds of years, or at least 100 years anyway, if we compare that to, you know, the genesis of implantology, which really has really, really taken traction over the last 25 years or so, when you compare that difference in experience, knowledge and research, you know, teeth, again, are superior in that respect, because there’s been more done on teeth has been more research on teeth in those sorts of situations, you know, a compromise tooth to a compromised implant in someone you know, in a loved one’s mouth, what one would you choose to have to treat for them? I would take a compromise, you would take compromised tooth. So again, that sort of paradigm, you know, that sort of not paradigm, but the association between teeth and implants, again, I think it’s swung back towards the teeth, even if it’s, you know, heavily restored, even if it’s looking tooth tissue I think that’s the way things will go.

[Jaz]
Really well. I’m mindful of the time. It is a topic that you can literally talk about for hours on end because I’m just like reading through the list you know, you said implant restorability interface, perio factors, endo structural, occlusal, aesthetic, patient litigation, and obviously a future development. So literally this episode could have gone in any direction. I’m glad it went the direction that it didn’t because we talked a little bit about occlusion, innovative methods. So it’s good to bring that all in together and talk about ferruel so thank you so much for that. I want to know a bit more about I think you’re doing an occlusion symposium in September? I’ll put the link out for everyone, can just please tell us about that.

[Aws]
Yeah, so you know, I we decided to do the symposium i think you know, lecture days are quite common a long time ago and lots of hands on courses have become you know, the norm now. But you know, this is a traditional lecture day with I would like to thank some for very good, high quality speakers. We’ve got Tif Qureshi. Talking about GDP, orthodontics and things like Dahl. We’ve got Sandra Brandari coming down from Manchester talking about cracked teeth and managing that endo restorative interface and occlusion and how to manage teeth and how occlusal load you want to endodontically treated teeth or indeed vital teeth effects things. I’m talking about occlusion past, present and future. And we’ve got Mahul, Mahul Patel who’s also going to be talking about controlling occlusion, you know, those certain aspects of maybe the crown provision process, where you know, you may look at a tooth after you know, you may have tried to restore it tooth the crown and those little things aspect of lack of control of the occlusion can result in, you know, maybe, you know, the crown not fitting appropriately or indeed the occlusion is not being as ideal as it can be. So, you know, it’s at the BDA, it’s 150 pounds and it takes about six hours of CPD.

[Jaz]
That’s firstly that’s a bargain. Secondly, I really like those people that have gone on board, Tif Qureshi, you know, he taught me Dahl technique. I actually went to listen to Tif Qureshi in Sydney, because I’m such a geek that when I was in Sydney at the time,

[Aws]
I mean, it’s a long way because he lives in South London. But anyway,

[Jaz]
I know right? I was on a different course, I was on my jollies. And I was there and I was, Oh my god Tif is coming and then my wife very kindly let me go. Because I thought okay, I might not get time to see him in London, because just the way life is. And I seen him in Sydney and his fantastic ortho-restorative course over two days talking about dahl and I was much more confident, you know, using dahl technique after that. So that is great. That is good talking about that. Mahul’s lecture sounds really clinically applicable. So as yours sounds like a very good day to take, a lot of nuggets. So I’ll be sure to if it’s okay with you put the link at the end of the podcast so people can look into that bargain of the day. So brilliant. Any last words anything you’d like to say?

[Aws]
I’m looking forward to subscribing and listen to future podcasts in the future.

[Jaz]
Thank you so much, Aws. I really appreciate that.