An Idiot’s Guide to Restoring Single Implant Crowns (Part 1) – PDP156

Jaz’s Introduction:
In that same style Devang covers over the crosses two next episodes, the Five Different Stages of Restoring the Single Implant Crown. We’re going right to the basics, starting from assessment all the way to screwing or cementing your implant crown, and we leave no stone unturned.

Hello, Protruserati. I’m Jaz Gulati and welcome back to the Protrusive Dental Podcast. For me, implants are super confusing. When I was in the first few years after qualifying, I did go on some courses to learn about restoring implants, even learning about placing implants. But I just decided it wasn’t my bag. It’s not what excites me.

Orthorestorative excites me, occlusion excites me, and implants are at the moment in my career is not something that I’m spending more energy and time on. I’m doing a lot more TMD now I’m doing restorative but who knows what’s in store for my future. But as we know dentistry is a long game and that could change in the future, but I definitely needed to serve my patients better by learning more about implants in general. I think we can all do with foundational knowledge and where better to start than learning about restoring implants which is exactly what Dr Devangkumar Patel will do today.

Now, please, no one be offended by the episode title, An Idiot’s Guide. If you listen to the end of the episode where we discussed naming of this episode, it’s a bit funny actually, but I mean this with the best intentions because actually when you listen to the interview, you’ll see that I’m stopping Devang and I’m like, hang on a minute.

When you say this, do you mean this? And I’m learning as we’re going along. And when we’re talking about internal hex and external hex, for me, that just got really confusing. So I made this analogy of like a belly button, like sticky-innie, sticky-outie. So, you’ll see lots of Jazz-isms in there about me just trying to break things down, trying to make it tangible. So please, no one be offended by the title.

Protrusive Dental Pearl
The Protrusive Dental Pearl today is from the recent webinar I did. I did All My Productivity Secrets Revealed. Because you guys ask me all the time, like, Jaz, how do you manage to be a father, work in clinic, have a podcast, do all these courses, social media, et cetera, et cetera?

So, I gave away every one of my 17 secrets from getting someone else to do your emails and getting a PA to getting a team for social media, to little things that which apps to use. So, I’ve covered that all on this webinar and it’s now available as a webinar replay. So, if you head to protrusive.app as the website, that’s protrusive.app and you make your login, you can access that right away. There’s even a two-week free trial you can use.

One of the secrets I shared is how I move from a to do list to a calendar. Because the problem with to do lists is that you make this very ambitious list, right? We often overestimate what we can do in a day, and we underestimate what we can do in a year. So, our daily lists are just way too long. And then at the end of the day, you feel really down that you didn’t even cross off half the things on your list. Instead, I now put it in the diary.

So, I know that this task will be done at 2PM to 3PM on this day, for example. By slotting it into a diary space, you know it gets done if you respect your diary. The problem is life happens and you don’t always get to do the things in your diary, right? So again, I used to hate having to move things and edit and move it to like a week afterwards and try and think where I can slot this task in.

Now I use something called Motion. So, Motion is like a calendar app, and it’s like a, it’s a replacement for Calendly as well. It’s a replacement for Acuity Scheduling, which I used to use. So, you can actually book meetings, ClinCheck reviews with patients. You can book meetings with others who sort of book into your diary.

So it’s a really good calendar tool in general. But what I love about Motion and the reason it’s called Motion is because let’s say you set some tasks in your diary; you diarize it. If you don’t complete it that day, it then figures out where in your diary it should place it in the future based on some parameters that you set, like how high of a priority that specific task is, which days you’re willing to work on these kinds of tasks.

So Motion actually decides using AI technology to where it should move your task into the future. So I love this. It’s been great for me. It’s pretty cheap. It’s about 170 pounds, $228 a year. So if you’d like to check out a free trial of motion, head to protrusive.co.uk/motion. That’s protrusive.co.uk/motion and just make sure it’s right for you like using it.

I did a seven day free trial first and it worked well for me. So I ended up taking it and by taking a membership, I was able to cancel my Acuity membership basically cause I was already paying for that for booking meetings and booking links and stuff.

This does all that. It is like Calendly and Acuity, but much more with the whole AI integration and your diary. I have to say I wasn’t that overwhelmed by the mobile app. So I use it on the desktop and I like how it syncs to my Apple calendar or whatnot. I try it for free. And then if you like it, then obviously go with it.

If not, then at least you tried something. It’s got to work with you and your workflow, but I’ve warned you. The mobile app is perhaps needs to a bit of work on it. But the desktop app is what I use. And that works really well. This is an affiliate link by the way. So protrusive.co.uk/motion does take you to an affiliate link.

So if you do sign up, we do get a small commission, which goes towards supporting this channel. If you want to catch all the other 16 secrets, then do check out my webinar on the Premium Clinical video section of the app. Now let’s join Devang to make implant restorations tangible.

Main Episode:
Dr Devang Patel Kumar, welcome back to the Protrusive Dental Podcast. You are a very welcome guest. Like I said before, if you haven’t heard of Devang’s series on Full Mouth Rehabilitation in 11 appointments, there’s a three part episode. People message me Devang saying that they learned more from that three part episode compared to big occlusion camps that they’ve been to. Can you believe that?

[Devang]
Wow, I’m humbled.

[Jaz]
It’s always great to have you.

[Devang]
You are very good at taking information out, Jaz. So, I think the credit to you as a host.

[Jaz]
Dude, I’m going to suck so much information out of you today about implants. But, let’s really make it basic. Talk to me like I’m five years old and I’m going to be placing my restoring, restoring. Talking about placing, we’re talking about restoring our first implant. Let’s say, and I’ve heard this before, Devang, is a really good place to start for a GDP is like a lower premolar or an upper premolar. There’s no mental nerve. And so an upper premolar is a great place to start. Would you agree with that?

[Devang]
Yeah. I mean, for restoration, it doesn’t really matter. Any posterior teeth is fine because we’re not worried about the nerves or any anatomical area because when you receive a case for restoration, you would have hopefully healing abutment in place, which you will go through anyway.

So any posterior teeth is generally ideal case when you start doing first. And if you are restoring, maybe you want to look at the CGDent guidelines on implant placement, actually, but it gives you some ideas to how or what type of things you need. Implant is, I always tell people, because I mentor, I used to, well, it’s hard work mentoring for implant surgeries, yeah?

So, but I mentor for some of my friends and I always tell them that, it’s all well and good for you to learn, but you need to be able to show here, at least in UK, because of the regulatory body. If something happens, you need to be able to show that you are capable of doing that. So it’s a very good document to go through where you need to really ideally have log, you need to have mentored cases. Because implant is completely different branch kind of as you’re learning dentistry all over again.

[Jaz]
I mean, this is the same also if you’re doing Botox, it’s the same if you’re doing sedation, if anything that you do that is pretty much a postgraduate discipline, it’s a really good thing to have a log, a reflective log and evidence to show our governing bodies that, hey, you know what? I’m doing the right steps to make sure I am well trained.

Now, before we go through the Five Step Process plus the bonus of troubleshooting. So, five steps from going to, Hey, there’s an edentulous region here to actually fitting your implant crown and checking the occlusion and then any troubleshooting.

So that’s the way we’re going to go across this two part episode. But before we go in, Devang, for some people who’ve been sleeping under a rock for the last year or so, and they haven’t seen the amazing things that you’re doing, just give us the, a quick one on you and your mission statement, my friend.

[Devang]
Okay. So I’m Dr. Devang Patel and I am the FMR guy. So I teach full month reconstruction to the dentist and I’ve created formula. I’ve written a bestseller book on full month reconstruction. It’s available on Amazon. I have a Facebook group called Full Mouth Reconstruction for GDPs and I run all sorts of courses.

I have a podcast as well, inspired from Jaz, called The Ultimate Dentist Podcast, listen to that. And I talk about full mouth reconstruction on that podcast. And my mission statement is really, I want every dentist, every general dentist practitioner to do simple full mouth reconstruction, and then take up from there because I see now cases on referral basis and I don’t see cases until general practitioners has identified.

And many times when you don’t do stuff you don’t even identify because you don’t you’re not even thinking and that’s why many people who do Invisalign they do more Invisalign because they are looking actively for ortho cases whereas if someone who doesn’t do Invisalign, they don’t do ortho treatment because they’re not looking for it.

It’s just passing through under their noses and ultimately the patient will benefit. And I always tell them, you don’t need to do MSC diploma certificate courses in order to learn full mouth reconstruction. You need a structured course and you need a structured training path in order to learn. So that’s my admission statement full mouth reconstruction.

And you may be wondering, why am I talking about implant today? Right? I’ve been placing implant for 13 years. I’ve placed over a thousand and restored over a thousand implants and I have a passion about it. Most of the cases I receive nowadays are implant related and then I convert them into full mouth reconstruction because many of them need a full mouth reconstruction.

But I’ve written a book now on implant and I’ve created an online course and I’m teaching implant because when I teach full mouth reconstruction. Many cases involve edentulous spaces and those that patient who wants full mouth reconstruction, they have a money power to go for implant most of the time.

And that’s why many of my course delegates asking me, oh, can you teach us implant? Because they like the way I teach. So they want me to teach them. And that’s why I created this cohort. That’s why I’m asking you to see if I can help anyone else really.

[Jaz]
Amazing. Now, you made some good points earlier that if you are trained in GDP orthodontics, then your antennas will be more receptive of crowding, base simple crowding that you can help your patients.

Now, let me draw a real world comparison, very relevant to our conversation today, Devang, which is if you are implant trained, then you see the dentures area and you think, hmm, can I get an implant in there? If you are not implant trained, you’re thinking denture and bridge as your default. You just are.

It’s just it’s the real. It’s the truth. I know the truth hurts and some people like, oh, give a patient all the options. But it’s true. Some implant dentists are probably doing implants where really a resin bonded bridge could have been done specifically, especially for lower anterior, single lower anteriors.

Why are we placing implants? That’s my feeling, Devang. You place implants. I don’t, but that’s my strong feeling. Whereas those dentists who are really doing elaborate bridges on like post crowned abutments. You need to be doing an implant, right? Or need to be referring for an implant.

So I think there’s a middle ground somewhere. Nowadays, implants have become a postgraduate discipline. Okay, it is what it is. You do some training. Where do you think it starts? Do you think that we should start by restoring implants first, placing implants first, or should we be looking at doing both simultaneously?

[Devang]
I’ll tell you my journey. At least I started restoring implant at when I did my MSc in Cons. So we were not allowed to place implant until we restored some implants, because the philosophy was that you when you’re restoring it’s failsafe. So, you know, it’s not as difficult as placing and also you will see what mistakes you’ve done the same philosophy where you make your own crowns and you see oh i’ve done under reduction. Does that make sense?

Like if you start doing your own laboratory work, you start noticing your mistakes and then when you start doing crown prep you understand, okay, I need to do this. So that was the same philosophy that I was trained. So I certainly started restoring implants and what says for something I would recommend everyone and then see whether that’s your cup of tea, because I’ve known a lot of dentists who invested thousands of pounds learning implant placement, and they’re not placing them because they don’t like it.

So I think it’s a safe start to start restoring implant. And then for sure, placing simple implant for a good restorative dentist is it’s really, really straightforward. So I would always recommend to start placing implant at some point, but start with restoring.

[Jaz]
Restorative consultant, Ken Hemmings, he told me once that taking an impression for an implant crown, obviously we’re talking about scans today as well, but taking an impression for an implant crown is easier than taking an impression for an actual crown preparation. Would you agree with that?

[Devang]
Ken was one of the person who taught me. So yes, I would 100% agree with that. So it is, if you know the principle, if you know what you want, if you have planned everything right, then I can now place an implant and restore it in totality of on the appointment within 40 minutes.

It takes me 15 minutes to place implant. A patient can be in and out within half an hour and then scanning will take another 5-10 minutes and then fitting will take another 5-10 minutes if everything works fine. And I can’t imagine me doing endo. Or even a crown prep. It takes me more than an hour to do a crown prep on a single molar.

So yes, it is simpler, but if you make mistake, the effects can be much more catastrophic as well. So it goes either way. And that’s why you really need to know what you’re doing.

[Jaz]
In my first five years, when I started to kiss a lot of frogs before you find your prince charming. And I was kissing lots of frogs, seeing which is the area of dentistry that I like the most.

I went on some implant courses. I went on some restoring courses and stuff. And whilst I, this message was received by me that, okay maybe I can restore implants. Maybe impressions are easier on implants, which obviously going to break down today. Just a sheer number of like connections. You have to talk about screw retain, cement retain, just a different combination.

And then to complicate it, different brands of implants, different screwdrivers. I know there’s a proper term for it. It just gets very, very confusing, and overwhelming, but anything worth doing. It has a steep learning curve. There’s not a low entry point. You have to do your hard work. You have to do your due diligence.

But a lot of people tell me that once you get there, once you’ve restored a few and become second nature, it can be very efficient, very profitable, and what a great service to your patients. Right? So let’s start my friend. Step number one is identifying. Oh, you tell me what step number one, because you’ve got it all laid out.

[Devang]
Okay. Yeah. So, the way I look at for any process, I look at it in steps. So again, if you follow me or follow through with my reconstruction, I look at things in steps. So the steps are broken down into five steps. So first step is your Assessment, really, and Treatment Planning step. The second step is Impressions. Third step is Communicating with the Lab because that’s really, really important. Fourth step is Fitting of the Crown. Fifth step is Maintenance. And then, obviously, you have Troubleshooting and complications and how to manage those complications. So, these are the six main steps.

And with regards to, let’s start with the step one where we do the Assessment. Before we do this, we need to understand that there is a difference between implant and a tooth. Okay, so the main difference is the implants fused into the bone and tooth has periodontal ligament and that gives you much more proper reception and because tooth has a periodontal ligament and implant is fused in the bone, the mobility of the tooth is different than implant.

So we know that if you if you push the tooth down it can intrude up to 25 to 100 microns whereas if you are applying jiggling forces again it can move up to maybe let’s say 56 to 108 micron whereas the implant is fused almost, it has a little bit movement because of the osseous, so the bone moves as well but in less than 10 micron and that’s one of the main reason we will come back to when we are going to discuss about occlusion in implant because you need to understand that the implants don’t move but the teeth do move, even healthy teeth and that’s how you need to manage it.

So having said that, let’s look at the time where patient sitting in your chair and now you’re thinking, shall I take this patient for restoration or not? Remember as a General Dental Practitioner, you are the person who’s going to see that patient first before your implant surgeon sees it, okay? So many of the decision need to be made by you and that’s why you need to understand the process of Implant Planning, Placement as well, even though you’re not placing it. And yes Implant surgeon might come back and do a consultation with you and decide, okay, whatever you plan is rubbish, but that’s fine.

You learn from planning. Okay. And that’s how I plan. I mean, what you don’t know, you don’t know until you start doing something, right? For any case, my first thing I’m going to check is patient expectation. Whether, am I going to be able to match or my implant surgeon is going to be able to match the patient expectation?

It could be realistic, but you’re not trained for it. It could be unrealistic or simply put you don’t like that patient or that you can’t get on with the patient. And that’s the biggest factor for me. If I don’t get on with the patient, I don’t treat them for their sakes really.

[Jaz]
And with implants, it’s like something that hopefully it’ll be a long term thing. And it’s kind of like orthodontics is that it becomes like a marriage, right? I know plenty of patients who like to go back to their orthodontist or the dentist who did the orthodontics to go back for their retainers and reviews and plenty of patients who, although we can maintain their implant for them now, they still prefer to go back to their implant dentist once a year, once every two years to do that. So do you really want to see his patient in the longterm? And if you’re not going to see eye to eye, then you’re totally right. Agreed.

[Devang]
Yeah. And with regards to long term as well, I tell all my patient from the day that implant won’t last for a lifetime. And that just breaks the ice and you then don’t have to tell them that there’s 80% chance, 85% success rate over or survival rate over 10 years.

And no patient has said no to me because of that, but you need to put it out for upfront and you need to tell them that they don’t last lifetime. Because many times-, I had a doc-, and I learned because I had a doctor, a GP. Once I finished my implant, this was early days. He’s like, oh, now this is, I’m set for rest of my life.

And I’m thinking you’re a GP, like, I mean, how many times we’ve done things and you know that it doesn’t last lifetime, not even teeth. Like you buy a hundred grand car. They don’t give you lifetime got a guarantee. So, but that’s something, a mentality really, we need to shift.

So once that’s done, then as you really importantly said, we need to really discuss different treatment options. So I am very aware that I’m biased towards implant. So I tell patients that, look, I am biased towards implants, but let’s figure out what’s best for you, not what’s best for me. And I have this open discussion with patients, and this is something I learned from Otto Zuhr and Markus Hurzeler.

They are good periodontists, and they are very aware that when we do one thing all the time, we get biased towards it. So we need to really have that separate mind which is not biased and think both ways.

[Jaz]
It’s like the saying where when all you have is a hammer everything looks like a nail and that’s been used a lot with a certain implant dentist who perhaps overzealously trigger happy with their implants where they could have been doing other modalities. So we need to give all the options that are appropriate.

[Devang]
I have had a situation where associates send a case to me and I say this tooth can be saved and they’re like, no, you can’t. And now I’ve went on and saved it because I do restorative treatment as well. But that’s something you need to really discuss.

So I discuss with patient all the options, denture, bridge, and sometime I’ve done bridges like 90 year old, 91 year old needs a big bone grafting. Okay, just do conventional bridge. There’s nothing wrong with that, so that’s something we need to discuss. Then, we need to discuss, we need to see smile line, if obviously, if you see your first few cases, I wouldn’t recommend touching the anterior teeth.Although if the implantologist has done a good job, they are no different, because the impression process is same, if your lab technician does a great job. Then you can just literally go straight to finish.

[Jaz]
But if you are going to do anterior teeth early on, you got to pick someone with a low smile line. So when they smile, they don’t even show their papilla ideally, right? In the first few cases.

[Devang]
That was one of the criteria, but you need to make sure you give patient a mirror and see how they look at it. Because even though patient’s smile is low, they might pull their lip up and look, trying to look. And if that happens, that’s a high lip line case for me, if that makes sense.

So you need to really also assess patient how they’re looking at their smile. Then obviously we need to look at the oral hygiene, whether patient’s oral hygiene is great, periodontal condition. This is something really important and many time implantologist misses that because they don’t have a restorative background.

You need to look at the adjacent teeth. Okay, we need to look at the contact points. Sometimes the teeth are tipped. Can we correct that? There are restorations which are sticking out which will create a point contact and I want sort of a surface contact if that makes sense. Can I adjust that? So we need to look at all this adjacent teeth.

[Jaz]
You’re talking about like amalgams, right? Amalgams with ledges, amalgams with the old amalgams, which are still perhaps don’t need to be replaced, but just actually polishing them, getting a red diamond and getting the right contact surface.

[Devang]
Yes. So that’s something which I even miss sometime, time to time. And I wish that we had technicians who would. Because sometimes, when I do my own wax up, I really, I’m sitting in calm. There’s no patient. I’m thinking, I wish the technician would take a lead on them and then when they receive a walk, it’s like, Dev, you could do with a little bit bonding on the mesial aspect of central to get the mesiodistal dimension perfect of both the teeth.

They’ll just restore the gap. But if we get some sort of a guidance, then that would be really helpful from technician. And then this is also come under secondary treatment. So you need to always look at whether patient need any whitening, whether they need any ortho because you can’t. It’s very difficult to do ortho after you’ve done implant.

It’s not impossible. It’s tricky. All patients need any full mouth reconstruction. And this discussion needs to happen before patient has implant, even if you think patient is not going to go ahead with it. So even if patient says, no, I don’t want full mouth reconstruction, at least you need to have a discussion because guess what I’ve replaced someone’s-, a few dent-, a few implantologists’ implants, implants were fine, crowns were fine, just patient needs full mouth reconstruction, patient wasn’t aware of that.

[Jaz]
I’ll ask you a tough question Devang. Obviously, you teach full mouth rehab and you’re also teaching restoring implants for GDPs. I think, and see if you agree, I think if you’re going to go on a learning journey with you, that you should learn full mouth reconstruction first, then implant, right?

Because if someone’s lost vertical dimension, they’ve got tooth wear issues, generalized, and the teeth are really, really short. And then you put an implant in there and try and conform in that bite. Really, they would have benefited from opening the vertical dimension. It’s much better to plan the implant from that new occlusal position, right? And same with orthorhontics.

Or have a eyesight on assessing which patient need full mouth reconstruction. If you don’t do it, refer to your colleague who does do full mouth reconstruction, if that makes sense. So, because I understand learning full mouth reconstruction and implant can be quite daunting like together and expensive because learning any of those two skills is not cheap.

[Devang]
But yeah, you need to have an ability at least to plan those cases when you are doing implant restoration. Then you need to look at the the space whether you have enough space because for restoration and that really matters. If you’re looking at interage because sometimes posterior teeth I actually saw a case two days ago one of my mentee showed me and this was on a full mouth construction we do a two weekly sort of case discussion and someone literally placed an implant on lower right seven recently two months ago implantologist and patient got collapsed bite patient, upper right seven is touching, healing abutment of lower right seven, which is equigingival.

So they are now considering explanting that implant and giving a patient refund and then doing another implant. So I mean, I had few thoughts about that in the sense that you could use the implant to literally intrude the tooth. If implant fails, fails. But at least you’re doing something with that implant rather than explanting it.But what I’m trying to say, the implantologist did not see, they just saw the bone, saw the edentulous area, placed the implant really nicely. But did not check the occlusion.

[Jaz]
Which is why it should all be restoratively driven. And that’s the basic thing. When the patient bites together.

[Devang]
Yeah, and that’s why I feel genuinely that as a general dental practitioner, it’s our responsibility. Because implant surgeons, they’re trained for surgery, not trained for occlusion or anything like that. So I don’t blame them. It’s our responsibility when we refer a patient to tell them that, look, this is the case, there is no inter-arch space. A patient will need something else doing or don’t refer a patient until you sort that out, if that makes sense.

So we need around five millimeter from gum to the cusp tip, at least space for the posterior teeth. You could do clever tricks and you can do alveoloplasty and you can do all sort of stuff to do that. But and I actually recorded a “supra erupted teeth” podcast episode. So that covers it a little bit more in there.

[Jaz]
What about mesial distally?

[Devang]
Mesial distally depends on the tooth. Okay. So, and obviously how tall is, and you gave a really good example of the lower central. I completely in agreement with that.

So if you have one lower central incisor missing. then you need to decide, okay, you can’t really place an implant without damaging. Having said that I don’t see that many cases where just one incisor is missing is usually perio or some issues where at least two of them needs to go. If that’s the case, even then I do tooth to tooth resin bonded bridge sometime, because placing implant right in the middle where most of the time other incisors are not good bone support either.

I just do that and then when the two laterals fail, then you can do two implants on laterals and replace four teeth and that’s more predictable with implant. So that’s kind of you need to assess, but generally you need to assess for the rest of the teeth. Mesial distal space, if you have enough. Now, if you’re placing, let’s say, whatever sizing plan you’re placing, you need to add three millimeter to it. So if you place three-

[Jaz]
Let’s make it very tangible, Dev. Like we could talk about every single tooth of the arch and then we won’t have time to record the other steps. So let’s say we’re doing an upper first premolar. Let’s just go with run with this one example and go deep into this one example.

[Devang]
What is the width of the premolar, that particular premolar?

[Jaz]
Well, actually, I’d like to know for you, what is the minimum that you want? And at what point does it become one and a half units? And then you’re struggling and there’s going to have to accept aesthetic compromises, you see?

[Devang]
Yeah. So basically for premolar, I would want ideally to place around 3.8 millimeter width of implant. It depends on the system. Yeah. So if you’re placing Ankylos, you have 3.5, which is fine for premolar. If you, I’m placing Bio Horizon. So you, at the moment, so I placed, I’ve used all, but right now I’m using Bio Horizon where it’s 3.8 is the size. So that’s the minimum I would want to use.

And then you need to add 3 millimeter on either side, because you want 1.5 millimeter safety distance between two teeth. Now I have encroached that safety distance in past and everything’s fine. So, you don’t need to panic too much. Even if you think the space is a little bit tight, maybe half a millimeter, you can still gain consent from the implantologist, let the implant surgeon decide, but generally 3.8 plus 3, 6.8 millimeter width you want between roots. Okay. And if you have around three millimeter on either side, then it almost becomes a molar. Now. If, let’s say, two premolars, which are next to each other missing, that’s a little bit tricky scenario because sometimes you can’t put two implants together.

Remember, between two implants, we need three millimeter distance. So now we place it, we need six millimeter, just a space, plus whatever size implant you use, two of them. So many times you may decide to have a cantilever bridge, which is not my favorite option. I prefer if there are two teeth missing, two implants and two teeth. But I would rather do a cantilever than put two implants next to each other very close together and then make a problem with that. So that’s how I make a decision.

[Jaz]
Implants are like trees. They want space. I don’t know, some famous implant surgeon said that once and I heard it. And so I like to, that’ll be my one contribution to this episode. Implants are like trees.

[Devang]
Yeah, so you need to really make sure that they have space, basically. Okay. They like breathing space.

[Jaz]
Yes. Whatever size your implant is, add three millimeters. That’s how much distance you need between the roots. And obviously you’re looking at between the adjacent teeth as well. Make sure for aesthetics that you plan for it. Often a wax up may help you in such scenarios. What more do you want to add in terms of the assessment before we move to stage two?

[Devang]
So assessment stage, quickly, you need to also make sure that you have planned for temporary or provisional. When you are doing these kind of planning these cases, because if it’s an anterior case, even premolar, some patients don’t want to go without, so my go to method is, used to be Maryland Bridge or resin bonded bridge.

The problem with that is they can come off, and if I’m working in 11 different practices. It’s a nightmare. So also what I’ve seen is I’ve used to use for canine. So if lateral incisor a lot, and if the resin bonded bridge, if you use it for a long time, some of my cases, like if I’m doing autogenous block grafting and soft tissue grafting can last for 15 months.

Maryland or Resin Bonded Bridge put on high for 15 months will create a space when you remove it. So the canine guidance gone. So I now use most of the time Essix retainer with the tooth. The problem with that is patient can’t eat on it. So I give them a denture but not to use it straight after surgery.

So that’s something you need to assess. Then you need to assess occlusion. We discussed that, the guidance. You need to really have a vision as to, after you finish the treatment, what type of occlusion patient’s going to have? So if you need to add canine rises to miss the implant, you need to do that before the treatment so that you get, you have the occlusion which is optimized. And then, of course, as I said, diagnostic backups. You need to make sure. that you have done diagnostic wax up in order for you to plan the treatment properly.

[Jaz]
Is this mandatory? Do you think this is a mandatory step with the dentist who’s starting to do a restorative implant?

[Devang]
If they’re starting, yes. I think it’s, I’m not there to make regulations. I can tell you that I don’t wax up all my cases. When you place over a thousand implants, you can really assess if the tooth is bound, that’s the simplest case to place implant because you’ve got the reference from either side. I do get waxed up when there are more than one implant I’m placing. So if I’m placing two implants next to each other, then you need to know exact distance you want these implants to be placed in order to get the good restorative.

But if you’re starting, I think you would be better covered if you have done diagnostic wax up or if you’re doing surgery then had a surgical stent made up. But if you’re restoring that, at least have a diagnostic wax up done and gain consent from patient.

[Jaz]
Okay, great. Well, that was a whistle stop stall of assessment. Let’s now get to the real deal, the meat and potatoes of restoring implants. Absolutely.

[Devang]
So now we’re coming to step two, where we are ready to take Impression. So what will happen is that once you refer to your case, in which I would recommend you plan with implant surgeon, not just refer the case, ideally stay within that consultation appointment, plan it together, and you learn more planning process and how your implantologist think, because everyone thinks differently, that he or she will place an implant and send back.

And do a exposure of the implant, send back the case to you, where you will see a healing abutment, which is in the implant. Now, healing abutment could be customized, so they may have customized the healing abutment to give you nice form of the gum, or it could be a stock healing abutment, which may look like a silver sort of a metallic color and would be round.

[Jaz]
For an upper premolar. What would typically come back with it? Would a custom one come back or would a standard one come back?

[Devang]
Usually it will be cost. It’ll be standard.

[Jaz]
Okay.

[Devang]
So you will have a standard healing abutment. Now, again, you would have known which implant system your implantologist uses. As I said, I would recommend that you observe at least five cases restoring that in person, restoring it before you start just jumping and start restoring the implant cases so you can log that you observed. And ideally for at least my mentees, I tell them that I would observe their five cases. So at least 10 kind of observed cases before they go on themselves.

It’s a bit of an overkill, but I think that’s the safest way to learn. So now once you get the back, you will have a healing abutment. Gum should have healed nicely. Sometime if the sutures are still there because they want you to take the sutures out and take the impression at the same time, which I tend to do if it’s a simple exposure.

Then you just need to take the stitches out. Make sure the gum’s heel looks pink. Sometime if the implant surgeon has done soft tissue grafting, it will take a while before it heals. But most of the time, as an implant surgeon, I only refer a patient back to a dentist once I know it’s complete, it’s ready to take impression, basically.

So that’s where you are. Now, when it comes to taking impression, you have three different ways to take impression. Okay, so you can take impression using closed tray method. You can take impression using open tray method and of course you can use digital impression as well. Okay, closed tray method is the least favorite method of mine because the way it will work is you put something, you take the healing abutment out, you put this impression post in the implant and you take like a normal conventional impression like you do for crown and bridge. And what would happen is whatever you put the impression post in the implant will come out. in your impression.

[Jaz]
I’m asking very noob questions here, right? So this is like, a very basic level, but the impression post, when it attaches into the implant, it’s not like fixed. It’s allowed to come out, come away in the closed tray.

[Devang]
So it’s not screwed in. So for closed tray, if you’re not screwing in the impression post sometime, and this is where the confusion comes, right? So some implant system has screwed in post and you will have a toggle on top, like a small insert on top. So you only get the insert picked up in the impression, not the whole post, but you will have to see, I’m just giving you a general idea because it’s difficult to cover every implant and how they work.

But generally the concept is you take a normal impression and this concept was developed because to make general dental practitioners life simple, plus to do an open tray impression, you need to be able to put the post, the screwdriver, everything in patient’s mouth. And if you’re doing upper right seven, you might not have access to do all that.

That’s the reason closed tray was one of the benefit of closed tray impression. Putty wash. Yeah. Just normal crown and bridge material. You could use ideally Impregum which is more rigid, but I do putty and wash most of the time to be on, because not all my surgeons, they don’t have impregnum.

So coming back to the issue of you’re not being able to access upper right seven is that if the implantologist has managed to place an implant, which is basically you have a driver, implant is on top, place all that in upper right seven, then there’s always patient has immediate effective mouth opening for you to take open tray impression.

So in last 13 years, I probably have done one open tray impression, sorry, closed tray impression. So now, I almost 99.9% take open tray impression, which is more accurate.

[Jaz]
Why are you so against closed tray? I’m still trying to suss out what is it that you don’t like about closed tray?

[Devang]
Because what will happen with the closed trays is, you know the thing you picked up in your impression? Then someone needs to manually put the impression post, click into that impression. Now when you’re doing all that faffing, you can move stuff. It’s easy to move. And make the impression inaccurate. And one thing we want to know, we want to do is when we take implant impression, we don’t want our impression post to move. We want it to be rigid. Because implant is fixed in the bone. Few microns here and there, the crown won’t fit very well.

[Jaz]
So just describe open tray, because what you haven’t mentioned yet, but I’ve done it before is, it’s like, do you always need a special tray? Or can you use a stock tray for these?

[Devang]
No, you can use, I use stock tray most of the time. Unless I can’t find a stock tray which fits in patient’s mouth properly. Okay. So when I put the, you select the stock tray, I select the biggest tray I can fit in patient’s mouth because I want material thickness, right? So you want thicker material in order to pick up the implant. So it’s much secure.

Okay. So let me go through step-by-step process of taking impression. Okay. So once you have your healing abutment, patients in the chair, you need to, before you do, you see a patient, you need to make sure you have all the components. You have appropriate impression post. You have all the drivers you need for the impression.

Having a short driver is helpful because sometimes it can get a little bit tricky. If you’re using a driver first few times or ideally all the time, you need to floss it just so that you don’t drop it down the patient’s throat. So you kind of have secured it. So make sure that you check because every implant system may have different impression force posts for different implants.

So check what implant it is. Check whether you have right post and make sure you have right components. Once the patient is in the chair, you will take the healing abutment out. I always irrigate with chlorhexidine to make sure that before I put the impression post, I’m not really putting anything in there.

My impression post will be in the chlorhexidine as well. I pick it up, put the impression post, try a tray in patient’s mouth and see where the impression post sticking out on the impression tray. Use a straight handpiece or a fast handpiece to create a hole. So then it sticks out of the impression tray so I can unscrew it once the impression material set right.

My nurse would then mix the putty and I would squirt some light body around the implant and occlusal surfaces of all the teeth. I will then place the impression tray and quickly find the post. It’s really important that you find the post. Otherwise, if your impression is covered, the post is covered by your impression material, you can’t unscrew it and the impression won’t come out.

[Jaz]
So just to make that tangible, like once you’ve got the, you’ve drilled the hole, like you said, you try the tray and you see where the impression post is prematurely hitting the tray, right? And then that’s where you drill the hole and now the tray can seat fully but once you’ve got the putty wash in. That’s all going to get covered in impression material and it’s about just searching for it with your finger. Is that what you mean? Right?

[Devang]
Exactly. Yes. So make sure you create a bigger hole than you think you’re going to need because the tray is not going to always go straight in that position. So make sure you have a little bit leeway and then you’re with your finger.

Really you press in the putty where you created a hole to palpate the tip of the impression post. Once you’ve got the tape, I would keep my finger pressed there so that the material, impression material doesn’t cover over while setting and then let the impression set. Then I’ll use a straight probe to flick the impression which is there on the screw access hole because you know there will be some impression material in the access hole.

Straight through, flick it out and then unscrew the impression post. Now, you need to make sure it’s completely unscrewed before you yank the impression out of patient’s mouth. The way to know that is when you’re unscrewing something, anything really, and if it’s completely unscrewed, it will click. So because the threads are jumping, right? So if you’re reversing, if it’s clicking, that means it’s completely undone, basically. Take the impression out.

[Jaz]
I’ll ask a question, another silly question, if you don’t mind. Is this impression post completely cylindrical.

[Devang]
It has notches and it has small grooves. So you can have the impression sort of get. Is that what, is that the question?

[Jaz]
Well, my thing is, I’m imagining now, this is years ago since I last did this, but if I am twisting and unscrewing it, then isn’t the impression material getting distorted?

[Devang]
No, so there’s a screw within the screw, right? Impression post has a hollow channel.

[Jaz]
The screw within the screw.

[Devang]
Yeah. There is a hollow channel. So impression post doesn’t move, but the screw under inside moves, same way you fit the screw, retain crowns, right? So the crown don’t move the screw inside the crown would sort of engage.

[Jaz]
Got it. Now I’m with you.

[Devang]
Cool. So, now you’re taking the impression out. I would irrigate the area with the chlorhexidine place, the healing abutment in which was there in the chlorhexidine back into the socket, right? Screw it, screw it back in. You don’t need to torque, and do not torque the healing abutment, just hand tighten and don’t use a torque wrench. Now, some people like to take x ray when put after placing the impression post just to make sure it’s seated properly.

I don’t because nowadays impression post comes with the definite seating. So, if it’s not in a definite position, it will not seat and you will see it click most of the time and that’s how you would know that it’s seated properly. However, if you want to really take an x ray, then by all means do an x ray to understand whether it’s completely seated. Now, one thing we haven’t discussed is there are two different types, two different main types of connection inside the implant.

[Jaz]
Before we get to that, if you don’t mind, because this is a really important conversation coming now. So let’s just finish off on the impression for the newbie dentists, really new in the world of implants here, which is what we’re targeting at the moment and helping the Protruserati out who’ve never done this before.

You don’t need any retraction cord. And is there usually a bleeding that you need to deal with? So this is what makes usually this kind of stuff easier than a normal crown, right?

[Devang]
Yeah, generally there is no bleeding. There is no bleeding when you take the healing abutment out. You may see a little bit of bleeding maybe, if the gum is still a little bit raw from the surgery, but no, generally there is no bleeding.

And if there is a bleeding, you don’t need to worry about bleeding. Even, let’s say you take an impression, and you know the impression pose where it connects into the implant, and you tip your impression, and you see usually crown, when you do the crown impression, you want to see the margin nicely.

You don’t need to worry about all that because if the margin is slightly uneven, some of the material is not a little bit flowed, it’s okay because technician can figure that out. It doesn’t, as far as you can, you’ve got the connection, right? The impression post seated completely in the implant. That’s all we want to capture.

So it doesn’t have to be like a crown prep and that’s where it is. So you don’t need to use a retraction cord. I don’t know about you, but if I’m taking, let’s say two, three crown prep together. It never comes up in one impression. I have to at least attempt twice to get all of them in one go.

[Jaz]
So, air bubbles are forgivable as long as the impression post in general fits very precisely into the impression, right?

[Devang]
Yes, and it’s not moving. Okay, in the impression.

[Jaz]
So now let’s talk about this really mammoth topic of different connection types. Because like I said, as someone who once ventured into learning this stuff, it got overwhelming. The different connection types, different brands. So let’s try and make it tangible now for me and for the Protruserati.

[Devang]
Okay, sorry, just to complete the impression steps, you need to then take the opposing arch. If any occlusion, you need to record, you need to take the bite registration. But for single tooth, generally, you don’t need bite registration because you can hand articulate, right?

And then once that’s done, you need to package it in a bubble wrap, put it in a box, and then, like a wood or cardboard box, and then send it. Don’t just put it in a bag and send the impression because you haven’t seen people collecting those bags. It gets, lots of things goes on top of it, right? So things can distort the impression post.

So you need to make sure that is secure before you send it to technician. Now, before you do that, actually, you need to write a prescription, right? So you need to make sure that you’ve written a prescription to the laboratory technician, and that’s where all the connections and everything will come in play, right?

So now you’re telling your technician few information, okay? So you are going to communicate with technician what you’ve just done basically and what you want them to do. Now before you do that, you need to know a few things, okay, about implants. So first is connection, obviously. There are lots of connections and it’s difficult to cover all of them, but there are two main connections.

You have external connection and internal connection, which means implant is solid and then the crown goes on top of it and externally hooks into the crown. Whereas internal connection implant crown will literally go inside the implant. So there are two different connections. Internal connection is the one which is most widely used. So there is a very high likelihood for a single crown, you will receive an implant with the internal connection.

[Jaz]
I’m a simple guy, Devang. Listen, I’m a very simple guy. Am I, is it an oversimplification if we call an external hex connection, an outie, like belly button, an outie and an innie, would this analogy work?

[Devang]
Yes. So you have the internal connection, like a belly button. So, you go inside and that’s the internal connection. And the reason is that it’s a bit more secure for the screw. Okay. So there’s less screw loosening with those connections, especially for single crowns. Generally for single crowns, you will not see external connection implant nowadays.

[Jaz]
Okay.

[Devang]
Now we decided, okay, we’re going to mainly dealing with internal connection implants. There are two types of internal connection, main ones. One is a butt joint, like surface on surface connection. And the other connection is a conical connection, like cone within the cone.

[Jaz]
Okay.

[Devang]
Okay? Now, if you imagine, surface to surface connection, it’s easy for you to know if it’s not seated properly. Like, if it’s not completely seated and there’s a millimeter gap, if you take an x ray, you will see a black margin. Does that make sense? Because there is an air in between.

[Jaz]
This is the butt to butt.

[Devang]
Butt to butt. So it’s a butt joint connection. You would know easily if your crown’s not seated properly. Whereas if you have a conical connection, difficult to know exactly whether the cone is completely seated or a few microns off. Okay. So that’s the difficulty with conical. However, conical connection gives you more secure connection than butt to butt. Because with butt to butt, butt joint connection, if the screw becomes a little bit loose, It just starts wobbling all of a sudden.

Whereas with the conical connection, if the screw becomes a little bit loose, the conical connection itself will protect the crown. So you get less screw loosening with that. Plus, this is for implantologists as well, that it gives you nice emergence profile and it prevents your bone. So bone stays better. So I prefer personally, conical connection. So when I use Bio Horizon, I prefer CONELOG implants in there because it has a conical connection. Does that make sense?

[Jaz]
So we like, yeah, it does. So we like sticky-innie implants, with a cone connection. But like all of this stuff, like for example, you said you use Bio Horizons. Do they have a Bio Horizon sticky-innie? Do they have a Bio Horizon sticky-outie? Or is a brand generally one type of way? So you can get every, it’s like a candy shop. You can get every single combination.

[Devang]
Yeah. And unfortunately, you’re not going to be the one who will select that because your implantologist would have selected it. You kind of mercy of them, whatever they select, you need to restore it. Right? So I have made a lot of my associates life difficult when I, by selecting some of the implant system, but that’s how it is. They all have ins and outs. They all have problems, but no system’s perfect. So it’s not that if you get a butt joint connection, it’s not good. You just need to know what it is and how to assess it really. So that’s one thing.

[Jaz]
But this is a feature of the implant that’s already in the patient’s mouth. You are just, A) finding the information of that implant, identifying it correctly. So this is something that your implantologist, when they send it back to you, hey, I used a Bio Horizon 3.8 sticky-innie internal hex, with a cone. Make sure you know this information. Is that kind of how it works?

[Devang]
Yes, exactly. So I always send my associate, someone who’s referred cases to me, a log sheet with the sticker because I might make a mistake in writing what connection it is. But generally when we place implants, we use a sticker from that implant to put it on a paper. I scan it and just send it to them. So there is no ambiguity as to, no miscommunication. And that’s something I give the patient at the end as well.

[Jaz]
Now Devang, before we continue again, I’m going to suggest, because I’m really enjoying this, I’m going to suggest we nail this part one. Right? Like really just slow down a bit. Let’s nail this part one. I think let’s re record for part two one day. But I’m just letting you know that I’m really, I’m learning a lot here as well. And I think this is really going to be like, for a lot of people new to implants, it’d be like, wow, the sticky-innie, sticky-outie. This would be really good for us, I think, if we just slow it down and keep finishing off part one, like we are. Is that okay with you, buddy?

[Devang]
Yeah, yeah, that’s fine. That’s fine. Yeah, no worries.

[Jaz]
Okay, cool. Okay. So now you know which type of implant it is. And then I guess the impression post will also depend on that information as well, like the impression post that you select?

[Devang]
Exactly. So you would have known this information kind of beforehand anyway. This is not the time you would know what, this is too late kind of. You would have known when you receive the patient, all the information, because you need to have all the components ready.

This is for you to tell your technician, right? But when you tell technician what implant it is, what platform size it is and what sort of connection it is, implant, the laboratory technician will know, but I’ll come to that in a minute. So first thing you need to know what connections implant has.

Okay. The second thing you need to know is screw retain crown and cement retain crown. That’s a big, two big different camps, really. Some implant, they are like truly believe that cement retain is the way to go and some people believe screw retain is the way to go. I’m in a screw retain camp.

As I said, I’m biased. The reason I prefer screw retain because it’s easier to manage if there is, let’s say a patient doesn’t like it. You fitted the crown and we all have this patient sometime to time to time where you fitted patient like yeah, everything’s good, perfect, and then you get a text message because all my patient has my mobile number. You get a text message or when patient come for a review appointment like mmm. I don’t like it. I want to change this.

Now, if you have used a cement retained crown, which I will go through the process in the next episode, that it’s difficult to take the crown out and change it. If it’s a screw retained crown, you can unscrew it, send it to the technician, and change it. Future complications, like if something’s chipped or broken, if patient’s broken the porcelain of it.

It’s easy to manage if there is inflammation around the implant. You want to take the crown out to assess properly. It’s easy to do that. So for me, and also the main reason I stopped doing it years ago, 11 years ago, doing cement retained is because there is a risk of pericementitis, which means that the cement can go into around the implant tissue and cause irritation and that can cause implant to fail. And this is a very well known, studied fact that many of the cement retaining plant fail because of this reason.

[Jaz]
Did you just say pericementitis?

[Devang]
Yeah, it’s just-

[Jaz]
Wow. Wow, I love this.

[Devang]

So it’s a made up word, but yeah, I think it’s been used quite frequently, not made by me. But I read it, but it’s not a proper, I think it won’t be there.

[Jaz]
Like I knew peri implantitis. Like was a first, like when I was a fourth year student and then someone said peri implantitis, me and my friend Clifton looked at each other like, wow, that this is a thing. There’s a word. And every time it’s like a running joke between me and him. But peri cementitis is like my new favorite implant term.

[Devang]
Yeah, exactly. So that’s the reason I don’t use a cement retained crowns and I do anything and everything and which will go in troubleshooting anything and everything to make my restoration screw retained crown.

Okay, so let’s say there are two cement retained crown. If you are doing it, it will come in sort of two pieces. You’ll have abutment, which you screw into the implant, and then you have a crown which goes onto the abutment. Whereas the screw retained crown will come in one piece, where you literally screw the whole crown into the implant.

Why the channel not so the crown doesn’t move you have a screw access hole. So you see the crown into the implant is snuggly seats in and then you screw the screw it from the channel to make it secure.

[Jaz]
Is anything that we talked about previously because you mentioned about the internal the innie and the outie. And the butt and the cone does any of them predisposed to, oh, because you’ve used this type of connection, you can now only do screw retain, or you can only do cement retain, or is there still, like, you could still go either way still?

[Devang]
You can still go either way, yeah. So you’re not dictated by implantology, if that makes sense, or what implant it is. Generally, you can do either in either. There are some system, which you, like the Encode, traditionally, Encode implant system, you are, you were meant to do a cement retained and that’s how the implant was developed. But most of my Encode restoration where I placed and restored, they’re screw retained. So, there may be systems who were traditionally evolved for cement retained restoration, but you can still make screw retained restoration.

Most of the system you can. I don’t see any reason why you can’t. Now, to make it even more complicated, the screw retained restoration has two different types. Okay. One type, which is the most favorite type for lab technician is you have a pre made abutment, titanium abutment. Okay. The technician will then cement in the lab crown on top of the abutment, create a hole so you can access the screw.

Okay. So it’s a pre made abutment cemented with Panavia or some sort of a cement. The crown is cemented on top. Crown is created a hole and that makes one piece implant. Does that make sense?

[Jaz]
Is that also called screwmented? Or not ?

[Devang]
Screw Mented?

[Jaz]
My second favorite word in implant. ScrewMented.

[Devang]
I didn’t even know I’ve looked for that word and I could not find anywhere, but I know where I got that word from. But I’m sure there’s someone who said it.

[Jaz]
I saw it from Pynadath George. I saw him use it once on.

[Devang]
Yeah, so screwmentable crown. So, the screwmentable crown is basically cemented outside. Obviously with any screw-it-in crown, you need to make sure you implant in the right position, right? Because if you let’s say doing central incisor and the excess, the implant excess is coming through the buccal. You can’t have a hole on the buccal aspect. Again, we’ll discuss in troubleshooting how to overcome that issue.

But, for now, just imagine the implant’s in a perfect place, and now you’re making a screw retained crown. Okay? So, she’s doing the screw retained crown. So that’s the one way to do it. The problem with this is that the stock abutment, or we call it Ti-bases, titanium bases. Most of the implant company would call it Ti-bases or a stock abutment.

They are very, very small that somehow that the height is not appropriate so you have a big crown tall crown cemented on a smaller abutment and you tend to see some de-cementation of the crown over the time like you see in a normal crowns unfortunately as a dentist who is not in the lab you would know the height you would not know the height of the abutment because the crown is cemented.

So when the crown comes to you, it’s in one piece. You can’t tell what’s the height of the abutment underneath it. And that’s something you need to tell your technician to send you a photo of the abutment height. I want to see the chimney height. So if I am using this type of crown, which I do now, I want my technician to custom mill the abutment of the chimney height.

I want the chimney height just one millimeter shy of the occlusal aspect of the crown. So it provides the full support to the crown. Does that make sense?

[Jaz]
But these ones, like you said, they don’t, they don’t exist in the stock. So does that mean they have to make it?

[Devang]
So it’s a custom. Yeah. So it comes in a custom screwmentable crown. So it’s a sort of sub sub category. Not many technicians do that for titanium. Okay. And that’s why the best way to do it, which I’ve been doing until now is always have a custom abutment. Don’t use a stock abutment. So I always use custom abutment until I found a technician who can turn the titanium.

Apparently that you can’t mill the titanium. You have to turn it. It’s a different procedure to turn the titanium. But until now I’ve used a chrome abutment because chrome is easy to mill and you can put a porcelain on chrome, like PFM. So it’s genuinely one piece implant. There is no like cementation or anything.

So the technician or a company milling center will mill the abutment to your specification, to the height, width, whatever you like. It will come to technician. Technician will then put a porcelain on top and make one piece implant. And that’s how implant, screw-retain implant started. And we tend to use to call it a UCLA abutment because, or UCLA crown, because it was there in America, UCLA university.

That was the university started doing that first. So we learned as a UCLA, but it’s basically a PFM screw retained crown. Okay.

[Jaz]
So this is like, previously it would have been perhaps waxed up and the standard PFM way, but now it’s all milled, but now it’s all milled and done. Okay.

[Devang]
So when I did my training, we casted that and then did it. So I made it myself. By casting, we didn’t have a milling machine. So we casted everything. But now, milling is much more predictable, and much more better than casting. You get much less error, and marginal fitting is better. Problem is, that the custom abutment, if they are chrome, chrome oxidizes, right, over the time.

So when you put chrome with the titanium, there’s argument, there’s no studies on that. but I’ve seen it, at least my 10 year old cases, if I remove the crown. You see oxidized gunk, you know the the process so which I stopped liking so this is me evolving really and that’s why I’m using now titanium because titanium to titanium is a better connection and better sort of for health wise as well biologically is better so I use that’s why titanium scrumentable crowns, but It’s turned, it’s custom titanium.

[Jaz]
But lots of dentists are still using the stock type.

[Devang]
Yeah because they don’t know, right? So I’ve done it. So I have, when I started my implant restoration journey, I used to tell technician, I want to screw it in crown. That’s it. And crown come out really nice, screw it in and then. You see, after three, four years, crowns start popping off because the cement’s failing. And then you see the size of abutment.

[Jaz]
Yeah, yeah. The ceramic is coming away and there’s a tiny metal peg left in the patient’s mouth.

[Devang]
Yeah, generally it’s a Emax or a Zirconia crown. So it’s a one piece crown cemented on the abutment. The whole crown comes out. And you see the abutment and think how the hell it lasted even four years. Like, it’s like small. Really, really tiny. So that’s something you need to know the difference between custom abutment, Ti bases, and chrome and versus titanium. Okay. Does that make sense?

[Jaz]
Okay. So this is really making sense to me and it is showing me a new, uh, light on in this entire thing in terms of the challenges and makes a lots of stent from a mechanical point of view. But in our lab prescription, if I was to summarize so far, you’re going to tell obviously which tooth it is.

[Devang]
I’m going to summarize it.

[Jaz]
Amazing. Perfect.

[Devang]
Okay, I’m now summarizing the whole thing, because I just want to make sure that you understand the basics when I’m saying what you need to tell the technician. So I’m just covering the basics to make sure you understand, or not you, but the audience understand what we are trying to do.

So the first thing you need, you need to write few things in your lab booklet, but once you and technician work together very well, most of this will be kind of assumed. So technician would know what type of things you want. But when you’re starting, it’s better practice to write everything down.

OK, so first you’re going to write down the type and brand of implant, what type of implant you use. So you need to write that down. You need to write down implant size and connection size, because just to give an example, BioHorizon has 3.8 millimeter implant with 3.5 millimeter connection and 3 millimeter connection. So by just saying that I have a 3.8 millimeter implant doesn’t mean anything. You need to tell technician what connection size it is. Does that make sense?

[Jaz]
I mean, it makes sense, because I’m accepting that this is the way it is, but this is a whole new level. So this is like, you’ve got the implant. You got the innie and the outie, but now you’re telling me there’s a connection. What’s this all about mate? Implant people, why are you making our life so complicated?

[Devang]
Yeah, they just want you to, I mean, and then there’s different screws you can’t interconnect and different drivers you can. It’s all a business game, isn’t it? I mean, but then I think I know why it started, right? So it started because probably there was Brånemark implant, one type. And then they say, how can we improve it? Let’s start something different. And then how can we, then people start, and then everyone prefers, I’m sure they’re like, in America, they use Bio Horizon, Bio Horizon is one of the biggest brand, and that’s a butt joint connection. They like, they love it. I don’t like it. Does that make sense? So I think industry is trying to cater everyone. And that made things a lot, lot difficult.

[Jaz]
This connection information, like that sticker that you said, which tells you if it’s a sticky innie, sticky outtie, why is the implant, would that also tell you the connection or is it something that you decide?

[Devang]
Yes, it will have the connection. So, it will have the details of the sticker, will have, so you can either just send it over to technician, technician know what to do with it. Or you write it down, if that makes sense. So you need to make sure that you got the written down. You then need to take, obviously, clinical photo for the shade.

So you need to make sure what shade it is. If you have taken periapical radiograph, or your implantologist has taken radiograph, then it’s good to send that to technician because technician needs to know how deep is the implant and where the bone is in relation to the implant. When they’re making emergence profile, many of the technicians, they don’t know how much gum to compress so to get the better emergence profile.

So it’s better for technician to have that radiographic evidence just to give some reference. Okay. So some sort of a radiograph with implant in place would be good. If you take a radiograph and you put the impression post that’s even better because they can sort of measure it from there. Then you need to mention what type of restoration you want the technician to make.

Okay. So we discussed screw retained restoration versus cement retained restoration. So you want to tell technician that please make. Screw retain crown for this. Now you would have had a discussion with technician, whether you want them to make screw mentable or UCLA type crown. Okay. You need to tell-

[Jaz]
So prefabricated versus custom, right, in a way?

[Devang]
They both are custom, at least for me, because I wouldn’t recommend Ti basis, stock abutment, just no, no, but screwmentable, as I said, you can have custom abutment, but titanium and titanium, you can’t put porcelain on it. So even if the titanium abutment is custom, you have to still cement the crown because porcelain won’t stick to titanium like PFM crown.

Does that make sense? So you can’t really fire the porcelain on it. So you need to tell the technician what it is. For the first few time, I would advise you to ask technician to send you photos of the abutment before they cement the crown. So then you understand exactly what they’re doing. OK, and then if there is any other specific detail, you want either side of the teeth to be adjusted or you want your technician to know what is the size of the crown.

Do you want your technician to tell you or dictate? Would you benefit from doing something like a restoration to either side of the teeth to get the better aesthetics, better contact point? Because sometimes, as I said, the amalgam sticking out and you missed it. You need your technician to guide you with that, yes, it’s a faff you have to take a new impression and all that but at least patient gets a much better restoration for rest of their life at least until the rest of their restorations life if that makes sense.

So that’s something you need to tell and then obviously you need to transport this securely as I said in a box with a bubble wrap to technician. Now we haven’t discussed when we discussed the impression, a digital impression.

[Jaz]
Right. Let’s talk about that because that’s the final thing I want to talk about before we do part two. But before we get to digital, a little bit, a few more points on this prescription. I think this is being very useful for the Protruserati who are thinking about it for the first time about writing their prescriptions. So just summarize. We’ve got the sticker information and you’re asking for a screw retained ideally.

Now, but you mentioned a really good scenario where if you’ve got a central incisor and the palatal bone is often more available. And so the implant is coming out facially. It’s like pointing at you. And therefore, if you did a screw retained, you’d have to put a composite on the buccal and it’s going to look ugly. So therefore, in that scenario, you might go for a cement retained. Am I right in saying that?

[Devang]
Nope. Now there is a suspense for the second episode. So I’m going to cover that in the second episode, how to manage these kinds of scenarios. So I don’t do screw retained. I don’t do cement retained, as I said, in 11 years.

And I made a lot of messes, I’ve placed implant where it shouldn’t, not in the right direction, let’s say, and I have recovered from it. So I will share with you how I did it. And what are the options? But yes, cementation would be one of the way to overcome that.

[Jaz]
Okay. But we don’t like this and I like that. So I like knowing that we’re super pro screw retain, so fine. So you’ll ask for a screw retained implant crown. One question I’d had though is. Let’s say we’re going for this, not UCLA approach. Let’s say we’re going for a custom titanium base, and then the technician will screwment it. So they will screw your crown on top. Is there any guidelines where, whether if Emax or Zirconia or any type of restorative material is your restorative material of choice?

[Devang]
Studies have shown that zirconia, poly zirconia has a better attachment of long junctional epithelium. So if you put a subgingival polycon, yeah. So it’s much better connection.

So, yes, I prefer polished zirconia for that. And then if it’s aesthetic case, then it should be, it would be layered on top, if that makes sense. So it’ll be layered zirconia for the coronal part, but subgingival. It will be polished just as zirconia monolithic. No layering monolithic. Yeah, no layering That’s my material of choice.

But yes, if i’m doing let’s say Emax veneers or crowns, then I may select Emax crown for implant as well, just to match the cosmetic or aesthetic aspect of it. But I generally tell technician, like, can you match it with the zirconia? And if they say yes, then I’ll still go with zirconia.

[Jaz]
Excellent. That’s really helpful. And it perfectly. But if we’re going to go for the UCLA approach, and then they’re going to custom make this metal abutment of the right height and size. And then you said that we can get the porcelain to bond and fuse to make it like a one piece thing. Does that mean now we have to use a certain type of material and we can’t use Emax and Zirconia anymore?

[Devang]
No, we can’t, unfortunately. So with UCLA type abutment, we have all the limitation what we have with the PFM crowns. So the aesthetic I find with UCLA type abutment is always tricky because technician has to mask that metal and the porcelain, because it’s feldspathic porcelain it needs to be fully supported.

So you can’t have a thin metal and a big bulk of porcelain because it will fracture. So you can’t build beyond it. And that’s the difficulty with PFM crowns. Even though you prepared a lot of preparation, technician can’t just have a thin metal and then lots of porcelain because it’s weak. So an aesthetic is my prime concern. I always go with screwmentable crowns because I have much better control over aesthetic.

[Jaz]
That’s amazing, and just reminds me of, and this is general restorative dentistry, it reminds you of me being on a consultant clinic at Guy’s Hospital. It was Mr. Saravanamuthu, and we were going around patient to patient, and this patient had this crown, just normal crown, not an implant crown, and the porcelain was chipping away, and then he goes into like viva mode, and he starts asking his questions, and he says, why did this crown chip?

And we’re saying, oh, not enough porcelain. There wasn’t enough porcelain here. He goes well not enough porcelain or too much porcelain and that made me think oh, wow okay, actually it was too much porcelain not supported by the metal underneath hence why it fractures It really changed my thinking is very relevant to exactly what you said there. Let’s now cover, Devang, if you don’t mind, digital. And when did you move away from impressions and to digital and what are the nuances of scanning for implant crowns?

[Devang]
So I had a, I use a Medit scanner. I bought it myself. So I’m now an owner, but my practice already had a scanner. So when I was an associate as well, I still am, I have a medic scanner and I had it in my car or with me for two and a half years. And I just started using it like six months ago. The reason being is that scanning it’s easy for us, but we are leaving, we are giving a lot of control to technician and finding a technician who really appreciates that does really good job was very hard.

I scanned now and then, and I had a very difficult work coming back and not great. So now I found a technician, which I’m working for, but six months is still pretty soon, but I’ve got a couple of technicians now who I work for and I’m kind of happy with it. And a lot of issues like movement of the post, occlusion, capturing the bite, goes away when you’re doing digital because it’s so much easier to do digitally, right?

So, I’m doing now my, all my full mouth reconstruction fully digital as well, because it just makes sense to move away from the traditional. Although I still do time to time, depending on what I’m doing, conventional full mouth reconstruction, I do my own wax up. But now I’m doing more and more digital.

With regards to implants, you need to have an appropriate scan body. That’s an impression post for digital impression. Okay. It’s called scan body and you need to have appropriate. Now, all the companies would have their own scan bodies. And if you’re technicians using company branded specific material, like a stock abutments, then you can use, let’s say, BioHorizon implant, you can use BioHorizon scan body.

And you can scan. So generally it would work is you would take the healing abutment out. Let’s say upper right five premolar, take the healing abutment out. You scan in medit, that’s how it works. You scan the jaw without anything. Then you put the scan body and scan that section and the medit will integrate that with the full jaw.

And then you do the rest of the scanning like you do normally. You take the impression scan body out and check the bite and take the bite as well. So that’s the scanning is pretty simple.

[Jaz]
I mean, this sounds really easy. I mean, there’s no gooey stuff. There’s no open tray. There’s no closed tray. This sounds ideal.

[Devang]
So easy. And then you need to obviously send it to technician and it’s all done digitally, as you know, so you can write down in your prescription what you want and goes with the patient, the technician. If you’re doing two implants next to each other. That’s even better because generally, traditionally, if we do take impression for two implants next to each other, it’s a lot of faff.

We need to connect them with the material so that they’re rigid. Then we need to separate them and reconnect them because connecting materials shrinks. It’s a lot of faff. With the digital, you can just take impression because they are kind of, they’re not going to move, if that makes sense. So two unit is like two implants next to each other is also fine digitally. So digital impressions. It’s pretty simple and safe, as far as the technician knows what they’re doing.

[Jaz]
But if you’re learning implants, if you’re the beginner, like the case of the example we’ve given you throughout this episode, if you’re doing your first premolar, what would be your advice? Like, for me, like, I’m very digital now. So if I’m starting to restore implants, just because I am digital, would you say, okay, because you are digital already, just go for the scan bodies? Or do you think I should take a step back and do impressions?

[Devang]
No, just scan it, scan it. Just make sure you and technicians are on the same page. Find a technician who has more experience so they can guide you. So my technician, when I started, I remember [name unclear], he’s from Italy. So I used to send my work to Italy because I got to know him very well. No, because I knew him from Fouad Khoury’s course, which I did for blockcrafting. So I sent him, it was really expensive, but amazing, because he would dictate, he’s like, yeah, your prep’s not good or like he would not fear criticizing dentists and I want someone to criticize me so that I can improve, right?

So, and he would say, look, Dev, add some composite on this. He was the only technician who I found who would tell me to do stuff, like do it this way, like kind of, I would, I would, I would not agree all the time. Most of the time would be right. So if you find a good technician, scan it. It makes your life so much easier. And that’s the technology is going and digital is the way forward. So yeah, scan it as well as you and technician, what are you doing?

[Jaz]
Brilliant. Now just give us a flavor of what we’re going to be covering in part two. And if you do mind, I’ve been thinking of the title of this episode series the whole time we’ve been talking. Is it okay with you if we call this a two part series and I don’t mean to offend anyone, I just feel like it’s very relatable, because like, I’m an idiot, I’m very basic, so if we call it, the innie, the outtie thing, as we were discussing, can we call it an Idiot’s Guide to Restoring the Single Implant? Do you mind?

[Devang]
As far as you think, you’re not offending anyone, that’s all. People tend to get, they offend quite easily, don’t they? But yeah, as far as you’re happy, I’m happy, I don’t mind that.

[Jaz]
And assume that the Protruserati know that I’ve got their best interests at heart. And actually the questions I was asking was genuinely for me, like, wait a minute. And I was, when I was interrupting you, it’s because generally, like, I need to be told, like, when it comes to implants, like I’m five years old and I found that the Protruserati usually thanked me for this and they don’t hate me for it.

So let’s go with that. Brave decision. Guys, let me know in the comments below, was this the right choice to call this a title an idiot’s Guide or are you offended? If you’re offended, I’m sorry, but grow up, grow a pair. So then what are we covering? I’m not doing the idiot’s guide to restoring this thing. What are we covering in part two, my friend?

[Devang]
In the part two, we are covering, which we are both very passionate about, which is occlusion. As we’re going to cover occlusion, we’re going to cover fitting of the crown and occlusion, maintenance of implant and really troubleshooting because when you start I remember this quote from Mike Tyson, that everyone has a plan until you get punched in the face.

So until you get punched in the face, like once you get the problem, you think everything’s fine. Does that make sense? So we’re going to discuss about some of the problems, some of the mess I created really over this 10, 11 years. And how I learned from it. So you learn from my mistake and hopefully you won’t do that again. So I’m excited.

[Jaz]
Standing on the shoulders of giants and all that Jaz, amazing. Devang, are you going to cover the scenario where you’ve done your implant crown, everything’s hunky dory, and then a few years later you come back and now there’s an open contact where there wasn’t before. Are you going to cover that scenario?

[Devang]
I will. There’s not much you can do to be honest.

[Jaz]
You will now.

[Devang]
Yeah. I will cover it.

[Jaz]
Okay, because that’s happened to me where I’ve seen a patient and then food getting stuck there. But, and I’ve read that this is a common issue and it’s due to ages related changes. And you can explain about how to manage those scenarios. It would be great, so troubleshooting. I’m very much looking forward to that. Devang, thank you so much. I’ve got to pick my kid up from school. He’s finishing earlier today because of the whole last day of summer, but we’re going to get our date sorted. Thank you so much.

[Devang]
Thank you.

Jaz’s Outro:
Well, there we have it, guys. Did you enjoy the Sticky Innie, the Sticky Outtie? Try and really make it as basic as possible. Like, I find it so frustrating, right? These implants, they all come with different settings and different types. And this is the real big barrier. This is what makes implants and learning implants and restoring implants such a steep learning curve, right?

It’s just getting your head around. All the different vast possibilities that you need to be some sort of genius to figure out the matrix and and hand on heart. This is what stopped me. I think one of the reasons it stopped me from pursuing this in the past. I just felt it was just too complex. It was just too much going on.

And I just liked some other areas of dentistry, which I do. And I’ve just gone all in with that. Maybe I’ll do implants and stuff in the future. But I hope you appreciate that it’s really important that we learn these things, right? Implants are becoming more and more common, so I hope you enjoyed learning about restoring single implants and the different nuances, and now you know what an internal hex and an external hex is as well. There we are.

If you’d like to gain CPD, an hour and fifteen’s worth of CPD, get a certificate, have somewhere that you can put your reflective log in, which will actually turn up on your certificate as well, that Mari will email to you, then join the app, that’s protrusive.app, you can actually use it on Android, iOS.

And the login also works on your laptop on protrusive.app. Or of course, if you’re watching on YouTube for free, I appreciate that. I still appreciate you watching all the way to the end. Thank you everyone for listening, especially the audio listeners. You guys are awesome. I’ll catch you in the next episode.