Rochette Bridges are a popular option for interim tooth replacement whilst implants in the aesthetic zone are ‘cooking’. In this episode with Dr Pav Khaira we discuss his interim restoration protocols using Rochette Bridges and Dentures, as well as gaining an insight in to custom healing abutments.
Which cement is best for Rochette Bridges? How do you remove them? Ceramic or Composite pontic? When might we consider a Denture instead?
We then expand in to soft tissue augmentation at the time of implant surgery to get the best pink aesthetics. This episode is packed full of gems even if you do not place implants – much of the benefits of soft tissue augmentation can be applied to non-implant fixed prosthodontics.
The Protrusive Dental Pearl: Steal my Resin Bonded Bridges consent form! It is a visual aid for patients and helps with information and consent for RBBs. If you are on Protrusive Premium, head to the ‘Protrusive Vault’ to download it. Otherwise you can request your free download here.
“It’s all about how you communicate the soft tissue grafting surgery to your patient” – listen/watch the episode to hear this absolute peach of a communication pearl!
Highlights of this episode:
- 3:40 Dr Pav Khaira’s Introduction
- 7:20 Interim Restoration vs Immediate Loading of Implant
- 10:12 TWO Golden Rules of Temporary Dentures for Implants
- 11:15 What is a Customised Healing Abutment?
- 17:40 Rochette Bridges Protocol
- 23:54 Temporary Implant Crown Protocol
- 31:36 Communicating Soft Tissue Grafting
If you enjoyed this episode, check out Success with Resin Bonded Bridges.
Click below for full episode transcript:Jaz's Introduction: If you've placed an implant or maybe your surgical colleague has placed an implant and now it's come to you as the restorative dentist, and you need to give this patient a tooth because they're not going to go for immediate loading, i.e, they're not going to have the temporary crown on this implant the same day.
We’re going to wait some healing, and therefore, how can you give this patient a tooth? It’s going to be a denture or a bridge of some sort temporarily. There might be some other ways, but these are the two most common ways to do it. Now, you might have heard of something called a Rochette Bridge. Rochette Bridge is basically like a metal resin bonded bridge with HOLES in it.
It’s very popular way. A lot of the implant dentists use to TEMPORARILY have a tooth there so that everything can heal, the soft tissue can heal, the implant can osseointegrate, and then you can take off this bridge and continue on with placing a crown for that implant. But there’s lots of nuances when it comes to Rochette Bridges.
So I’ve got on Pav Khaira today to talk about Rochette Bridges. Talk about dentures, like how do you make sure the denture’s not impinging on the soft tissues and on the healing abutment. Now if all these terms aren’t making sense to you, then I’ll make sure that Pav breaks down exactly what a healing abutment is.
So really is the bare bones of everything and builds you up and we build up all the way towards the end. We talk about soft tissues and how in many cases soft tissue augmentation to get a nice papilla is so important and Pav will share with you a very interesting stat about the number of people that show their papillas.
Have a guess, actually, if you don’t know this already, when people smile, when our patients smile, what percentage of them will show a papilla? At least a papilla, one papilla anteriorly, right? So what percentage of patients will show papilla, at least.
Protrusive Dental Pearl:
The Protrusive Dental Pearl I have you, is that you can steal my resin bonded bridge consent form. I thought it would be a good little gift to give to you guys. If you’re on Protrusive Premium, I stuck it on the download section already for you so you can download it. If you’re not on Protrusive premium yet, then you can now to protrusive.co.uk/rbbconsent. That’s RBB consent and I’ll send you my resin bonded bridge consent form, which I’m super proud of, because it’s pictorial.
It’s got Images. Like images of black triangles, images of long connectors and how on one place you might have a papilla and the other place where the tooth was extracted, you don’t. Now, patients get to visually see this. And what metal show through looks like and just, it’s really, really good to have these visuals for your patients.
It’s more like an information sheet, but this is a big hit. Every dentist who ever downloaded it as part of my resin bonded bridge course has always found this and the lab prescription form very useful. Now let’s join the geekiest implant dentist I know, Pav Khaira.
Pav Khaira. Once again, welcome back to the Protrusive Dental Podcast. How are you mate?
I’m very good Jaz. Thanks for having me back and as we spoke about just a few seconds, I’m going to push this out on my podcast as well, so it always feels twice as productive whenever we do it.
Excellent. Well, I’ve referred to you before as the ‘oracle of the implant world’, but the themes we’re covering today, and we’ll just get an instruction just in case someone hasn’t heard of the previous ones we’ve done and some of the group functions we’ve done, have been really well received because people message me saying, ‘Jaz, you’re covering these real world topics’.
And what we covered in those topics, like how you probe periodontally around implants, right? Things like that. Screw loosening. We covered these really big themes and so today’s theme, but for those listening, all watching on YouTube is a twofold.
One that will help every single dentist, I think, right? We’ll learn about rochette bridges. How do you take them on, how do you take them off? How do you put them on? What cement do you use? The selection criteria, that kind of stuff for like temporary, before they have the implant and while implant restoration, while we’re waiting for osseointegration and the grafting, et cetera.
And how we can optimize our temporary implant ground to better serve our future implants and soft tissue augmentation. So something in it for those who are already doing implants. So this is going to be a bit of a beast. But Pav, for those who haven’t heard of you and the lovely work that you do, including your podcast, just give us a flavor about yourself again.
Yeah, thanks Jaz. So I am a full-blown Titani-nerd. I mean, to the point where when my wife and I went out shopping for wedding ring, she was like, ‘I want that one’. And she was like, she said to me, ‘why do you want that one?’ I said, ‘because it’s titanium’. And she was like, ‘why don’t you want gold or platinum?’
She didn’t realize until afterwards that titanium is what her implant, because she’s not a dentist. That titanium is what implants are made of. So I literally live in breathe implants. I have placed over 10,000 implants. I have been very, very fortunate to have been exposed to a lot of surgery. So I’ve become very confident and proficient at it.
And, I still have a lot to learn cause I’m a great believer as soon as we turn around and stop learning. We do ourselves a disservice and we do our patients a disservice. And this is a philosophy that both you and I have in common. So I run the ‘Dental Implant’ podcast, which is kind of like, off the back of a discussion that you and I had a few years ago.
And you were like, ‘Pav, you know so much, why don’t you run a podcast?’ And I was like, ‘I don’t know how’. And you were like, ‘let me show you’. So, you’ve been my sage and mentor in that context. And now I’ve also set up and I run the ‘Academy of Implant’. So I’m busy, busy training, mentoring and everything relating to implants.
My daughter’s only two and a half and it won’t be long before I’ve got a motor in her hand practicing on models to place implants. So.
Excellent. Well, I can definitely vouch for your geekiness, like when I was a newly qualified, I think maybe 10, 12 years qualified, that stage and the amount of knowledge that you had on occlusion and splints and obviously osmosis. I try to absorb as much of that as possible. And I’ve kind of run with that and I have seen you diversify into implants and how you really take into that. So I think you’ve got this personality Pav, whereby when you take something, you properly latch on. Am I right in that?
It’s obsessive. I can’t help it. That’s just me. And that’s purely from a point of view. I’m a great believer if you’re going to do something, do it properly. And in order to really help our patients, and it’s a personal journey as well. I don’t want to get to the end of my career and think to myself, I didn’t do this, I didn’t do that.
I want to get to the end of my career and think to myself, actually, you know what? There’s nothing more that I could have put into this. Absolutely nothing. I’ve helped as many people as I can. I’ve trained as many dentists as I’ve could. I’ve gotten x number of, careers off the ground, and those people have helped more patients as well.
And I think you have to be obsessive about it. And that’s just my philosophy. If you’re not obsessive about it, you don’t have to be quite as obsessive as me, but you at least need to have a passion about it. There’s a difference between passion and obsession. I’ve got an obsession with it.
You need to at least have a passion about it. And the rewards that come off the back of that professionally, personally are just unmatched.
Amazing. And I think that’s valuable for anyone in their dental journey the early or later on. That’s really great to hear. Now getting moving to clinical direction now.
If you talk about Rochette Bridges, right? So for those who haven’t heard Rochette Bridges, I’m sure most of our colleagues listening and watching know this already, but, a resin bone bridge, for example, classically a metal wing with a ceramic pontic attached as we know so well, and then if you to get a round bur and poke holes through it, that’s now essentially a rochette bridge.
Now, commonly when I think of Rochette Bridge, I think of those who place implants favoring this type of restoration to make sure the patient has a tooth to smile, to chew or maybe to chew with, smile with while they’re waiting for everything to cook. Now, before we get into the sort of ins and outs of this, I want you to know from you Pav in your protocols like anterior teeth, for example, what percentage of the time are you actually putting, like the day you place an implant, you’re putting some sort of an implant, temporary crown on top? And in what percentage cases are you then relying on a denture? On a bridge? Or some sort of prosthesis?
I’d say it’s about 50 50. And one part of that is some patients don’t have the funds to go for immediate load as well. And that’s purely from a point of view that it does take more time, which you have to charge for. And some patients like I’m happy with the denture. I’m happy with rochette. Whatever it is.
There are also some instances where you can’t, from a biological point of view, while you’re waiting for everything to heal. But I like to go immediate load as much as what I possibly can. In fact, it’s probably a little bit more than 50%, probably about 60% of the time. And the reason for that’s quite simple is you get a lot of control over how things heal, assuming you do things properly.
And in addition to that, patients really appreciate it, they appreciate a fixed tooth over a denture or having a space. So I think it comes down to biological factors and patient factors as well. But the more that I can do predictably, the happier I am effectively.
And in those cases where you are let’s say it’s a lateral incisor, the patient may be used to have a denture and then you are now placing a tooth there implant and for the whatever reason, maybe patient can’t afford it or they want to space it out, or you want to give it more time to cook and heal.
You can either, I guess just gouge out a bit of acrylic on the denture and then let them use that same denture. Is that any nuances to that you want to add to before we talk about the Rochette bridge?
No, not really. I think what’s really important is, so let’s talk about two different factors. Here is the patient who already has a denture and the patient who has a tooth, and you want an immediate denture as a backup. So the patient who already has a denture, yes, you can adjust it, but you need to make sure that there is no pressure on the healing abutment or on the healing site at all. So you’ve actually got to create a little bit of space about it, underneath it.
How can you test to make sure you have got that? Because imagine after surgery, I mean, I’m sure your surgery’s very neat and you got the sutures on. It looks very good and probably you can eyeball it, but, I don’t know. Do you squirt some light body impression and just see if there’s space? I mean, how do you actually just be sure?
So I don’t like light bodied because it flows into the surgical site a little bit too much. What you can use is you can use a little bit of occlusal registration material. Because that’s a little bit stiffer. It’ll still give you the exact same information, but if you see any go down the side, you can just grab it with tweezers and pull it out.
So you need to use something a little bit stiffer using a light body or pressure indicator pace you’re actually causing issues in the surgical site. If I’ve got a patient where they need to have tooth removed and we are making them a denture. In those cases quite often what I’ll do is I’ll ask the lab, in addition to making the denture, there’s two additional instructions that I give them.
Number one, don’t suck it. And number two, don’t add a flange. So it’s literally a tooth hovering just above. And I tell them it’s specifically for an implant, and they normally keep it clear of where they think it’s going to end up by about a millimeter or so. And that ends up being really nice. But I always warn the patients beforehand, if we need to use this denture, you are going to absolutely hate it.
And then when they hate it, it’s just I did warn you about this. But that again is one of the reasons why I try not to do anything removable. Another reason why I try not to do anything removable is unless you’re doing a customized healing abutment everything starts to collapse. So not only do you get the benefit of having a fixed tooth and that’s obviously easier than doing a Rochette or a denture when you haven’t got a massive amount of occlusal clearance, because you’re not relying on wings, you’re not relying on acrylic.
But in addition to that, if you contour it correctly, it supports the soft tissues whilst the heel. So-
Now you’ll have to explain Pav. Because a lot of younger dentists and students may be listening. Even experienced dentists who just are new to the implant world. Customize healing abutment like you’ve placed the implant. Really break it down like I’m five years old.
Fine. So on a very simplistic level, once the implant’s in place, you need something to protect the head of the implant. Whilst it’s healing, whilst it’s cooking, otherwise, soft tissue’s going to grow into the screw channel and it’s a complete mess.
Okay. The neatest way to do it is with what’s called a ‘healing abutment’. That’s just something that screws onto the head of the implant. There’s two ways of healing.
Is that same as a healing cap? Is that same thing as well?
It is. It is the same. It’s different to a cover screw. So cover screw is basically the gums will grow over the top, whereas a healing abutment slash healing cap is, it will protrude into the mouth. So you’ll see a little a little stud in the mouth, and that’s the healing abutment. So when it comes to healing abutment says two ways of doing it.
You can use a stock one, which is just with your implant systems. When you’re ordering the implants, you ask the lab to send you whatever side. They come in different heights. Things along those lines. Different connections, depending on the implant system that you’re using. The issue that you have with that is, it doesn’t, it’s not really bespoke for the patient. It’s like getting what is it, you know there’s 3M crowns that you can get out of a packet and then you retrofit it.
So it’s not really-
Even like a whole crown as well, like hall crowns, like the preformed metal crowns for children’s teeth. They’re all, you have to make the tooth fit the preformed thing. Even like if I was to say like even sectional matrices, right? We have to, whatever tooth, whatever configuration the tooth is, you have to just select the appropriate sectional matrix, but it’s never going to be fully customized for your cavity.
That’s exactly correct. Now, imagine if you had something that’s fully customized. How much more predictably that soft tissue’s going to heal. And basically there are certain things that you need to look at when you’re doing this type of stuff. When you at the CEJ level and then underneath the CEJ level all the way to the head of the implant. There’s certain ways of contouring it, depending on the implant height and the position. So that it supports the soft tissue whilst it heals.
And the whole point is, is you go to this length because at the end of the day, you don’t want to tell the difference between an implant and a tooth. This should just look exactly the same. It’s very difficult to do, like with all things in the aesthetic. If you’re doing a single veneer at the front of the mouth it’s very hard to achieve and this is no difference, which is why we want to go to the nth degree to try to maintain that control, to try to mold everything and keep in control of as of much of what we possibly can.
Now I know we might be digressing from the main topic of the podcast, but I’m really interested in this, like, if you’ve got the stock abutment like, off the shelf and it’s not customized to a patient, fine, but then how do you actually make the customized, do you customize the stock one, like adding flow I’ve seen before? Or do you arrange this in advance by taking fancy impressions to do it? How do you actually create something that’s customized for the patient chair side?
You can actually do it both. So if you use guided surgery, quite often you can have a customized healing abutment made. I don’t see the need or point in that.
I think it just increases cost for the sake of it really. Because it’s actually quite easy to do, chair side. So instead of using a stock healing abutment, you can use what’s called a ‘temporary cylinder’. And it’s, think of it like a tall healing abutment, but it’s actually a little bit narrower.
So in that dead space between where the cylinder is and where the rest of the tip, that’s where you add your flowable composite. And then you can unscript on and off. You contour it to support the soft tissue correctly. You clean it, put it back in place, and then that’s kind of like it. And then what that does is it gives the correct contours, it gives the correct support whilst everything heals underneath.
And then the presence of a customized healing abutment as you explained that, you made it just that you explained it really beautifully. Now, how does that influence the denture versus bridge? Or does it not influence which type of restoration you might go for as your interim?
So it doesn’t really influence. So if the implant’s gotten nice, really nice and stable, you do that contouring subgingivally first, and then you can just add more material on to make your temporary crown. Or you can get like a shell crown made and just stick that all together. It’s just gluing bits together. The other really nice way of doing it is if your tooth is relatively intact is cut the tooth off just below the CEJ, punch a hole into it, and then you can actually use the existing tooth as your temporary as well.
Like the old living bridge kind of thing, but applied to a single implant.
Now there are histological benefits to that, which is a little bit too titanium nerdy for this.
Clever, clever. But by definition, if you’re doing that, you are then going down the immediate loading pathway, right?
Yes. So you’re going down the immediate loading pathway. So if you are not immediate loading, once you’ve done that contouring, everything’s kind of like just one millimeter above the gum height. So it is not really encroaching too much into your restorative space for your temporary, although it is a little bit, and sometimes at the front of the mouth, in in a high smile line, you can see it.
I was just going to say, it’s a nightmare in a high smile, a high smile line. How’d you, if you’re not going for a flange, how do you even cover that then?
This is why immediate loading is beneficial. And this is why patient communication is really important because sometimes you can’t hide it and you have to turn around and say to the patient, ‘I’m sorry, it’s going to look ugly and it’s going to look worse before it gets better.’
And what I say to my patients is, ‘look, I’m very, very good at what I do, but I’m not a genie. I can’t just magic things just because we want to. There are certain biological and certain biomechanical processes that we need to respect. If we disrespect those processes, we’re going to end up going backwards instead of forwards on one of those things. It’s healing time.’
And, I will always do my best, and I always say to my patients, even if I’m aiming to immediately load, give an immediate temporary restoration, I’ll say to ’em, ‘we’re having a denture as a backup, or we’re having a rochette as a backup.’ I’d rather throw it in the bin, but I’d rather have it and not need it, as opposed to going ‘mm-hmm can’t do this.’ and then not having anything. And then what? Walking away with a space at the front of their mouth.
Well, we’ve covered already with the denture. Make sure that it’s not touching the soft tissues. Make sure it’s not a flange. You mentioned make sure it’s not socketed for anyone who doesn’t know what that is, that’s basically you don’t want an ovate pontic, you don’t want the tooth actually going into the socket, obviously, because there’s an implant there and there’s a healing abutment there.
But, so in case anyone miss that, we don’t want that. So let’s now change gears and talk about a Rochette Bridge. Interestingly, Ken Hemmings, restorative consultant, I had a chat with him many years ago, maybe nine years ago now, and he was saying that, while he’s waiting for osseointegration or soft tissue healing, et cetera, et cetera, he didn’t actually like using Rochette bridges.
He actually used the unperforated retainer with Panavia, because his argument was like, ‘listen, my patients, they’re barristers, they’re this, that and the other’. It’ll be a travesty if they lost their tooth. Thought I pretty much treated like a definitive. And then nine months later, or whenever I made a that number up.
I’m sure you guys know the numbers better, but he will then remove the resin bonded bridge and then at that point you can actually design the resin bonded bridge to have some sort of a lip, which is going to be really super filled with cement. And then you can old sonic out and try and sort of lever it out.
But I guess we can talk about techniques or removing bridges anyway, involving forceps, et cetera. But, colleagues I speak to implant, they use Rochette, which are perforated. So what is your experience of using resin bonded bridges as part of your implant protocols?
I prefer rochette bridges as opposed to resin bonded bridges. Actually, for quite a simple reason is when you seat it. Some of that cement flows through those holes onto the other side, and I can smear it a little bit. It actually gives me a little bit more retention and for that reason, I really, really like it. I do not like GIC to hold these things in place.
I don’t think they hold particularly well at all. I’ll tell you what I have used very successfully before in the past. These are dual cure resin cements something like, RelyX™. I have used Panavia. The issue that I found with Panavia, it’s almost too good. Then removing it ends up being a real nightmare.
I imagine like you’re trying try and trying, like, I’ve done it before. You have to just drill away the metal. Right?
You drill it away, right?
Yeah. Yeah. And this again, is one of the reasons why I like Rochette is because they’ve got that little bit of mechanical retention, you’re not relying solely on the adhesive, on the cement is they’re they’re a little bit more robust for a cement that fails, a little bit easier for when you want to remove it.
I’ve also used Poly-F F before for these, which works really, really nicely, but like relyX dual cure or something like that. I tend to find, I get fairly stable results with, and I really like that.
Okay. And then same thing in terms of the pontic being well clear of the abutment, the stock healing abutment in this case, for example, all customized, like it’s going to be away from that healing abutment, not putting any pressure. And you’ve checked this, any guidelines, half a mil, a mil in terms of how much clearance you want?
Half a mil, three quarters of mill, something like that. There’s actually two ways of doing this. Aha. Just to make it even more complicated. So you can put your customized healing abutment underneath. And then put your rochette on top.
If you are putting a cover screw onto the implant, so you’re burying it, maybe the implant wasn’t as tight as what you need, you can actually have a slight ovate pontic on the rochette. The problem is, is you don’t always know which one you’re going to need until the implant goes into place. So you either make a judgment call beforehand, or you add a little bit of material to it, or you cut a little bit of material away.
Yeah. I mean, that makes sense to me, right? If you go with a ovate and then drill it away, it’s just takes time and it’s annoying, and you have to go through the polishing. I’m assuming what nice, highly polished surfaces against your surgical side right?
A hundred percent. And this, again, is why immediate temporization and immediate loading is actually better. There are actually certain kits that you can get, which actually help you make those contours, subgingivally. But you can really quite easily do it freehand as well. It’s just a bit fiddlier. That’s it.
And can you just add like flowable composite if you want to make it. Have you used flowable onto your ceramic as a sort of temporary shape builder?
Yep. Correct. That’s exactly what I’ve done. You just need an adhesive to get the flowable to stick to it or I don’t get the lab to make it in a ceramic. I’ll get them to make obviously the metal work. And then just get them to use composite, then it’s much easier composite.
That makes sense. Actually using a composite pontic rather than ceramic. And the lab bill will be better as well.
Correct. It’s only temporarily that doesn’t, it’s not designed to be there for a very long time.
Any other nuances that you think because I know you teach so much in your academy. I assume from the restorative dentist, new to this field, I probably have a lot of nuanced questions about rochette now.
I know we’ve covered a lot there in terms of cement choice, probably a popular one, the design of the retainer, that kind of stuff. Any other nuances before we move on to actually, stuff that will be helpful to those who already are practicing implants and placing implants? Any nuances on temporization in terms of going for a delayed approach and you want to put a tooth there temporarily?
So a lot of the finesse comes into the next bit that we’re going to talk about, but normally what I do, as you stated before, because it’s temporary, I normally get the lab to add a little notch somewhere on the palatal, normally underneath the pontic where I can get the crown and bridge remover in, and I like those pneumatic or those slide drill crown of bridge removers.
You generally tend to find that with a rochette. You just put it underneath slide one tap and it’s off. Comes off really nice and clean. Then it’s just a matter of just cleaning up the wings a little bit, cleaning up the excess cement, and then if you need to use it again, you can reuse it again.
One thing I’ve done Pav is, removing resin bonded bridges is using some gauze over the pontic and then using some forceps like extraction forceps, supporting the abutment tooth. Okay. And then just give it a good talk and that can help. But yeah, you got to warn the patient going to feel a bit of a yeah. And you don’t want to use it on anyone who’s got maybe grade one mobility, et cetera, once nice firm teeth obviously, and you in a controlled way.
But I know lots of dentists, I know Rajiv Ruwala taught me this actually many years ago, and I’ve used it a few times, but yeah, sometimes if you use Panavia, it’s really tough and then at that point you got to get the big boy burs out and really just thin out the metal. The interesting thing when you actually thin out the metal and you ultrasonic it a bit, it actually does come away. The last bit is it just pings off sometimes if you get lucky.
So I’ve experienced that as well. Okay. Well, let’s switch gears now and talk about top tips with restoring spaces with temporaries before you move on, definitive crowns. Now, when you mentioned, let’s say, in a scenario where you are immediately loading, so you’ve got, either the patient’s own tooth that you’ve gouged out or temporary one. Now, how will that temporary one be made? Is that always a lab made thing?
So the easiest way to do it is to have the lab make a shell made temporary with just a couple of simple wings that sit on the adjacent teeth. And that can be single tooth. There’ll be multiple teeth. Because what’s going to happen is if you’ve just got a shell temporary without any wings locating it, it’s not as easy as you just say, okay.
I’m placing an implant in the central upper, say, upper right, a one position, and then my lab will put a wing on the lateral and the contralateral one as well. That means once that tooth is gone, it’ll just kinda like drop into place and it’ll hook over the incisal edges and that way I can let it go without it falling away.
It’s like a locating lug, right? It’s like index, like a locate seating lug essentially.
That’s exactly what it is. So it’s not a wing because you’re going to adhere to it. It’s a locating jig. So you get the orientation correct. So I used to do it where I just used to make the shell crowns and then you got a try and orientate it correct with your fingers.
And then my big fingers are in the way while I’m trying to pick it up with flowable composite. And then I was just like, hang on, why don’t I just do this? That’s so much easier. And what I would do is I would get the lab to make the shell crown all the way up to the CEJ. So it is contoured nicely, but that’s not just contoured labially, but it follows the gingival contour from the labial aspect of the palatal aspect and then back around again.
So it’s like the crown is fully formed. It’s not like flat, it’s not like a flat 360. What you do at that stage, once the implant’s in place, you then put your temporary, what we call the cylinder in place, and that should pop up through the hollowed out temporary. And if not, then you can thin it out more.
Now with these hollowed out temporaries, I get my lab to really thin them out quite a lot because you’re going to add material and have it all picked up anyway.
They should be see-through, right? Pretty much. This should be very, very thin. Like we’re talking acrylic, right?
Yeah, we are talking acrylic. If they’re too thick, all that ends up happening is you’ve got to create that space first and you’re never going to be as neat as what your technicians are going to be. So I get the technician to do as much the work as possible. And that’s partly because I want to be as lazy as what I possibly can be as well. Okay.
Prav, I’ve been the scenarios, where I’ve done like, shell bridges and whatnot. And the technician has completely misinterpreted what I wanted. And they’ve pretty much milled these margins. Like one millimeter margin thinking I’m doing these one millimeter margins.
I was actually doing vertical preparation, so I had to, I was there ages gouging out. Then I would get the GC fit checker, you know that silicon stuff. Put it inside, seat it on, pencil mark. Where is it binding? Adjust it. We don’t want any of that. Just get the lab, have that conversation with lab. They want it as thin as possible. Eggshell thin, as they call it.
Yeah, absolutely correct. So then what you do is you should have your implant in place. You put your temporary cylinder in place and the shell should just fit over the top so that’s the first check. And then what you’re doing is you build the contour below the gingiva.
So you’re taking it on and off. You’re taking the cylinder on and off, you’re getting that contour correct. That’s a bit too technical for this because a lot of it is visual, so I can’t get into it too much.
We’re talking acrylic. Are you using like acrylic hand mixed acrylic?
I’m using flowable composite for that. Okay. And I want a really nice flowable composite so I can polish it as much as what I possibly can. Once you are happy with that subgingival a bit, you put the shell crown on top. You pick it all up with flowable and then you cut off the wings and you polish it, so it looks like a screw retained crown.
Okay, now let me throw some information at you. So Dennis Tarnow has done some research into this. Did you know that 98% of people have a smile line high enough that they at least show their papillae as a minimum?
I didn’t know it was that high.
It’s very, very high. So 98% of people will at least show their papillae. The issue that you have is when it comes to implants, when you take a tooth out, it doesn’t give the same support to the papillae. It doesn’t have the same blood supply to the papillae, and it’s very, very common to have blunting of the papillae when you are doing an immediate implant. If a patient’s got a low smile line, then it’s not a problem.
But what happens when you do have this smile on whether the papillae show or there’s a very high smile line. And the answer to that is really, really simple. You need to do soft tissue grafting at the same time as implant placement. So in anterior aesthetic zones, a lot of people say, ‘oh, we’re going to do immediate placement.’
We don’t raise a flap. You should be raising a flap. You should be raising a split thickness flap. Harvesting dense keratinized tissue from the palate. And there are certain ways of suturing, but effectively what you want to do is you want to augment over the sight of the tooth and the papilla either side as well.
And what happens is when you do that . Augmentation and you push the soft tissue thickness to two millimeters, that those papillae they will infill. Okay, over time they will heal absolutely beautifully is you get really nice stable result. So in high aesthetic patients or in patients with a high smile on whether papillae is possible, it’s my opinion that soft tissue grafting in the anterior zone at the time of immediate placement and immediate alone.
It’s mandatory. You can’t get away with it just by doing the temporary crown, it’s not enough because the biology changes. You need to give more strength, more soft tissue volume to the papillae themselves. So it’s not just augmenting over the site. You’ve got to augment the papillae either side as well. When you do that, that is when you don’t get papilla loss.
Well, how does that translate Pav to your surgeries that you do in the sense that if 98% of people are showing a papilla, therefore are you doing this connection tissue graft in 98% of cases?
Yeah, pretty much. Cause it doesn’t take a vast amount of time. Or again, the other thing that comes down to is patient communication. So I turn around and I’ll say to the patient is if they’ve got a low smile line, I just turn around and say to them, look, in order to get a perfect result, this is what we’re going to need to do.
The cost of it’s going to be X, but you’re not going to see it anyway. Patients go, fine. I’m not really bothered about it. There are other patients where you may see the papilla, but it’s not really a massive amount, or it’s the adjacent teeth are all, you can see composites on them and for those patients, you just have the discussion and you ask them whether we want to do it.
The patients where it’s absolutely mandatory are those younger patients or patients with very high smile line or patients who are very aesthetically demanding. Then I turn around and say to them that, look, It’s not just doing the implant because I can get the implant looking right, but it’s that balance between where the pink zone is and where your teeth are.
That’s what your eye’s going to be drawn to. I said, I guarantee you, because of the biology and the mechanics of what’s going on, if we just take a tooth out, put an implant in. You’re going to have a little bit, just small black triangle showing either side. I said the way to alleviate that, get around that is to do some very simple grafting at the time.
That doesn’t mean a second surgery site. It’ll be like you’ve bitten into a pizza that’s too hot. It’ll be sore and sore in your palate for a few days, but it’ll heal. And when you explain it to patients like that is quite often they’ll go, yeah, I’ll have it. And whether they have it done or not comes down to how you communicate with them.
So if you tell them that you’ve got to take a strip of gum from their palate and it’s going to hurt like hell, then they’re not going to have it done because in their mind, you’ve got to take a strip of gum from the pallet, it’s going to hurt. Whereas if you turn around and say to them, look, pretend you’ve bitten into a pizza that’s a really hot, and it’s burnt the roof of your mouth and it’s sore for a few days, but it settles down. It just had a big-
So much more relatable, isn’t it?
So much more related and I say to patients, that’s what it’s going to feel. Like I said, it’s going to feel like a bad ulcer for a few days and that’s all that it is, and to be honest, is your harvesting techniques and your surgical techniques is, they shouldn’t really be heavy handed.
I warn my patients of that, but very few actually come back complaining of pain. Because the amount of pain that a patient experiences directly related to how traumatic you are, which is not necessarily related to the surgery that they’re doing, but how you are doing the surgery. So using very gentle techniques plays a massive, massive role for a patient.
I mean, you taught me Pav a while ago, just cause I follow your posts and stuff about the importance, like did you take it to a next level, like a blood test? Because most patients will be vitamin D deficient, like you taught me. That kind of thing. And to make sure that they, you optimize their healing.
And all those Im important factors, their medical history. So I’ve absorbed that even though I don’t do implants, I’ve absorbed those details from you. But just interesting relating it back to the restorative dentist who may or may not be placing implants. Think to how important soft tissue is. Even for like resin bonded bridge cases, you’re doing a bridge conventional or resin bonded bridge, right?
If you are replacing a tooth, it slightly doesn’t have a papilla there. And to get a really good result, you need soft tissue augmentation, even with bridges and stuff to get a nice papilla. So you can apply to those as well. Now, if you don’t, you need to show the patient that either we accept a black triangle or you get a long connector.
So it’s also relevant in the restorative world as well. What I do love, Pav, I have to say, even though I don’t do implants, I love those photos of patients who, when you remove their temporary implant crowns, and just a beautiful tissue like with the scaffolding that you had in place, and they’re just perfectly ready for the definitive crown there.
I do love those photos and I used to work as a DCT and restorative. I remember unscrewing, some screw retained temporaries, and just looking at that beautiful soft tissue that is a thing of beauty.
Yeah, it’s great. See, you are a Titanium nerd. I knew it.
I just didn’t know it yet. Excellent. Well, Pav, you’ve covered things really well. I’m very happy how tangible we made it. I think for a lot of the dentists, some of those, the way you explain those certain things are brilliant. Even if you just take away that communication gem or hot pizza on the palate and how to talk about that. I think it’s great. How can we learn more? Now, I know you teach people who have zero experience implants, but also people who are doing a master’s at the same time. You teach them as well, and they all have something to gain. So tell us about how we can learn more from you.
So very simply is just reach out to me. You can go to the academyofimplantexcellence.com or you can find me on Instagram. I’ve got three Instagram handles, @academyofimplantexcellence and the @dentalimplantpodcast.
And just reach out to me. I’m on LinkedIn as well, Pav Khaira just reach out to me. And what’s really important for me is I speak to everybody before they enter onto the academy. I don’t just let anybody on because I’m building a network of people where, as you rightly said, some of them have never placed an implant before in their life.
And I’ve got other people who only place implants wanting to increase their knowledge and increase their skill. And I have to create a safe environment for everybody. So what’s important to me is those joining the academy, they are hunger. They’re hungry, they are keen to learn because when they have that attitude is they will love the information that I give them.
Because if somebody comes in and ah, I just fancy doing the oral implant now and again, the amount of information that I dump in, it’s just too, it’s overwhelming for them. So you need to be a Titanium nerd, but if you want to learn I just love helping and I love watching. When you’re speaking to people, you see light switches going on and there’s these aha moments all the time.
All the time. I love it. I love it. And in fact, I’ve actually swap switched recently. My working week, so I’m now focusing more on the academy and mentoring, but I’m still saying staying wet handed a couple of days a week as well, because I’m just at that point in my career now where I feel like I want to give back and I need to give back.
I’m just thinking about the practicalities of this Pav, like, is it online only? Is it in person? Cause I’m thinking I got lost of this from the US, Australia, Europe. Is it only UK that you can help out? How does it work?
No. So the academy, the theoretical part is it’s all online because let’s be honest, you can learn everything you need to learn about implants from articles and textbooks. If you knew which articles and textbooks to read. Or you can learn everything by somebody telling you and from somebody telling you. You can either do that in person or you can do it online while you’re in bed in your PJs on a Sunday afternoon, whatever it is. So in that context, I actually have delegates from Canada, America, Austria, and Australia as well, and it’s a fantastic group with regards to the actual hands-on aspect of it.
I do offer mentoring as well. That’s obviously easier in the UK than anywhere else. And you don’t need to be a delegate of the academy to get mentoring. Some people are just like, Pav, I’m stuck, or I want to learn how to do these complex cases, or I want to learn this. If I line up a day full of patients, would you come out to me? And the answer to that is yes. If you are a Titanium nerd, I’ll come out to help you. So, yeah.
Amazing. Well, Titanium nerds there we have it. Perhaps your answer if you need mentorship or if you want to take that next level in your implant knowledge. Pav, thanks so much again for coming to the show and making implants tangible.
There we we have it. Guys, thank you so much for. All the way to the end, I hope we made some aspects tangible, which perhaps no one explained what a custom healing abutment is and or if you’re already well versed with it. It’s good to learn Pav’s protocol of how he does his resin bonded bridges, using something like relyX cement and how he doesn’t favor GIC.
And even just appreciating the need for soft tissue augmentation to get that ideal result. If you want to learn more from Pav, checkout Academy of Implant Excellence, so I’ll put the link in the show notes that can of course follow him on Instagram as well. It’s @academyofimplantexcellence, and while you’re there, I know you’ll also follow @protrusivedental.
Anyway, we’ll catch you in the next episode. Thanks so much once again for listening all the way to the end.