Suction Lower Complete Dentures – Improve your Removable Prosthodontics – PDP073

Podcast: Play in new window | Download (Duration: 56:36 — 78.3MB)

Subscribe: RSS

Lower Complete Dentures are the bane of Removable Prosthodontics. I know many Dentists who ‘hate making lower full Dentures’, likely because they are difficult to master. So difficult that I got Dr Rupert Monkhouse to give the Protruserati a podcast masterclass on how to improve in this frustrating area of Dentistry!

Need to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl: The power of silence! When you present your patients a solution or treatment plan, or tell them the fee, there may be a silence. Embrace it. Expect it. Don’t panic. This is normal! DO NOT but in with a ‘why don’t you just think about it…’

In this episode we discussed:

• How can you predict if a suction lower denture is anatomically possible?
• What materials Rupert likes to use
• What and how to adjust at the Try in stages of complete dentures
• How to get the wax try-in to stay in the mouth!
• Communication pearls surrounding lower complete Dentures

If you enjoyed this topic, why not also check out the Master himself, Dr Finlay Sutton on Troubleshooting Chrome Dentures!

For details on Rupert’s Denture course, DM him on Instagram!

Click here for Full Episode Transcription: 

Jaz’s introduction: 
Now we all know how annoying lower complete dentures can be. I could probably think about four dentists in the entire world who liked doing complete dentures. And the secret is because they’re good at it, right. And one of those dentists that I can think of is Rupert Monkhouse, who is doing some sensational things with his patients, with his photography. It’s just absolute art. And I’ve got him because he’s so good at removal prostho. So today we’re talking about exclusively the bane of our existence in removal prostho, which is a lower complete dentures.

In this episode with Rupert, we’re going to ask about how to get more predictability, if that’s even possible with the lower complete dentures. What are the signs that actually you may be onto a winner and that you may be able to get a suction lower denture, that elusive suction from a lower denture, which you see flaunting on Instagram, I probably achieve this twice in my career so far. We’re able to get the lower denture suction, and both times you pull the camera out, you record it because it’s such a proud moment, right? To get suction on a lower complete denture.
So I’m going to ask Rupert, is there a formula? Or is it all luck? As well as that we talked about all the different stages that Rupert utilizes to help him get a really stable, lower complete denture.

Protrusive Dental Pearl
The Protrusive Dental Pearl I have for you is a communication one. It’s something that I think as a profession on the whole, we’re not very good at and something that we were never taught. And now when I learned this technique, I guess it’s a technique in communication, it really made a huge difference. And I remember one time in Reading, we were doing an Invisalign open day, and I had two other dentists in the room while I was doing a consultation. So we were taking turns, one person was right in the notes, the other person was filling like the radiograph requests, that kind of stuff. So we’re working as a team for this Invisalign open day.

And I went through my entire spiel, I showed the before and after’s I listened to the patient’s wants and needs and how we can help this patient to have a better smile. Now, when it came to the close, i.e., it’s going to cost this much and this much time, is this something you want to proceed with? Right, so that’s called a close when you close a treatment plan. When it came to a close, there was a silence, i.e. I finished speaking. And now there was an awkward silence.

Now what happens? Imagine you’re going to a patient, you’re going to say to a patient, you need an implant and three restorations and the cost will be 6000 pounds. Okay. And then once you said that, what happens next? Well, usually there might be paused for like, a couple of seconds before what happens usually after that pause? Usually the dentist might say, okay, you can think about it if you want, or the dentist might say, does that not make sense? Because for some reason that pause is something that we can’t fathom, is something that we can’t tolerate, is something that we kind of panic from that pause. Right?

So the lesson here, and what I did that day, was that I just let the pause happen. Okay, I zip my mouth shut. I said, it’s going to cost this much. It’s going to take this much time. Is this something you want to do? I just paused. And it was around about a 20-second pause, right? Imagine three dentists in the room and the patient, and there was a 20 seconds pause, that 20-second pause, seemed like probably like five minutes.

It was it seemed like an eternity, right? And the patient said, “Okay, fine, I can do it.” And then she’s now having Invisalign with one of the dentist at the practice. So the lesson we can learn here is A) respect the pause, he or she who speaks first loses, so don’t speak first, let’s give that patient the time. And the way I learned is that patient needs that time to just figure out “Oh, which day can I come in? How much money do I have? How can I afford this? Is this the right thing for me?”

In the patient’s head, they’re probably thinking they’re taking about three or five seconds to respond. But they’re in like a trance. They’re really just thinking about a few things. And once they’ve made up their mind, they will then answer. If you rush the patient, or if you interrupt the patient it’s so easy to say to them. Think about it. And what happens is they go home and they think about it, and the rational brain takes over, because why? Cosmetic dentistry Invisalign is an emotional purchase. Okay? And when they say, you know what, I rather go on holiday, and that’s it, they won’t be having the treatment anymore, which is a shame because who loses out?

I think you lose out but the patient also lose out because how many patients do you know who’ve had cosmetic treatment from you? And regretted it? Very few, probably none, because they all want to have a better smile are so grateful. And quite often you hear this time and time again. They always say I wish I’d done this treatment sooner. So that’s my elaborate communication Protrusive Dental Pearl for you. Start respecting the pause. Don’t panic. Give the patient the time to breathe and the time to think. Hope you enjoyed that one and I hope you enjoy the session with Rupert Monkhouse. I’ll catch you in the outro.

Main Episode:
Rupert Monkhouse, Welcome to the Protrusive Dental podcast. How are you my friend?

[Rupert]
I’m good, man. Thanks for having me on. I’m really excited to be on having a chat with you,

[Jaz]
Man, I am so stoked to have you on mine. The level of dentistry, level of just removal prosth that you do like it’s similar to what I said about Finlay because I know you listened to it, the Finlay episode is like the same thing I said to him, I say to you, you are making removable prosth sexy, right? Because sometimes I wonder and we were just having a chat before we started recording, I actually thought you limited your practice to removal prosth, but then I found out you did extirpation today, you did some fillings or whatnot. And just it’s amazing that the level that you’re doing this and the way you’re documenting. So the first thing to know is for the listeners, test a little about yourself and how you got into removal prosth. And why not composite veneers? Why not facial aesthetics? Why this seemingly specialized rule of prosth, which you’ve made sexy, which is great.

[Rupert]
Yeah, I mean, I graduated in 2017 from Kings. And that’s really where it sort of came from. Mainly as my third year tutor we did removeable started that in third year. And I just had one of those tutors that’s just so passionate and such an incredible teacher.

[Jaz]
What’s the name of the tutor?

[Rupert]
Andreas Antonopoulos. He’s out in Cyprus now. But he was running [maxbox] prosthodontics as well. I think he still pops over to guys to do that. And so yeah, he was my third year tutor and just got me sort of sucked in with it. I went and did my FD up in hole and they had the sedation contract for the area. So we’d have once a month loads patients coming in for sedation. If they didn’t have complete or immediate dentures, they got sent to the FDA to make up a pair pretty [sharpish], I got loads of experience there. And we had an in house lab there as well. So I was always popping in with a technician and we had a CDT there. So yeah, it’s just sort of really thrown into it. And I just like the amount of change you can get especially like completes I think I said on a post the other days, it’s a blank canvas, you’ve got a lot of control on what you can do. And yeah, I just find it enjoyable. I do all general dentistry, but my practice on Instagram is limited, removeable is at least.

[Jaz]
Man, your passion just shines through. And I love hearing people’s origin story. Because a lot of people, a lot of dentist ask how do I know what my niche is? How do I know what kind dentistry I want to sort of niche down into it? And I love your story that hey, you had an influential tutor in dental school. And then you were in, you happen to fall into a practice whereby there had this contract with sedation, and you were seeing tons and tons of removal prosth, which obviously just fueled your passion more and more.

And now you’re in a situation where you’re really taking wonderful photographs and these brilliant cases. And listen, today is all about suction lower dentures, right? Because lower dentures are the bane of all dentists. And it all came about because recently on my Instagram, I posted one of my few cases I have where I managed to achieve suction on a lower full or lower complete denture. And in the comments on someone there and said, bring Rupert on I think that’s how it went. I was like yes, totally this this sounds amazing. So I’m happy to have you on and I had Mark Bishop on, we talked about all things complete dentures. Then I had Fin about Chrome dentures. So I’m being a bit harsh to you. I’m giving you the most difficult thing to discuss in removal prosth, but let’s go with it.

So the first question I have is, how do you know which case you have a chance? Right? When do you know Okay, you know what, I’ve got a chance, or do you always have a chance? Or are there some situations where maybe you want to throw in the outward classification something that you think you know what it is impossible to get a suction lower denture. Give us a flavor of that.

[Rupert]
I wouldn’t want to ruin the episode straight at the start and everyone logs off. But I don’t think you can know, as you say, like outright, this one’s going to be great. This one isn’t. Because I’ve seen like the full range I’ve got a couple of videos on my page was probably ones that you’ve seen or people have asked to see. And the one chap he’s got the most beautiful ridges, big wide awesome ridges, great upper no suction and then I’ve got a lady’s got these non-existent inverted and it’s got suction as well. And so you’ve got the two extremes and you get it but I don’t think you can ever know for certain. But as you say, I think you can achieve it with any ridge you just got to sort of back yourself and go through with it.

[Jaz]
So, Rupert, what percentages do you think is luck? And what percentage do you think? It’s because I put it down to luck when I get it. I was lucky. I just got lucky. Right? But how much a skill on a different patient that might not work but on this patient, it did? Is that a fair question? I don’t know. You tell me.

[Rupert]
I think it’s 50-50 to get it [where you don’t isn’t it?] So now I think you’ve got to do everything the same all the way, that each time you do it. And then it’s sort of it’s going to even itself out over the course of it. But I’ve had patients where they’ve come in and thought oh this is going to be an awesome good chances suction here and I’ve text my technician with the primary instance they are they made this going to be a good one. And we haven’t quite been able to get it. But I think actually though it comes down to is suction actually important to what is going to make it a successful treatment for the patient as I’ve never had a patient come and say I really want a suction lower denture, please. They’re gone. My lower denture is not that great. I want to make a new one. So it’s great to have but I don’t think it’s not the be all and end all. I think a supportive denture is probably better, because then you’re more likely to get that stability, which is what they really need.

[Jaz]
Brilliant. And by supported you mean, like some implants. So Implant Supported dentures, you mean?

[Rupert]
Just supportive in terms of that would be if you go right back to my third year tutor, and you’re saying he had the stability triangle. So your stability is your balance of your support and your retention, resistance away from the tissue support, resistance towards the tissues. So particularly for the lower gravity is helping you I think issues that patients have is when they’re biting and there isn’t that much support, and it brux it displaces you’ve lost the stability. And no matter how much suction or retention you have, if you’ve got rubbish support, you’re going to lose your retention anyway. Because it’s not going to be able to overpower that see soaring or whatever it is. So I think actually, I personally, I don’t focus on getting retention, I focus on getting support, because I think I know 9 times out of 10. If I make a really nice supportive denture, it’s going to be better than what they walked in with to see me at the consultation.

[Jaz]
Make that really tangible, Rupert, like what do you mean, how can I make a- Because I test for retention, I test for stability. But there’s a poor concept to me is yes, we read about and stuff, but it’s not something I looked at denture. I thought, okay, how well is it supported? What do you mean by support? You mean, how well the lips and soft tissues rest over it? Or how well it just sits? Give me a bit more about the support and how we can improve the support of our dentures.

[Rupert]
Sure, I think your support in terms of finger resting on the side on the fives and sixes regions pressing down, is it resisting against it? Is it feel like it’s rocking? So let you see those little mini complete dentures where the flanges essentially like the width of the teeth, when you know they’ve got buccal shelves, they’ve got a lingual extension, because we all have that even when there’s that full resorption you might lose the height, but you’re still going to have the width of the mandible bone that’s not going to go anywhere, it’s going to shrink downwards, but not necessarily inwards. So I always look at seeing how far I can get it out towards the cheeks. Yeah, that’s then going to play into your support of the cheeks and the lips. Because we’re not just replacing the teeth, we’re replacing the bone, the hard tissue that’s been lost as well. So if you’ve got those kind of nice, extended flanges, posteriorly, you’re going to have a much better support and it’s not going to move around. And that’s going to improve that stability, which is actually what the patient means when I don’t have a tight fitting denture or at least that’s what I think.

[Jaz]
Brilliant. That really helps. There have been some times in the past especially the DCT. I made loads complete dentures back then. And sometimes I had overextended and if that’s the right word so basically in the lower molar region of my complete denture, I had gone too far buccal or too far towards the cheek. So how can we how can I minimize that problem? And how do you know where your special tray should end in a buccal direction in terms of how far does the periphery go in terms of the buccally if that makes sense towards the cheek is that only landmarks are used to draw that out.

[Rupert]
I wouldn’t definitely say [Lamaze], I think your frenal attachments are going to help you because obviously there’s not going to be a massive extension beyond the frenal attachment. So you can be a little bit realistic there. I think I always deliberately try and overextend the primary impression, one to make sure I get all the landmarks that are going to help me so if you want to get support all or even retention, if you’re looking at retention, you want compressible tissues, posteriorly your retromolar pads, you want to get the buccal shelves, you want to get a lingual extension. So you want to make sure you get all that in your primary impression anyway, so I do try and overextend it, and then I look at trying in my tray, making sure actually there is a free bit of sulcus around it that we can work into. So when we do a functional border molding impression, we’re going to have the suitable thickness of material there. And we’re not overextending it so if you’ve tried to try-in and it’s absolutely cutting into the cheeks and yet the patients have wrapped the lips around and it’s knocking your you can feel it moving around you know you’ve overextended that.

[Jaz]
Awesome that helps. So I think next is find out step by step. Okay, just talk us through, obviously, you can you can go on three, four days teaching about this. There’s not some you can learn a podcast episode, let’s just give a flavor. Just give us some step by step some things that you think have been instrumental in helping you to get better supported, better retentive, better stability from your dentures. Lower dentures.

[Rupert]
Just stick to the lowers and yeah, so I think first off, like assess the patient fully. I think Mark covered it really well in his episode, it’s like it’s not just a treatment plan about lower complete denture. Have a good look at the patient. Have a look at what do your ridges look like? Is it really flat? Is it nice and wide and thick? Is there a bony undercut? Does the patient have a large tongue? Have they not had a lower denture and the tongues and floor the mouth has expanded in and things like that, look at those landmarks that you’re going to get. I was looking at what the patient has already what their denture is, like, if they’ve got one of those little tiny dentures or thing, happy days, I’m probably going to be able to improve this if they’ve got one with really nice looking flanges or start to get a little bit worried. And assess other things, what’s their saliva like? Because if they’ve got bone dry mouth, you’re not going to get anything there. You need that from [filmer] saliva. And I think you need to assess how good the patient is at wearing dentures as well. Now, I had a lady recently, just when we came back from lockdown, and she came in and she was a full denture wearer and she’d been wearing for 40 years, and she just went, ‘I just want something that looks nicer.’ And I thought happy days because Ricardo will sort that for me. And she had no bone at all. And her lower denture when I was asserting, it was absolutely swimming around all over the place. And I was like, ‘how are you with that?’ And she was absolutely fine. She’s one of those. I like to use that analogy, like riding a bike, when you’re riding a bike, you’re super stable, but one legs going out one legs going down. But you’re super balanced, and you’re fine with it. And she was riding the bike, this denture is moving everywhere, but she was absolutely fine. So if you’ve got a patient like that, happy days, you might improve it, but it’s not really the end of the world to them.

[Jaz]
I mean, that patient has a superior neuromuscular adaptation, right? That patient is a good denture wearer it’s like you said, so these patients are kind of sometimes, don’t never get complacent, but they kind of home runs where they’ve got this crappy denture and they are wearing it. And those are ones that I like to take on. And when it’s not that criteria, I like to refer them to you.

[Rupert]
I’m only down the roads, you know where to find me if you want to.

[Jaz]
Absolutely.
[Rupert]
Yeah. So I think those I think those ones are as you say they can be the homerun, I think the toughest ones are patients that are transitioning like perio patients transitioning maybe from a partial to a complete or like [add a chat,] the ones that I’ve been sharing recently, the fancy signature ones where he’d actually never been wearing a denture yet a really bad gag reflex. He’d never worn dentures, but he’s been edentulous for 10 years. And that’s like, you’re saying, you’ve really you’ve got to learn this, like it’s a skill. And I use that riding a bike analogy. And I think they sort of get that. Those are the tough cases. And especially in a media when they’re not everywhere, and their lips are pushing it all out already, because they can’t move them. I think those are the challenges. We’re the ones where they’ve happily worn for 45 years and the expert denture wearers, happy days.

[Jaz]
Sweet. So you talked about the patient profile, like what you just said, you talk about your primary impressions where you’re trying to get overextended on purpose. Let’s move on to maybe some pearls in the special tray, because that’s really such a key appointment to get your final impression. You mentioned greenstick. And I didn’t think that you mentioned border molding. But my question now is, can you describe your technique for border molding? Do you use green stick?

[Rupert]
Yeah, so one little thing that I didn’t mention earlier on the on the primaries as well, I think just use putty. Don’t just stick alginate in there, because you’re not going to get that retraction of the tissues. You mentioned green sticks and stuff there as well for your secondaries. You want to make sure you’re attracting those tissues, because you’re not going to get the buccal shelves, you’re not going to get it back to the retromolar pad and you’re going to end up with that, that tooth wide denture again. And the secondaries, I don’t use green stick, I just don’t like using it. It’s just really fiddly. I prefer using putty, but actually do my secondaries in a three stage impression. So I do the first stage might be a little bit different to what sort of people do so I’ve deliberately overextended not massively, but overextended. So I know where the frenal attachments are so recorded and cut them back. And then what I’m doing is I’m placing that tray in and checking it, seeing that I can see that I’ve got my two to three millimeters of free sulcus. And then what I do is I take a little bit of putty, and for a lower, I’m going to do three balls of putty in the tray. So I’ll do one each side in that sort of buccal shelf retromolar pad area and I’ll do one in the incisal. Place the tray in, get just patient relax, place the tray and check that I can see all the way around my three millimeters of buccal sulcus and just leave it there for it to set. Once that sort of half set or mostly set you can take that out because it’s just as a guide. But what it means then is every time I place it back in, I know I can push down and I’m not going to push it too far in and overextend it. And also it means that every time I put it in for the other two impressions, it’s locating in the same spot every time.

[Jaz]
That is awesome. And that is a fantastic pearl. I’ve never thought through that for so I’ve definitely learned something there. I’m going to write that down. That is a beauty right there. So what next, so you got your putty balls, you’ve got like a triangle, something that’s quite stable, like you said, and you can visualize that three millimeters which is genius. What next?

[Rupert]
So next I’ll do my border molding, I’ll do the main body of it again in putty. So you could do green stick. If you want to do green stick, like Happy Days go for it. I just prefer the sort of the feel and use of putty. So I’ll do putty around the edges, get my good border molding. So then I know that when I placed this in, and the putty’s got that thickness of three millimeters, placed it in, get a functional impression going, and I personally do it completely patient driven. I don’t like doing lip pulling or anything like that. I think that distorts your sulcus shape. If you pull a lip, you’re going to have the muscle being long and thin, whereas a muscle in function actually is shortening and fattening. So it will make it’s probably only a marginal gains thing that your sulcus shape is going to be slightly different. So I’ll place that in my receipts or my soft tissue stops or stopping it from overextending, then wrapping the lips around the ooze, the eeze opening wide, obviously for a lower moving the tongue around left and right forwards and backwards, and then they’re compressing and pushing that back up. So then hopefully we’ve got exactly the functional depth of the sulcus rather than just the static depth of the sulcus. And I think it’s really important with if you’re doing that kind of patient driven border molding that you’re really I really get into it, me and my nurse end up probably doing it under our masks as well. But you sort of really hype them up and explain how important is and you say, well, you know, if you don’t do this properly for me, every time we try and say all look at that your denture is going to pop out because your lips are pushing it up. So and really getting to exaggerate it and you can have a bit of fun with it really and patients quite end up laughing half the time which is quite good because most people hate impressions and things.

[Jaz]
That is great. And I think it’s so important to know these things that you say so ooze, the ease to get that sort of functional movement of the muscles. My favorite thing learning as a DCT from Professor Mike Phelan, are you familiar with the Professor Phelan?

[Rupert]
Hm-mm.

[Jaz]
So he is fantastic Irish accent I don’t know if I’ve said this episode before, but he’d say to patients smile like a politician, pout like a supermodel and all these things are just patients love that and it’s a great thing to make them laugh and stuff. So I think you definitely got the right idea. They’re brilliant. So you’ve done that with more putty now. You mentioned my green stick I don’t like using it. Have you used pink stick before?

[Rupert]
I haven’t. Talk to me about pink stick.

[Jaz]
Pink stick is like green sticks like sexier cousin like it’s so good. Like I used it at Guy’s are still ones because my consultant then [sarutobi a poor] our little hack was green stick is rubbish. Don’t use it use pink stick. It was so much better to handle and I never I don’t know what to order from I never order it again. I don’t do enough dentures. But check out pink stick. Let me know what you think might be cool to see what you think of pink stick but pink stick was- Please do let me know what you think, man. But cool. So you’re using putty in that way. You’ve now done your initial three balls, you’ve done your function, the ooze and ease, you made the patient laugh, you’ve made something out of it. What’s the what’s the secret sauce?

[Rupert]
And then the third stage, either I’ll use a light body and medium body, you can use an alginate. Again, if you like it’s just getting that fine detail. But I prefer using a silicon. So because what I think is if you use in the silicon, place that over wash impression style, and then exactly the same border molding again, hopefully you’ll get lice little sort of strips of light body around the frenal attachments, you’ll see it just about wrapping around. But again, yes, I placed it in mainly for lower, it’s going to be get the tongue up first so that you’re not trapping that and you’re sitting it down nicely. And I think if you have the tongue up and out of the way, first, you’re not going to, if you’re dragging that impression down against the tongue, you might be pressing material away and you won’t get the full depth lingually that you might be able to. So again to roll the tongue right back, push it forwards, left and right as far as they can get into press into the tray as well activate the anterior sort of floor of the mouth. And then you’re squeezing the lips doing your palate as you say, say in ooze, cheesy grins and E’s opening while wiggling the jaw left and right. That’s more for the other really get the coronoid processes and things like that. But then, light bodies like that, and the way the reason I like the silicon is actually I can take it out, put it back in, and I can assess almost straightaway. How reliable that suction is because I think you can do an impression if you put a load of alginate in there and there’s loads of saliva trapped and it comes out and it makes a lovely substance only thing happy days. But actually it might have been that it was just stuck in an undercut or whatever it is. But if you’ve you can repeatedly put that tray in two or three times. And you know that’s a reliable repeatable suction.

[Jaz]
Any concerns about any bony undercuts, is there anything we should be doing with the significant bony undercuts?

[Rupert]
Yeah, I think undercuts, I’ve not actually made a complete yet with sort of big mandibular tori or anything like that, that you obviously want to avoid them because they’re going to be sore particularly tori [but] the gingiva is so thin there anyway. So again, that sort of try and capture them in that primary impression. Make sure your technicians aware that you want to avoid those and get the tray if you’ve almost got to sort of do deliberately get it a bit wrong in the primary to be able to get it right in the secondary that you want to be avoiding that. Really because it’s going to just cause you a nightmare in terms of where you’re going to end up with extending it and you’re going to end up cutting about loads when it’s rubbing and it’s all like that they have not actually had that’s probably like the one sort of thing that I haven’t had yet for a load of I need to get so if you see one send it send it to me.

[Jaz]
You’re going to hate me, man. This is cool. I like what is going so you really described quite beautifully the impression stage I think loads of people are driving right now chopping onions running, and then next lower denture they’re going to be like impressions days that yes, I’m going to do exactly how Rupert described it. Because I think you described it really clearly. What are the other in regards to go exhaustively into other appointments, but just a few pertinent points in terms of what you think is important to getting a good lower complete denture?

[Rupert]
Yeah, so obviously, like you’ve done some good [imps] you’re going to do your read your appointment, gold standard, you want to do on an acrylic base, rarely one, if you’re doing that off your secondary impression, then you’re going to know pretty well how good your secondary impression is. And if you want to, you can always then rely on that if you concern light body so a whenever you want to do but also obviously having an acrylic base, it’s going to make it more stable, you’re going to get a more accurate registration. I think the best thing if you want to talk about the reg and stuff is go and listen to the other complete denture Episode [promarkers.] I think you nailed that. really well. Look at previous photos. I’m not sure if Finlay mentioned it in his episode, because it wasn’t really on a clip but he’s a big advocate obviously of photos from before. The classic class two patient palatal class two you may come class one for a complete and their lower denture keep pinging out because their lip is pushing it backwards because you’ve massively invaded the neutral zone. Check those kinds of things, if you can, that’s where like the photos are really, really good. If you see someone is a bond or palatal class two make sure that you’ve adjusted your rooms suitably and appropriately. And wax try in, there’s not really I wouldn’t say there’s much special stuff there. I think what I try, I try and avoid if the patient thinks it’s overextended in wax, I will say just bear with me and let me process it because I’d rather polish off in acrylic than accidentally lump off a massive bit of wax. I don’t know if he’s sort of agree with that. But I think sort of I’d rather have the control of a straight bur rather than sitting there with a wax knife and accidentally take off half the flange that I’ve worked so hard raising the tongue and doing an Rm 4.

[Jaz]
100%. I don’t want to see my wax work. I think that was my stressful moments. As always with a wax knife in hand, a Bunsen burner, and just a mess of wax on my nerves just looking at me like what the hell is he doing? So definitely share that sentiment. I think it’s good to tell the patient in that way. So really the wax try-in for you is more aesthetics and phonetics?

[Rupert]
Yeah, 100% I think, especially with sort of more of the cases that I’m doing sharing now is obviously there’s quite a high aesthetic component in them, or at least for me and my technician, we’re pushing the aesthetic side and patients don’t always appreciate their lovely for [an iris to] teeth and things but we do and but yeah, we’ve had a few cases recently with old photos and things like that, which are really fun to do. So it’s more checking that and, and yet again, you can get an acrylic base inside your wax try-in if you want to again, assess that stability, support, retention, whichever you want to sort of worry about the other one,[the orchestra] in Germany is my favorite appointment. You’re really anxious about it first, because you think it could all go terribly wrong. But generally, it’s like the easiest appointment there. Yeah, and if you’re a little bit worried again, just like if you’re feeling like your wax try-in particular, if you haven’t got an acrylic base, if you’re thinking it’s not feeling that stable, I’ll always just again, just put in a bit of light body seated in reborder mold, and at least then it’s going to be even if it’s just the fact that it’s in wax, and it’s not retentive, because it’s wax rather than acrylic. That’s just going to make it stable gives the patient confidence. If you send it back in and your technician looks at and goes, No, it’s fine. It fits fine. It’s not a problem. They can just peel it off. If they think oh actually that might be quite good. I’ll recast that and, and use it almost like a reline impression, then you’ve not lost anything. So I think that’s a little thing that I sometimes do at the wax try-in.

[Jaz]
That’s not a little thing that’s a massive thing, that is a huge gem. So usually I just maybe put some fixative in or something but the light body it’s just a genius idea because not only are you improving the situation then and there but then your technician might find that information useful. So that is a huge pearl. Really appreciate that. So use light body, that is wicked. Do I was just I was thinking the story. I remembered a patient I saw a guy’s hostel. And he’d had, he’s not a great denture wearer. He’s about 85. And he’s on his fifth complete denture in last six years, so you know where it’s going. The ridges looked okay. And it fell upon me as a DCT to inherit this case. So I started making these complete dentures and I got to the wax try-in stage on that day, my assistant just wasn’t around. So I was by myself, right And the patient goes to me, I wish there was a way that I can test if there’s going to be good. I know I want to eat something. And I thought to myself, is this [kosher?] I mean, can the patient try and eat something now? And you know, lo and behold, his [Kara] and him they had a peanut butter sandwich. So on his wax try-in upper lower wax try-in complete dentures, he started to eat this peanut butter sandwich. Do you know this is a good way of assessing anything? Or that’s an absolute waste of time, because I felt was a massive waste of time. And it probably just went back with like peanut butter residue back to the lab. But at the time, let’s give it a go. Why not?

[Rupert]
Yeah, I think I mean, Ricardo gets a bit touchy, if I let the patient bite down a little bit too hard, and the teeth have moved a fraction. So I think he’d kill me if I did that. I think the problem is with wax, unless you’ve got it like a processed acrylic base, the fits never going to be as you and I always say that before. Before I’ve even taken out the box for the workshops, I look, this is wax, it’s not going to be great. It’s not isn’t going to fit way, way tighter when it’s plastic, the saliva doesn’t work the same. And so I think if they’re worried and it could be a stability thing, I get a do a little cotton roll, pop it in one side, give a little bit of a bite, a little bit of a bite. Because then they’re not going to be really crunching through. It’s more just again, just testing that sort of support and stability. And I think if I sent Ricardo a peanut butter covered completely, he’d probably not work with me ever again. I need a new technician.

[Jaz]
Okay, I remember had flashbacks. But yeah, nothing I don’t advise. But for sure. I thought you’d agree with me in that sense, as well as a stupid thing to do. But hey, it’s something I did back when it could become the story at the wax try-in stage. What if you? Are you really thoroughly checking the occlusion? Because, like, are you checking for any interferences to centric relation, because at that stage, in the past, I have sort of just heated up my wax knife made some of the teeth, or the wax underneath the teeth a bit loose and get them to bite again, sort of intrude that tooth? Is that something you’re doing? Or do you do tend not to also mess with the occlusion until you get to? Unless is way off? Or how do you manage that?

[Rupert]
Yeah, I think the main thing I do try and do with wax try-in is I pop them in and just try and instantly start talking to the patient about something else and just let them sit with them in for four or five, six minutes. annoying, I’ve got a really big mirror in my main surgery that I work in. And I try and deliberately stand in front of it. So they can’t spend any time looking at it. Yeah, and just literally let this sit there and let them wear them for three or four minutes. And then see what they think obviously, if they’re falling straight out and you need to that little, light body, reline on them do that. But I try not ask too many questions or think about it too much. I’ve got the luxury of [ABS] I’m doing it all privately. So I’ve got loads and loads of time for my wax try-in and things I’m not squeezing in a 15 minute wax try but I think just let it sit and settle there for a little while. And then just ask them how does it feel? Is it comfortable? As you know, do you got the OBD right and I think have a good look at it. And yeah, if there’s an obvious point then absolutely, I’d do exactly the same as you hate the wax knife but sort of get it underneath allow them to then intruded themselves into a position that feels more comfortable. I think the main thing though, is photos and full face photos for wax try and even things it’s like a slight midline shift. But we had a case that we did and I needed like a nose to chin one. And Ricardo was fuming because he wanted some eyes in there to be able to because we felt the midline was slightly off and he managed to fix it because he’s that good but take photos of your wax try. Take photos of your wax rim with your midline because again I had as a window impression as you post about it as a window impression case I did and I drawn the line and you’re not going to like mount the patient and sit exactly in the middle of them I do I do it from the left or the patient’s right and align round and I’d done the midline and a slight angle probably five degrees or something when I looked at the photo when all that’s obviously wrong and center to recall we have everything in a Dropbox and things like that and we’ve got a full face photo and you can see that the top of the line is exactly right where the nose is and then it comes off to the side like that and he was able to just to adjust it and then it’s absolutely fine. So I think that’s the thing as well that take photos of everything. Wax rim, take photos of that in the mouth, and you can check your smile line you can check your interpapillary you can share your ala-tragal if you want to confirm the photos, I think even if you did a I’m doing a presentation. Middle of February for some undergraduates and I realized I don’t actually have any I didn’t have at the time anyway, any bite plane pictures of the patients. I just took them on a nurse and she was a little bit sort of class three. And at the time I took this side on for ala-tragal and it looked great. And then I put it in Keynote to do the slides and I drew the line ala-tragal, duplicated the line for the angle and dragged it down and she was off by 10 degrees and I was like oh I would probably would have thought that looked fine, actually. And I might have I done that with some cases. So that was a big thing for me is that I’m going to start taking the side on photos and confirming these things on keynote with no, either with Ricardo later, or I might even start doing in surgery. But yeah, I think lots of photos, because you can rescue a lot of things. But I try not to change too much or wax try-in. Going back to the original question.

[Jaz]
No, and that’s great. And to two main takeaways is take the full face photos because they’re so valuable. And also find your Ricardo. Everyone should have a Ricardo. It sounds great, man. He sounds like he in a banter way. But he pushes you and he gets you to do things in a certain way. Thank you, you guys be used to feed off each other. And you guys are both very passionate. So find your Ricardo. And at the end, you can tell us how you can find someone like that. But yeah,

[Rupert]
Yeah, we’re both as [sad] as each other. Really. I think that’s the thing. And he makes me look good. So definitely find yourself a Ricardo, but not mine, because he’ll get too busy.

[Jaz]
Shoutout to Ricardo but please don’t use Ricardo, or we might not see as many.

[Rupert]
Shoutout to the VRdentstudio.

[Jaz]
Due to the shattered population.

[Rupert]
I tagged him in everything. So VRdentstudio, I tagged him in every single post. So yeah.

[Jaz]
well, that’s very good of you. Because there’s some dentists there who post these beautiful veneers and stuff. And they don’t credit the technician where they’ve taken a monoblock patient to these beautiful tranluscencies, but it’s actually the ceramist, who’s on all the work or the or the complete denture cases. So it’s very good of you to shout out your technician, every case that you do, that’s amazing.

[Rupert]
100% I mean, we built up a really good relationship, and our cases wouldn’t be as good if it wasn’t with his work, as we sort of push each other, we understand each other. And it’s just about building that relationship. I think that’s the kind of thing with these kinds of cases is about consistency. It’s like consistency with how you take your impressions consistently, how you assess the case, what you ask for, with your lab work, and not with your technician. And it’s difficult when maybe you’re in NHS or in a mixed practice, and you send it to that lab. And it’s, you know, it’s a corporate lab with 20 technicians in it and you don’t know who’s getting it and you get one thing back from one person or one thing back from another and they never read the doc here, that person, it’s coming back from them because they’ve done the wrong thing or, and so I think even if you’re doing it, sending it to a lab like that, try and get to know someone there and because there will be one technician there that wants it. And it might be that, all the all the great technicians will probably work in a place like that at some point. So chances are, there’s probably a great technician in the making there and find them and go along for the ride with them. Rather than I’ve just sort of piggybacked on Ricardo when he’s already been smashing it, there’s always a chance you might find that person and work together and grow the I think Finlay covered that, didn’t he with sort of what he was doing.

[Jaz]
That’s it, he said, find someone roughly the same age as you and grow together. And I think you’ve given a good tip there. But even if you’re sending it to a corporate lab, like visit that lab, if you can and find that one guy who might be that dark horse that you know you’ve never met before you seen their name on the on the sheet before now you get say hello to them and say would you like to buddy up with me, we can do cases together and in only if you see that fire in their belly, and a twinkle in their eye that you can start saying, you send it to a corporate lab, but 123 but FAO, whatever their name is, and then you sort of you know, or that case will always go to them and build that relationship which is awesome. Someday we’ll cover that as well. So now on to the fit appointment, my friend, onto fit appointment, talk us through your workflow, like I know some dentists will try it in and see how it goes. Some dentists will straight away put on what’s that green stuff by coating the pressure spot indicator that straight away before they actually get the patient try and what’s your what’s your protocol?

[Rupert]
Yeah, I just similar to the wax trying-in, just pop them in. And again, try and instantly start talking about something else or not even thinking about it, like make it really matter of fact thing, we’re going to pop these dentures in happy days. See how they feel? I mean, I try and even not adjust them at all on the day if I can. Unless and this is an obvious sore spot. It’s definitely digging in somewhere or there’s an undercut that we’ve slightly gone into or something like that, then then obviously I’ll adjust that. But I think with these cases and we said keep saying about the little tiny denture with the non-existent flange realistically, I’m probably making something a lot bigger. And I’ve already said that to them appointment one, I think it’s really really important in that assessment appointment that you manage those expectations straight up. It’s going to be bigger, it’s going to take you some time to get used to you’ve got to retrain the muscles it’s going to rub, I use this like fit appointments all about like a shoe analogy. Yeah, even if I’m doing these super fancy signature characterized dentures, you say well, no matter how expensive pair of shoes They’ve always given me a blister, it’s going to take time to break in my 300 pound pair of churches or my 10 pound prime up pumps, you know, they’re going to rub either way. So give them a little bit of a chance. And it’s a new set of trainers, you’re not going to run a marathon on day one, you’re going to go for a walk around the block first aware around the house, you’re not going to head out and do a 42k straight off the bat, you’ve got to give them a little bit of time. And yeah, for those ones, where they’ve had a teeny tiny denture before, I sort of say, well, let me make it gold standard, or let me make it as textbook as I can give it a week, give it two weeks. And if we have to compromise, that’s absolutely fine. We can adjust it then. But then it’s a bit like the wax trying thing, I can trim it off, it’s a whole lot harder to make a flange longer after I’ve made it, I’d rather cut it back then, try and add it on again, that’s because that’s just not going to happen. So yeah, just try and get it in as best as I can. And if there’s an obvious, you know, source for Sunday’s polishing, then then fine, but I try not to touch it too much. Because you can sort of say, well, we’ve made it as, as potentially as good as it’s going to be textbook or whatever that is, and you sort of, it’s all about feeding that in throughout the entire process. And that’s where, again, having a technician that you know that they have accountability. Ricardo is mentioned in my first appointment, I mentioned by name because we’re going to do photos of everything, the pre op, full face photos at the first appointment, and you sort of you build in how much work you’re doing. And I think the way that I do them probably like your chat with five dentures, I doubt the other five dentures were made in the same way. So they sort of go Oh, there is a process here. Like, get behind that let’s do what he says let’s give it let’s give it a week. Two week review. And they believe in it more I think site like psychology is really really important in, in denture wearers.

[Jaz]
What percentage of your patients when they come back to you a week or two weeks afterwards will have an ulcer at the flange area?

[Rupert]
Probably about 20-30%. Usually lingually because I tend to really, really go for it lingually because that’s like, that’s a gimme, there’s loads and loads of sulcus steps there. And mostly that never ever had a denture there before. She said, it’s, he say the shoes again, you say it’s not only your new set of shoes, but you’ve never had a shoe that long before it’s going to rub. It’s going to rub in a different place. You know? I’d say probably about the 30%. Maybe.

[Jaz]
That’s remarkable. I mean, how many dentures? I mean, do you have you ever done a denture and maybe I’m sounding stupid here but were you have given the final dentures, they’ve gone away and they come back, everything’s fine. And you don’t need to adjust anything. For me. I just can’t imagine that ever happening. But maybe you’re going to prove me wrong.

[Rupert]
I mean, I’ve had two in the last three months that haven’t seen for review, because they just cancelled it and never came back. I’m hoping that’s a good thing. Because they’re happy. Yeah, we’ve been like in touch with one guy was work, work related COVID at work and things like that. So he’s been in touch. He’s like, No, I’m fine. I don’t need to come back. And yeah, a lot of the time they’ll will come back for a chat anyway. And I’ll say that I want to see them or do some more photos. Maybe particularly, it’s like an immediate.

[Jaz]
The review aka the photoshoot.

[Rupert]
Yeah, that more or less, that’s what the review is most of the time. Yeah. So quite often, actually. It might just be that it’s a slight Polish or they found at one specific movement. Maybe there’s a slight interference somewhere. And it’s just a little occlusal adjustment or something. But I’d say generally, probably about 30% need something doing but most of the time, they’re quite happy.

[Jaz]
That sounds crazy. That’s like witchcraft to me. So wow, that’s very impressive. Totally. That is wow, just remarkable. Tell us about when you have been able to achieve a suction lower denture? Is it obvious at that appointment? Or have they sometimes gone away with? You haven’t got that suction when they come back for review but they now have that section after review. Well, how does it happen usually?

[Rupert]
I mean that the I think the two videos that I’ve got on they are day of fit videos are literally just pop in here, the squelch say sit there for two minutes, give them a little squeeze together for me. And I think that’s really important. They don’t just pop it in and expect it to be suctioned straightaway. You’ve got to let it bed a little bit. So yeah, both of those they were straight in. But yeah, I’ve had a couple where one of the chaps that the guy who had the COVID cases work and didn’t come back that oh, the bottom one feels so much better. Now it’s fitting really nicely. And this is the child who’d never worn any dentures at all before. Then he had a massive tongue to be fair, which probably helps sort of keep it support it and balance it. Yeah, I think you can definitely learn to adapt the muscles because it’s more again about that stability and not displacing it. Learning to ride that bike not displacing or knocking it out which is going to interfere with having a continuous maintain suction but generally If you pop it down you and you hear a squelch, then happy days you’re probably going to be alright.

[Jaz]
Now for us normal dentist not at your level, Rupert, with complete dentures. One tip I want to give to the more average dentist at removable prosth. Is that one of the piece of advice that was given to me by [Linden Cabo] I think as a professor or doctor, Dr. Linden Cabo, he told me that sometimes as dentists when we give complete dentures, just have patients, we attempt to, we’re so tempted to do something, pick up the handpiece, do some adjustments, whatever, just let them go home with it’s like you do. And then sometimes they just need more time until the situation improves, and improves, improves and you haven’t done a thing and then suddenly, they’re able to keep it in. So sometimes they just need some more time. Is that a fair thing to say?

[Rupert]
Absolutely, that we said it before that muscular control that’s really, really important, especially for lower, that the upper, you’re going to, you can get that suction cup effect, and then you’ll be fine. But the lower you need some element of skill to maintain it, and even [seeds] and that you’ve got this, you heard the [swells,] right? And they go, yeah, and you say, well, it’s going to be lost because your tongues flapping around all over the place. And you’re constantly pressing it and moving it, you’ve got to learn that you’re sort of subconsciously realize that seal is wearing off, and oh, I just need to bite it down, or I need to press rest my tongue over the top of it. And actually, it’s that rather than thinking that you’re going to pop it down, it’s going to sit there quite happily forever not move is a no, no, you’ve got to keep updating that seal that suction, you’ve got to keep pressing it back down with the teeth. But you’ll get used to that you won’t have to think about that in a week, two weeks. And that’s where you get the improvement over time is that they’ve just been learning subconsciously. They’re not thinking about the fact that it’s got, it’s losing the seal, and it’s getting loose. They’re just biting it down. And that’s it. No, that’s definitely right. As long as they’re just trying send them off. Unless there’s a glaringly [obvious fit], that’s occlusally wrong, or definitely you got a flange wrong, and you haven’t got the extension right, adjust that. But if it feels pretty comfortable, and they’re good to go, I’ll just try and send them out the doors as well as you can.

[Jaz]
Amazing. Well, before we go, I want to ask about some of the educational stuff that you’re putting on. But before we get to that last question, because we can’t do an episode on protrusive, without talking about the occlusion. Just tell us about the fit appointment, and maybe the review, what’s the most common thing that you might do for the occlusion? I mean, do you actively look this BULL rule, buccal on the upper and lingual of the lower do try and do that, give us a bit of a minute or so on the recipe for success with occlusion. With dentures.

[Rupert]
Obviously, you’ve taken that from your reg appointment, make sure you’re getting your simple things, right, you’re ala-tragal plane, you’ve got it, getting a nice lower lip line and the things that that so that everything is where it should be and you’re not making the patient work harder than they should, in terms of the fact that the angles off and they’re getting contact too early, or you’ve got this odd shape lower, that’s having to work with the sort of wrong occlusal plane of your upper, I think really, it’s about making sure they’re comfortable and get them in a protruded or position that feels comfortable for them. Make sure that they’re happy with it. And then make sure they’re not a blatant class two, or class three that you’ve missed. And just set them up. And I think as well, maybe it’s a NHS mindset of, for appointments, get it done, but I don’t mind doing three wax try-ins, four waxed try-ins to make sure I’ve got it 100%. And you say that to the patient, you say we’re going to do the first try-in, and even the fit appointment half the time, I might say, we’re going to try it in the plastic, or we might still want to make some changes. And a bit like, you can sort of set for crowns as well, we’ll try it in and we might need to, alter this little bit and send it back and like you would with maybe an implant crown. But I think yeah, like don’t be afraid to do another try-in, and make sure the patients are 100% happy as well. But I think you can sort of tell quite quickly occlusion wise, the worst is when you pop it in and you’ve suddenly got like a two unit midline shift. And they’ve got a complete [scissor] by on one side of saying you think what have I done here, but it’s just because suddenly they feel like they’ve got a denture in rather than a wax block is that they suddenly bite in a completely different place. And I’ve had that a couple of times, not like not quite that drastically, but where it is just a little bit off. I think, see, if you’re happy with the upper. Get set, make sure the upper set, right, I think Mark said in his the upper is the beauty, the lower is for the function, and, you know, I do a lot of taking the posteriors off the lower. If I’m happy with the effort the posterior is are 4, 5, 6 don’t put sevens on, don’t put sevens on completes because they’re just going to give you more problems. Take the 4, 5, 6 off, leave the incisors if you can, and potentially just rearrange them at that point because they’ve got an incisal. Hopefully the incisors then might go into the correct place. You can reg them then and just get them get your technician to reset it up there. If you completely off. Dig out your wax room. Hello waxaa and hopefully they haven’t destroyed it. But yeah, I think it’s Don’t be afraid of doing multiple waxed try-ins and build it into cost of private treatment or, yeah, and just again, be upfront about the whole thing, you know, be super upfront early on, because if you start making, if you start saying things are difficult at the white shrine, it’s an excuse, if you told them three appointments ago, or they go, Oh, you did say that, we might have to try in a few times. It’s all about just not being negative or pessimistic, but just being reasonable. and managing those expectations.

[Jaz]
Brilliant, because the communication is half the battle. Now, Rupert, as you know, with protrusive, I’m a massive promoter of education, and with people like you who just do so much for our dental Instagram community, and you post these beautiful cases, and I’m sure we get DMS all the time that hey, you know what, can you help me with this case? or How can I get photography like yours? or How can I get dentures like yours? I saw that you promoted a course recently. Please tell us about that. Because I know a load of the Protruserati, it will be interesting that so give us a flavor, man.

[Rupert]
Yeah. So we announced it was a couple of weeks ago. Now it’s Ricardo and myself. And we’ve teamed up with [Roger Thomas] I’m sure everyone will know who Roger is. Because actually, Roger was a big inspiration for me and how I do the secondary impressions I do. So I’ll see in some of the pictures that he was putting on. I know he’s got that name, sort of known for it on Instagram. But he’s got he takes some incredible impressions and made some amazing dentures. And I sort of looked at what he was doing and tried to reverse engineer it and experiment. And so we did his art of resin course, which is awesome. And we started talking about dentures there. And yeah, so we’re looking at running a course it’s called the art of completes. And the plan is that so it’s a two day course take you through start to finish with a live patient with Ricardo in the technical stuff in between as well, which try to cover that start to finish on how to get hopefully, a reliable suction things. I’m hoping I didn’t give too much away in the secondary impressions, chat that we did, otherwise, I might get it.

[Rupert]
But honestly, we really appreciate that. I think we really appreciate I think anyone listening should really appreciate that the level of detail that you’re going to give us so much there. But there are so many, many steps in gems, that it’s impossible to give out in a podcast episode, but you gave massive value there. So guys, if you like Rupert’s content support him in the course I have no doubt in the world would with yourself involved and Ricardo that’s going to be a highly educational really supportive course on something that just doesn’t get taught well enough. At dental school because of a lack of cases, we just don’t do enough cases. And before we start getting fancy, it’s about getting those foundations right, would you get are so good at covering.

[Rupert]
Yeah, no, I think I actually had someone write to me today saying that are there a recent graduate and they you know, they’re worried about x, y, and z and reorganizing the OBD into it, and I was just like, just like wind it, wind it back a sec. And just, I think prosth actually is quite not easy. But it’s, it’s has a few basic concepts. If you master those, and then sort of extrapolate them, you can work out more difficult cases, you know, think about balancing your support. Just think about those three basic things. And then you can do more challenging cases like big fibrous rich upper, we’re talking low as well, you know, big fibrous Ridge, that’s just that you got across your cross your Ridge, you’ve got an imbalance in the support. And if you just put one uniform piece of plastic there, it’s going to rock in rotate. So how can you get around that and that’s why I like his eyes problem solving. And it’s just yeah, working through things like that. But I think Yeah, work on the basics, and then that will open doors for yourself in doing more challenging things and talk to your technician as well. If you’ve had any cell saying about the occlusion and things like that, I want to do my normal copper answer on Instagram, which is my technician actually sorts most of it. So I asked him and he’ll be able to point you better because yeah, I think that’s probably asked their opinion and because it’s a team thing at the end of the day.

[Jaz]
Amazing. Rupert, thanks so much for bringing so much value on suction complete lower dentures. I hope everyone listening got a lot of value from that. I know I did. I picked up a few gems I wrote down so excited on my next lower denture, which might be a year away. As you can see, I don’t do that many. The next really crazy one I get is definitely coming your way. So thank you so much.

[Rupert]
Cheers, man. Thanks for having me on.

Jaz’s Outro:
Thank you Protruserati for listening all the way to the end. I hope that helped you to be more confident on lower complete dentures. Do check out Rupert’s work on Instagram it’s absolutely amazing. His Instagram handle his dentist Rupert do also follow at protrusive Dental if you’re not already, and just check out the quality of his photography, the quality of the treatments he does. He takes these fantastic portrait photos of before and after. And these dentures I tell you, they make these patients look about 20 years younger. So Rupert, keep up the amazing work you’re doing and I hope you’ll catch me in the next episode, which is Five things your technician wished you knew.