JOIN US on 16th November for Treatment Planning Symposium 2024 – Online Event OR In-Person – you decide!

Implants are great but they are not always the best solution for our patient.

There are many times a bridge or denture may serve the patient’s goals, aesthetics and budget better.

So how do we decide between bridges and dentures?

Is it acceptable to use root filled tooth as a bridge abutment?

Are single tooth posterior dentures risky? Or do patients love them?

How do we begin to communicate aspects of replacing teeth with our patients?

Join me with our guest Dr Michael Frazis as we discuss the art form of communication with our patients and some outlandish cases including roundhouse bridges. This will really help upskill you on dealing with patients with missing teeth.

Protrusive Dental Pearl: Failure is inevitable for our Dentistry, but try to set yourself up for smaller failures and not giant catastrophes! The real magic is in proper case selection. Practise at the EDGE of your comfort zone, but NOT out of your depth.

20% OFF Guaranteed on RipeGlobal Fellowship Programs + Free access to their portal – Click here to register for this! protrusive.co.uk/rg20

Follow Dr Michael Frazis on Instagram

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC LEARNING OUTCOMES: A and C

AGD Subject Code: 610 Fixed Prosthodontics

Dentists will be able to:

1. 
   
2. Demonstrate improved decision-making skills in treatment planning, particularly regarding non-implant tooth replacement options.
   
3. Apply communication strategies to better explain treatment options, manage patient expectations, and gain informed consent, especially in high-risk cases involving implants, bridges, or challenging restorations.
   
4. Recognize red flags and understanding the risks involved in specific dental procedures (such as implant failure or the use of root-filled teeth as abutments) and how to mitigate these risks through careful case selection and patient education.
   

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content. This includes videos on Overlay preps and the famous ‘Vertipreps for Plonkers’ series.

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

Highlights of this Episode:
00:01:37:00 Protrusive Dental Pearl
00:03:51:05 Introduction – Dr Michael Frazis
00:10:43:10 Growth in Dentistry
00:14:10:10 Non Implant Tooth Replacement Options
00:18:15:10 Treatment Planning Bridges and Dentures
00:24:35:10 Ideal Treatment vs Budget
00:30:15:10 Single Tooth Dentures
00:36:58:10 Thin Implants vs Bridges
00:39:25:10 Bridge Spans
00:49:20:10 Root Filled Teeth as Bridge Abutments
00:55:35:10 Failures
01:05:35:10 Wrapping Up – Contact Michael

If you liked this episode, check out PDP132 – Resin Bonded Bridges

Teaser: I'm doing that bridge 11 times out of 10. If they're a patient that has money to burn and they want their teeth to be individual, they want to be able to floss their teeth because that's just what they have as their goal. I will go crown implant- And I don't think we as dentists tell patients that. If there's something you can do as a clinician to mitigate that risk, could you use that word, tell them what it is. So to give you a concrete example, when I'm taking out a tooth, I will say-

Jaz’s Introduction:
Implants are awesome, but they’re not for everyone. Now this could be financial. This could be something to do with their medical history. And actually there are some scenarios where a bridge or a denture can be superior. And so many of these scenarios, we need to help the patient decide between a denture and a bridge. We’re going to do a deep dive into decision making and treatment planning when it comes to these modalities. I’m joined by Dr. Michael Frazis from Adelaide, Australia. He’s one of the educational directors for Ripe Global. And very soon he’ll be coming to our event in the UK to talk about treatment planning and failures which will be a live in person event and also a live stream.

In today’s episode, the real world questions we cover are ones like, is there ever a place for a single tooth posterior denture? Can you ever justify using a root filled tooth as a bridge abutment? And how big of a bridge is too big of a bridge? Is there ever a place for a roundhouse bridge? And generally bigger picture stuff. Implant considerations, denture and bridge considerations.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This one’s actually full of some great communication gems and one of them today is what I’d like to make the Protrusive Dental Pearl. To highlight the event we’re doing on the 16th of November on treatment planning and failures. I want to take this opportunity to pitch the notion that you’ve already heard before, which is failure is part of life.

It’s part of dentistry. All our dentistry will eventually fail. And sometimes you make poor decisions and we learn from them and they’re powerful teachers for us. And we experienced all sorts of different modes of failure. And every time we fail, we hope that we will learn and improve as clinicians. But I want to take this one step further by encouraging you that when you fail, try and fail as safe as possible.

And the way you can do that is case selection, but also just generally making sure that you are pushing your boundaries and challenging yourself, but make sure you are challenging yourself at the very edge of your comfort zone. You want to be at the edge of your comfort zone, but not to beyond your comfort zone because that fall from when you go too far beyond can be quite big and when you fail you can fail hard. Let me give you an example. If you’ve never done veneers before, please don’t pick a class 3 patient with crowding who’s got features of a high force bite and a high smile line. Do you get what I’m trying to say?

You’re setting yourself up to fail hard. And sometimes we take these cases on because we really want to do them, but I would encourage you, it’s good to challenge yourself. It’s good to be out of your comfort zone, but please don’t be out of your depth. Now, if you’d like to join the live stream and the 30 day replay of our Treatment Planning Symposium with Lincoln Harris and Michael Frazis, and my very clinical lecture and all the different failures and mistakes you can make in restorative dentistry.

Then please do head over to protrusive.co.uk/rx. The early bird rate is almost over and I don’t want you to miss out. It is an absolute steal at the moment. If you’re able to attend live and network, enjoy that magic of people. Then it’d be great to see you there. But if you can’t come to London, then do join us on the live stream and, or the 30 day replay.

One of the things we’re going to have is a live patient, unseen case. So Lincoln Harris will do like a live consultation on stage and we’re hoping to learn some communication skills, but he’s going to dissect that with us. So we get a better understanding of treatment planning in the real world. And sometimes by going through a case, that’s when we learn the most.

So please do head over to protrusive.co.uk/rx and pick the in person or the live stream pass, whatever suits you best. Now let’s join the main episode. I’ll catch you in the outro.

Main Episode:
Michael Frazis from Adelaide, I believe it is Australia. Welcome to the Protrusive Dental Podcast. How are you mate?

[Michael]
I am very well, Jaz. Thank you for having me.

[Jaz]
I’m really excited to talk about all things non implant replacement like the nitty gritty questions we usually have about, can I restore this with a denture? Can I do a bridge here? But also talk about the overarching theme of replacing teeth, but I just want to fanboy a little bit, man.

Your content that I see, your development that I’ve seen over the years, even back in the day we used to have this page, you should probably still have it, Everyday Dentistry with Michael Frazis. I’ve been following you for probably 10 years now, man. I love what you do, you bring great value to profession, and I’m so excited that you’ll be coming to London as well to share that passion live with us. So I guess I want a little bit of an origin story. How did you get into this sphere of making this educational content?

[Michael]
Well, I was actually making a completely unrelated webinar for some like dental students for next week. And it’s advice to my graduating self. And I’ve been looking through old photos that I’ve taken, back when I first graduated, and old videos that I took, like the first kind of videos that I was doing.

And they were just videos that I was putting on YouTube. They actually probably still are there. Where I was giving instructions to patients on what to do after an extraction or how to look after their teeth, like floss and all that kind of stuff. The stuff that dentists try to do online when they first get out there.

And it was so cringeworthy. I’m so glad that people actually stood by me through these 10 years of growth that I’ve had because I wasn’t looking at the camera. The words were mumbling. I had like the, like it was a 10 second millennial pause at the start of the video just to make sure the video was on, but I still uploaded it.

So weird. But the way that I started was I didn’t have a lot of confidence when I first graduated, mainly because I was told I was too confident and too cocky when I was in dental school, and it didn’t match my abilities. I had very low clinical abilities because I was a student, but I was overconfident.

And so the confidence was beat out of me, rightly so, to keep patients safe. But then what happened was I was very low confidence and very low competence. And so I graduated. I was like, well, I’m really bad at doing everything. And I don’t believe in myself. So time after time, I’d go to courses, I’ll do this, I’ll do that.

And then eventually. I stumbled on like courses with Lincoln Harris and he managed to instill confidence in myself again by just inviting me back to things because after you do one of his courses, if you’re okay enough, he’ll invite you back to help at other courses and then that slowly progressed into a professional relationship within the friendship that has then grown into all the things that I do now.

But I’ve basically done all these things because I realized that there’s that gap between the confidence that you have in yourself and the confidence that you need to create. And so I’m trying to instill confidence in other dentists and young graduates so that they can see that there is a pathway for them to achieve their dental dreams and achieve their goals in life through dentistry, basically.

[Jaz]
So the effect that Lincoln had on you, now you are spreading those vibes in your own style. Now, in your own way, I kind of saw you and I hope you don’t take offense by that. I’m sure you won’t because you’re good, but you’re great buds with Linc, but like, protege, right? I don’t know if you find that cringe worthy or whatever, but I think you know, I see it, but I know, you become your own brand, you become your own person, become your own educator.

And when I look at my sort of journey in education myself, one thing I look back is the taxonomy of learning, the hierarchy of learning, if you like, right? And you know very well that when you teach someone, like when you go on a course and you go back and you teach the other associates you’ve just gained. That’s how you really cement it.

That really pushes you as a learner and so that’s what attracted me to it always and some of the stuff they’re putting out there is absolutely golden. But can we learn about also you as a dentist you as a person tell us give us a little background. So those listening and watching around the world know a little bit more about Michael Frazis.

[Michael]
Yeah, so I was born in Australia. I migrated to Greece. My family was originally from there, so I was raised in Greece for the first three years of my life, then came back to Australia, then lived in Adelaide ever since. I went to school there, went to university there. Graduated and stuck around.

[Jaz]
You went to uni in Adelaide?

[Michael]
Yeah, I went to uni in Adelaide.

[Jaz]
In Australia, it’s like a cultural thing whereby, maybe it’s changed now, but maybe about 15 years ago when I was looking through this stuff, someone Australian told me that if you grew up in Melbourne, you go to uni in Melbourne. If you grew up in Sydney, you go to uni in Sydney. Was that the case? And is that still the case now?

[Michael]
It was and still is the case. The thing with a lot of the universities for dentistry in Australia is Adelaide was and is still one of the few that is an undergraduate course. A lot of the other ones changed to be a postgraduate course. So we had a lot of people from interstate coming to ours only because they just graduated.

They didn’t want to go and do like an engineering degree or a science degree and then go and do dentistry. So we had quite a few interstate people out of the class of 80. That was my year. People came and went in that 80. I think we had 17 that were from South Australia, from Adelaide. Everyone else was interstate or overseas. So the vast majority of people in my year were from interstate and overseas.

[Jaz]
Great. And tell us about you and your interest family.

[Michael]
Yeah. So I’ve got a wife, two kids. I think we were talking before our kids are very similar age. I’ve got two boys, five and two and a half. And, yeah, I’m trying to get them to start coming on these little adventures and stuff with me.

Because it gets a bit lonely on the road when you kind of leave your family behind and then you’re sort of off teaching other people. That’s the lonely part of the education side of thing is no one realizes that when you go back to your hotel room it’s just you by yourself watching Netflix when your family’s at home. So, I want to start getting them to come with me a little bit more.

[Jaz]
Michael, I actually encourage this. I’ve been talking on this podcast about this theme of whether you’re teaching or not doesn’t matter. If you go on a course, even as a learner, if, you know, whether your spouse is a dentist or not a dentist, it doesn’t matter, right?

Take, try and take your family with you. Go on a couple of these courses, but make a nice holiday out of it. I’m a big fan of that, right? So at least some part of it is tax deductible, whereas the other part, you make memories. And so it’s a great thing to do, to travel around the world. You get to learn, so outside of your sphere, wherever you are, US, Australia, wherever you are in the world, you get to learn different perspectives outside your sphere, and it also creates memories that you’ll cherish for the rest of your life.

So I know you’ll be bringing your good lady when you come in November. And I’m actually been invited to speak in Malaysia or August next year. And I’m like, okay, let’s take the family. So I’m a big, big fan of that. So on the topic now of growth, okay, before we actually go to the clinical topic.

Just a, a quick one, if you don’t mind. What do you think is the number one thing? A nice little tip, A juicy tip straight away, right? What do you think is the number one growth? That when you look back at your career, what’s the one thing that made you grow an exponential rate compared to everything else? Because there’s so many things that we, tips we give, but what was the number one thing for your acceleration?

[Michael]
Clinical photography, in all honesty. Taking photos and then the brutal, honest, and fast way of doing it is taking photos of your work and sharing it with strangers online. No idea, Looking back why I did it.

I thought that the internet was a safe space because I was young and naive and maybe it was back then, but that’s just what I did. And then, you get people messaging you and if you do something severely atrocious, you get people private messaging you and telling you, no, that’s not how you do that prep.

This is where you went wrong. This is what you did. This is all the issues that you’ve had. Lincoln would annotate something and then send it back to me and be like, oh wow, that’s exactly what I need to do. And then I’d go and fix it. And so I was getting people solving problems for me without going to their courses, I had Jason Smith and telling me about my preps or my anterior case, or I had Lincoln doing this or Melkers saying something about this and all these people that are big names now and were big names back then as well.

We’re just commenting on my stuff because they say, if you want to get the right answer really quickly on the internet, post the wrong answer first, and then someone’s going to correct you. So if you ask the question, oh, Hey, how do you do a good crown prep? Radio silence. No one’s answering that because like, oh, whatever.

Okay. Post a bad crown prep that you’ve done. A thousand people are going to tell you how to do a good crown prep. But you have to be vulnerable in order to post it in the first place. Some people can do it. Some people can’t. That’s fine. There are a lot safer ways of doing it these days. There’s private groups, there’s forums, there’s all that kind of stuff.

Back in the day, there was, there’s Dental Town from America. There’s DPR in Australia. I know I’m in the UK one. I can’t remember what it’s called, but there’s all those ones. So there’s little subgroups and you can always DM someone these days and just send them a photo of your work and say, hey, can you help me out? And that’s honestly how I grew to where I am now, is just clinical photography and sharing with people online.

[Jaz]
And one thing, because I’m so much into creating this community of letting everyone be vulnerable and share with each other, which is so, so important for your growth and mistakes will happen and your preps won’t be perfect and you gain so much, just like you said.

But the worst thing people can do now is just like you said, how to do a good crown prep and then radio silence. Another way, sometimes you post this long essay describing the malocclusion, describing the issue, whereas one photo, which has done everything and everyone just like to engage as much easier, pictures of 1000 words.

So top tip anyone if you’re not yet taking photos and you’re wondering why am I not progressing at the rate I want to, that’s probably the number one thing holding you back. And the next thing is actually to share those photos to mentors, to strangers, and you will grow so much. You mentioned the term vulnerability and you’ll be talking a lot about that when you come to London about failures.

So the topic I’ve allocated you is to share 10 years worth of failures. So eating humble pie will be great to see you do that. And I’ll be sharing some of mine as well, my video. And maybe at the end, I’ll tell you, ask you about a tooth replacement type failure for this episode. But before we delve into non implant, tooth replacement options. One thing I asked you before we hit recording is that I said, Michael, do you do implants kind of thing? And so you do. So what I like about that is if I was talking about these kind of options, okay, and like let’s say I was the headline guest, you’re the headline guest, but if I was the headline guest for this kind of episode, I’d have a huge blind spot because I don’t do implants.

I’d be massive blind spot. So I really appreciate that you’re a good guest for this because you’ve taught on this topic of non implant kind of tooth placement options, but you also place implants, which is really valuable. So the first question I’m going to pitch to you is, nowadays, with implants being so in vogue, what percentage of your cases do you think are okay? Yeah, this will be an implant and do you think this is increasing as you’re as you’ve gotten better and dentures and the bridges are getting less. It’s more of a dying art.

[Michael]
I think I’m not at peak implant yet. And so the implant side of things is ramping up. I think Andrew Thorpe talks, he’s a oral surgeon in Australia, if people don’t know him. He talks about peak implant and you kind of get to a state, and you do this with anything in dentistry, like peak crown, peak denture, peak aligners. You basically are doing so many that you basically are just churning so many out, more than you actually should be doing, and a lot that you probably shouldn’t have done in the first place.

I don’t think I’m just at that point yet, but I’m probably in the next sort of year or two going to approach that sort of peak implant side. The amount of implants I do for replacing missing teeth has probably dropped a little bit in the last few years just because of what’s happening globally with the economy and things like that.

And there are a lot of people that are saying not yet to an implant. from a financial point of view. So I want to give them an option that allows them to have an implant later on. So you kind of need to keep that in consideration. But there are other patients that are coming to me wanting that all on X kind of procedure where they want everything removed and have implants, but they’re 33.

And I’m like, I cannot in all good consciousness, just take everything out and put implants in not because I can’t. Not because you don’t need it, but what happens in 20, 30, 40 years time when you’re still alive. And those implants start failing. What is your option then? And that’s what I need to start telling and describing to these patients.

Hey, maybe for you, we need to do a denture and a bridge or whatever. So that we can get you through for the next 5, 10, 20, 30 years. And then do that all on X procedure. Because everything’s got a lifespan. And that sort of circle of dentistry, the clinical dentistry wheel where you go occlusal filling all the way through to an implant, you want to slow them down as much as possible.

And if you jump from, carious lesion all the way to implant, you’ve kind of bypassed a lot of good dentistry along the way. And we’re just trying to slow down the progression. So a lot of the times it’s a financial reason or there’s a lot of medical ones as well, but it tends to be a lot of these days, like you probably could get away with something else for a few more years before we go down the implant pathway because you are quite young.

[Jaz]
It’s better to have an implant when you’re 50 than you’re 30, as we know, and I think that that’s exactly what you’re saying. And so you’ve already covered some reasons where you know how when someone’s got a gap, you give them all the options. So do nothing, denture, bridge implant, if everything was on the table, if everything was on the cards, then the kind of reason that someone may not go for implants, could be because of age because if you want to give someone 21 an implant, cause the growth is still happening, right?

There’s alveolar changes and that’s bad news. Financial consideration is a big one for patients. Maybe a reason why they may opt for a bridge or they may opt for denture. Another one could be whereby you already have a crown next door that just needs replacing anyway, and it would make a good bridge abutment and therefore we just need to be strategic in that individual, even though they’ve got plenty of bone, the implant will be simple.

Sometimes you kill two birds with one stone. Tell us more about how the treatment planning comes against. I appreciate it’s a high level question. How do you begin to actually assess this patient for all the different options available?

[Michael]
Because I’m part of the ripe global family, a lot of my treatment philosophies are going to be skewed by my mentors, by Lincoln Harris, by Michael Melkers and kind of that sort of filter system where you have to have obviously the patient’s goal at the start, like what do they actually want to achieve with their smile, with their mouth, with all those things and patients come in and they look at me weirdly.

It’s like, I want to replace my missing tooth. Okay, why? Because it’s missing. It’s like, yeah, it’s missing, but it’s been missing for 15 years. Why do you want to replace right now? Oh, I’ve got a wedding next week. Well, an implant’s not going to solve that problem by next week. So immediately you’re starting to think, okay, to solve this problem, it’s not an implant.

It’s something else. Maybe an implant later, but not yet. So you start to ask enough questions of the patient. How do you want it to look and all those bits and pieces that you’re saying to ask in your head and ask the patient. And I ask enough questions until I can come up with a suitable solution for them based on everything I’ve learned about them.

So it would be based on your goals as I understand them based on the budget that we’ve discussed, all those things, the most appropriate treatment for you is X. If you can’t afford that, that’s fine. We will do this compromise situation. So what I tell patients, like in the scenario that you were talking about, where they have an implant and I’ve got, I think, three at the moment, in the last couple of weeks, I’ve spoken to exactly about this kind of situation.

Two teeth either sides, either have crowns that are roughly failing, or need crowns either side, and there’s an implant in the middle that could possibly be done. Super straightforward case. Put an implant in the middle, two crowns. Or, the exact same scenario, just do a bridge. Or, there’s no, generally most people aren’t going to go down the denture pathway if they’re already choosing between a bridge and an implant.

So I tend not to give them that unless they’re going down the budget pathway or need it for other reasons. And I just go to them and look, ideally we could put an implant in there like you want. However, it’s actually going to be less expensive for you and less work for me and you get it faster if we go down the bridge pathway.

Oh, what are the difference between a bridge and implant? And then we go down those nuances between a bridge and implant. Some patients ask, oh, which one lasts longer? They both last about the same in the literature. They have different complications, but the same complication rates. One has more mechanical issues.

One has more biological issues and all those kinds of stuff. So it depends on what the patient is wanting. If they’re going to have more medical issues, if they’re diabetic, they smoke and they don’t look after their teeth and they’re a high risk of having perio implantitis. I’m doing that bridge 11 times out of 10.

If they’re a patient that has money to burn and they want their teeth to be individual, they want to be able to floss their teeth because that’s just what they have as their goal. And I’ve had a couple like that. I will go crown, implant crown, and that’s just because that’s what they want. They don’t want the bridge where they have to use a special little pickster or a super floss to get underneath it. Some people were just a bit weird.

Interjection:
Hey guys, just Jaz interfering here. As you know, I have a strong affinity for Ripe Global. I am a shareholder. I am an educator on the website and I see people like Michael Frazis, Michael Melkers, Lincoln Harris as my friends and mentors.

And when I got asked this question about Jaz, which course should I do? I’m looking to do a diploma. I’m looking to do a bigger course, something that spans over a year or two years. Then the one I’m recommending is the Ripe Global Fellowship. I’ve seen the incredible results and the growth that my colleagues in the UK and around the world have experienced.

And I mean around the world because Ripe Global is truly global, no matter where you are in the world. They’ve got cohorts at different time zones, and their teaching is top class. Now, because I believe in their education, I believe in their fellowship, and they’ve got one in implants, ortho, and their main flagship one, which is a restorative one, we’ve teamed up to offer you a 20 percent discount.

Now, you might see on the website up to 20%. This is the only way to guarantee 20 percent off one of their fellowship courses. Now, this is an affiliate partnership, and I am a partner. But if you prefer to pay full price, fine, go ahead and do that. But if you want to take advantage of this Protrusive 20 percent discount for any of their fellowship programs, head over to protrusive.co.uk/rg20. That’s protrusive.co.uk/rg20. It’s a one minute form to fill in, and you’ll get sent all the brochures, the fellowships, and more information because it is actually a big step, right? Like, it’s a much bigger course, it’s a big commitment, both in terms of time and money.

But if you’re looking for quality education, confidence, treatment planning, mastery, and communication skills mastery, then the fellowship is the one for you. I’ll put the links in the show note. I hope you enjoy the rest of this episode.

[Jaz]
I think what you’ve done here is answered a really tough question because it was so high level in such a concise and beautiful way. And I think the main message worth emphasizing again is if you’re not sure what to recommend, you haven’t asked enough questions, right? And therefore find out, do they want something? Are they happy to consider something removable? So you don’t have to say, do you want something fixed or removable? Cause they’ll always say fixed in a way, but it’s sometimes, okay.

Would you consider something removable? Or does it have to fix them? But I might consider something removable. And then there’s other considerations like budget and that kind of stuff. And so you, once you ask enough questions, cause some people are very much not, I definitely, if they associate with aging, an old person, so they definitely don’t want same removal and they already decided that then great, 20 percent of the options now off the table.

And so once you can whittle it down, it’s like playing guess who, right? You want to let last couple of people left and you help them, you show them in the face and they pick the face kind of thing, probably not how you play guess who, but you get the idea. You help them give you the answers of what they need. And then the last thing to just discuss is the budget and that kind of stuff as well, which is mega important. It might be something that sways them.

[Michael]
Exactly. And I think the guess who analogy is amazing. And I can’t believe I haven’t thought of that already. And I’m going to steal that in my next lecture slide. I’ll make sure I credit you. But, essentially, yeah, if you haven’t figured out what they need, you haven’t asked enough questions. And I think people ask the budget question too early and pigeonhole themselves. We should always treat and plan dentistry to the ideal. And then work backwards to the budget, especially when you’re doing higher level dentistry or more comprehensive, complex dentistry.

You don’t want to be limited by the patient’s budget when you’re thinking now. When you’re doing bigger, more complex cases, like full mouth rehabs and things like that, the budgets can be a little bit easier because they tend to go in brackets based on material choices. Like if you’re doing a full mouth rehab in resin, it’s going to roughly sit in kind of here.

And if you’re doing everything in ceramic, it’s kind of sit up there. You can get a little bit fuzzy when you’re going, okay, we’ll do the front ones in ceramic, the back ones in resin or vice versa, we’ll do a denture instead of implants. It can mix around a little bit. But that’s where you go.

Okay. If we did everything the best of our abilities implants and crowns everywhere, you’re going to be, I’m just going to use US dollars just because I off the top of my head, like, 30, 000 US dollars. If, however, your budget is 20, 000, that’s fine. The compromise we can make is instead of implants, we go down to bridges.

And then suddenly you get down to 25, 000. If you want to get to below. That 20 grand mark. I can’t remember what I said their budget was, they said it was 20. Then you have to go down to a denture or compromise the material of the crowns. And that’s when you go, either you need to compromise your goal or you need to increase your budget.

And so patients sometimes need to go, okay, my goal is this. I will achieve it because I don’t want anything removable, blah, blah, blah. If I pay an extra 5, 000 dollars, pounds, whatever it is. However, I can’t afford to do that. And so I need to compromise my goal and figure out a way to be okay with having a denture and just say that to them and then stop and just be silent.

Because a lot of the time, and I caught myself about to say something with a patient the other day. And it was really, it was dragging on. It’s the first time I ever met this man. And he was really comfortable with the silence. And I was like, someone needs to say something. And I hope it’s not me.

[Jaz]
He who speaks first loses.

[Michael]
Exactly. But he was like, how about we have a, because this is one of those patients that mouth full of cracks, had been seeing a dentist for six months, every single time for the last 15 years. And I don’t want to be the, I don’t like being the guy that’s like, look, you actually need crowns on a lot of these teeth. It gets a bit awkward having that conversation sometimes, especially when you’re doing it.

[Jaz]
Especially with a stranger. First time you meet them, there’s no exact buildup of rapport.

[Michael]
Yeah, exactly. And so he was like, how about we’ve got the photos now? Cause that’s really important. Taking photos so they can see that there’s cracks. So I’m not lying to them. How about we see what they look like in six months or a year. And if they look worse, we’ll do the crowns then. I was like, okay, that’s a great idea. Let’s do that. I could have easily talked myself out of a couple of crowns in six months time. I’m happy to wait.

But if I had filled the silence, if I had preempted what he was going to say with his budget, with his treatment options, with his goal, with whatever, and didn’t allow the patient to express what’s within them to you, then I would have put my own bias, my own spin, my own prejudice, there’s a lot of patients that I prejudge walking in and they’ve done some of the biggest, best dentistry that I’ve ever done in my life.

And I’m super happy and proud. One of the best dentures, my most favorite denture that I’ve ever done, full upper, full lower. And he grew a mustache to rival yours for my after photos. It was amazing. He was a government patient, government voucher patient. He couldn’t afford to even pay the voucher fees to do the full clearance.

And then he’s like, I’m going to save for six months. I’m going to come back. You tell me a price for the dentures. I’m going to get money and I’m going to get dentures by you because we just got along really well. And I was like, oh yeah, whatever. I just threw a number out there and he was like, done.

I’m going to do it. Came back six months on the dot. He didn’t have enough. He borrowed money from a friend and he paid up front the full amount. And it was the most fun I’ve ever had making a full up a full lower denture and he was just a guy that couldn’t afford to pay his government voucher fee like the equivalent of NHS stuff and yeah, just don’t prejudge patients. Let them-

[Jaz]
Don’t prejudge. Don’t diagnose wallets, which is a recurring. You’re all guilty of it basically, especially earlier on a career. We’re all guilty of it and I think to emphasize a really good point in case anyone missed it that Michael made is the whole concept of having this conversation with the patient and then using this term of okay, we have your goals, but are you willing to compromise on those goals?

And just, you’ve set an anchor now, you know what they could have, right? And some people will adjust their budgets accordingly, right? Me personally, I’m in the market at the moment, right? I’m in the market at the for one of those robot Hoovers mops. Have you got one of those?

[Michael]
Yes, we do. It’s awesome.

[Jaz]
The buying decision, right? I’m going to use you a really quick buyer. Yeah. Everyone says like, it’s the best thing ever. So I’m a really a quick buyer, but this one, I’m just like, oh, okay. I kind of decided I want the eufy X10 because the other one had too many compromises. So I completely, my wife’s budget is down here.

My budget is way higher. And I’m like, okay. But I don’t want to compromise all these other functions. I want it self cleaning, self everything. I don’t have to do anything with it. Right? So sometimes when you learn about the compromises, you adjust your budget because that’s what you value, but sometimes it’s not possible or they don’t value it enough and that’s the way it goes.

Now, one thing you mentioned is that scenario whereby you had the potential implant, but you’ve got two crowns either side. And so you mentioned about dentures, usually not an option there. Let’s talk about this theme. of single tooth dentures, like single saddle bounded, right? So I rarely do this. I’ve probably done it in one count in one hand, how many times I’ve done this, but it’s a popular question that comes up on Facebook actually.

And it seems to me that actually, lots of dentists. There’s a cohort of dentists out there doing this a lot. That’s like their go to for a single missing unit. So I’m obviously missing something and I need some education here because I’ve never done a flexi denture ever. And I know people are fans of those and they suggest that it might work well for that scenario.

So tell me single tooth replacement, they’re like bounded saddle areas. Just a single tooth dentures. How does that work?

[Michael]
So we’ve got three different options for a denture. We’ve got the flexible ones. We’ve got Classic acrylic with some clasps and, or sometimes, the little flipper ones, which don’t have any clasps. And then we’ve got the chrome. I’ve done a couple of the chrome ones. They are really, really secure. They basically look like a spider or a crab. One of them actually accidentally did because I was trying to do like a small little flipper denture for like a pre implant case because they wanted to have something and while everything healed and I don’t know maybe the lab got confused or maybe I wrote the wrong thing on the lab form and it came back as like this chrome thing and I was like, wow, that works. It has a lot of clasps, more clasps than tooth, but it works. So they tend to work really well. Acrylic ones, sometimes you need a couple.

[Jaz]
Can we just pause on that, Michael, on that chrome one, right? So I can imagine if you just prep some nice guide planes and you have enough undercut on the adjacent teeth, that actually that can be quite secure because one of the worries here is a patient swallowing, inhaling, that kind of stuff, right? Obviously you want them to remove it at night, but still it’s a concern. But that kind of denture, I can imagine it having a nice path of insertion and quite a snug fit.

[Michael]
Correct. And then it’s the same thing with the acrylic. It’s just a little bit more looser. You can cover the roof of the mouth a lot more with the acrylic. I’ve done chromes that are single tooth with cross arch support, mainly to make them bigger, but also to minimize the chance of it actually flipping off. The problem with single tooth dentures that are only on one side of the arch is because you don’t have the cross arch support. If it lifts from one side, then it doesn’t actually get held in by the opposite side. So it’s the RPI system for dentures, where you need the rest or the reciprocate. Anyway, I can’t remember-

[Jaz]
It’s the rest plane, guide plane and the eye bar, right?

[Michael]
Yes. Yeah, pretty much. But the point of that system is basically, so if you put a force on the free end saddle. It actually doesn’t cause the denture to sort of dig in and then sort of, it disengages. It’s a similar concept when you’ve got the cross arch support because if you lift the denture up on one side, let’s say you bite into a toffee apple, lift the denture off, the other side actually kind of grips in on that and kind of resists it from being pulled completely cleanly off in a lot of cases.

If you’ve only got the one side, then what happens is it just lifts cleanly off and you can swallow it. I’ve really tried not to do them. Like you, I can probably count on one hand the amount of times I’ve done it in ten years. It’s probably three. And this is completely unrelated to dentures, but my cousin had a upper expander.

This was back when we were like 13, 14. I remember the story because I wasn’t involved with it. So he was on a fishing trip with his dad, sleeping with the expander in it. Obviously they had loosened it a little bit or it had loosened overnight, fell, and then he inhaled the expander. So it’s not even like a single tooth denture, it’s an expander that he’s inhaled.

And then his dad had to like, put his fingers in and sort of fish it out. So I’m very wary of using really tiny devices in patients mouths because I don’t want them to inhale something. And then that’s in the middle of the ocean as well. Like, it’s bad enough if it’s happening to your kid in your house, let alone the middle of the ocean.

Obviously everyone’s alive. Everything’s good. So that’s your normal tooth. A lot of people, when they’re doing single tooth ones, will use the flexible dentures. The problem with the flexible dentures is obviously chrome dentures tend to be tooth supported, acrylic dentures tend to be sort of soft tissue supported.

The flexible dentures tend not to be supported by anything really because they’re flexible and they move and what happens is they look great when you first do them but because they’re flexible and when the patient bites it moves it doesn’t have that support and can actually just strip the gum.

They’re called gum strippers. They just strip the gum off the adjacent teeth really, really quickly, a lot faster than other dentures do. We know that there’s recession and things that can happen with dentures, but they just cause more issues. And I don’t think we as dentists tell patients that. Often enough because if they knew that would they actually choose that as an option?

I don’t think they would I’ve only had one person. I don’t know if there is big in Australia I’ve only had one person asked for one and I said no. I generally don’t ever give them as options for anyone to see that are acrylic or chrome and just for those specific reasons.

[Jaz]
Yeah, same here. I don’t feel comfortable with that mode of modality just because lack of experience as well, lack of education, right? And so it’s not something I offer, but sometimes patients come in with these requests and I’m sure there’s someone out there, one of the Protruserati saying, you know what, I do a lot of these, reach out to me. I’m happy to learn and we could talk about how to get success with those. There’s always a patient who may benefit from that, but it’s nice to do an overview.

So I guess we can conclude that by, yeah, you can do it, but there are some concerns and some safety. And also perhaps there are some other things out there that are superior. And so me and you don’t do this a lot, but it is an option.

[Michael]
Yeah. I mean, I break that when most people say single tooth dentures, they’re talking about the posterior ones. Cause we have all done single tooth anterior dentures. We’ve all done it. We’ll continue to do it when I’m talking about, like, can count on three fingers, how many I’ve done, we’re talking like a pre molar, a molar, a single incisor. We’ve all done that. And that’s fine because you’re covering a reasonable amount of the pallet or you’ve got clips, you’ve got this, you’ve got that. And it’s very unlikely that it’s going to cause issues.

[Jaz]
So, Michael, give me a perspective on this as someone who places implants, right? And please feel free to disagree with this statement, right? Because remember, I don’t do implants, right? So I’ve got a bias, right? I strongly believe with my blindsidedness and the fact that I don’t do implants that for the lower single incisor, that implants are a stupid option.

But that’s what I believe. Okay. And I just think that when you have something like Resin Bonded Bridges, which can be so successful for incisors, especially lower incisors, right? Then why would you try to fudge an implant and mess about with the biology? Cause you’re dealing with a small space and now they come out with thinner and thinner implants to try and meet that. But I just think at this day and age, why would you do an implant when you can do a resin bonded bridge?

[Michael]
I don’t disagree with you for a single lower incisor. I have one patient and she’s a very difficult patient and she’s also a hemophiliac. I didn’t do the implant but I referred it to the oral surgeon. So he did the implant because she insisted, like, insisted that she had to have a surgical procedure as a hemophiliac. And I’m like this is not going to be for me. I’m sorry. You can go somewhere else for them to do it.

[Jaz]
Too many red flags there, because the hemophilia is there, but you’ve got thin bone, right, in that area. The tough, the crappiest type of bone, right? I mean that, you can tell me that.

[Michael]
Yeah, yeah. There are too many things to potentially go wrong. Now that doesn’t mean that they shouldn’t be done in some specific circumstances. I think a lot of times I tell patients, Look, let’s just do a resin bonded bridge.

And then if and when it fails, we can then consider what our options are at that point in time. And what happens is 15 years go past, and then nothing has failed, and then they’re all fine. And then they’ve forgotten about the implant, because they’re like, oh, well, that worked for like a really long time.

Can we just do that again? It’s like, sure, let’s do that. Also, the other reason they tend to fail, like, sorry, lower incisors, you tend to remove them, is for perio reasons, because they’re mobile. So that’s also a really bad place to put implants, is next to where all the calculus happens in perio patients.

So there’s a lot of red flags that happen with that. That doesn’t mean that they shouldn’t be done and that they can’t be done. I have a couple of patients that have really big lower incisors. So be they could probably put like an actual normal size implant in there. I just a smaller one, but just a normal size, not a mini one for those patients you might be fine to do it. For that little old lady, that’s a hemophiliac with perio, resin bonded bridge, all the time.

[Jaz]
Well, on the topic of bridges, then let’s talk about another common question. One of the questions I had for you for this episode is the span of bridge. Cause then sometimes we’re thinking, you get a bridge too far. And so let’s take a scenario which actually can work well, which is the canine to canine bridge. Okay. I myself had reasonable, good success. I’ve had in the limited few that I’ve done, I’ve not had any Issues with them yet. Okay. But I’ve been practicing for 11 years, so that’s still to come. I expect, obviously it will fail eventually, but I’m having enough confidence to treat and plan that because I think these canines make great abutments.

And then, so that is now obviously a six unit bridge in a way using two abutments and four pontics. And so we can forget about the whole Ante’s law. Let’s just say that we disproved that, Ante’s law whereby the total surface area of the roots that you are replacing should exceed or match the surface area of the abutment.

So that’s a myth. And we know that in periopatients, bridges can do really well as well. And so that was, I think, Nyman and Lindhe data, if I’m not wrong there. So the question is, we know the canines in canine can work well, but at what point do you think we should start worrying about the span?

Because I’m sure you, maybe you’ve seen as well. Some other countries, when they do bridges, they do bridges, like they do a full arch.

[Michael]
Like a grandest bridge.

[Jaz]
Yes. I’ve never done one. Okay. But I’ve seen a few and I’m like, how, this is amazing. I just like take photos. Like this is spectacular. So sometimes it’s roundhouse bridge, you take the OPG and there’s maybe it’s like an all on four, but the four is not implants.

It’s actually just teeth. And so the original all on four. So I have no knowledge and experience about this. Tell me what do you know about this kind of bridge and then what kind of guideline can we suggest to dentists listening and watching about the span of bridges?

[Michael]
Yeah, so I’ve done those six unit bridges, those canine to canine bridges. They work really well, they can be quite predictable. The main thing to consider with those ones is not the distance between the canine to the canine, but more so the degree of overjet that you have from the canine to the anterior. So the anterior posterior spread of the teeth. There are some patients that actually have quite a narrow arch in their anterior teeth.

Actually, the ridge actually protrudes quite forward. And in those cases, it’s really probably not the most favorable thing to be doing a canine to canine bridge that goes around the curve. So try keeping things as straight as you can, but obviously following the ridge a little bit. You’re not going to just completely miss the ridge and go completely straight.

So those can work quite well. The forces on the anterior teeth are much different to the posterior teeth. Studies of preliminary data that Michael Melkers and his wife did where the amount of force that is produced by the teeth decreases as you move from the molars to the premolars to the canines to the central incisors.

And so it’s about 30 percent of the force at the central incisors compared to the maximum at those, at the molars. It’s only 70 percent at the canines. So the drop off is really significant from canines to the central incisors. So having the canines, which are built in design to be robust teeth and take all the force in the lateral sort of excursions, really helps stabilize them as bridge abutment teeth.

So, which is great. The problem when you do sort of your roundhouse bridges, your bigger kind of cases, when you go like molar, let’s go ideal situation, molar to canine to canine to molar. The forces are different in the posteriors compared to the anteriors, okay? Over the molars and what we want on pontics is going to be very different.

So with anterior teeth, it’s very similar to pontics. You don’t generally have an occlusion on the anterior teeth or if you do, it’s very light. So it doesn’t really matter if they’re touching or not. With your posterior teeth, they’re going to be touching. So it’s very difficult if you’ve got that many teeth to just have things not touch, because then the patient’s kind of only occluding on two molars the back.

Very easy to overload things. When they’re moving left and right, you only want them to be touching on the canine, if there’s a canine initiated guidance. You don’t want anything happening on the pontics. The problem is when you have everything splintered together, if you’re pushing on that canine, that way, towards the left for the people who aren’t sort of watching the video, if you’re pushing everything towards the left.

The rest of the bridge is connected to that canine, and it’s going to exert a force of there’s going to be compression, there’s going to be some tension happening on that bridge at some point in time, and depending on the material you’ve chosen, then there might be some flexure of the material.

There may not be some flexure of the material, like if you’re doing a zirconia bridge, and that might also be an issue, because instead of flexing, it might crack. If you’ve got a metal substructure, it’s going to take a little bit more of a, maybe a slight flex before it actually, cracks, but still there’s a maximum force that can be applied in the protrusive, in the lateral excursions.

What we also forget is underneath all of these super amazing materials that we have in dentistry, there’s a tooth and the tooth is just biological, mineralized tooth structure. It’s a series of tubes. It’s got enamel. If you’ve got any enamel left, it’s dentine. It’s alive.

Hopefully it’s vital because obviously the success rate of a bridge drops if it’s a non vital tooth even less. So if it’s got a post in there, what we forget is that flexure that can happen can also open up micro gaps between the bridge, or the crown and the abutment and the abutment tooth and then allow passage of bacteria to happen and go in.

So you’ve got a lot more biological issues that can happen a lot more mechanical issues that can happen. And that’s just me talking about the fact that you’re just a normal human being moving left and right. We’re not also talking about the fact that you’re doing these kind of cases on patients that have already destroyed the rest of their dentition, either through wear or decay, where they do come into the play is in the cases like I was talking about before, on that 33 year old who desperately needs an all on four, but you’re trying to push it forward as far into the future as you can.

So she really wants to do all on four. I really want to do a big ran house bridge on her because actually I don’t to be honest because she doesn’t have any anterior pierce. It would be like two molars with like a massive bridge going all the way around. That’s too silly. I actually want to do a precision denture for her, but I don’t know.

That’s a separate story. They’re for terminal dentitions. The dentitions that, this is their last hurrah. You know that it’s going to fail. You’re just trying to do the best you can for as long as you can. They’re not for, what tends to happen is, John goes to Bali, has his bad teeth removed, and comes back with a new massive bridge.

He probably could have had a couple of those teeth fixed or done various other bits and pieces. People just tend to just join all the crowns together for some reason. Because they splint all the teeth because they have really tiny preps, and so they just split them all to stop them falling off.

So that technically is a big ranthouse bridge just with more abutments everywhere. There’s a lot more biological issues. There’s a lot more mechanical issues that can happen and the forces on anterior teeth are different to posterior teeth. But when you’re joining everything together, everything is sharing in the forces.

[Jaz]
I think you hit the nail on the head in the sense that, there’s a place for everything in dentistry. Including a roundhouse bridge for the right patient. And sometimes it is that patient who, like you said, it’s the last hurrah. And sometimes they’ll be there for 10, 15 years. And that’s great. And now you also have to think about the patient as a whole, right?

They’ve got weak muscles, low occlusal risk, and the upper, let’s say the upper is a complete denture. And then the lower you got some teeth and you know what the we know how troublesome they can be and they haven’t got maybe implant money or implant medical complications, then maybe a roundhouse bridge in that patient could work.

And so there’s always these considerations. I think always occlusal design is important, making sure that everything is shared and well considered. And one thing we haven’t actually mentioned on is the technical aspects of yes, material design and time to pick up the phone and speak to your lab, but also the path of insertion, trying to keep things as parallel as possible. It’s a really difficult skill, but nowadays with the scanners and stuff, and you can observe that. So that’s pretty good. Anything on that before we move on to the next topic?

[Michael]
I think that’s probably a good place to talk about year old and day dentistry, like fix movable bridges, where you have a bridge that is in two parts where they connect at sort of that little pier abutment.

So you insert one half of the bridge and then you insert the other half of the bridge. So instead of having, and they work a little bit well when you’re trying to connect a molar to a canine or something like that. And that doesn’t mean if I’m doing like, a molar to a canine, I’m going to do a fixed movable bridge.

It just means that in some cases, if you have a path of insertion issue and you need to have two separate path of insertion, they can work well. If you’ve got an issue where you’re like, I know this canine wants to go left and the molar wants to stay exactly where it is. I need to have a little bit of flexing in the bridge so it can take up some of that slack. Then a fixed movable bridge may be the most appropriate thing. So they can work quite well in some cases when you have those differing forces.

[Jaz]
Yeah, so that negates the need to make them parallel. Great point. I actually did one last year on my father in law and then a few over the years. Hat tip to Paul Tipton, did a really good episode on fixing bridges. I think it was episode 50 something on the podcast and that gave me the confidence to look into that. But again, it’s something that you want to speak to the lab about the first time I did it with the lab. It all went horribly wrong because of the height issues and actually prepping for the connector part was not long enough.

And so you, you learn and maybe we’ll talk about it in our lecture on failures and learning. So I’ve actually got that documented. So we’ll be able to talk about that one. You mentioned a little bit about root filled teeth and how things, the prognosis decreases. And so having that knowledge and someone called professor Martin taught me this at dental school.

It’s just always that same thing always stuck with me you know that root filled teeth because the fact that a root filled tooth is more likely to have less residual tooth structure, less stiffness, there will be some degree of taper for a root canal, the less pericervical dentine, less proprioception, so many reasons why root filled teeth don’t make great bridge abutments.

And so I would say I’m very, very risk averse when it comes to doing a bridge abutment for a root filled tooth. And maybe I would say it’s a big factor in why I don’t do as many bridges because a lot of teeth seem to be root filled and I don’t involve them. I kind of really reduce it. And maybe I’m being a little bit too, I’m taking that by too much gospel, any guidelines you can give in terms of involving and was a topic in the community as well involving root fill teeth as bridge abutments?

[Michael]
So obviously you want to minimize the amount of root fill teeth that you are using for bridge abutments. There’s nothing wrong with doing a crown on a root fill tooth. We know that they need full occlusal coverage. I want to get away from saying they need a full contour crown or anything like that.

There’s a lot of research now that it’s just full occlusal coverage. It minimizes the flexing of the cusp, because at the end of the day, like you said, root field teeth, root canals aren’t done on healthy teeth. They’re done on very broken down teeth, all that have had very large restorations for long periods of time.

And so everyone always goes, oh, it’s the crown that caused you to need a root canal. But why did you need the crown in the first place? Oh, you had a five surface amalgam with a crack in it for 15 years. Okay, that’s probably the reason why the bacteria got in, not the crown that we did. But anyway, so you always have to assess that individual tooth that you have in front of you.

So the literature is great to give you an overview of statistics, the probabilities, all that kind of stuff. But at the end of the day, you have to discuss the patient in front of you with the patient’s tooth that’s in front of you. So I’ve had a couple of root canals where it’s like only the mesial half is missing and it’s only really because it’s just a really deep mesial occlusal decay that really got into a high pulp form.

I know the rest of the tooth is pretty okay and so I might go look there is a higher than normal chance that that tooth will break but if it did we have these options down the track and the patient goes that’s fine I don’t have the budget for an implant let’s go down that pathway or if they do we go this needs a crown anyway and we can do an implant.

And they say that’s fine. But as long as they understand what the risks are long term and it’s an