Protrusive Dental Podcast

Teaser:
So it’s about understanding how to manage those forces. The one, the thing that I noticed, if it’s an issue is screw loosening of the crown and an implant that tells me straight away, I have some of axia loading on my implant. So I need to deal with that straight away. As soon as I fix it, I am not tightening that screw for, I’m just not tightening it, maybe years before an issue arises.

When you then look at the literature on risk for those category of people that are more likely to damage your implants, for example, bruxist patients, parafunctioning patients, they are three times more likely to cause failure. So when we look at met analysis, it says, occlusion in those patients that really damage the teeth, so they are more likely to damage your implant.

Jaz’s Introduction:
Maybe, like me, you were taught that your single implant crown should be out of the occlusion, i.e. it should not be holding shim and there should be approximately 30 microns of clearance. What if I told you that’s false? That’s a lie! Because every time I see patients come back with implant crowns and I check the occlusion, you bet that that implant crown, which probably initially was out of occlusion, is very much in occlusion.

So what should we be doing? Should we be adjusting ceramic or adjusting the opposing tooth and doing this every year so that your implant crown is always out of occlusion? Let me suggest a better way to you through this podcast. I am joined by Professor Riaz Yar, one of my oldest mentors in the sense that he was my first first educator.

Like, when I qualified, the first course I went on, the first workshop you had as a DF trainee, was his. And he gave me the bug of occlusion, he inspired me to no end, and it’s a great pleasure to have him back again on the podcast. Even if, like me, you don’t place implants, you don’t even restore implants. There’s so much to gain. As general dentists, we owe it to our patients to understand because our patients have implants and we want to know what a good occlusional implant looks like.

This episode is eligible for CE credits and enhanced CPD as per GDC criteria, but also we are a PACE approved provider. All that happens through the quizzes on Protrusive Guidance. If you literally listen to every single episode, it is the best value for education you will ever get because now you get to reflect on the content and test your knowledge and retention. You get to download the premium notes and the PDF transcripts and all the goodies that come with the episodes.

Dental Pearl
Speaking of goodies, today’s Protrusive Dental Pearl is related to implant assessment. I’ve been on the hunt for a really good form. So if you’re someone who’s placing implants and you’re having that initial consultation, what should we be looking for when we’re assessing our patients? Now it’s been under my nose the whole time because one of our own Protruserati, Dr. Pav Khaira, who’s so active on our app, on our community, Protrusive Guidance, he has a wonderful form.

And as part of the pearl, we’re giving it away to you for free. Head over to www.protrusive.co.uk/implants. Just simple as that. Implants. And we’ll show you a fantastic form. It’s actually a really responsive pdf because you’ve got like drop downs and you can complete it on your mobile phone, on a laptop.

It covers everything from the patient expectations and goals, the biotype, the occlusion, very relevant to today’s episode, and it’s all for free. Plus you get an eight minute video of Pav Khaira just going through the entire form with you. That itself has so much educational value. If you’re someone who’s placing implants or restoring implants, or just a humble general dentist who’s referring, it is a great thing to familiarize yourself with.

So I want to thank Dr. Pav Khaira for allowing me to share this with you. And the website is protrusive.co.uk/implants. Hope you enjoy that download. I’ll put the link in the show notes, but let’s join our guest, Professor Riaz Yar, and I’ll catch you in the outro.

Main Episode:
Oh man, all that heartfelt stuff I said, Riaz.

[Riaz]
I know, I know. Now we’re going to have to fake it. Now we have to fake it.

[Jaz]
Guys, if you’re listening to this, right, Literally, we just had a lovely, like, 7-8 minute exchange. I gave, like, an amazing intro that Riaz deservedly. He just deserves this beautiful intro. I have to, like, fake it again. And so, here we are again. It’s pitch black outside. Told my wife I’m recording in the morning. And she was like, okay, who’s the guest kind of thing? Where’s the guest from? And I said, It’s Riaz. Okay. It’s Riaz. He’s been on the podcast for, he’s a very welcome guest on the show.

And it’s because usually it’s Australians that like to book this sort of 6. 15am slot if you like, but it’s great to have you Riaz. I said before, unfortunately, that unfortunate event of the recording not happening is you have inspired me in such a huge way. You were the first sort of a workshop or course that I did as a VT.

So, the sort of plan program, and that was absolutely amazing. It mentioned it in our previous episode that your teaching style inspired me to no end the way that you like to really ask and help us to understand why it really inspired me as someone who eventually, I always wanted to get into education always from the beginning.

I did my PGCert in dental education very early on, but you were really the catalyst that really confirmed to me that, you know what? When I grow up, I want to be like Riaz. So for those who don’t know, very few people who don’t know you, do check out the other episodes that Riaz has done. Do check out all his wonderful stuff that he’s involved in. But Riaz, just tell us about yourself as a clinician.

[Riaz]
Now that we’ve had that intro and I’m going to have to cut it really short. I’m a specialist in prosthodontist based in Manchester. Jaz talked about sort of me inspiring him, but actually he’s continued to inspire me. So I’ve been blessed to sort of two people meet, meet each other on a path.

And how sometimes I can sort of trigger something in you and you’ve definitely triggered something in me, just by sort of the way you’ve continued to educate and keep me motivated and keep me going. Okay. I like that approach. I think we do have a very similar sort of approach and outlook on, on things. So, thank you actually for continue to push me.

[Jaz]
As for those who don’t know everyone who knows you as knows this already. But those who don’t and you may be listening to it the first time or see if the first time one of the most like humble people you ever meet right? So just sitting next to him at a tubule’s dinner or just seeing you around the real nice guys in dentistry really nice really humble, always has time to.

So thank you for what you do for the dental community and how you inspire an absolute generation. So that’s amazing. Implant occlusion Riaz, we need to talk about this really important thing because it is touted as potentially the major cause of implant failure. And I kind of asked you, and I’m going to ask you again now, because we’re now actually recording this time.

Well done Jaz. It is of all the different types of failures that we can experience in implant dentistry, this could be screw loosening, this could be porcelain fracture, this could be actually peri implantitis, this could be due to the host having, let’s say, diabetes, low in vitamin D, this could be because of poor placement, this could be because of poor materials used. Where does the occlusion actually rank as like the cause of failure?

[Riaz]
I mean, it’s clearly going to be one of the causes, but where does it rank? I think it’s always going to be difficult to say, okay, it’s number one, because one, the clinician delivers, most people deliver the occlusion low, infra-occluded, and the guidelines actually say, do it infra-occluded.

Now, so that means you’re not getting any static loading. Definitely for, it could be a couple of weeks or a couple of months or even depends if the patient puts tongues in between the teeth, it may not even overreact. So from a sort of data perspective, it’s very difficult to measure. Even human studies, animal studies haven’t really categorically said, because you’ve got dog studies, super proud, never caused any bone loss.

And then you have some that do. So I think we just look at biology. I think I’ve always tried to answer questions on understanding the biology of the system. So the modulus elasticity of bone, for example, is the same as teeth. And that biologically makes sense because when you overload the tooth, the force transference is through the long axis and sort of focuses at the apex.

So the fulcrum becomes the apex. Once that occurs, the teeth become loose, they become mobile. So you have a built in safety mechanism. Whereas the modulus of elasticity of bone to an implant, implant is about 10 times, five to 10 times difference, means that when you overload an implant, it’s going to get forced concentration at the neck of the tooth.

So biologically, if you overload it, the risk is that you’re going to get bone loss around the neck of the tooth, just from a biological perspective. That then means, okay, how do you apply those forces? And so if you apply those forces at a tensile, at an angle, that’s definitely going to occur, but static forces, it’s still going to get some transference through it.

So it’s about understanding how to manage those forces. When you then look at the literature on risk for those category of people that are more likely to damage your implants, for example, bruxist patients, parafunctioning patients, they are three times more likely to cause failure. So when we look at meta analysis, it says occlusion in those patients that really damage the teeth. So they are more likely to damage your implant and that makes sense because they damage the teeth. Why would they not damage?

[Jaz]
It’s an overload mechanism and that gets transferred to the implant. And then with peri implantitis, like for example, we know that and please do correct me, right? We know that occlusion and occluding is a factor in in perio, but you know perio really is like a host response.

There’s so much a genetic element into when it comes to periodontal disease and occlusion overloading the teeth is a bit better term actually can play a role. Those jiggling forces can exacerbate a periodontal condition but in itself it’s not the initiator when it comes to periodontal disease especially in someone who’s not as acceptable. So how can we apply that to peri implantitis? To what degree can overloading an implant be responsible for peri implantitis?

[Riaz]
I think it’s back to, and you’ve already sort of alluded to it. You sort of, there’s loads of other factors. So when you’re going to think about peri implantitis of an implant, you’ve got to look at the rest of the mouth. So if they’ve got pocketing elsewhere, they’ve got other issues elsewhere, then yeah, I would say perio issues, poor hygiene, just as much of a factor as the occlusion. Cause you’ll see on those patients that have peri implantitis, most of the time they’re infra-occluded. The restoration isn’t touching. So you kind of go, how much of it is a factor, then you’ve got mobility of the remaining teeth.

So, how we look at mobility, I think has been, we use two probes. We just use that. I mean, I’d still like to use my fingers and just move around and grab the teeth and just shake them and see if they’re actually loose. Because functional loading is probably more important than static loading.

You’ve got patients who are horizontal chewers and they get missed a lot and especially anterior teeth. The natural teeth are worn, they have some mobility built in the remaining teeth, but the implant doesn’t have that movement. You’ve got to look at functional loading and how I do that chewing gum.

I just love the chewing gum test, always putting chewing gum in. Let’s look at how they chew and you can see when they chew cycle in and then they cycle out and that cycle out is a long horizontal because they’ve lost the wear on the canines to give them that protection to open up. They’re actually just going full horizontal and they’re wearing the teeth. That’s going to cause peri implantitis. That’s going to cause the screw to come loose. The implant-

[Jaz]
Lateral loading of the entire mechanism, right?

[Riaz]
Lateral loading. So your issue is totally, is that you’re going to get patients who have lateral loading, horizontal chewers, you’re going to go, this is a factor, but that’s if they have no pocketing elsewhere.

So it’s looking at the individual implant in relation to the rest of the mouth will tell you the answer of whether the implant occlusion is a factor. So look at the remaining teeth. How worn are they? Are they mobile? Is it, cause if there’s no pocketing elsewhere and you’ve got it around your implant, you can safely say it’s occlusion, but you’ve got to analyze the occlusion. And that’s where for me chewing gum is now really quite crucial analysis.

[Jaz]
The first time you do this is really quite, when you see that horizontal chew, it’s really quite like, how does this person chew like this? This is really absurd. When you see it, have you found a head? Can you suggest a good way to actually view it?

Cause usually give them the chewing gum, and their lips come together, and they’re chewing with their mouth closed, and then it feels very awkward. And you try a retractors. I know you like to use your fingers. I guess with the Modiaw, you can track all that, which is just amazing. Any tips you can give us, too, when we’re checking for the chewing gum test?

[Riaz]
Yeah, so basically, you’ve got to be very careful. So, try and get your finger up onto the eminence of the canine. And so, that kind of the first finger ports and is resting on the canine eminence. So when you’re looking at the left side, it’s on the left upper canine. Once you’ve lifted that up and then you just open up the lower lip as well, now you are going to have some patients who have very strong oral muscular control, which again gives you an idea of how strong their chewing is because if they’re using a lot of their oral musculature to really keep back control of that.

Now one, they’re a closed mouth chewer. So you’re going to have some people who chew really well with their mouth closed, hate the fact that they could, even their teeth could be visible. It’s a training thing. It’s a manners thing, a social etiquette thing. You chew with your mouth closed.

So you will have some people who have really strong oral musculature. So you then got to be gentle and got to get them to just relax their lips as they chew, because they’ve been trained to chew with their mouth closed. Those that chew with their mouth open are the best patients. Cause they’re just the ones that you just, it’s very soft.

You can just place your finger on it and I just rest it and it’s basically opening a window. So yes, the question, and yes, you’re right. I use the Modiaw for the axiography chewing. But when the question I asked myself with the Modiaw was by putting a clamp, and even though it’s a plastic clamp, very light.

Does that affect the chewing? We started to video the patient, without Modiaw, with Modiaw, to try and overlay the chewing motion. And it is similar. If someone is a horizontal chewer. We’re chewing without Modiaw. They are with Modiaw also a horizontal chewy. They don’t become vertical just because we put some device in. So yeah, I’d already, that was already something that I questioned when you are looking at the data, cause I really need to know what I’m collecting is real.

[Jaz]
Without taking too much of a detour, but it was a nice little tip for those two who’ve never done it before. It’s amazing when you see it through a cow, as I call it, right. And really how much their mandible swings is really quite fascinating. You have to think, yes, we always look at training. We look at excursions inside out, for example, the grinding, but actually what we failed to look at is the chewing, which you talk about so much, which I love the work that you do, but now just going back to implants.

Cause we can go in a real tangent. We’re all over the time, the time struggle today. So my big question I’ll ask is I’ve been told and I’ve been taught, okay. And as someone who does not place implants as someone who does not restore implants, so very much, I’m going in blind and I’m being led by you is I’ve been taught to get clearance by about roughly 30 microns, right?

So make sure you put one shim stock in. Let’s say it’s an upper premolar implant crown screw retain, right? Make sure it’s not holding shim. You get two shims or double it up. It’s not holding. Make it three. It’s not holding. Four, it could be holding.

That’s okay. That’s kind of what I’ve seen in terms of what’s been taught. But, Riaz, and then this part two of the question will be, but whenever I see implants on my existing patients, I’ve had implants elsewhere or for my colleagues, when I get that shim in, it’s holding, okay? So that’s a two part question, okay? Number one is, is that what the guidelines are or any other theories or guidances on what the guidelines are for occlusion on a single implant crown?

[Riaz]
Yes, there is guidelines. That guidelines is the ITI guidelines. Charlotte Stilwell was sort of, when she was doing her occlusion implant roadshow, was addressing that. My question always to everybody who does that was, okay, how easy is that? How easy is it for you to make it 30 microns light? And the reason why it’s so difficult to do is because none of them have a protocol for their lab. So they don’t even have any control over the lab side. So let’s say, let’s just go through the process.

You take an implant scan, you send it to the lab. They then make the restoration. So now they’ve got the restoration ready and they screwed it into the model. Now they are using a one lab screw that they use for probably 10 or 15 cases. Because they don’t want to use the new screw that’s been sent with the work.

So they’re not using the new screw, they’re using an older one. So then they screw it down and they hand tighten it down to, let’s say, 15 Newtons because that’s what hand tightening roughly is. So let’s say they’re not hand tightening it, it’s between 10 to 15 Newtons. They then do the occlusion. So if they’re following you, they’re saying, let’s make it 30 microns lighter, 4 micron, 4 shim stock paper, which is just simply folded over.

You just sort of one piece, fold it over twice. That gives you 32 microns. They then do that. They go, okay. Oh, it’s touching at 32 microns. It’s not touching it, anything more than that. So they’re like, it’s done. Sterilize it, send it to you. You now have the restoration. You put it in the mouth.

You tighten it to 25 Newtons because that’s the typical guidelines for your implant system. Some tighten it to 30 Newtons. So if you’re baggaging or other systems, 30. So you’ve got straight away two different screwing protocols on discrepancy. So your restoration is automatically by default infra-occluded because you screwed it more into the implant.

So if it was 32 at the start, by the time you’ve screwed another 10, 15 Newtons into the mouth, and no one’s measured this, it’s probably another 15, 20 microns light. So straight away, your lab protocol’s all skewed. Then it’s infra-occluded. Can you fix infra-occlusion? No, you can’t. Once it’s infra-occluded, you’ve got to remake the restoration. So you can’t correct an infra-occlusion, you can only correct a supra-occlusion.

[Jaz]
And realistically, no one does this. In the real world, no one says, oh, my implant crown is 60 microns out, I better send it back to the lab and incur inconvenience of time and that kind of stuff. No one does that.

[Riaz]
No one does that. No one. And the solution is really straightforward. You’ve got to make sure your lab have two new screws. That’s number one. So they have a new screw for their lab side they’re using and new screw they’re going to give you. Cost per screw is about 30 pounds max. That’s a high end. So you’ve got a spare screw, which that, and I say to the lab that comes back with me.

I want that lab screw. So they don’t keep it. I get two screws back. One’s that’s a no and I keep that spare. So that’s a good spare screw for any time any issues occur. They fracture it or something happens. I’ve got a spare screw for the patient. Brilliant. That’s number one. Number two, they tighten it to the required guidelines.

Number three, it’s not infra-occluded. So most of the patients that do not power function in my cohort will get the same occlusion they would get as if they had a crown onlay done on a post crown. You wouldn’t make your post crown infra-occluded in static. You might think about it in dynamic, but in static you’re not going to make it infra-occluded ’cause it’s going to touch anyway.

So any restoration that you would that have periodontal mechanism receptors, you are giving a static occlusion. So I don’t make it light. The only person I make it light for is parafunction patients and I make it 20 microns light. So we have a protocol where it touches at 40, light at 20, and the protocol is patient-

[Jaz]
Like aiming for a shim hold?

[Riaz]
Like it would be teeth. Because it’s going to be a shim hold in my tooth-

[Jaz]
Question. Yes, exactly. When I see them, they’ve already got shim hold. And so I used to think, hey, hang on a minute. This patient has a shim hold and I don’t think the implant dentist or the restoring dentist intended for this.

And so now we think, okay, do we need to now adjust the ceramic or the restoration to actually just free it up a little bit or the opposing tooth to then do that? For how long does this cycle continue? Because teeth are dynamic. They don’t constantly over erupt. So how do you manage that long term?

[Riaz]
It’s crazy. It makes no sense. Because biologically, if your teeth are in a healthy patient, no parafunctioning, maximum 20 minutes touching is static and dynamic. So if we’re going off the study by Leah, and that’s in the 60s, if we’re touching the teeth for 20 minutes a day, for example.

Then in a healthy patient that is going to have no bearing. If anything, the micro strain amount, as long as it’s within the normal amount will be okay. It’ll actually stimulate. Marcel LeGall actually showed bone regeneration when he created functional guidance on his implant. So if you look at Marcel LeGall’s work and he’s passed away and he was at my sort of main occlusion mentor, actually look, repeated PAs over time, he said, look, I’m getting regeneration around the implants.

When I give them functional loading, but he would spend incredible amount of time adjusting the occlusion. The most of us are not going to do that. So static loading normal as if it was a tooth, because I know if I leave it in for occluded in two months time, in a week’s time, in six months time, it’s touching and that’s uncontrolled.

I would rather make sure the contact is through the long axis of my implant. I control that factor rather than letting nature control that factor.

[Jaz]
That’s such a great point. I think if anyone’s multitasking and missed that, to have control over it, give you the long axis that you want rather than be shy. And then when it does eventually over erupt in most circumstances, it will, and then it’d be off axis. And then that’s where you can get your porcelain fracture. If not the implant failure, you get a restoration fracture over time.

[Riaz]
Yeah, screw loosening, that’s the first thing I’ve noticed, if I’ve done a case with multiple implants in regards to restoring the teeth as well, the thing that I notice if it’s an issue is screw loosening of the crown on an implant.

That tells me straight away, I have some of axial loading on my implant. So I need to deal with that straight away. Soon as I fix it, I am not tightening that screw for, I’m just not tightening it, maybe years before an issue arises.

[Jaz]
And so got your shit hold, which is great to know. That’s how everybody else is doing it for the single unit, which is great. And then for young dentists starting out checking excursions, cause we’re taught to take excursions. You might do it differently. You might be checking more of the functional, but for those who are checking excursion, is that important?

Cause what we don’t want is that premolar, the buccal cusp to be taking all that load, it should be guided off the implant only it should be kind of shared or it should not be the only tooth taking the excursive loading especially in a parafunctional patient. So what guidelines can you offer to dentists listening to that?

[Riaz]
Analyzing the occlusion beforehand. When you look at dynamic movement both inside out you look at it from the cusp tip being guided in off an incline. And actually, when you look at functional movement, that actually isn’t the case. It’s not because of tip, because when you look at the in between abrasions, between the four, the five, the six, for example, the buccal cusp of the four comes in between the four and five abrasion space.

The five buccal cusp is between the four and five, the three, four, four, five. The mesial buccal comes off in between the five and six. It’s the distal buccal cusp that actually, both distal buccal cusp of the upper and distal buccal cusp of the lower that are actually the most important cusps of the first molar.

If you actually look at first molar teeth in your children patients, when they were up, look at how they tend to tilt slightly inferior. And when you see that again and again in nature, you’re going, and that’s interesting. And that’s interesting because the distal buccal cusp does come off more that way.

And that’s why sixes are up first. It’s why lower incisors are up first because they’re what establish our functional chewing pattern. So we’re very trained to look at cusp tip contacts and that’s correct in static. Cusp tip hits marginal ridge. Cusp tip hits fossa in static. In dynamic, it’s more incline against incline rather than particular cusp tip against cusp incline.

You will get that off maybe the distal buccal against distal buccal, but typically it’s inclined against incline. And that makes sense because chewing is about breaking food down. And so you want to surface kind of breaking the food down, not a area, not a particular point. You actually want a surface doing the breaking down of it.

So those sort of inclined, those in inward movements are designed to be inclined movements, incline against incline. So I think for me, the first thing I would look at in dynamic is where’s my molar in a molar relationship. Is it a class one? If it’s a class one, I know I’ve got my typical arrangement of teeth.

If they’ve had ortho and they’ve had premolars extracted, then I’m going to look at their molar relationship and see where that is. Because ortho really does destroy functional occlusion. It’s not done. I mean, if, unless you’re sort of following Alberto Domingo and those guys in face group, and they’re looking really at chewing motion and stuff.

Generally, orthodontics is about flatting the curve of spee. Giving canine class one canine so you can disclude to have no interferences. That isn’t actually an efficient masticatory system. So you’ve got to really analyze that. Now, if I can, I want to give functional occlusion, but if I’ve got a power function patient, they get no dynamic loading.

So it’s safer for most of us clinicians to avoid dynamic loading. Put it on the natural teeth and not on the implant. That’s safer because you’re less likely to put any force distribution at the crest. You’re less likely to have any screw loosening. And it’s harder to do. It’s basically harder to replicate.

So it’s easier for you to have no excursive movements on the implant. Have it on natural teeth. When you have full arch or quadrant dentistry, you’re going to have to share the loading. Because that way you’re getting forced distribution amongst all the restorations. And this isn’t easy, it’s an adjustment process. So I would always, if I’m like-

[Jaz]
For you in those larger restorations.

[Riaz]
Yeah. I mean, what I’ve used Modiaw more for is because in larger restorations, patients don’t have a chewing motion. So they’ve not chewing on that side. They’re chewing on the other side, if they’re missing all the teeth on the right. So you have to go through a retraining process with them.

So my retraining process. for patients is chewing on that side for five minutes with chewing gum every day and getting them to chew. And if I’m doing bilateral, five minutes one side, five minutes the other, and I record how the chewing is before and I record how they are with it over time. So with Modiaw, I’ve noticed, yes, patient’s chewing gets better.

So I use composite to retrain. Once I have the shape right in composite, I will copy that into Zirconia or whatever it needs. But it’s that adjustment process. I like in quadrants to go into composite and then I like to see how they were that in. I do not like zirconia. I think it’s too hard for training in of a patient composite to train in zirconia to finish if you’re once you’ve got the right chewing motion and you want to maintain it.

But otherwise, if you’re doing single tooth, it’s easy for you guys to just take it out where it’s there. Keep it on the natural teeth. So if you’re doing a premolar, let the three and five and the six do the excursive and take the four lighter out of it. But if again, if you’re a parafunction patient-

[Jaz]
But we don’t have excursion on that premolar. But obviously you gave a broader picture, stepping back and looking at a whole, which I think is the main lesson here in the interest of time. It’s going to ask you just one scenario. If you have an implant bridge, let’s say replacing the upper right posterior. So we’ve got premolars, molars being replaced by a large implant bridge on the upper right, for example.

Now, if we follow those same principles of a single tooth, it’s probably inappropriate, especially if you follow the guidelines. There’s no occlusion. Now, obviously you just helped us with massively and saying that actually it’s going to erupt anyway. And so how about we control the occlusion and get the shim hold, which now helps me, but assuming that clinicians are not doing that, then if you have one side in hypo occlusion, you are inducing in some way a dysfunction, the muscles will be all over the place until the patient adapt.

And then the teeth over erupt, then you get that occlusion. But I guess what you’re going to say is try and get the same occlusion as you would do on a bridge, but you’re the man here. Tell us how we should manage a bridge scenario that is pretty much half the occlusion, if you like, compared to a single unit.

[Riaz]
Yeah. So if you’ve got, let’s use a scenario where you’re missing three, four, five, six, seven, you’re missing a total quadrant of there. So you’re strategically going to place your implants to try and share the load. So you might not do a three to seven implant. You might do a three to six.

And maybe a single tooth on there. So you’ve got, in essence, three implants to help the patient save money. So you’ve now got four units on two solid implants. Let’s use that as an example. In these situations, first, most people tend to go to a uni abutment, multi abutment level. So they’ll put an extra component into the implant to make the connection super occluded that helps several reasons that actually helps the force distribution.

It also helps cleaning and oral hygiene for the patient but actually also gives us passivity of the work. So it means that actually when we are screwing it to the implant we’re screwing it at a level above the gum and you’ve got more flexibility in error.

Whereas if you try and screw it into the fixture of the implant if it’s not exactly precise or passive. You’re going to put forces on your implant. So it won’t be occlusion that caused the implant to fail. It would have been simply the fact that your impression was imprecise and you screwed it under tension. Once you screw it under tension, you are automatically, you’re putting stress and the risk is that the implant itself will fracture.

And we will think, oh, it’s an implant. It was occlusion and it wasn’t occlusion. So first thing is when you’re doing big bridges, bring the connection out of the implant. So not into the fixture, bring it supragingival. And how we do that is we put another component in there called a multi uni abutment.

Once we’ve screwed that in, that’s now given us passivity. It’s given us room of safety, safety margin. Easier to do that now. You fitted it to the multi uni abutment. So I will typically make, if it’s a big bridge, I would like to do something composite first. Now that has several reasons. One, it allows me to test occlusion, get the occlusion right, and also sculpt the tissue.

So if I’m wanting to make the pontics look like they’ve always been there and so on, I will either do it in PMMA. I prefer composite, but it gets more expensive. You can do it in PMMA and I will then sculpt the tissues there. Now, when you’re using PMMA, you do need to use a primer bond composite to PMMA.

So you just got to sandblast it. So when I’m then adding material to build the occlusion up and then adjust it in, I can then just use a PMMA primer, which links with composite to build up and sculpt it in a gum level. But also sculpt it occlusally and get the chewing right. So that’s sort of once I’ve adjusted it where I’ve got shared loading, which is then group function, you’d call it in your dental world, we’d call it group function on implants. That’s what I want. I want shared loading on the whole of the infrastructure. So it’s distributed through the implants as well as we can. So, and then once I’ve adjusted that in.

[Jaz]
For the absolute newbie, the main thing I wanted to establish was that what you don’t want to do is leave an entire side out of occlusion. We definitely want an occlusion on there. And like you’re saying, you want it shared. The implant and the implant system as an entirety gets the shared loading.

[Riaz]
Yeah. And I collect EMG. So if you infra-occlude the right side, what ends up happening is masseter in particular will increase activity to try and bring it into occlusion. So the reason why you will get teeth back in occlusion. One is through muscle, increased muscle activity, and two through supra-eruption of the teeth. Because the proprioception is what maintains stability of the remaining dentition. So you will end up-

[Jaz]
That’s been a huge takeaway from this episode for me, Riaz, which is how you made a great point that, okay, if we leave, if you follow the guidelines and we leave an implant crown out of the occlusion, it’s just going to, in my experience, when I observe, I told you at the beginning, I’m just seeing shim holds everywhere.

I’m not seeing that scenario where it’s out. And so if it’s going to happen anyway, how about we take control? That’s been a huge takeaway for me. And I know for everyone else as well. The last question I have before I go and help with the school run is when I do, when we do a resin bonded bridge, right?

Let’s say we’re replacing a lateral incisor resin bonded bridge. Okay. I train my patients and I say, listen, to smile, what I don’t want you to do is get cold chocolate from the fridge, put it on your pontic and bite together. Okay, that’s a no no. I also ban them from having corn on the cob. Okay, because at the day, it’s a resin bonded bridge. Okay. Do we need to go to such extents for implant crowns?

[Riaz]
Yeah, you do. You need to give, it’s still porcelain, it’s still ceramic, it’s still a glass. So yes, my rule is no granola. The granola goes. Hard nuts, roasted nuts and so on. There you go. And seeded bread. That’s a big problem. Seeded bread because it’s the seeds that get caught in the fossa and it suddenly changes the forces from a compressive force to a tensile force.

So seeded bread is out. Granola is out and hard nuts are out and I say anything that’s incredibly hard, be conscious of it. So pork scratchings, I remember I had a patient who had a pork scratch and broke his natural tooth. And I said, well, it’s when you’re having to move your jaw into an obscure pathway to try and break that material down, you’re going to break your restoration.

So they’ve got to be careful. You’re absolutely right. Corn on the cob is a good one. But cold chocolate from the fridge is a good one. But we just want them to be sensible about it. If they bought a car, they’re not going to scuff it against the kerb. They’re going to look after the trims. I just want them to look after my work.

[Jaz]
And I don’t know if you remember this, but 11 years ago, roughly this time, 11 years ago, the first case you showed in your lecture, do you remember which one it was? 11 years ago?

[Riaz]
No, I can’t remember to be honest.

[Jaz]
It was a premolar. It was a friend of yours. It was a premolar. They had something as an olive, a lemon pip, and they fractured the premolar in half. That was the first case that you ever presented to me.

[Riaz]
Yeah, that was the other. Andy, my very dear friend, he literally, he just Senior lecturer, Glasgow, and he was on his way to see me actually. So it was like, literally we were recording some stuff on occlusion. It was really like an unusual story. And it was a tuna, it was a seed. He had a tuna sandwich, which had seeds in it. And he just spit in it, fractured it, it’s palatal cusp. And I was like, yes, I mean, I was sad for him as well, but I was also, yes, let’s go photograph this now, like, and he’s a parafunctioning patient. So, he’d obviously weakened it and they just took the seed to fracture it. But, it was a paradox, wasn’t it? We were sort of sad for his tooth, but happy for our learning.

[Jaz]
It was a great lesson. It was a great lesson. But Riaz, I appreciate you waking up early or you’re up early anyway. But to make time for me this morning, I really appreciate it. And to help everyone, I think you’ve really introduced for some people, this will be a paradigm shift for other people is like, yeah, you know what, I’m already doing these protocols or they’ve already observed in nature, this happening whereby teeth are already coming into occlusion with your implant.

I wish we could go for a whole hour, but time constraints. I do apologize, but Riaz, I know you’ve got a great new program on implant occlusion. There’s so much more to learn here. We’ve barely just scratched the surface. Okay. Along with your other occlusion programs, along with everything you did at Elevate. Please tell us more. How can we reach out? Which websites to go to? How can we learn more about your programs?

[Riaz]
Well, first thing was I’m actually wearing the fire t shirt. So yeah, so the one thing with Nik Sissodia, Martin Wanendeya, top amazing guys, Sanjay Sethi, Nik Sethi and myself, we’ve created that implant restorative program.

So if you’re interested in restoring implants and I thank you Jaz for letting me plug this as well. It starts in February again, our new cohort, we’re going to teach you how to restore implants in a predictable way. You’d then sort of, yes, I do the implant occlusion day, which is just a one day on implant occlusion.

That’s on my profriazyar.com website and Elevate Dental. We run all our education programs through that. So if you want to learn more, if you’re listening to this, you’re going to be probably the type of person that will align with us well, because if you listen to Jaz, you’re going to be similar to the way we think as well. So yeah, come and join us.

[Jaz]
I would say wherever you are in the world, even if you’re in the States or wherever, I know you’ve got great connections, States, Canada, UK, wherever you are. It is well worth to come to the UK to hear Riaz speak, the way he’ll make you question everything and really make you think is brilliant.

One of the best educators I’ve come across full stop. So please continue to do what you do in this just short 45 minute podcast. Think about how much you’ve gained already. And some of the stuff that Riaz has touched on was higher level and stuff, but we owe it to ourselves. If you are, I mean, unlike me, but if you are restoring implants.

If you are increasing how much implant work you do, then to respect the occlusion side, and then to learn from someone like Riaz is absolutely key. But he’s got also all these other programs as well. So I’ll put the note in the link in the show notes for the implant occlusion course, but also all the other things, Fire and Elevate and stuff.

Even the sleep medicine stuff you’re doing. It’s just so much that you put out for us colleagues, but I urge you all to learn more from Riaz. Thank you so much for all your time and everything you’ve done for me and the podcast.

[Riaz]
No, thank you, brother. Thank you. It’s been a pleasure. Thank God for having a gift to share. So it’s a blessing.

Jaz’s Outro:
I appreciate it. Well, there we have it, guys. Thank you so much for listening all the way to the end. How good was that, right? How important is it to have clinicians like Riaz Yar to talk sense into us, to really question and challenge some guidelines that we have? Because guidelines are just exactly that.

They are to guide you, but we need to make sure it makes sense for us. So I’m hoping that resonated with you and it really resonated with me because now it just makes so much sense to me to get your single implant crown in occlusion exactly where you want it, rather than relying on what will inevitably happen, which is super eruption or overruption over time. And then you lose control of where that dot is going to go. It could be off axis. It could be on a marginal ridge that’s not well supported. And that never really made sense to me.

Now, obviously we barely scratched the surface. So if you want to learn more from Riaz, I’ll put the links in the show notes. And the best place to access the show notes is on our free app, Protrusive Guidance. All the episodes go on there for free. And then you can also get community access and paid plans to get CPD and CE certificates. If you managed to listen and watch all the way to the end, please let me know. Comment below, give it a thumbs up.

Subscribe if you’re listening on Apple and Spotify. This is how the podcast grows. And I really appreciate all of you, many of you, who have been following me now for coming up to six years. Can you believe that? I’m really excited because this is the last episode I’m recording before going on a family vacation, we’re going to Doha.

And to be honest with you, I’m really burnt out. I really need this holiday so I can come back, re energize and create some good content for you all. And man, I’m really looking forward to quality time with family. I timed this episode out. That’ll be old news, but I just want to share that with you. Thanks again.

And I’ll catch you same time, same place next week. Bye for now.