Chairside Denture Reline and Repair - Fast, Easy, and Durable

You're listening to the Phil Klein Dental Podcast. So chairside dental relines are one of those few dental procedures that have not really changed very much. Technique, of course, is pretty important, but as important is using the right materials. So today we'll be talking to Dr. Ian Shuman, a dentist who has been making dentures and doing chairside relines for a very long time, probably over 35 years. He will share with us some key tips and tricks and his favorite materials that he says never lets him down. Dr. Shumanhas been named one of the top clinicians in continuing education since 2005 by Dentistry Today. An educator and author, he is a pioneer in developing advanced, minimally invasive techniques, including the development and production of the V-Doc, a device used to measure and determine patients' vertical dimension of occlusion. Dr. Shuman, it's a pleasure to have you on the show. Thank you. Yeah, we're very happy to have you on. I know it's a hectic day and getting clinicians that are actually working every day to do a podcast isn't that easy for you. And we really do appreciate your time. Back in the middle of my nap time. Oh, you're in the middle of your nap time now. Well, that's even more valuable to take you away from that. Very valuable. I really mulled this over. Do I want to do this now? Do I not? Yeah, well, we could have only always done it after your nap. But yeah, they say napping is actually good for you. As long as you don't, you know, extend it too long and you don't get anything done. But napping, I think. Yeah, there you go. So I assume depending on the patient population of a given practice, some practices obviously are fabricating more dentures than others, right? I mean, that just makes sense. But overall, would you say that? Almost every general dental practice is involved with fabricating or repairing dentures at some level? No, I think at some level, for sure. Definitively. I mean, unless you live in a place where you're just seeing young people or children, for the most part, and most of us, you know, the older population that has dentures, frankly, it is an age-related thing. And they live in a lot of the places that we practice. I mean, think about Florida. You know, Florida is saturated with older patients with dentures. There isn't a practice there I couldn't imagine that wouldn't have to do some type of denture work or have some knowledge about it and do it in-house, by the way. Right. So what is this stigma about dentures where some dentists, some younger ones, especially that have been out for less than 10 years, don't want to really do a lot of dentures? with the demographics the way it is, with the aging population. I mean, dentures is a fantastic solution for some patients. What's your thought on that? What is it that they are doing? Is it a lot of crown and bridge? Is it a lot of implant -related, more exotic-type restorations in the mouth? What are they doing? Yeah, I guess they're probably focusing on more of a hybrid approach using implants. Yeah, and by the way, there's nothing wrong with that. I participated in a study. I think it was about before COVID, maybe about five years ago. And it was sponsored by one of the denture adhesive companies. I can't say which. The idea behind it was that there was a taboo when I was taught in dental school, and I'm sure you probably were taught the same, that denture paste or denture adhesives is a no-no. When in reality, it's actually really much a part of the game. So all these things, you know, doing these hybridized type cases, you know, with implant retained overdentures, which I love, by the way, I think they're fantastic. You have to have some type of background. And the more you have, you know, if you were taught in school to make a denture from scratch like we were. including the lab technique. We had to process, we had to buy our own denture flasks. No doubt, Dr. Shuman, things are changing rapidly in the profession and things are going digital. And as many things as you can do digital and replace analog, that's the direction we're moving in. And yeah, many of the dental students that are getting out probably aren't familiar with making a denture from start to finish, for sure. So over the years, how has the typical denture reline procedure changed, if at all? I don't think it's changed at all. I don't see a digital alternative to relining a denture. There's only two ways to do it. Both require manual labor. You know, both require an artistic touch, whether it's the laboratory doing it or you as the doctor. And you as the doctor have to participate on some level because you have to get an impression of that area of a full denture -less arch. And if you weren't taught that, how do you know how to get that? How do you know the anatomical landmarks that you're looking for? You don't. So you mentioned to me that you've always enjoyed doing dentures, even from dental school, right through your career. Is that still the case? I enjoyed it. It was my first, happened to be the first credits that I scored to end that part of the curriculum in dental school. It was the first because I got so many done so fast. So what part of your practice is dedicated to doing dentures? And that includes relines. Believe it or not, it's not huge. It's really not. I still have a, I'm still a small practice mentality. It's still just me and my front desk. After COVID hit, I lost my hygienist and dental assistant because we just couldn't keep them there for the three months that we were told to shut down. Yeah, I do. I miss people. You know, I miss the people I work with. It's kind of a jolt to the head. It's a kick to the head, really. No doubt, Dr. Shuman, COVID shook up the industry for everyone, especially hit the hygienists hard due to the fact that they were on the front lines of the aerosol. And some hygienists decided to move on to doing something else, either teaching or moving on to a completely different profession. And also what I'm hearing is the attrition rate. In hygiene school is rather high. Apparently some of the stats are showing 25%. So there is certainly a shortage of dental hygienists and dentists. Dental practices are feeling that challenge all the time. We need our team to be successful without a doubt. So getting back to the focus on this podcast, talk to us about the denture reline. How do you approach the patient with that option and what happens after that? Okay, so right away when I look at a patient, who comes in off the street, you know, or usually referrals most of the time. I'm going to decide within just a matter of seconds, am I going to rewind this denture or do they really need a new one? OK, that's a split second decision based on lots of different things. But I am going to interview them first so I can I can kind of get a feel for what it is they're looking for. Most of the time they'll tell me what they need. Most of the time, if you listen carefully, your patient will tell you what they need. And most of the time, if it's a reline, then we go ahead and we do our reline work in office chair side without having to involve the laboratory so that everything can be done while waiting by the doctor. And you can train your assistant to do this too. This is not a doctor required treatment. A dental assistant can be trained to reline a denture chair side. As long as the doctor checks it off and make sure that everything looks good and there's nothing sharp, could cut the patient, you know, nothing that looks weird, no bubbles, you know, just basic stuff. So you certainly have tremendous experience in doing realigns. You use the best materials. Are you looking at a timeframe of about two to five years for these realigns to provide good service on that day? assuming the denture is in pretty good shape when it comes in? Oh, yeah. Two to five years is actually a very optimistic number for most doctors. But to my practice, it's a reality that we have every day. We use Tokuso Rebase. It's called Hard Rebase by a Japanese company called Tokoyama Dental. And I've been using that. system, that product for about 25 years now. And just as a FYI for our audience, Tokuso Rebase was the predecessor of the newer Rebase, which is called Tokuyama Rebase 2. Sorry to interrupt, Dr. Shuman. Keep going. So yeah, I'm very, very familiar with it. And we do get about... to five years worth of life out of our relines. So you talked about the hard reline. Let's talk about the soft reline as well. What clinical applications would warrant a soft reline versus a hard reline? Well, let's say you're doing a pickup of an implant case. You have locator attachments on a couple, let's say four implants on the low. Of course, you would use the hard reline for that. That's not a place for soft silicone. But the hard reline is really easy to use. You just powder liquid, mix them up, dispense it into the denture. and place it in the mouth. And there's a couple other little things that help. Lubricating the teeth with like a Vaseline, a petroleum product. And then you don't have to worry. You're not going to sit there picking reline off the teeth because that's a problem. You can wind up breaking denture teeth like that. I know because I've done it. And regarding the flanges of the denture, any recommendations regarding how to treat the flanges versus the base of the denture? Well, you want to border mold a case when they come in and you want to aggressively border mold it. You really want to get an intimate contact and a very nice, even smooth kind of flowing arc to that denture base where it touches the flanges. So what are the typical signs that a dentist should look for in a patient that is wearing a denture? where a realign could be a fabulous solution to tackle that clinical problem? So generally, two things to look for. One would be burning, a burning sensation, which means that the denture is impinging on either the mental nerve, right guys, or the nasopalatine nerve. the incisive nerve, whatever you called it in school. And then the other thing are denture sores, sores in the mouth, just areas where when the patient, you know, bites down and they close and they're functioning, it's causing a repeated jab into that soft tissue. And generally, for both, both can be solved pretty much through occlusal adjustments. And doing that occlusal adjustment, that's after the reline is finished. That's after the reline is finished, for sure. Yeah. So after the reline is completed, it's important, obviously, to ensure that the VDO is ideal. How do you measure that and determine and discern that the VDO is where you want it once that procedure is done? We have a device called the V-Doc. VDOC, Vertical Dimension of Occlusion Caliper, and we use that to measure, take a pre-measurement from the ear to the outer canthus of the eye, and that measurement is the same as vertical dimension on opening. So we deduct three millimeters, and there's our vertical dimension, and we measure it from the nasal spine and under the chin. Those are both bony landmarks that never move. When I was in school, we were taught to draw a pen on the nose and the tip of the chin. And the problem is the patient doesn't come back the same, you know, week to week with spots of ink on their face. So if you notice after a reline that you've lost vertical dimension from that device that you just explained, what do you do then? If you lose vertical dimension, you need new dentures. To reestablish, reestablish vertical dimension through relining only. If you've lost enough to make a difference, then it's time for new dentures. Or option B is to just build the denture teeth up. You can do that chair side with composite. Yeah, with composite. Yeah, you sure can. So you talked about the hard reline using Tokoyama Rebase 2. What about the soft reline? I know there's something called Softliner Tough, and that comes in a soft and medium version. Tell us about that. Yeah, that's the soft line version of Tokoyama's denture reline products. So one is a little firmer than the other. The soft of the two, or the one that's softer, I generally will use indentures if there's healing right after having implants placed or dental or extractions, tooth extractions, or any kind of oral surgery where they might have sutures involved, that sort of thing. The medium body, that's more for doing a full lower reline, for example. Patient has a full denture and they need the whole thing relined. That's when you go to a medium body material that won't be as likely to peel off or break down. So if a dental practice has an armamentarium of the rebase two for the hard reline, and then they have the soft reliner tough, which comes in the two versions, soft and medium, then they're all set. to do denture relines. Yes. Okay. And what about finishing these dentures off after you do the reline? What do you use as far as rotary instrumentation to finish them off and polish them up, the flanges? The hard reline, very, very little. I'll go to Brassler makes. They look like bullet-shaped burrs. They're like all silicone. And they come in three colors, but I can't remember the name of them. One is blue, one is pink, and one is white. Yeah, I just pulled them up on my screen, Dr. Shuman. They're called Acrylopro, Acrylopro, as in acrylic. They're silicone acrylic polishers. So those are the ones you're talking about. And they are by Brassler. We use those to actually remove any excess hard line material. And at the same time as it's removing the material, it's also polishing the denture base at the same time. I like to solve problems two to one, you know, makes life a lot more pleasant and it gets me to the next case. And what do you suggest to adjust the soft liner material? Soft liner, real easy. You just take a blade, a really sharp blade and cut it, cut the excess and that polishes it right there. And that's it? Yeah. Getting back to the hard reline, what kind of preparation is necessary to be performed on the inside of the denture? With a hard line, there's very, very little you have to do. Because remember, you're adding to it. And taking away material from the denture base, which I think some programs have been teaching to do this, but I think it's wrong. The best thing to do is, because if you take away material, it won't seat properly. You know, it doesn't have that, you know, proper orientation. And then you're really screwed. Then the patient needs a new denture. Then you've ruined any chance of fixing this thing. So the best thing to do is buy yourself a sandblaster, a micro etcher. I got mine from Danville years ago. I don't know if they're still selling those. But micro etcher and we blast the inside of the denture and that gets it ready. It cleans it and it gets it ready for a bonding of the hard liner. Right. And you also need to bond the soft liner too, right? With some sort of primer? Correct. Both come with primers. They both come with their own primers. Do you suggest one coat of the primer? Because I've heard that if you put too many coats on, it can actually compromise the bond. The opposite. We have been teaching the doctors to put on about three coats of primer for the soft lining, a soft liner. For the hard liner, just one coat is enough, I found. The reason the silicone liners need more adhesive. So let me switch gears for a minute here, Dr. Shuman, and let's talk about revenue. You know, we are running a dental business. Every dental practice is a business. We have to pay our bills, pay our staff. We have to make money. make a profit and take care of our families. And that's, that's, you know, a big part of it. So how profitable is relining a denture chair side? Can you make that a profitable procedure? Well, if you're working with insurance, nothing's profitable, unfortunately, you got to do a lot of it to make money. But fee for service, it's highly profitable. Absolutely. If I'm sure I basically charge $500 an hour. regardless of what I'm doing. Generally, that's my fee. $500 in it. You need to figure out what you need to charge in your life to have your retirement and all that. All right. All that good stuff. So figure it out early. Have your accountant do something. No, that's an interesting point. So you don't take insurance or you just... No, we work with the PPOs primarily. But outside of that, no HMOs or managed care, nothing like that. So if someone's in the PPO model, you accept whatever their insurance pays? We do. And so accepting that fee is usually about half of what we charge. Okay. And I'm not prepared to pay a lab fee on top of a reduced fee for a denture reline. Right. Yeah. So how does, in wrapping up this podcast, how would a lab be involved with this if it's a chair side procedure? The lab can use the same material chair side. Labs are, I think they have, I don't know if they have kits specifically for labs, but the labs can certainly call and find out. But yeah, we have labs who use that stuff in their laboratory. The reline material? Yeah, for their relines, yeah. Okay, but if the patient's not there, they just do it on a model? Yeah, they do it on a model. Correct. I see. I see. Interesting. All right. Well, I think we covered everything. It sounds like to me that it's important to have the right materials. You've been using the same stuff for a long time, so obviously you're sold on it. I don't know how many other companies even make re-line materials. I assume others do. Yeah, very, very few make them. Very few. I think you've given us some really good insight into doing chair-side re-lines. Again, we appreciate your time on our show. Thank you. Okay, sounds great.