Dentistry Uncensored with Howard Farran
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285 Today's Concepts On Overdentures with Joe Massad : Dentistry Uncensored with Howard Farran

285 Today's Concepts On Overdentures with Joe Massad : Dentistry Uncensored with Howard Farran

1/11/2016 6:42:37 AM   |   Comments: 1   |   Views: 642




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AUDIO - DUwHF #285 - Joe Massad



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VIDEO - DUwHF #285 - Joe Massad

  • Dr. Massad’s mentors
  • Proper prognosis
  • Bar vs. Stud vs. Fixed Implant Prosthesis
  • And more!


Dr. Massad is in private practice in Tulsa, Oklahoma, a Fellow of both the American and the International College of Dentists, a Regent/Fellow of the International Academy for Dental Facial Esthetics, and is a honorary member of the American College of Prosthodontics. Currently, he holds faculty positions at Tufts University School of Dental Medicine in Boston, Mass; the department of Comprehensive Dentistry at the University of Texas Health Science Center Dental School in San Antonio, Tex; Adjunct Associate Professor, Department of Restorative Dentistry, Loma Linda University, and Associate Professor in the Department of Prosthodontics, the University of Tennessee Health Science Center, College of Dentistry, Memphis, Tennessee. He has previously held a faculty position at the Oklahoma State University College of Osteopathic Medicine Oklahoma, is a past Director of Removable Prosthodontics at the Scottsdale Center for Dentistry in Arizona (2006 to 2010), and from 1992 to 2003 was an associate faculty at the Pankey Institute in Florida.


www.joemassad.com 




Howard: It is a huge honor for me today to be interviewing a legend, a complete legend in removable prosthodontics, doctor do you like to go by doctor Joseph Massad or Joe Massad?

Joe: Well my friends all call me Uncle Joe, so that would be fine. 

Howard: I want to be a friend, I'm gonna call you Uncle Joe. Uncle Joe Massad is in private practice in Tulsa, OK, a fellow of both the American and the International College of Dentists, a regent fellow of the International Academy for Dental Facial Aesthetics, and is an honorary member of the American College of Prosthodontics. 

He currently holds faculty positions at Tufts University school of Dental Medicine in Boston, the Department of Comprehensive Dentistry at the University of Texas Health Science Dental Center in San Antonio, adjunct associate professor, department of Restorative Dentistry Loma Linda University, Associate Professor in the Department of Prosthodics the University of Tennessee Health Science Center, College of Dentistry of Memphis. He has previously held a faculty position at the Oklahoma State University of College of Osteopathic medicine Oklahoma, is a past director of removable prosthodontics at the Scottsdale Center for Dentistry in Arizona from 2006 to 2010 and from 1992 to 2003 was associate faculty at the Pink Institute in Florida. We both have in common that we're both good friends with Jennifer De Saint George.

How did you meet Jennifer?

Joe: Actually she was in Tulsa and gave a little talk, and I was impressed. That's when she was with Demoland and Demoland, that was way back when.

Howard: I did not know that she used to be with them.

Joe: Yeah. Then she was going to be in Dallas, so I took my entire staff and it was just really our staff and one other office. We did some training way back when, this is like in the 70s. Known her ever since. I even filmed her once doing some things which was a lot of fun.

Howard: How did you become, I mean, when I went to dental school in '83, you were already a legend. How did you become a legend in removable right out of the gate? I have to admit, most everyone agrees, removable dentures, especially the lower, is probably the hardest thing we do in dentistry. I don't think anybody, most people would you have met did not like removable? They would rather do a crown or a filling, something far more predictable than a removable denture.

Joe: I would say everyone tried to stay a long way away from that. Or, they would say I'm going to charge you so much for the upper denture and give you the lower one free. I guess to answer your question, early on, my first major case after I graduated from Loyola in Chicago, I came back and I bought a prosthodontic practice. The individual was actually going to the VA, didn't even stay the anniversary to his patients. I was able to jump right in and then the very first patient I had was my mother in law, and I'd been married for two years, she's a lovely lady, but never really looked in her mouth. My father in law said this time you need to take care of your mother in law, so she was the first patient.

When I took a look in her mouth and she had upper and lower dentures, I took the upper and lower out, it was hollow. I saw an upper that was as flat as a pancake, and the lower was worse than flat, it was actually curved like the inside of a canoe leaking water. I'm looking at this oral space and you have plenty of space, but then how do you take care of tissues that are like cellophane and sub-negative ridge cases? I tried what I knew from school, things didn't work as well as I wanted, so then I began to seek out 5 individuals who were much older than me and didn't think they would even talk with me, and I was able to reach out to Thomas P. Shipman from Memphis, who is just an amazing individual in prothodontics, and then to Dr. L.D. Pankey, tremendous individual. Then I went to Dr. Kenneth Rudd, Kenneth Rudd and all these people had passed, was one who wrote the purple textbook in partials, and he was the one who appointed me 25 years ago at the University of Texas.

From him I met John P. Thrush. Dr. Thrush was the man who developed dentalgentics. Fisher and Thrush published aesthetics and cosmetics before anyone was talking about it and about how to make people look good. Then 5th, and the only one still living today, is Dr. Frank Cesure. NO one heard about Frank and he had a textbook out that came out the year I graduated from Loyola in Chicago. Him and Dr. Vic Breeson, and I sought after these 5 individuals and asked help. I've got this case, I don't know how to solve the problem, can you help me?

Each individual took me in as if I was family, I don't know why, but they did. I know there was something special about that, and they all gave me an idea. They all said how about this, how about this. One individual says put in a soft liner. The other individual, Dr. Shipman, said put them in a metal base, lock hold it down with weight. Everyone kind of gave me an idea. Then Dr. Cesure said what she doesn't have any bone, does she have any musculature? I said yeah. Let's now think about using the muscles of facial expression and mastication to shape the outer bounds of that prosthetic and that way it will be held in almost like you're holding a newborn baby where you hold the baby to your chest, and you're holding it in so it won't fall. 

Then I began to put together a metal base with the soft liner, because we heard about soft. Then I decided now not to put people from the retro-molar pad to the cuspid and draw the pound line because now we take a look and there's really not much anatomy in the mouth, it's reabsorbed. I said well how are we gonna do that? Then we actually took the muscles of facial expression, mastication, we were able to measure those and that became the 3rd dimension. Then we began to, I did trials on my mother-in-law, and the first one I did she said it felt too tall. She thought she was going to fall off. Like you spin up a chair and your legs are dangling and you feel like you're going to lose your balance. I found out the metal base needed to be closer to gravity. 

One thing led to another and I was able to solve her case within a few years with combining. Then my waiting room, and I wish there were still people there to attest to this, began filling up with people with negative ridges. I can tell you as of today, people who are not able to have implants, I can make them a lower denture, and an upper, with flat ridges, and they can open their mouth and it doesn't move. 

As testimony everyone who comes to my in-house courses, they will actually themselves look into negative ridge cases and we will actually take a muscle impression and we will show them how that lower prosthetic doesn't move when they open, doesn't pop out.

The key was not one but taking multiple methods and beginning to bring them together in harmony and really just kind of taking some of the politics out. Not that dentistry was doing anything wrong, I had 5 different text books when I was at Loyola. Think about, that's a lot of textbooks in removable dentures. Over a period of years, we began to perfect it to where that was the alternative to these people with negative ridges. The 5 individuals who helped me that I named I show them at every single presentation and say I would not be here if it wasn't for these individuals. I still talk with Dr. Frank Cesure, who is 94 years old, and fighting cancer. I took his book and went through it a dozen times, and by the way his book, you've probably never heard of it because it didn't get out. It got out to only a small group. There's not a school today that has the textbook. The textbook is out of print. It was amazing. It was just slightly before it's time, and therefor, there's so much information now why take something else?

I was doing veneers in '75. Hand cut veneers in '75. Where dentistry is advancing not really realizing that we would have as many dentures patients as of today, not realizing that we were gonna be living to 85, 90 years old. Most of the studies in denture construction was reported from Berkeley's study in 19 ... they state in 1936 the life expectancy of a woman was 60.5 and a man 56.5, because that was the study they did. Most everything was predicated on people living to be around 60.

If you think about it, 60 still has a little bit of muscle tone. Now today you incorporate age, and you incorporate with all the different medications that people are getting which actually what effects musculature. It was a missing link. Now I've been very honored and I have some great co-authors, we will be publishing the neutral zone, contemporary applications of the neutral zone for all of prosthodontics. That will be hopefully out, Wiley I think will actually be releasing that February of '17.

It's a compilation of the missing link that doesn't just work in dentures, it works for replace implants. In 2000 either 6 or 7, maybe in 2009, the JPD awarded Dr. Dave [Cagna 00:12:11], myself, and Dr. Frank Cesure the adjusted [hickia 00:12:10] award for the best clinical article of that year. I didn't know how big of a thing that was, and that article was, we were placing implants from making a prosthetic differently than we did before and incorporating the muscles of facial expression and mastication, and so we actually had the outer [archamial 00:12:38] surface and within that [chamial 00:12:40] surface is where the implants were placed. As opposed to on the [osseous 00:12:45] ribbon, where implants may be like a picket fence and you have to make that prosthesis around that picket fence and therefore it doesn't feel natural to the patient.

It was a long answer but I had to kind of get it out because that's what it was. It came from 5 individuals who took me under their wings. They've been in my homes, I've been in their homes, we were friends, and we worked together for many, many years until they all passed but one. Frank calls me and I call Frank at least every week, just to say hi. So Dr. Cesure is still out there. 

Basically, that's how it began, everyone said he's the denture guy. Well you know what, I'm proud of it. Not only am I proud of it, I'm doing more fixed cased and more implant cases, more implant denture over denture cases, than I've ever done in my lifetime and it's with a protocol on an algorithm that has been developed with a new method of making a prosthetic.

Howard: What are you thinking today when you're making removable dentures?

Joe: The very first thing we do is we do what Dr. Pinky said, which is almost impossible, which is get to know your patient first. It is very difficult to get to know your patient. What we'd advice, and I do this over many, many years, an assessment and evaluation that will give us not just a diagnosis, but a prognosis. We have to begin by analyzing the patient, as they are the day they're in your office. I don't know if I could even show, I just did a little screen capture here, but basically if you and I could take a look ... now if this doesn't work you tell me, I don't know where the camera is on this one.

Howard: Very nice.

Joe: Take a look. I'm going to make an assessment of a patient the day they're in by taking several pictures. In this case I can double click and I have the patient's face as they are just barely opening, and then I can analyze that with examples of different mid-line discrepancies, asymmetrical discrepancies. 

This was the one thing that almost all the dentistry would complain about. I got the case done, ad the patient was upset and they thought the mid-line was off, or they thought they showed more teeth on one side than another side. All the problems that we had, we analyze those, and then my philosophy turned to be anticipate everything you do will fail. If you anticipate failure you can intercept it. Because if you go around the globe, which I have been so fortunate, people are people, they have the same problems, dentists will have the same problems we have. You could do the most gorgeous dental work and yet a patients perception of what they should look like is going to be different than what we believed.

We assess them as they are. If they have diminished capacity, they've lost fat in their face, if they're concave or convex, if they have asymmetry when they speak maybe on one side versus another, and the mid-line is all in the eye of the beholder. All of this is now identified with the patient and we sit down and we say here's where you are, and here's the things that we're going to be able to do. By the way this mid-line discrepancy is pretty normal, but you have one. 

We are now letting people know in advance of all the problems that we've heard from other dentists. Now we intercept this, so the first thing we do is a facial analysis and then a very complete evaluation on that patient. By the way, it takes 15 minutes. It's all on an app. The app actually will, I published this in 1983 in compendium, then we went on and said gosh, now we've got to take it to where these guys won't do it unless they do it in 10, 15 minutes. Now you can do an evaluation in about 15 minutes. Your assistant does a lot of the photo taking and you don't need a separate camera. It's all done with a mini iPad. Everything now drops in, and then you can analyze they're bony contours within minutes and it gives you a conclusion, it adds up all the numbers, you let the patient say here is what I believe I can do for you. Now we have diagnosed and we are now prognosing what we can and can't do. We understand that.

Once the patient then accepts then we have to do our job. We must make the absolute best foundation, we got to prepare the tissues for an impression. You just don't make an impression. The tissues have to be healthy. So we get the tissues healthy, and we make an impression, and we're able to do it in a single appointment in 12 minutes, better than what we did in two appointments. We could eliminate that one. Then we developed a protocol, tested the protocol, and then we developed the algorithm who does what. Who's on first base, who's on second base, and so forth so we could now mimic what others have done in medicine. 

What is the number one thing in medicine in the last 100 years that has saved more lives than any other procedure?

Howard: What?

Joe: It was the bypass procedure developed by DeBakey and Cooley. The heart pump was developed way before that in 1952, but then they utilized the heart pump to bypass why they took out Venus and now they're doing arterial grafts, and they then perfected the grafting procedure which is all over the world today. They had a protocol and they had an algorithm. Who did what, who is responsible for what. Dentistry only got that when Dr. Branemark developed the implant he had a protocol. Round burr, first [reimburr 00:19:29], two reimburr, second reimburr, slowly increasing this. Then he had an algorithm with that.

In dentistry needs to continue also, we have a protocol of a diagnosis prognosis, and then we have a protocol for impression making. Whether it be this is a very atrophic patient, whether it be the implant patient, whether it be an over denture, whether it be a fixed case. Impressioning now has really changed significantly and we're scanning also. If you look at full cases, you have to make an impression. There's too much tissue there. Are you going to scan the impression? Or do you actually make a cast? We have a method of doing a cast in six minutes that is very accurate and one of the rationales is I would rather scan the cast because I have control over what I want to be scanned. If a non-dentist does a scanning of the dentious ridge, they may overlap the borders more because they don't know everything you're looking at. If you and I take the impression, and with a method that we've developed you will box everything out except the part that you want to be utilized. Then the film cast becomes really someone who is not as educated as you and I in dentistry, they can do it.

What we wanted to do was look and who's doing this work and we can do that in six minutes. Doesn't mean I'm not also scanning the impressions, I'm doing both. I will tell you from a practical standpoint where we are today that is a much more accurate method because we have to be responsible as dentists where that needs to be.

Then we went from impressioning and what was the number one problem of course was diagnoses and treatment plan. Number two was fit. Dentists would put in an upper denture and they'd get nervous because as soon as they would put it in and then they would begin to move their hand away from the upper they were afraid that the denture was going to follow their hand - this is an upper not a lower - and they would get nervous and sweat and their heart would beat. That was not predictability. We should be able to predict the retention and demonstrate it to the patient at the time of the impression.

That was the very second thing we did, perfect the impression process following a specific protocol with an algorithm that has been studied many times. Published probably now 20 times.

Then we went to what was the next thing? Taking occlusal records. We've always had that. If you are without teeth, we find that it's much much better to use a new improved graphic arts tracing device. These were developed in the 1800s about 10 or 12 different variations. It's easier for us to get a patient not to give us resistance. When you grab a jaw, especially of a dentious patient, they don't have the same appropriate reception you and I have. They begin to resist. We did surveys and four out of five dentists said yup, every time they get ready to manipulate they have resistance.

Actually I had a student and he admitted to me mind you I'd fall asleep. Now for me to do that insistently in a private practice every single day becomes difficult, because you really have to be focused. Then we said now we have to perfect the bite. How do we get the best occlusion we can? From there we had to now look at how do we now take the muscles impression? Now we take a neutral zone impression of the patient's swallow and we take the inward pressures of the lips, cheeks, and the outward pressures of the tip and the laterals of the tongue, and then at the time of the try in we do a cameogram.

People haven't heard about cameograms. It will be published in March Dentistry Today. It's a new term in dentistry. Basically that is the third dimension. So you have a height dimension, but where's that horizontal position? Do I know the thickness of where I should be? Do I make it real thin? If a patient has very weak musculature, I can do a cameogram and fill out their lips from the inside before I put any type of fillers in. We're doing fillers but we can do a lot less if they have poor muscular, we can cameogram these patients and actually now fill the outer surface. 

Then that leads to, when do you do a fixed implant and when do you do a removable? If you have deficient facial features, you're probably better doing an over denture because you can use the flange done correctly with an impressioning of that space, that will help the patients fill their faces out. The of course your vertical we can open and help that. If you're doing a fixed case, it's a little more difficult to project too far out, because then you get far away from the implant it's a little harder to clean.

All of what we've done in removable is now being transferred to everything we do in all implant cases for people who are needing immediate dentures. If you have all your teeth, and I'm going to remove them, do I have to put them right back into the same place that you have them? Ir could I do something different? Could I make them project better? Could I do some characterizations? I don't know, until I do a cameogram. 

So I will cameogram the ... I will inject material into the vestibule all the way through the teeth and have them go through a smiling sucking motion and if whatever I'm left material, it may bleed all out, then I know I can't really move them. There muscles are too strong. Many times these older patients I will get a cameogram that can be two to three millimeters in thickness. If I've tested that and I'm sure of that, I can take those teeth and I can bring them out labially. I can actually now create an immediate that looks much ore natural and I don't have to follow everyone's individual tooth, where it was. It's altered what we do in removable prosthetics.

Now a byproduct of that is patients will say, and we've done multiple studies, I'm not tired with these in my mouth. They also say, I don't get food underneath my prosthesis like I used to. Then here's the third thing, and it's all the same they're just saying different things. This is what you want. I am not aware that I am wearing an artificial appliance. That's it. They're not aware of it. They're in the equilibrium of the inward and outward muscles. They're within the confines of the neutral zone, which you know Dr. Dawson always talks about, and those people don't have an awareness they're wearing artificial appliances. In fact it's comfortable for them.

When you start out and said how did you find it, I found it by going to five individuals and researching literature to try to help my mother-in-law. Then as time went on we began to look at what other applications it has. It's never been published yet, our first publication, it will be right before our textbook will be in March. I did this with, actually prosthodontic faculty were my co-authors from Tennessee. It was pretty amazing because they got it. Immediately. They got it. These are top-notch prosthodontic individuals and they get it. 

Basically now we have a protocol. Did dentistry accept this? Not for a long time. The reason they didn't is because they were doing other things. My first publication in JPD, which Dr. [Pankey 00:28:40] and Bill Becker down there, and Pankey encouraged me, was highly criticized. That was probably the best thing that could have ever happened. We had negative criticism. You're violating this. You're doing this. Dr. Hickey, rest his soul, who was the first editor or Journal of Prosthetic Dentistry said Joe I'm going to have these guys go ahead and write in their comments and you can rebut those, and we did. Multiple times. It went on and the awareness now is what we got. 

Yes, maybe people thought I was a charlatan, that's okay. The awareness. It took from 1987 until 2008 for that one publication to get the top Justin Hickey award, best clinical article. Dr. Cagna, Dave Cagna, who was the primary author who did all the research, it was my case that I worked on, and Dr. Cesure, at my office editing the case with me, received the award at the restorative academy. Now he's Associate Dean at Tennessee and had a graduate, a very, very intelligent man, but was not afraid to look beyond what we had in dentistry because it was the right thing to do. It's been there, it's been right in front of yours and my eyes, we just didn't put it together. I'm just a recipe guy. I just took some stuff and made a new recipe and then started applying it differently.

Everything we have in life is loaned anyways, so everything I have has been loaned to me by someone, so it's my go to try to get the word out to as many as I can because we are effecting implant placement, we are effecting the overall final restoration for those patients who are having full mouth implant restorations. Still helping those people who cannot have implants because they have such diminishing ridges that you can't even see the ridge. All you see is a little bit of the chin because they've got negative ridge cases, the tissue's like cellophane. Yet we help these people. 

I've always said, if tomorrow's my last day, I've had a great run. Even with the early on criticism, I didn't flinch, because I had these five guys behind me and they were saying keep doing it. They didn't even know the recipe but they gave me a part of it. As we put it together they started pushing me to go speak. I said I'm not qualified to speak. They said yes you are. Go do it. You've got to shake it up. I did. It's been great and we're applying this to most of dentistry today.

Howard: Let's go to the next step. If someone already has a denture and the dentist is thinking well maybe I should do an over denture. We have 3M has [M-Tack 00:32:06] with the housing unit, you have the Sterngold where they have a square and you don't need a housing. There's hater bars, Dolder bars. Will you talk about adding something fixed to the denture and what are your thoughts on those today? That's been a long evolution.

Joe: When a patient has the ability to have implants with a decent prognosis, that would be what we would recommend. You and I we really don't know what that patient really wants. They probably all want what we can't give them, but still, I don't over-treat a patient. If they come in, they've been in dentures for years, I have to know what's upstairs and downstairs. Am I doing something upstairs? Am I going to do something on the upper ridge, or just the lower ridge? I did something just on the lower ridge, I would actually then plan on maybe doing studs and not necessarily a bar or a fix because then if I put something too heavy on the lower, and they're not doing anything on the upper, when they close with their fore speed increased, the upper begins to loosen. You must tell them that. Now they're going to chew and they can press the soft tissue on the upper and the upper begins to get a little loose.

If I'm going to do double jaws that's a different story. If I'm only going to do a single case on the lower only, then I would gear toward something simple, something easy to clean. We have a protocol of implant hygiene which is very, very important. Every patient has this agreement to do. If we're doing just for example an over denture, let me pop this off, and you've got all different types of attachments, I think this is probably the, there we go. I think this is probably the newer one for the Locator for example.

Howard: Who is that made by?

Joe: This is Zest Locator, now I think owned by someone else. They have now a little different profile. They have the original and they just came out with the newer one, okay.

Howard: Okay.

Joe: Also [Zurgotte 00:34:41] has come out with a small ball attachment. The difference in their ball attachment is the retentive element. Everyone complains when they get stud attachments, whether it be an ERA, a Locator, whatever, that the nylons wear out and patients have to have those changed. There's reasons for all that. They don't clean, they get bowel form and calcious in there, they have high alcoholic content or they have acid regurge or they put them in materials that they shouldn't. Or we have very a-parallel, non-parallel implants. 

That becomes an issue in advance letting the patient know that there is maintenance. Every patient is different but the newer little ball attachments, they don't have nylon, they have a silicon ring and we have now changed about at least 30 or 40 from the original either ERA or Locator and put these little balls on there with the snaps and it's amazing. These patients don't generally come back every six months or every year, they're much longer. The silicon in my opinion, and even those early on, so this is just my clinical experience and nothing in the literature yet, I think will outlive the nylon. I think eventually the manufacturers will be looking on how to improve the resilient material that goes into those. 

If we're doing an over denture, over a dentious upper, it's fine. Now let's say I want to do a bar. Why would I want to do a bar? Well maybe I have natural dentition on the lower, I'll put a bar on the top. That makes a lot of sense now because the teeth only have so much movement with periodontal ligament. If I just did a stud upper, which I could, there would be a little bit more buoyancy, because remember the denture on an over denture stability is the ridge. The retentive elements just keep it from falling out. If you're really going to look, stability and retention are different. Retention is from that.

Then maybe I would think about if I had natural dentition on the lower, I may go ahead and consider doing a bar or even a fixed case. When you look at a fixed case, I think it's important. This is just a bar case here, and this bar we had some micro ERAs, and then on the back we had small little hater bars where I put gold clips, because gold clips would take the least amount of space. Wen you have space issues.

What has not been addressed, and is being addressed more and more, there is a rationale for a rule about how much space from the ridge to the face do you need for a stud? How much space vertically do you need for a bar? How much space do you need for a fixed case? You've probably seen some cases where people have had maybe even studs and you look at them and they have big long teeth on the bottom and long teeth on the top. Maybe that's the aesthetic way, but, what happened was they didn't have enough room between the ridge and the face so they had to overbuild the prosthetic and do what? Violate the occlusal plane. 

As rule of thumb, there's been multiple publications on this, we need an average of 10 millimeters vertical height from ridge crest to the lip it rests, for example, either upper or lower, to put in a stud. A bar we may go 14 to 16 millimeters and a fixed case could go maybe as low as 13 because you're going to be screwing in, with the zirconia you can screw right into the teeth, to 16. There is a range. The less vertical space you have, then the smaller the denture has to be and you can't make them so small that they're going to break. We have to know spacing. That's another factor.

If I'm going to do an upper and a lower, this only shows you the bar, this is a bar lower. This happens to be a two-in-one, it's a little bit different aspect here. We could have done a fixed in this case, but what we did on this case, this was in individual who was about 350 pounds, he was a football player, ex-football player, gigantic, he was a class three. I wanted to make him something he could clean, but I wanted to make him something that I could repair. I figured he was going to break it. 

What we did, is we had a bar fabricated and then over the bar you'll see I have another bar and there we go, and this other bar, okay, if you can see that, the inside of this. Look at that. Slides right on. This is where all my teeth are. You see those little studs? I made the denture and I transferred it and I made two of these. So if he breaks one of these I can fix one and then put this back on and the patient doesn't have to go without anything. Now I'm looking at practicality for this patient who came from Chicago to me, in Tulsa, to fix his case. I said you know what, we're going to do something. I'll give you two of these things and I'll give you one of these and you gotta go see your periodontist every three or six months to make sure your gums are clean.

The on the upper, we could have done the same thing. Here's the outer surface and there's the inner bar. However, because of the [perosti 00:41:16] the bone on the upper not being as dense as the lower, I went ahead and changed this design because this is where the teeth went. It just slides right on. It has a little hooking mechanism. I decided to go ahead and just make him an upper denture, but there was a reason for that. NO just because I only had four implants on the upper, is because of the amount of pressure he had. He was a class three, and he was over closed. Being over closed gave me the ability to rotate his jaw open to get a better [inaudible 00:42:07] space, bing the jaw back. I still really couldn't get the teeth until I did a cameo impression with his natural dentition. I was able to project those teeth from a muscular stand point of view to where he got to be beautiful end-to-end case. I couldn't have done that with this type. I needed the flange for that. There's a rationale why we would do that. 

Plus it was a little bit I think safer for him, because of his bite. In fact he broke a couple of the provisionals which gave me another indication that this guys is going to have some problems. When we have the ability to do fixed, even though we have had some early failures with some cracks, we are now, if room permits, we are now doing a metal and now a zirconia goes over the metal. Very similar to what we did here. We would have a metal bar and then we would screw in the zirconia into the bar. We have seen a little bit more positive successes on those. Not that full mounted zirconia is bad, it isn't, but you could have the perfect occlusion and we do see, and I'm getting dentists who are calling me often, they're getting little cracks in them. Very soon we'll have that problem resolved. We keep resolving problems. If I have a problem, then I have to resolve it.

If I have to anticipate that what I do will fail, I have to anticipate that even an over denture will break, even though I put metal frame in it, or they're break a tooth. Then I have to intercept that and I have to know what to do. I have to know how to maintain them, inform the patient of maintenance, and let them know what the cost is going to be to clean them. 

For example, to take this bar off, there's six screws. What's the recommendation? They don't really tell us. When you take this off and clean it you need to change the screws. Those screws are not inexpensive The patients needs to know that. Why do you need to change them? It's a safety factor. If you ever put one in and couldn't get it out it's because the thread stripped a little bit. The locking screws you could slightly over torque them, and then you can't get them out, or if you do get them out, you know. Patients are told maintenance is going to be X, Y, and Z.

To answer your question a little bit more fully, natural dentition on on the lower, I would probably put a fixed or a bar on the top. It all depends on the space that I have and do I need to project the patient from an aesthetic point of view, or can I leave the patient's teeth without having any flange? One is going to be based on cosmetics also. How much I can fill the face,

If I have upper and lower, I can do fixed over fixed. I could also do an over denture if maybe I flt the upper face needed to be filled out more, then I could probably do an over denture to get more of a cameo surface to help give us better appearance, you see? Now it all becomes what's practical, but I would not consider doing a fixed zirconia on the lower with a dentious upper, because now you're going to be pounding on that. 

If the patient is just going to be transitioning and know that they're going to do that, then that's a different story. We do transition patients from a few implants to more.

Does that answer your question there?

Howard: Yes, were those mini-implants or were those larger root form implants?

Joe: Those were just conventional standard implants.

If you want to get the small diameters, we do those, they generally do not have changeable platforms. The way I gear those is a patient in their mid 70s for example, you look at their life lines, and you don't want to do a lot of bone trimming because they have narrow bone. If the distance between the ridge and the face is acceptable, there' nothing wrong with doing small diameters. I actually gear those to a one-time use basically. Hopefully they'll be in there the rest of their life, but I wouldn't put one one necessarily on someone who is 35 years old because I could never change the platform and you know things are going to wear. If I do age specific and health specific, older patients, not in the best of health, but they need something to give them that nice quality of life. That would be a great thing to do. You're able to give it to them for a nice cost. You can do them right in the office. I have some small diameters that have been in for, I don't know, eight, nine, ten years. They're still there. They still have to clean. These are generally older patients.

That doesn't mean you can't do them on younger patients, I just do not have any many options because I had the single platform, you see.

Howard: You have amazing DVDs and programs online. If one of these dentists is listening to you right now and wants to learn more, how could they learn more of your technique? How can they see more of the whole Uncle Joe process?

Joe: Rather than waiting for the textbook to come out, they can go online and there are three different locations and I have close to something like 20-something hours available. If you go to ADA online, see online, they have a series of presentations. Also, University of Texas, San Antonio Health Science Center, I think I have eight or nine hours in that area. It's basically on their streaming video sites. Then also if you go to dentalcare.com, which is actually a Proctor & Gamble website for dentistry, you go to their education section and just type my name in, you'll see a lot of case studies. You'll also see the examination process. 

I probably have maybe five or six hours on there.

There are still videos that are being sold, that I've done, DVDs, even though we've improved them, the principals of those DVDs are the same. Why are we not doing additional DVDs is because we're going more digital and it becomes much easier.

Let me just show you. The manufacturer who makes some of the things that we've actually developed, they have a little card, in the card is the USB. You see that little USB?

Howard: Yes.

Joe: They've got eight videos of directions for use of each and every product how you use the tray, how you use that. They did a good job when they said we're going to put a little USB and just give it to everyone. Plus you can go online, their website, Nobillion, they've got them all online. You got to my website, which is joemassad.com, you can find tons of things there, including tips of the day, which are free.

We have done our best, besides that and YouTube, to get out as much information as we can. Me being a private practitioner I'm not a businessman. I probably should have you consult with me early on my years. Basically the people who are making the products are much more business orientated then I am, so they know they have to get the information out. 

I also do about 25 to 30 U. S. presentations a year, and then I'm doing overseas anywhere from, years change right, anywhere from five to seven. I go to China almost every year. I think I could got here for 20 years I'd still ... there's a lot of dentists there. They're placing lots if implants, and yet they don't have some of the information we have. I'm kind of waiting to see if they're going to have a failure rate on that. They're exciting and excitable about dentistry.

I actually even go through the Middle East. I'll be in Egypt in October. I'll be in India right after that. I do a lot of, in fact there's a lot of articles in India now on our methods, by some of their top docs. Which I really feel good, I'm honored that they are picking this up, and I know that not everyone is going to follow what we do, but it's not anecdotal anymore. If you take a look at my articles and look at my co-authors, I think these guys are smarter than me. My co-authors.

Yet I just took the simple way, I just looked at all the methods and we started mixing them and then we actually did patient studied to verify and make sure that what we were doing would be good for the profession. Not a one day course that we thought up. Even to the casting of the implant. I do all my own implant impressioning, implant load for example. I then will put in the analogs, I make the small tissue, I pour it up. That responsibility really should be in my hands, or in the dentist's hands, because unless you really have a lab who really, really understands what you're doing - remember, it's in our brain, not theirs - it could just be five microns that bar won't fit, you see? Or that thing won't fit. I want to test it. We do our own verifications. 

Everyone has to, but single teeth is not the issue. I'm talking about full cases. They're not teaching in the schools that it is the responsibility of the prosthodontist. I'm a GP. I've learned what I have from some of the top guys. A lot of people have never heard of. John P. Thrush, my gosh, I mean his name is, he developed the Swiss [inaudible 00:54:11], you remember that right?

Howard: Mm-hmm (affirmative).

Joe: He developed the Acumen system, even though we don't use that, but at the time it was the best thing we had to use. It was a good system. Now that we have different materials, PBS's and different things, we use other materials. We're just growing.

Think about all these different individuals they had so much knowledge they were just dying to hit me on the elbow and give it to me, and I followed them. I even pushed them in their wheelchairs on the way to lectures. Their wives couldn't make it they'd call me up and say Joe can you meet up with Tom and I'd say I'm happy to and I'd meet them somewhere and go into the lecture.

We don't see that much dedication. We see a lot of dedication but these guys, to the grave. They just loved it. 

I love everyday I come into the office, evry day is a new day, new experience.

Howard: How could we get your courses on Dental Town? Dental Town has 205,000 dentists from every country on Earth, and we put up 50 courses they've been viewed over half a million times, and I just so want to have the master of removable dentures, yourself, I would give anything to have your courses on dental town.

Joe: You want to start out with the ... if you want to start from the basics. I know it's kind of a hard sell when I said diagnosis and prognosis, but without that ... The first time it may take you two or three hours, but after that it's in and out. It is so much fun. When you walk into a room and you analyze as they are that nanosecond in their office and you show them exactly the pictures either compared with male or female. So males, male pictures. I think you're closer to this, what do you think? Yeah, you're right doc. What you're doing, you're co-discovering. By the end of the examination, the patient says I have never had an examination like this before, but all you really spent in there was a few minutes.

You have to increase your knowledge a little bit. That's the toughest to get through, and the most important. Then, it's sailing through. I hate to say this, because I don't want to be demeaning to anyone, but I got a good plumber and I said I taught m plumber how to take impressions. What I'm trying to say is, when you have a method, and a system, and if there's reason to change you change, but not until you reason. Every one of these has alternative. If you have flabby tissue you do this and then you do this. I could do a diagnosis prognosis and then we could go into let's do the foundation the impressioning. You learning everything from [inaudible 00:57:26] but you apply this to virtually implant cases, partial dental cases. All impressioning the protocol is the same, but the types of material you use, the viscosities alter a little bit.

Dentate patients, you always will use a very flowable over the teeth, because you want to be able to get it out of the mouth, number one, and number two if you are going to make a stone cast, you don't want it to break when you pull it off. IF you have a heavier viscosity you'll break teeth.

Mobile teeth, taking jaw recordings with mobile teeth. You can't use a leaf cage, and leaf cage is great, but how do you do it with mobile teeth? You put it in there and the teeth move.

Then we will go into now number three, which is the bite which is the problem, number one diagnosis treatment planning. Dentists say it's fit and occlusion. What they really mean is I didn't diagnose it right. I've got to diagnose it right first, then we can go forward. By doing the diagnosis and prognosis it takes so much pressure off of the dentist. Now the dentist can have fun. Not worrying about a mid-line discrepancy, they already got one, I'm going to do the best I can to fix it. They show more on the left than on the right, so big deal. They know it, we know it, so we're going to do the best we can to fix it.

Now, you don't have that monkey on your shoulder. You're always worried you go home, you get this gut feeling, this patients come in for their 19th adjustments. Our studies show that we average 1.5 adjustments and this is under an FDA guideline that we did multiple studies. That was it. We ask them t come back because w want them to refer someone to us, you see.

Everything is done up front and it doesn't take that long. It always takes so long to do the Massad thing, it doesn't. It just takes a long time to get it. Long time meaning a couple weeks. You can't stop the first time, you do three or four cases. You want me to hold your hand, you Skype me and I'll - I do this all the time - I'll walk you through that step. Once you got it, you got it, and you can't go back. Dentists who have finally got it, you can't go back. All the sudden they had problems.

They call me and say Joe I did everything you told me and still had a problem. Okay, tell me about the patient? What was her three way space? Oh God she was so closed, about 20 millimeters. I say did you do orthopedic resolution? No. I said well that's the one thing that you have to do. You have to put in a splint to do what? To accommodate the pateint to the new spacing, but also to improve the engrams of tenacity to the muscles that have been so flaccid for so many years before you now take your muscle impressions.

If you take someone who's over closed that much and just put them in a new denture and open them, they're going to fight you like ever. If you resolute that, orthopedic resolution, those patients will adapt. You've tested them, they've got training wheels. They come back, you make their prosthetic, and there's really no feasible change. Maybe a millimeter or two for aesthetics purposes, and your freeway space is what, two, three, four millimeters? One to five is what's been in the literature for 200 years, so we always split the difference, you know?

Howard: Well we are out of time, that's an hour. What could we do next to put your course on Dental Town?

Joe: Let me make a special one up for you. I can just film it in my office.

Howard: That would be amazing.

Joe: I'll do it with a patient, which I think would be the best way to do it. Me and the patient interacting. We'll get that edited with my textbook, it has taken me a little big longer because I've been concentrating, but I think give me a couple months to get this. Normally I could do it instantly, but I have to turn in the final portions in May . If I turn it in too soon they don't let me change anything, so I have to wait. We're even doing digital tie-ins right now. We take the information we have today and you're old school, you're not doing digital. No, I want that to be my slave. The computer has to be my slave, I'm not going t be slave to the computer. Once I have this information I can do anything with it. I've no taken all this information that we've done from the patient and with the muscle impression and all, and we're printing tie ins and we could actually finish the whole prosthesis. The reason we're not is because it's not necessarily affordable to d all these right now, and it will be. We've proven we can do it with our technique and also anyone else's.

If you'll get back to me after this show I'll be more than happy to try to get something together. I could probably send you, just so you would see, a pre-loaded mini iPad and you could actually look at ... it is very dynamic, very moving. The dentists just feel so good. Here you are Mr. Smith, it's what you've got, here's what you can do. The questions have all been vetted. We know what questions to ask to elicit responses.

Howard: That's on your app?

Joe: Yes, that's on the app.

Howard: Where does a dentist get your app? Where can they get that?

Joe: They go to uniquedentalapps.com. It is a website just opened. It's in school now. We've tested at Loma Linda, Tennessee, we just got back from Iowa, we let the schools try these out. Uniquedentalapps.com, one version is out now, the second version will be aesthetics only. That will be a great one because you can do this for anything, whether it be dentate or not. We have an aesthetic only separated from the edentialist one. It goes with both dentate and edentialist readings, so if you have combination cases. 

That is available now. I can send you one just to play with, I think you'll have fun.

Howard: I would love that. I would love that. Thank you so much for spending time with me, thank you so much for doing this. It is just an honor to have the number one dental legend in the world on removable dentures to spend an hour with me today. 

On behalf of the 205,000 dentist on Dental Town, Know they need to see your course so bad, and I hope that we can give this to them, that would be the ultimate Christmas present.

Joe: A lot of this I can do quicker. Impressioning I could, because it's every single day of the week I'm doing this. I'll give you a fresh one. How's that sound?

Howard: I would love it! Okay well thank you so much, thank you Uncle Joe for all that you've done for dentistry.

Joe: You're welcome, and when you see Jennifer, I'll tell her you said hello.

Howard: I will, okay, thank you very much.

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