The Most Important Part a Beautiful Smile – Pink Esthetics with Dr Tidu Mankoo – PDP208

Protrusive Dental Podcast

Are you focusing enough on pink aesthetics in smile design?

What role does gingiva play in achieving a truly stunning smile?

When should you refer for recession around lower incisors or upper canines?

Can you get the gum to grow back through orthodontics? And how about class 5 restorations? Should we do them, or should we work on the gingival recession first?

In this episode, Jaz is joined by the expert Dr. Tidu Mankoo, who shares his extensive knowledge on the importance of gingival health in aesthetic dentistry. They dive into the crucial role of the dento-gingival complex.

https://youtu.be/Ao_vgJ-IbOg

Watch PDP208 on YouTube

Protrusive Dental Pearl: Shade Matching

1. Composite button technique – a small blob of composite is applied to a dry tooth without etching or bonding to assess shade match and translucency, avoid excess thickness, which can affect opacity and aesthetics (Jason Smithson’s Tip: take a black-and-white photo to evaluate the composite’s value and ensure it matches the natural teeth)
2. Using a custom composite shade guide like Smile Line by Style Italiano for more precise shade matching.

Key Takeaways

• Gingival architecture plays a vital role in aesthetics.
• Dentists should focus on patient-centered care.
• Understanding tooth position is key to treatment planning.
• Orthodontics can sometimes resolve gingival issues without surgery.
• Communication with patients is essential for effective treatment.
• Aesthetic dentistry requires a comprehensive approach.
• The dental field is evolving, and practitioners must adapt. Root coverage procedures can be effective with proper techniques.
• Understanding prognosis is crucial for successful treatment outcomes.
• Aesthetic considerations are a primary reason for root coverage.
• Restorative dentistry should consider the position of the gingiva.
• Crown lengthening should not expose root surfaces unnecessarily.
• Mucogingival surgery plays a vital role in implant aesthetics.
• Education and training are essential for dental professionals.

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

Highlights for this episode:

• 4:29 Protrusive Dental Pearl
• 6:16 Dr. Tidu Mankoo’s Journey and Inspirations
• 11:48 Reflections on Comprehensive Dentistryand Lifelong Learning
• 15:59 Balancing Work and Family in Dentistry
• 17:52 Understanding Gingival Architecture
• 19:49 Creating a Harmonious Smile
• 21:52 Addressing Gingival Aesthetics & Limitations
• 26:56 Orthodontics and Surgical Interventions
• 29:40 Root Coverage Procedures
• 33:49 The Value of Early Diagnosis and Referral
• 35:01 Indications for Root Coverage
• 36:03 Root Coverage vs. Class V Restorations
• 39:50 Managing Gingival Zenith Irregularities
• 41:23 Role of Mucogingival Surgery inImplant Success
• 47:47 Course on Mucogingival Surgery with IAS

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

This episode meets GDC Outcomes B and C.

AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY

(Esthetic diagnosis and treatment of intraoral soft tissues)

Dentists will be able to –

1. Discuss when and how to manage gingival recession, including the role of root coverage procedures.
2. Explore the anatomy and function of the dento-gingival complex and its influence on smile aesthetics.
3. Promote the value of early diagnosis and timely referrals to specialists for successful treatment.

🚨 Join the Ultimate Masterclass on Implant Soft Tissue and Complex Cases! 🚨

📅 Dates: April 2024
🌟 Event: Implant Soft Tissue and Complex Case Masterclass

Join this two-day masterclass to elevate your skills in:

✅ Implant soft tissue management

✅ Root coverage and crown lengthening

✅ Complex case planning and aesthetics

If you loved this episode, be sure to check out PDP035 – Case Acceptance in Smile Design with Dr Gurs Sehmi

Click below for full episode transcript:

Teaser: Young dentists are limiting their knowledge and experience because there are cases where you're not going to have simple wear and simple misalignments. You're going to have complications. You're going to have teeth that are structurally compromised or endodontically compromised or periodontally compromised.

Teaser:
What are you going to do then? Then it’s not just edge bonding and composite bonding or injection molding or whatever that’s in the current fad. And it’s not only tooth position, it’s root talk. So sometimes, particularly in a lot of, we see this in a lot of orthodontic cases, patients who’ve had ortho, particularly in lower interior region.

You see, sometimes the roots have been placed too far buccal outside of the bony envelope and you see clefts and recession typically in the lower incisal region, often as a result. And in those scenarios, if you’d correct the torque, will the gingiva settle?

Jaz’s Introduction:
If you get the white aesthetics right, what I mean by that is having the incisal edges in the right place, the correct anatomy and surface texture and alignment of your teeth, yes, that’s going to give you a good smile.

But what’s going to give you an amazing smile is getting the pink esthetics right. Think of the gums. Think of the dento gingival complex. That’s when your smile design really goes up. And in your career, as you become more comprehensive, you realize that having the gum line and the gums in the right place is so important to an esthetic outcome.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast, where I’m joined by an absolute legend today, Dr. Tidu Mankoo. Dr. Mankoo is a world renowned expert in all things dentistry. He’s got so much to share, so much experience, extremely comprehensive dentist, super experience in advanced cosmetic dentistry, and so very excited to share this episode all about getting the pink esthetics right.

As a foundational thing, when should we consider referring for that lower incisor with that recession? How about the upper canines that got recession because they’re too buccally placed? Can you get the gum to grow back down by doing orthodontics? And how about class 5 restorations? Should we do them or should we work on the gums first?

Should you never do a class 5 restoration? And if you did do a class 5 restoration, where should you finish it to make sure that any future gingival surgery is going to work better? At the very least, Protruserati, let this episode inspire you to think beyond just the white esthetics, to consider what the gingiva is doing and to allow you to read more about gingival esthetics, listen to more about gingival esthetics, inspire you to learn and grow in that field.

Dental Pearl
Now every PDP episode I give you a Protrusive Dental Pearl and today’s pearl is inspired by the community. Dr. Arti on the Protrusive Guidance asked about a scenario where she’s trying to match Genial Composite to the teeth and she’s finding that she’s struggling to get the right shade match. For example, the B1 of Genial was not quite matching the Vita B1 shade.

So what I did is I made a quick little video. I went live on Protrusive Guidance, which by the way is our community. It’s a community of of the nicest and geekiest dentist in the world. I don’t pump any money into ads. I don’t advertise this community. I try and keep it to those people who listen and watch the podcast because those people like you who choose to spend some time with me and the guest, really going geeky, really immersing themselves with deep education, wanting to constantly be better and to reinvigorate your passion for dentistry.

These are the kind of dentists I want parts of the nicest and geekiest community of dentists in the world. So they are living on Protrusive Guidance. There’s over 2, 000 of us already on our community. So do join us on protrusive. app if you’re not already there, especially if you ever feel lonely in our profession.

The Protrusive Guidance community is an absolute far cry from the BS you see on the Facebook groups. We seem to attract the nicest and most caring and most empathetic dentists there are. Anyway, so I went live in the community really quickly during lunch, and I explained that acrylic shade guides, which is what they are, you know, the Vita shade guides are acrylic.

How can they accurately represent a composite shade? They can’t. And the other truth is that all composites are built differently. Certain brands of composite will have naturally more value. A B1 of one brand will have more value than the B1 of the other brand. Venus composites, which I use a lot of nowadays, Venus Pure, for example, is more opacious.

Estilite, which I also use, is more translucent. So you’ve got to kind of match it to what kind of tooth you have in front of you. So you’re thinking, okay Jaz, what’s the pearl? What’s the pearl beyond recognizing that you can’t just go with a Vita Shade Guide? Well, here are two ways. One which is cheap and easy, and one which is more sophisticated to be able to better shade match to teeth using composite resin.

Number one is composite buttons or composite blobs. Just dry the teeth. No etch, no bond. Make a little blob. Place it on the tooth. You don’t want it too thick. The thicker you make it, the more opaque you make it. So remember the thickness of the composite will also determine the esthetics. So a good technique is to put a little bit of blob half on the incisal edge and half like cantilevering off the incisal edge so you get to see the shade match to the tooth.

And you get to kind of assess the translucency. So I get to talk about this composite button method of shade analysis. You kind of see, hmm, do I need to put another button here, which is a different shade, which will give me the recipe that I need to use to recreate the esthetics here for this composite.

For example, if you’re doing a class four composite. Now, a tip that Jason Smithson gave some episodes ago was to take a black and white photo. That will tell you if you’ve got your value correct, how light it is. And that’s a really good technique to take a quick black and white photo. But if you want to go at a really high level, then I would suggest using a custom shade guide.

Something by Style Italiano, aka Stil Italiano, which I think is called Smile Line. I have one of these whereby you can make your custom composite shade guide. So essentially you get the brand of composite that you like using, the paste, you put it into the mold, you press it together, you cure it. And now you have that B1 shade of composite, that is your composite that you use, so that’s much better to have that ready to assess against the teeth than a vita shade, which is not composite.

Vita is acrylic, so you could do one for A one B, one B, bleach white, A two. You can actually make your own shade guides, I think opt selling in the UK, and I’m sure there’s some US and worldwide distributors, wherever you are. I just want to open your mind to a few different ways of checking the shade for composites.

Now, moving back away from the white esthetics, moving towards the pink esthetics, let’s now join the legend, Dr. Tidu Mankoo, to dive deeper into something so critical in A Beautiful Smile, that’s the dento gingival complex. Enjoy.

Main Episode:
Dr. Tidu Mankoo, it is an absolute pleasure to host you on this podcast. How are you?

[Tidu]
I’m very well, thanks Jaz, and it’s a pleasure to be here. Thank you for having me.

[Jaz]
I don’t know, if you remember this, but it was about 2014, I was at one of your lectures, I think you were doing it in Leeds at the time, right? And I remember being sat, I usually sit in the front row, and I was just amazed, like all of it, as a new grad, okay, this kind of stuff that you’re covering went above me, because I still don’t do implants, right?

But it was clear to me, like what you were showing was like world class, and then only once I saw you speak there, did I realize how big of a deal you actually were. I didn’t actually know what I was witnessing. So only later when I spoke to people, I was like, what you sought Tidu Mankoo kind of thing. So your reputation is amazing. Can you tell us for those people who haven’t heard about you, can you tell us about yourself, your passions, your interest in dentistry?

[Tidu]
I qualified a long time ago, back in 1981. So I’m one of the ancient guys, but been around in practice for what, 42 years now. And still enjoying it and still feel pretty much I’m still at the top of my game. So I’ll keep going as long as I feel that way. When I first graduated, I realized that I didn’t want to just be a normal dentist. I wanted to sort of expand my knowledge. And I really went on a journey fairly early on. One of the things that inspired me was I got exposed to, I went to a course back in 1984, I think it was.

And I saw David Garber, who Garber-Salama, the famous atlanta team. I saw him do a lecture and it really blew me away because he was talking about back then sort of mixing interdisciplinary treatment. Okay. It was very basic. It was crown lengthening and veneers. I’d never seen anything like this.

You know that people were talking about gums as well as teeth and you could do this stuff to make everything look better. And that inspired me along with a group called the International Society of Dental Ceramics, ISDC. There was a chap called Dr. John McLean or professor John McLean, which you some of you all should really know about him. He’s the father of modern day ceramics and he wrote some textbooks the fundamentals of dental ceramics back in the 60s and 70s.

And he was one of my mentors and I learned a great deal from him and others. And then I got exposed to the European Academy of Aesthetic Dentistry back in late ’89. I guess it was around about 1990 and those of you don’t know the EAD or the European Academy of Aesthetic dentistry is this group, which is like all the top lecturers in Europe in this group, and it’s an incredible group of clinicians really working at an amazing standard and they set this incredible standard and I got exposed to.

At the time, a chap called Gianno Ricci, who’s a periodontist from Florence, and he’s still one of the major sort of perio guys. And you know how great the Italians are at perio now, and they are the sort of world leaders in sort of muco gingival surgery, the Zucchelis and so on. But I guess, joining that group really stimulated me to sort of wanting to be dentists.

I remember seeing David Garber and said, I want to be like this guy. This is a dentistry I want to do. So I went on a journey. I became a nut about reading journals. I used to read voraciously. I read, I think, every single textbook going. Dawson back to back. I learned everything about occlusion I could because I was so fundamental to being able to do decent restorative dentistry.

And I went on so many courses and lectures and went all around the world, traveling, to learn from the very best people and then joining this group, the EAD really sort of stimulated me because those guys, everyone’s passionate, everyone really is trying to do superlative dentistry.

And that’s what I decided I wanted to do. And I was able to start working with my dad in 1984. I joined, he had a spare room in his small practice attached to his house. And I set up a little surgery there, a little squat started from nothing, just built a little patient base after being an associate for a couple of years and a group practice in Wokingham.

And I moved to Crowthorne where my dad was and then I stayed there for 10 years and I remember his first words to me. He said, you know, son, there’s no scope here for private dentistry. This is really NHS. And I said, dad, I just don’t think that’s true. The interesting thing, five years later, we both went completely private.

He did as well. And because he showed, I showed him, look, this is what you can do. You just need to talk to people, you need to explain what possible options are and if you can back it up by producing really nice work, your reputation build. And then I guess in 1994, I had the opportunity to move to Windsor, where I’m now at the Windsor Center of For Advanced Dentistry.

And we have an interdisciplinary practice there, which is that I built. And it’s been basically that’s it. I’m ongoing there. I guess you’ve got to be passionate about dentistry, passionate about wanting to do your best for the patients. And what I really believe in is trying to do what’s best for the patient in their best interest.

And I think, a lot of dentistry today, I have to say I’m a little concerned that a lot of dentistry today is about what’s in the dentist’s best interest sometimes and financially maybe, and business is taking a very strong sort of, I guess influence on decision.

[Jaz]
Like a commoditization, I guess, of dentistry.

[Tidu]
Yeah, I think so. I mean, we see so many practices that are, I don’t want to knock, so all on four, for example, all on four is a great technique in specific indications, of course. But, there are so many practices where you go and basically that’s their business model and you go there and that’s what you’re going to get.

Whether your teeth can be saved or not. And certainly in my view today, I think, it’s a pity if we as clinicians don’t really expand our knowledge base so that we can do comprehensive dentistry in a true way and really offer our patients what’s best for them rather than what’s convenient or what we like to do and so on.

And I guess, after 40 odd years of practice, you really learn to be a little bit more humble and understand that you have, I guess if you’re passionate, then you really want to do your best. And doing your best is also stretching yourself, is going outside of your boundaries, comfort zone to learn things.

And after 40 years, I’m still passionate about learning, taking on new technology. There’s digital transformation that’s happened in the last several years and ongoing, always trying to do better. And I think the day you stop, then that should be the day you stop.

[Jaz]
Brilliant. I mean, never say stagnant, keep learning. So the key word I like to use there was comprehensive as well. It was essentially what today is about because dentists, we fall into this trap when we’re learning about smile design, we focus on nowadays. Okay. Nowadays it’s GDP orthodontics, which is very exciting, you know?

Leveling those edges, simple crowding, getting the edge bonding, sometimes the veneers and stuff. But sometimes what makes a good smile to a phenomenal smile is that dento-gingival complex, which is so, so important for the esthetics. And we’re going to be talking about that. Before we get into that, just reflecting on what you mentioned in your career so far, I would love to know your credentials. Like from what I heard from someone, in quotes, comments, you’re just a BDS, right? So is that true?

[Tidu]
Yep.

[Jaz]
And that was so inspiring to me. Like that honestly, like I talk about this to lots of people when they’re saying about, oh, should I do this? Should I do that? And I often say your name. I often also say Chris Orr’s name. I say, look, these guys. Ah, quote unquote, just a BDS. You don’t have to pursue the letters to be a phenomenal clinician. What do you say to the new generation, which are qualifying with less and less experience? Do you now look back and think, yeah, you did the right thing by not pursuing the letters, by just pursuing the education? Or do you think now times have changed and perhaps you are encouraging the new generation to take on more structured courses? What are your thoughts on that?

[Tidu]
Well, you have to remember, back in the early 80s, there wasn’t the availability of many courses. There was a course at the Eastman, which was at the time, a very traditional kind of restorative conservative type prosthodontic course.

And, or there was going to the U S. And there wasn’t anything much in between. In Europe, there weren’t any options for English speaking courses, certainly at that stage. Today, there’s so many more options. So I would encourage new clinicians to go on structured courses because it’s easier and quicker to learn that way.

People like myself, we made a decision to take a personal journey and invest in educating ourselves by paying for private courses and going and reading and learning, and you don’t have to go on a structured course to become an expert, obviously, as you know, I have shown. But I was very eager to learn everything. So, as I said, I learned everything I could about occlusion. I learned everything about perio, perio and muco-gingival surgery, so prosthodontics, ceramics.

[Jaz]
It sounds like to me that the drive is more important than the means.

[Tidu]
Absolutely.

[Jaz]
The drive and the desire to practice at a certain level and what helped you, which is a common theme of the guests we get on the podcast, is that they saw someone around about two, three years out that just really Inspired them.

Like they saw something that they didn’t know was possible. They didn’t see that before and that really triggered them on a pathway to learn more and more. And then the next question I had before we dive into mucogingival esthetics and how we can apply that to our daily assessments is just a work life balance one, if you don’t mind, right?

At that time, obviously now courses are a doorstep, lots online, lots to do from home and stuff, which has its place. When you had to do all that traveling and stuff and lots of personal sacrifice time away from family and stuff. Did you find that was difficult in terms of trying to grow as a clinician but also when they keep the home life stable as well?

[Tidu]
Yeah, I mean, it’s obviously a challenge. You have to have a wife who understands or a husband spouse these days. It doesn’t matter. Another half, let’s say, that understands what you’re trying to achieve and is prepared to share that journey with you.

There were times where it was challenging, obviously, because when I was lecturing a lot, I mean, I’m not lecturing as much as I used to do maybe 10 years ago, where I was traveling, probably two or three times a month abroad to speak some way or the other.

And at that time, yes it was more challenging, but I used to try my best to go and come back very quickly. If I’m lecturing somewhere, I’d literally go the night before, come back the night of or the day, the morning after. So I try and reduce the time away from home, but yes, I mean, there’s a price to be paid, but nothing comes without some sacrifice.

And it’s just making sure that obviously from a marriage point of view, that you communicate well and you ensure that you’re taking care of business when you’re at home. And I have five children as well. So, it wasn’t-

[Jaz]
Wow.

[Tidu]
Yeah. So, when we were young, so I was a very hands on dad and always, as soon as I came home, it wasn’t putting my feet up, vegging in front of the telly. It was right, getting stuck in, changing nappies, doing stuff, being a home, a help.

[Jaz]
A whole new level of respect. I didn’t know that. I didn’t know you had five. That’s a whole another level of respect. We’ll have to have a separate podcast just about navigating fatherhood, I think. But let’s get the clinical nitty gritty bits.

Okay. Pink esthetics, why are they so important to a beautiful smile in the sense of we get taught about a golden proportions, we look at the teeth, but when I was studying at dental school and then qualifying, it took me a few years to truly appreciate it, truly appreciate how to go to that next level. Do you think that it’s underplayed and perhaps it is a realization that happens afterwards?

[Tidu]
Yeah, absolutely. I mean, going back to my first training, all about crown and bridge and because at that time we didn’t have veneers until the mid eighties. That came later, but so, it was crown and bridge.

And my journey with the ISDC was all about learning about ceramics and how to make ceramics look natural and real and learning from mentors like Willi Geller, Klaus Mutterthys, and Bob Winter and all these amazing clinicians and ceramists. And I think it became obvious that no matter how good the ceramics are, if the frame for the smile, as in the gingival architecture is not harmonious, then somehow you’re not really making it really, truly, aesthetically pleasing.

And so you realize that in order to make it aesthetically pleasing, you have to think more comprehensively, more interdisciplinarily. And, I think, that was what that lecturer went to see, Dave Garber back in 1984, which was actually on a course given by a veneer company selling their techniques.

And it was Dave Garber, it was a guy called Ron Jackson, who’s from Canada. He’s passed away now, but Dan Nathanson, another one who’s no longer with us, but I mean, these guys were masters. And when he showed that it just wasn’t about the teeth, it was about creating a beautiful smile with also the pink architecture.

[Jaz]
With young dentists and students to do then, what we can start with is just back to basics. What do you think creates a harmonious smile with respect to gingiva? And particularly speaking, like, we learn about golden proportion, we learn about smile design when it comes to teeth and width and stuff.

But we know that, it has to be a bespoke individual, bespoke individual’s face, and obviously with the gingival architecture, so much of it also hinges on their facial skeleton, their lip mobility, and all those other factors which you can totally go to, so it’s very complex.

[Tidu]
It’s not something you can just cover in a…

[Jaz]
Exactly. We’re giving a flavor, we’re inspiring them to look beyond the teeth.

[Tidu]
I mean, today you have to look at the smile, the dynamics of the smile, the dynamics of the lip architecture, because it’s not just about high lip line, low lip line, it’s about how dynamic. Because some people can have a low lip line, but when they talk and laugh, they show everything, the curtain raises right up.

And so, it’s understanding those limitations. It’s not just about mucogingival surgery is orthognathics is orthodontics. It’s everything brought in. You talk earlier, you mentioned earlier about the current. Very popular fad of edge bonding and aligners and this thing, which is I know is a very popular thing these days, but again, it worries me a little bit that young dentists are limiting their knowledge and experience.

This kind of becomes a recipe for everyone and that’s not really managing patients with what dentistry can do for the patient’s benefit because there are cases where you’re not going to have simple wear and simple misalignments. You’re going to have complications. You’re going to have teeth that are structurally compromised or endodontally compromised or periodontally compromised.

What are you going to do then? Then it’s not just edge bonding and composite bonding, or injection molding or whatever that’s in the current fad. So I think we’ve got to move away from this sort of fad based dentistry and really get back to fundamental principles and learning and understanding. And expanding our knowledge base so that we really understand and know what is possible and then, learning how to do it.

[Jaz]
When we look at the basics of gingival architecture, the most classic thing is, okay, the central gingival zenith, so students is like the top part of the gum base of the gum line, and then the laterals being a little bit lower down and then the canines being higher up again.

But then what I came across the literature is actually, that is one example of something that the public perceive as esthetic, and actually it doesn’t have to follow that, it can have some nuances. But perhaps in the interest of this podcast is, what do you think contributes to a unesthetic smile?

What do you see commonly from cases which was a real letdown? What is a major, if we were to give you an example, in orthodontic terms, the midlines being off isn’t as significant, but a midline can’t, can be quite significant. Any features you could tell us about the gingival architecture, which is a big no no?

[Tidu]
Well, I think when you have asymmetry close to the midline, okay, that’s the biggest one. So, the typical thing I see, and I see it on Facebook a lot, posted, particularly patients showing in some of the forums talking about maybe a single tooth implant, for example, and you see the single tooth implant and the tooth next to it, the gingival level is completely different.

But, they’re just showing this, oh, I did this case and I’m pleased with it. But, you haven’t really treated the patient. What you’ve done is you’ve replaced the tooth, but you’ve not looked at the patient. And that frustrates me a great deal because it’s like, well, you had the opportunity, you’re already doing a surgery.

You could have corrected that at the same time. If there was a recession or maybe the opposite, maybe the implant is much longer than the natural tooth. And when you’re close to the centrals, of course, the closer you are to the midline, the more obvious it is. And so it has more impact if we’re just purely talking about mucogingival esthetics, then that has more of an impact.

I mean, the further you go, as you said, typically the centrals will be higher, laterals a little bit smaller, canines up, and then you follow the balance round, but it’s not a rule. It’s basically, that’s the pleasing architecture, but that’s not the only pleasing architecture. It’s creating harmony and balance, and that may be bespoke for a particular patient.

You have to see what’s going to work for that patient. And how do you manage that and correct it? And of course, it’s not just about mucogingival surgery, of course, because orthodontics has a big role to play in mucogingival architecture, because tooth position has a lot to do with where the gingival are.

If the tooth is palatally positioned and positioned slightly further back, then typically the gingival will be more coronally placed. If it’s further out forwards, then it’s apically placed and you’ll see more recession or apparent recession compared to other teeth. So it’s understanding what’s the right way to manage that.

So when you see a case where you have gingival architecture that is disharmonious and you want to improve it, then you’ve got to diagnose what is the essential problem here. Is it simply muco gingival? In other words, is it simply we have recession or is it recession combined with bone loss? Is it recession due to tooth position? Is it a problem with the architecture?

Because the teeth are uneven and some teeth are more palatal, some teeth are more buccal, and therefore you get an architecture which moves up and down and is not harmonious. And obviously what you want to try and do for the patient, if the patient, wanting that obviously there’s some patients that are quite happy as they are and they don’t want to change it. And that’s fine that you accept that.

[Jaz]
It’s our duty to diagnose and communicate because if we don’t do that, we deny them an opportunity to correct it.

[Tidu]
Yeah. And exactly that and what we do is, you need to diagnose it. You need to see it. You need to explain to the patient what the issues are and be able to understand how would you best manage that? For example, crown lengthening is crown lengthening, which is a common thing to do these days.

If you have a slightly gummy smile or you want to create a more harmonious smile, perhaps if some teeth are shorter than others, clinical crown-wise you may consider crown lengthening. Most commonly in a sort of gummy smile or if teeth proportions are small. And of course everything in, when you’re thinking about this, basically your first and fundamental parameter is incisal edge position.

So everything starts with the central incisal edge position. So if you define the correct or the ideal central incisor edge position, then going forwards from there, you can make all your diagnosis and go ahead. So for a classical, in a wear case, for example, the first thing you need to do is establish where is the correct central incisor edge position.

Once you’ve got that, then you can say, how long is the clinical crown? Where is the gingival architecture? Then you elaborate, go further, look at the lip and smile, do we want less gum, more gum showing, and all this sort of thing. But it all boils down to define incisal edge position. And then there are other things you need to go from there.

Where’s the cemento-enamel junction? Where’s the bone? What’s the biologic width of that particular patient? And these are things that when we do a course or something, we can actually go into details and give people sort of a greater understanding.

[Jaz]
For those inexperienced to do for those inexperienced people listening to you now. Oh, yeah, this makes sense. That’s interesting. That’s good. But for those with experience are listening to you to do and thinking wow Jaz is asking some really tough questions because it’s actually really tough to start. I’m realizing now how tough this is to summarize in a podcast. So I’m going to ask a tangible question, a specific scenario thing, which we discussed about. Imagine you have a scenario whereby you have reasonable gingival architecture but you have upper canines which have got lots of recession.

Because, and the diagnosis here, because of the fact that they are crowded buccally and therefore there’s less bone coverage, it’s kind of almost out of the bony envelope. And so you can imagine this scenario that we can all see in patients whereby they’ve got recession localized to the canines.

Maybe bilateral, maybe unilateral because of the tooth position. So it’s a tooth position problem. Can orthodontics alone, so imagine you get now the tooth to sort of bodily move in right? Through your orthodontic mechanics. Can the bone and gingiva adapt or will that case always need surgical intervention?

[Tidu]
The answer is yes. Sometimes the bone will adapt and gingiva will adapt. So you don’t always need surgical intervention. Sometimes you do, sometimes you don’t. In those cases, we would always do the orthodontics first and then re evaluate and decide. But if you have a problem where you have a healthy periodontium, we have a normal keratinized mucosal band, and your mucogingival junction is at the normal level, but you have a recession as a result of tooth position, you will nearly always gain coronal migration of the gingival margin as you correct the tooth position.

And it’s not only tooth position, it’s root talk. So sometimes, particularly we see this in a lot of orthodontic cases, patients who’ve had ortho, particularly in lower anterior region, you see sometimes the roots have been placed too far buccal outside of the bony envelope and you see clefts and recession typically in the lower incisor region, often as a result.

[Jaz]
And in those scenarios, if you’d correct the talk, will the gingiva settle?

[Tidu]
It improves, but you may also, depending if you’ve now developed a serious cleft, you may then also have to adjunctively carry out a mucogingival procedure to root cover. However, if you have a mild case of tooth position, the patient’s not willing or not saying, well, maybe I don’t want to ortho, and it’s a case where, look, you could manage it without ortho, then obviously you could do a root coverage with a variety of different procedures, coronally advanced flap, tunnel, modified tunnel, modified flap, combination procedures as well. They can all work.

[Jaz]
This leads very nicely to, okay, which teeth are amenable to root coverage? Because you’re right in the sense that crown lengthening is something that we’re exposed to. We’ve talked about in this podcast a few times. It’s something that is, esthetic crown lengthening is a buzz thing as well, but for root coverage, it’s like a little bit more comprehensive, a little bit more scary for general dentists. Less general dentists are doing it compared to the amount of general dentists that are happy enough to do esthetic crown lengthening.

Obviously to go on courses, obviously to skill up. But can you give us like an idiot’s guide to root coverage in terms of which teeth might be amenable and at what point we should be considering referring? So what informs a prognosis? We’re general dentists now, seeing these issues that you’re talking about, how can we be sure that, hmm, this could have a good prognosis for me to at least discuss with a periodontist or someone in the practice who likes to do this kind of work.

[Tidu]
The thing is, I was saying, I don’t think you should be trying to do root coverage without having surgical skills, training in perio, or if you familiar with doing implant surgeries and you have soft tissue management skills. So that’s really important. But any tooth that has recession that is periodontally sound and healthy and there’s in the absence of bone loss should be amenable to root coverage procedures as long as tooth position isn’t the main driving factor.

Obviously the tooth is very buccally placed and you’ve got to correct that first. However, if you’ve got a tooth that’s in reasonably good position and you have recession through incorrect tooth brushing technique, aggressive brushing, which is commonest one and patients with a thin biotype. A phenotype which is thin, which is more prone to recession, then a root coverage procedure is possible and indicated on those cases for sure.

[Jaz]
Do you look at how important is the Miller’s criteria, Miller’s index?

[Tidu]
Well, I mean, that and others is the Cairo index of Miller’s index. I mean, there’s a newer, they are essential in terms of Miller one and two, you can generally get a, do some gain. I mean, in Miller one, you should be able to gain full root coverage.

[Jaz]
Can you explain for the dental students, the young adults, what Miller one is. Just Miller’s one, just to understand.

[Tidu]
Well, let me simplify outside of that because Miller is not the only classification used, but essentially you’ve got to look at essentially how our teeth do they have, because there are complicating factors as well, because it’s not just about bone, it’s also about where’s the mucogingival junction, how much keratinized tissue you have.

[Jaz]
Lots of dimensions.

[Tidu]
Yeah. So, but if we simplify it all, essentially a patient with normal bone situation, in other words, healthy bone levels. An interproximal bone in the correct position is generally very predictable for root coverage procedures. Where you have some element of bone loss, then it becomes less predictable. If it’s mild, and you still have interproximal bone peaks that are more coronal to the maybe buccal bone, then it still is a more predictable procedure.

You may not get 100 percent coverage, but you will gain and cover. Where you have periodontal, where you have horizontal bone loss, in other words, you’ve lost the interproximal bone peaks and you no longer have a scallop, then the root coverage becomes unpredictable and probably not worth doing. In those cases, if we need more tissue, we would then think about orthodontic extrusion and bringing the bone housing and the roots down and reshaping the teeth.

That’s the way we’ve managed those. And those are the more sort of periodontal cases, obviously. And those are more tricky and they have to be done in an interdisciplinary team that really understand what’s going on.

[Jaz]
Yeah, you need to definitely involve a team and a lot of general dentists will be identifying it and referring to a local periodontist or someone who’s got those suitable skills. But it’s really important that one thing I want people to gain from this podcast and this time with you is, just opening your eyes to actually seeing it, because sometimes we look for caries, we look for perio, and then only some years later do you appreciate what a wear facet looks like, because you just learn, you’re constantly learning, and then you’re looking for the wear, and then looking for this, and then eventually you learn about, oh, gingival esthetics, and you start looking for that, maybe you start doing more esthetic work, and then you start noticing these things, and then you have the confidence to talk about it.

So, how important is a timely and early diagnosis and referral perhaps for that, you know, the one isolated recession of a lower incisor, for example, how much is that loss of pink aesthetics or not even aesthetics, loss of the actual keratinized tissue going to be an issue in terms of the longevity or the prognosis of that tooth and how important is it to get a timely referral?

[Tidu]
Well, for the classic lower incisor, the typical cleft that you can see, like a localized recession is usually either related to a thin phenotype with a reduced keratinized tissue band and commonly also with frenal attachments. Maybe you’ve got a frenal attachment in that area that’s pulling and you’ve got a mobile mucosa, but it’s also often to do with post orthodontics or in crowded dentitions where the tooth is more prominent and therefore it’s more receded.

You often see recession on canines because when people are brushing and they’re using an incorrect brushing technique, of course, the canine is the most prominent tooth. And as you brush, it will get the bulk of the pressure. And that can often cause a traumatic recession of the tissues.

Let me simplify it another way. What are the indications for root coverage? Okay. Number one is esthetics. Okay. Number two is root sensitivity. Number three is if you’re going to be carrying out restorative dentistry, and it will improve the general prognosis and the relative position. In other words, you want to do veneers, for example, but you don’t want to place veneer margins on root surface on dentine.

You rather stay in the enamel. So then maybe that you want to root coverage, you want to bring the gingiva back down to where they should be so that you don’t have, otherwise you have longer teeth, but you’re finishing your veneer margin on a dentine or on cementum. Where the bond is less predictable long term and you may have more chance of leakage or fracture and so on. So it’s kind of thinking about those factors and the third option is where if a patient’s concerned if the patient if it bothers the patient. At the third indication, sorry, if a patient says that I don’t like this then obviously, patient is concerned about it.

They want to improve it. That’s fine. But what I do see is, a lot of cases where we are very quick to put in a class 5 restoration and because, I mean, let’s face it, a lot of our patients have non carious lesions on the buccal aspects of premolars, canines, and even molars.

[Jaz]
You haven’t used the word abfraction. Do you believe in abfraction? It would be nice to know what you believe in.

[Tidu]
Yes, I do believe in it. Because nowadays we call them non carious lesions. But because there’s some controversy, but I mean, abfraction, yes. In some cases, I think abfraction occlusion has something to play with that.

I do believe that. And if you look at a lot of cases that have non carious lesions, often it’s a tooth that’s a lateral guidance situation is getting pretty hammered. And I do believe that you see some flexing of the tooth and the enamel pings off at the weakest point, which is at the CEJ and particularly in some teeth where it’s very thin.

So I think that has an element, but we do see a lot of non carious lesions and yeah, in many cases, the appropriate treatment is to place a class 5, but in many cases it might be better to do a root coverage because, so that you restore the missing gum with gum rather than with filling. And in some cases, if it’s practically in a younger patient, I think there’s a calling to think about it earlier because a class five in a 25 year old or 30 year old, how long before you have to replace it, and each time you replace it, it becomes a little bit larger, more complex, and wouldn’t it be better in that younger patient to actually restore the gingival tissues. So that that patient then doesn’t have future recession?

[Jaz]
Where they have loss of volume in that scenario of a NCCL or abrasion, for example, should it be the course of action whereby you get that periodontal opinion because maybe to put a restoration there because it’s sensitive, for example, reduce the prognosis of the periodontal surgery?

Is that right? Or any guidelines in terms of if you do a composite or GIC, whatever everyone’s doing for a class five, is that still needed? Because if you have a deeper class five defect, I’m just thinking about the gingiva being advanced more coronally in that area, but now it’s still, there’s a defect there. Does that still need restoring?

[Tidu]
Yes. The best way to do it, well, basically you’ve got to restore the gingiva to where it should be and the tooth contour to where it should be. Now you can do it before or after the surgery, it doesn’t really matter, but it’s easier to do it before. Because if you have recession then what you should do is place your class 5, and I would recommend to do it in composite, not in a glass IMO.

I would use a flowable, personally, and use that. And it’s very easy if you have a recession, then you don’t have so much complications in isolating the area. You should then place your class 5, so the margin, the apical margin of the class 5 restoration is where the CEJ should be.

That’s where the filling should terminate. And then the gingiva can be brought down to that level. So it’s restoring the correct anatomy of the teeth. That’s really the things. So, yeah, I think it’s important to restore the correct dental architecture and then do the restoration, but you can in some cases I do the surgery first and then feeling afterwards. It depends.

[Jaz]
I guess the sin here is not diagnosing, not speaking to the patient, not involving someone with a periodontal set of eyes, but also doing that classified restoration and extending it all the way up to that recess gingiva where perhaps if the periodontal outcome would like it to be, just like a really good guideline you gave was at the CEJ, which I like.

In the interest of time, I’m just going to ask you a higher level question. Basically, when you have that scenario, where the gingival zeniths are just all over the place. Some are too coronal, some have had recessions so they are too apical. Is it a predictable procedure to have certain teeth you’ll do crown lengthening on, certain teeth you do advancement or root coverage on? And does that happen in two stage or can that happen, I mean, obviously quite advanced stuff, but does that happen at once?

[Tidu]
You can do it at once. It depends on your skill level. I mean, I think this is clinician dependent what you prefer. It can be done in one surgery. I often do it in one surgery. Sometimes I do it in multiples. Doing the root coverage is a more difficult procedure. So do that first probably and do the crown lengthening after that’s a little bit easier. So, because often the crown lengthening is a simpler procedure and, to do then the root coverage part, but, in many cases it’s about understanding again, the bone and the influence, where’s the bone, what’s the biologic width of the patient.

And whenever we do crown lengthening, the important thing is that we don’t crown lengthening purely for esthetics, if when we crown lengthen, we’re going to expose root. That we should never do, unless we’re going to then cover that with a crown or something like that. If it’s a case, for example, a patient already has crowns, for example, and you need to crown lengthen, then okay, then it may be justified to do it. But if you’re going to expose root, then the correct treatment for that patient is orthodontics.

[Jaz]
Orthodontics.

[Tidu]
You can’t crown lengthen onto the root surface.

[Jaz]
The CEJ is our guide.

[Tidu]
Yeah, it’s a guide, yeah.

[Jaz]
And so I know your area of special interest is muco gingival, especially around implants, which is a whole other level. Like, one of the reasons I don’t do implants is because, I’m really going deep in other areas of restorative dentistry and also TMD management, occlusion, that kind of stuff. And I just know that once you go into implants, then the next thing you got to do is, okay, soft tissues around implants. And then different systems.

So you’ve got to really go all in. I’m not ready to commit to that, but there’s so many complications that can happen with soft tissues related to implants. What is the role of mucogingival surgery in terms of getting a truly excellent implant? Do you think those who are restoring implants, do they need to have some sort of skill and training?

Or is it those who are just placing the surgical aspects? And in what percentage of cases do you think someone would benefit from having those mucogingival skills when it comes to implant esthetics?

[Tidu]
Well, I typically would be the surgeon that would be doing that aspect of the treatment. I mean, If you’re, in many cases in the UK, the surgeon and the prosthodontist are the same, people like myself, I do the restorative and the surgical and the barrier and everything along with that.

So you can manage your, I mean, the muco gingival component is hugely significant and important. We know more and more, and we have a greater understanding. People like myself, I mean, I’m not, you described that, that’s my special interest. That’s not my only special interest.

[Jaz]
I know that.

[Tidu]
It’s my special interest, but obviously I have a great deal of expertise and experience in the implant field. I started doing implants 35 years ago. So, obviously have published and stuff on particularly on the esthetic zone, because that’s so critical in terms of getting optimum results going forwards.

And the key thing is that, to understand that it’s a synergy between bone soft tissue and the components that we’re utilizing and that everything has a biological consequence. So in implant dentistry, if we want to simplify it, everything we do in implant dentistry is to compensate for what the biology is going to do as a result of the tooth loss, as a result of the components that you’re going to position place in that patient and the surface chemistry.

The shape, the form, the materials themselves, the surface topography. There’s so many influencing factors that can influence the outcome. So it’s really understanding how do you optimize the patient. So you’re really thinking from the case of obviously from the prosthetics themselves can influence the way the tissue behaves.

The positioning of the implant can, and angulation can influence the way the tissues behave, and obviously the thickness of the tissue, which is very important. We know today that we need to ideally create a situation where you have the supracrestal soft tissue component, or what we’d call the biologic width on teeth, and we can call that the same thing on implants, has to have sufficient thickness to accommodate the biology.

And the biology means that you have a sulcus, you have an area of junction epithelium, you have a zonal connective tissue, and then you have the bone. And so your implant must be placed at the correct position relative to the tissue thickness. So for example, if you have thin tissue, you have two options.

You can either augment the tissue and then create an adequate thickness of tissue so that the biology can be adequately contained in that situation, relative to where the bone is and the implant connection is, or you place the implant deeper so that you allow for the creation of a normal biologic width or supercrestral mucosal seal.

I have to understand that, if we have the data shows us now, and many of us have understood this for many years, but the science is also sort of caught up with it. In the sense that we know that the tissue bone remodeling is inevitable around an implant and is very dependent on a few things, but let’s say, as we’re talking about tissue at this point, it’s very reliant on the tissue thickness at the site.

And if you don’t have adequate thickness, then you’re more likely to see more bone remodeling occur, and then you get some crestal bone loss. And if your rough to smooth surface interface is not placed at the level of the bone where it will be at after the remodeling, then you expose rough surface, which then becomes more prone to peri implant issues like mucositis and peri implantitis.

And I think, certainly in my practice, we’ve seen a significant drop in peri implantitis since in the last 10 or 15 years, have started thinking biologically. And making sure that we place our rough to smooth interface where the bone is going to be. At the end of the remodeling process rather than at the, where it is now.

So very often implants tend to see bone place implant at the bone level or just below it, and that’s their job done. But the other thought is, well, how thick is the tissue? Should I be placing, have I got adequate dimensions of tissue for the biological width? Because if I don’t, then the bone’s going to disappear and you’re going to expose some implant surface.

So it’s quite complicated and you have to really know your stuff. But of course, the mucogingival surgery aspects is critical. So, we routinely would place connected tissue grafts, for example, around our implants, particularly in the esthetic zone, or we augment the soft tissues in other ways, roll flaps, maybe the tissue is already thick enough and so on.

It’s really understanding the patient and doing what we’re going to do to, as I said at the beginning, compensate for what the biology is going to do. So, in other words, it gives us the best chance of long term success.

[Jaz]
What I usually echo when colleagues like yourself who are so experienced in implants and it all goes back to begin with the end in mind and you just add another dimension when it comes to the pink esthetics around implants, which is so, so huge.

One of the best things I see is when I see a case and I can hardly tell which tooth is the implant and that’s often because the gingiva is just wonderful. And that’s what really hides it. The ceramic work, obviously we applaud that, but it’s a gingival architecture, getting that right, which takes a lot of behind the scenes work and the grafting and planning from the beginning. This is obviously something that you teach a lot about as well.

I’m aware with IAS, you’ve got a course coming up. I’d love to, you tell us more about that. Cause I know, like you said, you’re teaching less and less now, so people’s opportunity to learn from you is always valued. IAS, obviously, we’ve got a very good relationship with your Occlusion Foundations course there. Tell us more about your course and what you’re looking to teach there.

[Tidu]
Yeah, so it’s the first time I’m working with IAS, so it’s a new idea. I actually, I would like to actually do more teaching going forwards again. I think, I’m at a stage where I want to share the knowledge.

[Jaz]
You have so much to give.

[Tidu]
So not just in implant dentistry, but in every, every aspect of dentistry. So, I think that’s something what I’m going to be focusing on in the years to come now is to think about, well, doing more teaching and starting to do more lecturing again, sort of cut back a little bit over the last few years, but I think I’m going to sort of pick that up again. So what we’re doing in IAS I think it’s a two day course. It’s a course that there’ll be discussion about mucogingival surgery. So soft tissue management around teeth and then on implants as well. And I guess, it’s a big topic, that’s really all together a topic for at least a week to be fair, but we’ll cover a lot of scenarios in both crown lengthening, root coverage, discussion about different techniques and what we can do wear, where orthodontics is indicated, etc. And diagnosing and making the right decision on what, which technique is appropriate for which case. And then, obviously, there’ll be videos of how we do it and stuff so that people can actually see the technique.

There’s no hands on element in this course because it’s it’s not really long enough to do that, but it’s a foundation course I guess really get deep into this aspect of dentistry. And I think it’s a course that’s probably more suited towards people with some experience. So that-

[Jaz]
Experience in implants? Would you prefer for those who to gain most of it? People who have maybe started in the implant journey? Is that the ideal learner?

[Tidu]
Yeah. And even people who’ve been doing implants for a long time, take it to the next level. I think it’s patient people who are maybe even considering that journey because, I mean, much like my experience of being exposed to really high level stuff before I was doing it. That was really perfect because actually when you’re exposed to that, you know where you’re aiming for rather than starting at a lower level than trying to build up. It’s good to say well, okay actually, that’s where I need to be. So that’s my end game, my end point, I need to start my journey. How do I get to this point? And that’s really-

[Jaz]
Definitely when I saw you speak 10 years ago, like fair enough, I never went into implants, but you’re talking about comprehensive dentistry and global diagnosis. That was really inspiring for me. So I can totally vouch for that.

[Tidu]
Thank you.

[Jaz]
Well, the masterclass is called Implant Soft Tissue and Complex Case Masterclass. I’m just reading it now from the website. It’s on 10th and 11th of Jan. So, I’ll put the link in the show notes. So, if you guys have the opportunity to learn from Tidu, he’s vast experience, and obviously this was a podcast, there was no visuals, but I’ve seen firsthand the degree of cases and follow ups that Tidu shows, which is just something else.

High level. I would love to know Tidu. Any advice you can give to fathers, mothers, parents, basically. Cause we have a lot to learn also with how you somehow managed five. I’m struggling with two here. I don’t know how you did five. What’s your number one parenting tip to raise happy children?

[Tidu]
Oh, just love them, love them and support them, encourage them. It’s encouragement, love, and-

[Jaz]
Are you strict when it comes to their education and looking at how they’re doing academically? Are you strict or are you like, not so much?

[Tidu]
You know, I probably wasn’t strict. I was stricter with my first, probably. I went on a journey. I became much more relaxed as a parent. And probably less disciplinarian as you know, as I had more than I was the first time, because mostly you base your parenting on your own parenting, right? When you start, or at least, and in some ways you kind of know, well, I don’t want to do that because I didn’t like appreciate that aspect of my parenting, but I want to do it this way.

But, the fact is that no one gets any training on parenting. But there are a lot of resources available to us. I’m part of a, I feel like a church group as well. And that was really helped me with parenting aspects, because there’s quite a lot of parenting sort of advice and stuff you can go to, but there’s a lot of resources as well online for good parenting and marriage and stuff like that.

[Jaz]
It’s true, Tidu. I did this 28 day challenge and it was called 28 Challenge Not to Yell at Your Children. I lasted six days. So, give me more courage, everyone. Tidu, thank you so much for sharing that. I appreciate it. Thanks for talking about, your busy time, when you had that aspiration, how things can get better.

Because people need to hear that, right? And you can’t just aspire to excellence and do that. There has to be communication with your family. There has to be some sacrifice made, but looking at you reaching for the stars and doing this incredible work is very inspirational. It was a tough podcast for you.

I thought to do, I think you did brilliantly. You gave us the foundations, but you also catered a lot for those experienced listeners we have that are doing this day in, day out. And I hope that they’ll check out more content from you to do, thanks so much for your time today.

[Tidu]
Jaz, much appreciated.

Jaz’s Outro:
There we have it guys, thank you so much for listening all the way to the end. It was actually a really tough topic, like how do you break down all the different dimensions in terms of lip mobility, tooth position, gingival biotype, and the gazillion different types of different flaps you could do and names of different gingival procedures which are far too clever for me.

But like I said, I hope inspired you to look beyond the white esthetics and to really consider learning more about how to manage the pink esthetics. That will really raise the game of your esthetic dentistry.

If you want to learn more from Tidu, I’ll put in the show notes the link to join him with his course in January 2025. And of course, if you want to claim an hour of CE credits or one hour verifiable GDC assured CPD, then you can answer our quiz. If you get 80%, then we’ll send you a certificate. If you just listened to half the episodes the entire year, that’s it. Half the episode in one year, you easily get 25 hours of CE credits. And I’m sure you agree, it’s incredible value for money.

You’ll also join a community of dentists, of the nicest and geekiest dentists in the world. So head over to protrusive. app to make your account. Thank you so much again. And if you haven’t yet subscribed to the podcast and you keep coming back to it, can you do me a favor?

Can you hit that lovely subscribe button for me? I’d really appreciate that. Thank you. And I’ll see you same time, same place next week. Bye for now.