[Occlusion Month] Indirect Restorations For Guiding Teeth – PDP196

Protrusive Dental Podcast

Plant it low and watch it grow? Is that serving our patients?

Should we keep our crowns flat to avoid ‘interferences’?

How about guiding teeth – how can we recreate and build in guidance and the correct cuspal inclination in our indirect work?

https://youtu.be/b2KA84dXhnI

Watch PDP196 on Youtube

As part of Occlusion month I am joined by my dental technician Graham Entwistle and Occlusion geek Dr Mahmoud Ibrahim. We discuss foundational occlusal concepts relevant to our daily indirect restorations.

Protrusive Dental Pearl: Bleeding papilla? Use the HOW technique to QUICKLY stop bleeding – insert a Wedge obliquely (Haemostasis with Oblique Wedge technique) as taught by Dr Sunny Sadana from Drecomposite.com

Treatment Planning Symposium 16th November HYBRID EVENT

Basics of Occlusion Live 2 Day Hands-On Course with Jaz and Mahmoud

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

Highlights of this Episode:
0:00 Introduction
03:31 Protrusive Dental Pearl
05:16 Introduction – Graham Entwistle + Mahmoud Ibrahim
08:25 Guiding Teeth
11:40 Why is Guidance important?
16:35 What information should we provide our technicians?
20:00 Excursions and Patient Case
28:00 Complex crown creation
33:33 To Facebow or not to Facebow?
34:40 A Technician’s POV
49:50 What is the Technician aiming for?
51:06 Perfect Contacts – technician perspective
53:23 Final Thoughts

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: 180 Occlusion (Occlusal functional concepts)

Dentists will be able to:

1. Understand the importance of guidance and occlusion in crown design, ensuring restorations contribute positively to occlusal function and patient well-being.
2. Improve communication strategies with dental technicians, including providing crucial details such as shim holds and occlusal plane guidance, to ensure optimal restorations.
3. Make informed decisions about the distribution of occlusal forces to prevent damage and maintain functional integrity in prosthetic designs.

If you liked this episode, you’ll love PDP137 – Q&A with a Dental Technician

Click below for full episode transcript:

Teaser: If there's one thing people take away from this podcast, it's this point right here, which can easily be missed, okay? When we send a bite to our technician, whether it's a physical bite or a digital bite, more often than not, okay, it's wrong.

Jaz’s Introduction:
Welcome to Occlusion Month on Protrusive Dental Podcast 2024. I’ve just been a little bit excited for this theme. It’s one of my favorite themes to discuss because it was Occlusion, learning Occlusion. It’s what allowed my dentistry to become more fun. Allow me to move away from single tooth dentistry and through a series of episodes this month, we’re going to help you do the same. Ultimately occlusion is just really good restorative dentistry.

It’s part of the package, but It’s perceived as it’s like this dark art, this incredibly confusing thing. I think sometimes it’s pitched that way to sell more courses, etc. But me and Mahmoud want to convince you that occlusion is easy. It can be simplified. Have faith, stick with us this month, and we hope to demystify some elements of occlusion.

In today’s episode, we’re covering a theme whereby when you have a guiding tooth. Now, when I said guiding tooth, what did you think of? You probably thought of a canine, canine guidance. So let’s talk about that scenario, okay? Let’s say you’re replacing a canine either with direct restorative material or a crown.

Crown’s easier to discuss. If you’re replacing a canine with a crown or even an implant, how do you design the occlusion on that tooth? How do you ensure that you get the correct guidance from that tooth. Now, actually the real world scenario is not canine guidance because very few of our patients are actually canine guided.

Most of our patients are in some sort of group function. And so let’s say the next time you’re replacing a molar or a premolar, you check the occlusion beforehand, you get the patient to grind left and right, recreate their power functional movements. You see these wear facets lining up and you realize that this MOD amalgam that you’re about to replace with an overlay or a crown is actually serving that patient in their occlusion. That tooth is being used as a guiding tooth.

So you’re probably thinking, okay, so Jaz, where are you going with this? The theme of today is how do we ensure that that is replicated in the final crown? Do we want it replicated in the final crown? Because let’s agree on one thing, right? If a molar is a guiding tooth, it’s involved in group function, and now you’re going to put a crown on it, do you want that tooth just to be completely flat? Of course you don’t, that’s not adding anything to function, it’s not serving the patient anyway. So really what it boils down to is how do you get the lab to give you the right anatomy to give you the right occlusion?

Both in static and in dynamic, i. e. moving the jaw around. Which is why I’m joined by not only Dr. Mahmoud Ibrahim, but also one of the technicians I work with, Graham Entwistle. He does all my overlays and vertiprep crowns, and he does a wonderful job, and he has his own ideas and philosophies around occlusion.

And so I’m so grateful that he joined us today. Some of those episodes in the past where we’ve had a technician, including him when he came on an episode we did, Five Things Your Technician Wished You Knew. They’ve been received really well. We need to do more collaborative episodes with technicians.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. This episode is eligible for CE or CPD. We are officially PACE approved, so all the docs in the states and around the world can also have that validation, and we submit it to the AGD on your behalf as well. The way you get CE or CPD for listening or watching these episodes, It’s through our app, Protrusive Guidance.

If you’re on Android, make sure you make an account on protrusive. app first, probably the best way. Go on that website, make an account, and then you can use that login on your app that you download from the Play Store or from the App Store.

Dental Pearl
Every PDP episode, I give you a Protrusive Dental Pearl. Today’s one is really cool. I think you’re going to really love it. It’s very, very applicable. When you have that gingiva that just does not stop bleeding and it’s really annoying you and it’s ruining your day, it’s ruining your plans. What are you going to do? You could use some astringent, you can maybe get a cotton pellet, soak it in ViscoStat™ Clear and apply some pressure for three minutes, or you can get your laser or something fancy, but a really easy thing that you could do that every dentist in the world has access to is use a wooden wedge, but not in the way that you think.

You see, this is called the HOW technique. H O W. It stands for Haemostasis Oblique Wedge, as taught to me by Dr. Sunny Sadana. So a little turban tip to Sunny. So what you do is if you have a papilla that’s bleeding a lot, instead of inserting the wooden wedge, it has to be a nice meaty wooden wedge, instead of inserting it in like the normal way, right, when you go completely through, from the buccal to the palatal, for example, this time you’re going to angle it so the tip is angled towards the gingiva.

Can you imagine it being angled down towards the gingiva? Now, you’re going to get your tweezers, the back of the tweezers, and push. What you’ve essentially done is you’ve kind of stabbed the gingiva. Can you imagine just the gingiva being stabbed? I jokingly call this in a WhatsApp group, I call it stab-o-dontics.

But you know what? How is probably a nicer way to frame it. And what you’ll find after about a minute is that the bleeding just stops. The vessels are essentially temporarily occluded or the pressure just stops the bleeding and it can get you out of jail. If that’s not tangible enough, the second part of this pearl is that I will be adding a video.

The video will first go on Protrusive Guidance. Because that’s where everything always goes first, to our community, the community of the geekiest and nicest dentists in the world. And then I’ll add it on YouTube as well, so do check that one out. If next time you’re stuck with a bleeding papilla, use the how technique with the wedge in an oblique fashion. Hope you enjoy this episode, I’ll catch you in the outro.

Main Episode:
Graham Entwistle and Mahmoud Ibrahim. Welcome back Protrusive Dental Podcast. Today’s a special one. We don’t usually do like a, well, I don’t want to call it a three way, but let’s call it a threesome. threesome, a dental threesome. Good to see you guys again.

It is a special because very rarely do we get to have a technician input. So it’s great, Graham, we’re always privileged to have you speak. Mahmoud, always a pleasure. And it’s a great topic because it’s something that we don’t talk about enough, right? Guiding teeth. Okay. And we’ll talk about what guiding tooth is and basic crowns.

Now, before we hit the record button, there was a few things that we discussed, right? Between us three, we have 10 kids, right? With most of the heavy lifting being done by Graham with five, 10 is good. It’s probably the most number of children, most number of offspring on this podcast ever in one show.

So Graham, how on earth do you still have a pulse? How are you still sane? How do you still produce wonderful crowns that you send me. How does this work?

[Graham]
I’m very lucky. I’m graced with a wonderful team at home and within the laboratory now. And without the support I wouldn’t be able to do it. So, I’ve only got those people really to thank for my sanity

[Jaz]
And Mahmoud, what do you do to keep sane, my friend, from your lovely three children, by the way? What do you do to keep sane?

[Mahmoud]
Oh, well, I mean, similarly, you’re only as good as the team around you. So, yeah, at home, my amazing wife is always there making sure I’ve got the brain space to do what I need to do. For me, it’s things like I play basketball. So that keeps you saying it’s something about sport, competitive sport. When you’re there, you literally have no space for anything else in your brain. That is a huge for me. Once a week, I need that.

[Jaz]
Well, my son now is in the holiday club. I’m recording in the gym. I’ve never done this before. So I’m recording in the gym, little quiet, quiet area. And Ishaan’s at his holiday club, four hours. Don’t worry, Graham. It won’t take four hours. I got a lots crowns and stuff to make, lots of wax ups to do. But we’re talking today about guiding teeth, but while he’s in holiday club, I’ll give you a flavor of my week, last couple of weeks, right?

My son, my youngest son, Sihaan, has got moderate sleep apnea. He wakes up every 90 minutes, okay? And a lot of the times, I need to go downstairs and do a milk run, right? Wash the bottle, put some milk in, microwave, bring it back up, give him some milk, right? So, he’s one night, I woke up six times to go downstairs as a zombie, make some milk, right?

And then twice, my five year old decided to have growing pains. Twice, at one at two a. m. and one at four a. m., started crying with growing pains. So, this is my sleep deprived. If anyone asks you why Jaz, why are you sleep deprived? It’s not because I’m working too much. It’s because of parenthood and all the wonderful things that come with it. But anyway, I just thought I’d-

[Mahmoud]
Have you thought about putting a microphone [inaudible]-

[Graham]
Always something. Always.

[Jaz]
When was the last time, Graham, you had like a full night’s sleep without any disturbance?

[Graham]
Actually, the weekend just gone, my wife and I, we actually went to London for the weekend, childless for the first time in seven years, so we had an amazing weekend.

[Jaz]
Well, that’s why.

[Graham]
So, yeah.

[Mahmoud]
It’s funny how you pay for a hotel somewhere abroad just to sleep.

[Jaz]
The other one is the irony of people who are desperate for sleep trying to beg those who don’t want to sleep. Okay, to go to sleep. So that’s the irony. But anyway, enough about parenthood and sleep. I just wanted to share a little bit of a father-isms with everyone listening today. Guiding teeth now to talk about the scale of this issue Graham. I thought I’d ask you something what percentage of of the work that you get. Firstly, first question is what percentage of the work you get is single crowns?

[Graham]
So that’s 70, 70 to 75 percent actually.

[Jaz]
It’s the bread and butter, right? So bread and butter. And equally for us as dentists, yes, we like, we’re into occlusion. We do more wear cases. We do the lovely work, but our bread and butter, our bills are paid with single crowns, right? So what now here’s the next question, Graham, follow up, right? What percentage of those single crowns in the posterior, so in the posterior region.

Okay, what percentage of those single crowns are not likely involved in some sort of guidance, i. e. when the patient bites together, grinds left and right, okay, they are not involved in guidance. So for example, how many of those patients are in beautiful canine guidance, and really you can get away with a lot there. So what percentage are not involved in some sort of occlusal guidance?

[Graham]
Probably about 50 percent, again.

[Jaz]
Fascinating. I would have thought it would have been less. I would have thought that posterior teeth are more, cause like to find that perfect canine guided patient is not so common. However, sometimes you have a patient with a canine premolar, premolar, and then the second molar isn’t involved in any guidance maybe, and so maybe that’s what you’re referring to. That’s interesting. Mahmoud, any insight on that?

[Mahmoud]
Well, I think the question probably should be, A, how many crowns do you design to be in guidance versus how many do you design to purposefully avoid contact in movement? And is that usually just something you’re doing or do you normally receive some sort of instruction from the dentist as to what they want?

[Graham]
Yeah, so normally I get asked to put teeth in a guidance kind of feature within the occlusion. Generally, if you’ve prepped well enough and give me enough space, I can put a tooth that doesn’t go into any sort of guidance, occlusion itself anyway. So Jaz’s question is a bit difficult to answer actually on that front, because it’s how I make it for the most part and whether I think it should be guiding or not as well, and sometimes, say to my clients that this four could probably do with being like in a guidance itself and share some of the forces with some of the other teeth, because the occlusion is like all over the shop and obviously this tooth is being restored for a reason.

And the teeth around it are going to be restored for a reason. So can we make actually the situation better for the patient? So yeah, there’s always lots and lots to actually think about, although you’re just looking at some teeth on a cast, but actually it’s not quite as simple as that. And can you improve things for that patient?

[Jaz]
What percentage of occlusal prescriptions does a dentist tell you about, not only just occlusion, but then do they actually extend and continue on to say whether they want the tooth in guidance or not want the tooth in guidance or any sort of input into the guiding part of the occlusion rather than just the static?

[Graham]
I think I’ve only really got a handful of dentists with probably

[Mahmoud]
They’re all called Jaz

[Graham]
The knowledge of the guidance itself and what they want. I think a lot of them just kind of leave it to myself to make those decisions for them.

[Jaz]
Fascinating, isn’t it? Fascinating. So let’s talk about why this is important, okay? So when you have a single crown in an otherwise dentate patient, lots of teeth, okay? Simple one. Let’s start basics for the dental students, young dentists, okay? When you do a crown, okay, it would be a disservice, right? Let’s agree that it would be a disservice if you give the patient a crown and it’s completely out of the occlusion, like way out of the occlusion by a millimeter, like it’s just completely not contributing to the patient’s chewing, the patient’s clenching, it’s just not helping the tooth.

And yet, when you fit the crown, the patient says, oh, it feels great. It feels as though I’ve got hardly anything at all. And the patient will be happy, right? But actually, you have done a disservice. But if it’s just one tooth, and I’m not condoning this, by the way, but if it’s just one tooth in the entire mouth, then you might get away with it.

I’m trying to say that patients are very adaptive, very tolerant, and you might get away with it. But suddenly, when you have less and less teeth, right? And suddenly, the right side molar is the only molar in contact, and you don’t give that tooth some sort of occlusion. Then you’re really disservicing our patient, right? So just starting with basics, occlusion is important at the very basic level just to at least get a tap tap tap. And then we’ll talk about excursions. Mahmoud, anything to add on that?

[Mahmoud]
Well, kind of like what we say in terms of why bother, the tooth will just erupt into occlusion or whatever and as you say when you’re dealing with simple cases single teeth, it’s fine. But if you ever want to get into doing more interesting dentistry, veneers, the restored, the rehab cases, et cetera.

You need to start worrying about these things because you can’t do a full arch of preps and say, leave it lightly out of inclusion. It doesn’t work like that. And it’s building the skills in the small scale that you can then translate onto the bigger scale.

[Jaz]
Graham, when you’re designing, when you don’t have any instructions given to you, let’s say you’re replacing a first molar crown. So you’ve got the crown prep. Okay. The dentist has sent you in A3, E max. That’s it. Right. What’s your stock? Just tell us, think out loud, what are you thinking in terms of when it comes to the occlusion and the anatomy? What’s your thought process?

[Graham]
So, my initial thought, so it’s going to be a monolithic crown, and I want to make it look like a new tooth, but obviously you can’t go too far with that, so you’ve got to make it look like it’s in that arch. At least somewhat, or it has been part of that arch, although everything else is gone.

[Jaz]
What do you mean by that? Extend more about that, because I’m loving what you’re saying, but just tell us more about that.

[Graham]
So, you’ve got to make the occlusion look like almost the rest of the occlusion, but you want to give that patient something new at the same time. So you’ve got to find a balance between doing something that’s bling bling with all the details, all the cusps, every tiny little ridge, and something that’s completely flat without any occlusion at all. So you just got to really think about what points of contact you want on the tooth and how you can share the load between everything else, how light it’s going to be in that occlusion.

Obviously, if your dentist has given you any instructions at all on like shim holds, and sometimes it can be really helpful, especially if digital bites aren’t always the best and like give you the correct position as such because patients can protrude forwards, et cetera, et cetera. So, but with Emax, generally we handhold everything anyway.

So, that’s absolutely fine. But yeah, I’ll just look at the cusps and then we’ll just start doing a wax up instantly when we’ve got everything ready and just build up from there and we make our decisions at that point really as we’re building the wax into the actual.

[Jaz]
At the very basic level in this very open ended question, I appreciate it’s very imaginative right, but at the very simple level are you wanting this crown to be holding shim or not without any instruction from the dentist. What is your stock? A thought process. Are you checking with shim to make sure that the other teeth are holding shim as well as this one? Or do you want this slightly dragging shim or not holding shim? What is your like slightly dragging?

[Graham]
So I would like the tooth to literally just hold some resistance as I’m pulling through my shim basically.

[Jaz]
And then what about the guidance? Because if the dentist hasn’t told you anything, what are you looking at to come to a decision and say that? Hmm. I’m going to now wax it up into guidance or not.

[Graham]
So I look at all the wear facets across the arch, and I’ll just start hand manipulating basically the articulation of how the jaws actually work in how everything moves and does it need to be an occlusion generally a six I wouldn’t have put in a shared occlusion unless it’s a lone standing tooth along with like maybe something in the anterior region. Just mainly help the function and the longevity of the tooth. But yeah, on the whole, I generally wouldn’t put a molar into that situation.

[Jaz]
I think the reason why you’re saying that, Graham, is we know that molars are not great with lateral forces. They’re better in compression, and our materials are better in compression, something Mahmoud always raves on about, right? Teeth are better in compression, materials are better in compression, so I understand that logic. But sometimes, when everything is shared, Mahmoud, why would you want to recreate a guiding tooth? My question to you is, what are the features you’re looking at to think that, okay, when I send this up a first model to Graham or my technician, I’m going to actually write a few sentences to tell him to recreate the guidance, because surely for the longevity of the crown we’re thinking hang on a minute if we just okay at the one end of shoddy dentistry, keep it totally out of occlusion that crown might just last forever.

All right, okay, but it’s not really contributing much to the patient, but on the other end you’ll you have it in all sorts of horrible occlusion and it’s completely too much occlusion And that’s the other side and you’re there adjusting it for ages. So what are the what’s the middle ground? What do you aim for?

[Mahmoud]
Well, ultimately, I think it all needs to start with examining the patient, right? So the same tooth with the same fracture or decay or whatever it is might not get the same prescription depending on what the rest of the teeth look like and what does the patient do with their teeth. So you need to start by, first of all, looking at the patient.

Do they actually have any wear on their teeth? Now, if they do, and there is wear on the tooth, you’re restoring in sort of these guidance, right? The patient is grinding on this tooth and you’re going to restore it. You need to ask yourself, do I want the patient to continue to be able to do this on my restoration?

And some might think, well, no, obviously you don’t want that. But actually, again, there’s a question to be asked because if you remove the guidance off of this tooth, yeah, and you create a flatter restoration, patient can’t grind on it anymore. Guess what? That grinding force is going somewhere else.

So to give you a hypothetical example, your patient has a crown on an upper canine and an upper first premolar already. And they’ve got decay underneath the crowns, and you’re going to replace them. When you do the occlusal examination, you find that when they do grind to that side of those crowns, they’re touching both those crowns, and there’s actually some mild wear on them.

And you think, okay, what I’ll do is I’m going to make my life really easy. I’ll change the crowns, and I’ll just have it so it’s canine guided, right? We know that canine guidance is panacea, right? Just give it canine guidance, the patient’s going to stop grinding. It’s absolute nonsense. What you’re doing when you’re removing the guidance off of that premolar is you’re adding that force that was going on it onto the canine.

Can the canine handle it? Maybe, maybe not. It depends on how much decay there is, right? So you need to make a clinical decision and pass that information onto your technician as to whether you want to move the guidance maybe solely onto the canine, or do you want to maintain it the way it is? Because as the force is shared, each tooth is less, is getting a smaller share of the total force. Does that make it a bit clearer?

[Jaz]
Mahmoud, that reminds me of the lecture that you have on OBAB of converting canine guidance to group function. Okay, and why would you need to do that? It’s exactly that principle. You have to look at the biomechanics of tooth. Can you know, you’ve got to think about where is a load going?

And you have to kind of become an engineer to think about this. And also, obviously the other thing, obviously we’re talking about grinding. The other thing that the slopes of these teeth contribute to is function. The slopes allow the jaw to find the home position and outside in. And so if we did deter too far away from there and suddenly every tooth is that gets restored.

We’re just making it flat, flat, flat. You’re really confusing the patient’s cycle of function. So that’s to be said as well. But for just the bare basics, we want the tooth to be there, to be taking tap, tap, tap. Usually we want the tooth to contribute to occlusion. And then it’s a case by case decision making whether we would like to have this tooth in guidance or not.

So that’s where we start first. Do we want to have guidance on this tooth or not? Maybe it was never in guidance before and you want to add it to guidance and then you’ve got to have that sort of prescription to your technician. The other thing which we haven’t, we’ve talked about but I just want to give an analogy is, and we see this on social media all the time, right, where we see a really worn tooth, okay, old amalgam, flat amalgam, okay, caries.

The amalgam is removed, the cary is removed, rubber dam on. You see the most exquisite composite restoration on social media, right? Rubber dam is still on by the way, okay? And the anatomy is fantastic. It’s the anatomy that you would expect a seven year old to have, right? And there’s so many things that I, I wouldn’t say plagiarize, but I always credit my mentors who taught me this, but this is my own rhetorics, my own thinking, so I’ll, I’ll claim this one, right?

And I’m always thinking, why are we giving a 54 year old a seven year old’s tooth? So I always think of the shape of a tooth in terms of an age, and I think we have to make our composite restorations, for example, appropriate to the age, but generally to that patient. More important is the patient, not just the number, but generally there’s going to be some physiological wear.

We need to recreate that, okay? We need to look at the opposing tooth. And if the opposing tooth is very flat, very worn, we’re not going to be able to get away with having a very curvy and exuberant restoration on the opposing. So we need to make it fit in the arch, just like Graham said. We need to fit in that mouth, in terms of the opposing tooth.

And then also make sure that it fits within the TMJ and muscles. So that, for example, one thing that you might not want to do, and here’s an anecdote for me, remember, nine, eight, nine years ago, I did an Emax onlay for a lady. Lower right molar, okay. This was in Singapore. Lower right molar. I bonded it in.

Everything looked great. It was fantastic. Tap, tap, tap. Holding shim. Just like the other teeth. So it was shared. On that occasion, I forgot. Many years ago. I forgot to check the excursions. I saw her again for a reassessment in about four months, roughly. And we just got talking. It was part of my screening.

Even then, I was talking about headaches and stuff. And she said, yeah, you know what? For about three months, I’ve been getting headaches. And I felt her muscles, right? And compared to the left side, her right side was really, like, tight. I could feel the tight bands on the musculature. And I was thinking, hang on a minute.

Could I have contributed to this? So I checked the excursions, right? So she bit together and grind left and right. And guess what? Her jaw just could not move. It was stuck because the molar and the way that I designed it had too steep of a cusp or incline and the patient was what we call locked in. Okay, the muscles want to move, but they couldn’t.

Okay, so what I did is I adjusted the occlusion what I should have done three, four months ago. And now the patient was able to freely move her jaw. Okay, and when I saw her again two months later. She’s like, whatever you did, my muscles feel normal again. My headaches are gone. And so that really served a lesson to me at that point.

I’m not saying that everyone is acceptable to this. It’s a susceptible patient, but that’s a lesson of why we don’t want to overdo it and over go crazy on creating the cuspal inclines. Cause if now that’s the only tooth in guidance or stopping the jaw from moving, you could get fracture of the restoration, you can get the muscles being overloaded. And this is not the scenario that we want. Any thing to add on that Mahmoud?

[Mahmoud]
No, I think you covered it really well. The analogy is amazing actually, because a lot of the time the consequences don’t necessarily hit us unless the patient comes in, sits in the chair and says, what you did here is hurting, right? Any other consequences go unnoticed by us, but you could be doing all sorts of stuff. And actually a couple of minutes of just checking what the patient has and then communicating that to your technician and then checking it afterwards. You can avoid so many issues.

[Interjection]
Hey guys, it’s Jaz again for a quick announcement. It’s that time of year again for our annual Live Protrusive event this year in London, the Sheraton Skyline Hotel. We’ve got Dr. Lincoln Harris from Australia and also from Australia, Dr. Michael Frazis. They’ll be joining me on Saturday 16th of November for a full day. Now, because you guys on the community couldn’t decide between the topic of treatment planning or failures, we combined them both into the Treatment Planning Symposium: Learning from Failures.

So in the morning, I’ll be kicking off showing you some of my own failures and what lessons I’ve learned that I want to pass on to you. And the most unique thing about this is because I’ve been videoing my procedures for a long time, some of these restorative calamities that I’ve made. I’m going to reveal all.

I’m going to show you all and how I actually fix them as well. That lecture itself will be worth your entire day. Then I’ve got Dr. Michael Frazis talking about his failures in the last 10 years, both in clinical and in communication. And what I appreciate about educators like Dr. Michael Frazis, is their willingness to share failures and talk about it.

And of course, the main event, the headline act, Dr. Lincoln Harris. Last time he was talking about de stressing dentistry, this time he’s doing a treatment planning masterclass. We’ve actually got a live patient in store. I’ve taken the photos, I’ve got the radiographs. Patient will be there with him live, and he will be interviewing the patient, taking a history, coming up with a treatment plan, and communicating it to the patient.

Live, on stage, under real time conditions. And then he’ll talk about all his lessons for being an effective treatment planner and communicator. The tickets are on sale right now and they are at a ridiculously low price for an event featuring two international speakers. We also have a live stream so wherever you are in the world you can catch it all live.

Including the live pound discussion, the live patient, and all our lectures on the day. So if you’re a local or someone in Europe, please come to Sheraton Skyline Hotel on 16th November. Come and network and feel that live magic. But if you’re unable to attend, then we’ve got the live stream with the 30 day replay at a really good price.

We’ve got an early bird offer at the moment, so head over to protrusive. co. uk/rx. Rx as in treatment, right? So forward slash Rx and the early bird offer ends this month. So book your ticket now to avoid disappointment. Once again, protrusive. co. uk/rx and look forward to seeing you there.

I’ve remembered another lady, really sweet lady. I’ve been seeing for just over a year now. And she had basically, she was gosh, maybe in her fifties and she literally had again the teeth of a seven year old, naturally. It’s a minimal wear, okay, in a physiological wear, but she was in her fifties. And because her teeth were too cuspy, her teeth had too much detail.

It’s a bit like, imagine getting two study models that have got just too much detail. You can’t get the cusp to really fit in the fossa, because not enough wear has happened to allow it to sit together. So the consequence of that is that she had a messed up occlusion in the sense that she kept deprogramming herself, her bite kept changing, that was a reason she was referred to me.

So, part of the therapy was, she had an anterior open bite as well, which wasn’t helping, but that’s a red flag, the fact that she had an anterior open bite and minimal wear on her back teeth, okay? So, the way I explained to her, look. You have a seven year old’s tooth. You have a 14 year old’s tooth, I used to tell her.

And then once we actually ground in and equilibrated, gave her a stable occlusion, okay, that’s it. She’s now got a stable home. So we need a little bit of wear, physiological wear, to find our bite. And so one of the theories of why children brux is to actually, as the teeth are erupting, right, to come into occlusion, we need a bit of bruxism to actually move them into the right position, the arch, and actually get them to bed in and actually lock and mesh together. I just wanted to add that basically.

[Mahmoud]
It’s like using chewies, right? When you’re doing Invisalign.

[Jaz]
I like using chewies. Absolutely. Next question I had then, so we talked about what is a guiding tooth, why we should recreate guiding teeth surfaces. Okay. It’s part of being a conformative dentist.

Okay. Conformative meaning that we’re trying to give the patient a similar bite to what they had before, because generally their bite is working for them. They don’t need any major dentistry. We’re trying to keep things simple and replace one or two teeth here, and therefore we don’t need to change 28 teeth here, and so trying to fit into the patient’s mouth, and so we are being conformative, and we make a decision whether we want to have guiding or not guiding based on what we discussed.

Now, the next thing is, Graham, and correct me if I’m wrong, it’s much easier for me to say to you, please design this crown to be holding shim in static, but I want no excursions, okay? I’m assuming that is easier for you to design then, please make this whole shim, and I would like it to be shared in group function, along with the upper right premolar, first premolar, and canine. Am I right in saying that?

[Graham]
Yes, yes, you’re right, because there’s less to get wrong. Because obviously there’s lots of variables in how we make everything and how we receive the data anyway, so if there’s anything that’s slightly off, there’s just more chance of things not being quite how you’d like it. But from an actual technical point of view, when you’re doing the waxing yourself and you’re actually designing the tooth, it’s not such a big issue. You can design it really easily.

[Jaz]
But there’s more things that can go wrong. There’s you can miss the mark a little bit, get too much guidance on it, not enough guidance on it to share. There’s a lot of parameters, but yes, with the technology that you have articulator, it’s pretty good at. So trying to match the cuspal inclines of the adjacent teeth, right?

[Graham]
Whether you do it virtual articulator or by hand. Generally, I try to do everything with my hands still, everything’s still handmade and pressed, so it’s hand waxed. So, when I’m doing any sort of guidance, I try and get the most shallow guidance possible. So, I try not to make it any steep angles, so the most shallow guidance possible on everything. And I feel that that just really helps the TMJ. I think you’ve mentioned this earlier in one of your comments, which just really helps the TMJ to relax a lot more and not become locked in that function.

But virtual articulators also depend on how you’ve taken and registered the bite clinically. And it can be a really big issue, especially if I’m doing a zirconia, for instance. And all of a sudden I’ll get everything back. I think it’s really gone really nicely. I’ll snap off all my supports once I’ve checked the occlusion. And actually a lot of cclusion is miles off, so then I’ve got to sit there grinding the crown in and that’s when it becomes difficult to put that function in as well because I’ve got a hard material now to work with and it takes a long time to adjust that.

[Jaz]
But in that scenario, when I have, for example, asked you to make sure that this distal buccal cusp of the first molar is in group function all the way along, in that kind of a scenario, what tools do you want from us as a dentist to make that easier for you? Would you, in that case, would you love to have a face bow on your favoured KaVo articulator to get this correct?

Or do you feel as though you can get this correct just by looking at the cusp or incline of the adjacent teeth? How can dentists help you better to give them what they want in terms of the correct guiding tooth?

[Graham]
If you just tell me where the shim stock holds are, and then I can make sure that the positions of the teeth are correct. So, if I don’t feel it’s right from the position you gave me digitally or analog wise in, in your bite that you’ve sent along, you’ve told me where the shim holds are, and I can then put it on an articulator in that position with the holds exactly where you said they are. And I’ve got more chance of survival there and get it right.

[Jaz]
Can I just stop you there, Graham? Because I think I want to just double, triple emphasize this one point. If there’s one thing people take away from this podcast is this point right here, which is easily missed. Okay. So if anyone’s multitasking, please reeling back in. This is really important. When we send a bite to our technician, whether it’s a physical bite or a digital bite.

And Graham will vouch for this. More often than not, it’s wrong. And what you’re getting, you’re having to do some adjustments to actually get it to look like what it should. So to give you the shim holds, it’s so incredibly important to make sure that you’re getting the bite that we are seeing. Is that correct?

[Graham]
Yeah, so it’s more helpful if you tell me where the shim holds are, if the patient’s got an anterior open bite, or just something about the bite, if it’s irregular. So most patients bite quite nicely in MIP. And I’ve got a natural home position like we’ve said earlier, but some patients have like interferences and they find that home position difficult.

So when you tell me where the shim holds are, that’s very important. And it gives me the chance-

[Jaz]
To verify that the occlusion that we’re seeing on the patient is what you have on your desk.

[Graham]
Exactly that.

[Jaz]
Because if that’s wrong from the first position, then the whole case is wrong.

[Graham]
That’s right. And even with digital records as well, I’ll find that certain clients might actually give me a digital bite record where the patient’s actually like clenching and they’ve gone probably too hard on their bite and then obviously sometimes it’s the other way and they’ve gone too light.

And as a result of them being too light, the jaw’s just moved slightly out of position and they’re just not in a natural position at all. So if I was to make something to that position, then it’s going to be wrong and you’re going to phone me up telling me, hey Graham, that bite was off. Actually, what you’ve given me was not so great itself, you know.

[Jaz]
So top tip is everyone get your shim stock out, get your Miller’s forceps out. And give upper right six holding shim against lower right six, upper right second premolar holding shim against lower right, whatever. And just to give you that detail allows the technician to verify that the bite that they have in front of them is the same bite that your patient has.

Because yes, all sorts of issues with scanning the bites, all sorts of issues with physical bites as well. So that’s a top tip. So then to add on for that, as well as the good shim holds, what else could we be giving you to help you recreate that guiding surface on the tooth that we’ve just told you to create a guiding surface on? How imperative is it to have a facebow in your opinion, Graham, or are you thinking that you can create it just fine without a facebow? It’s a top question that we get for a single crown.

[Graham]
For a single crown in the posterior region. Don’t really need a facebow. It’s just my I mainly use that for the occlusal plane exactly to work out where that is. And it’s detriment for anterior teeth. Especially like when you’re trying to work hand.

[Jaz]
And when does that change at what point do you think that okay at what point how many units does it might change that you actually to get the predictability here? You may desire a facebow record from your dentist.

[Graham]
Oh, so like if we’ve got a posterior quadrant perhaps that’d be really helpful, helps us to get the buccal corridor looking nice and get all the cusps in the correct places. So visually it’s important for the aesthetic.

[Jaz]
And fellow articulator stroker Mahmoud, tell us about your thoughts on to help create the precision in the occlusion when it comes to recreating group function or getting the technician to get the guidance correct. Okay, because an easy case and another plus point of canine guidance and why can guidance is popularized is that technically speaking for a technician to create canine guidance, it’s may easier than saying, can you make sure the upright canine first premolar, second premolar, first premolar, but not the second premolar, but the wisdom tooth are involved in the excursion, right? It’s so much easier to make sure that it’s just one tooth.

So that, but when we’re going to actually recreate and conform and we want this premolar or this molar to be adding to the occlusion in excursions. Mahmoud, what are your strategies that you feed your technician to help with this?

[Mahmoud]
First, I want to say that the job of getting it right happens in the mouth. You can get as close as you can try. Well, you can try and get as close as possible on an articulator, whether that’s virtual or whether it’s analog, whether you’ve used the facebow or not. The chances are you need to do some adjustment in the mouth. Now, for me personally, what I want to do is get it right in the mouth and then get the technician to copy what I’ve created.

So I think one of the best ways of doing it is whether you’re going to do a direct composite mockup if you want to call it a functionally generated path. So if you’re doing it in, you’re doing it on a pre molar, for example, you can take some composite, you don’t bond it on properly.

Create the shape that you want. You work out the occlusion in the patient’s mouth, and then you can take a scan of that, for example, and send it to Graham. However, one of the main questions when I spoke to Jaz about setting up this sort of this three way, this threesome was, I really wanted to know from your side, Graham, if I give you contours that I’ve checked in the mouth, so let’s say I’ve got canine and premolar and I’ve shaped the provisionals perfectly, they’re exactly how I want them. And I take a scan, and I send that to you.

[Jaz]
A pre prep scan, for example.

[Mahmoud]
Yeah, yeah, yeah. Over the provisionals. Okay, so everything’s the way I want it. I want you to just great-

[Jaz]
And think of that patient recently, and Mahmoud, it’s great you’re asking this, because recently I sent, literally like two weeks ago, Graham, I sent you that case, initials ME, because I wanted his retainer to fit perfectly over his new onlay that I did.

And so what I did is, he made that face. So what I did is, I kind of recreated in a temporary crown exactly how I wanted the shape to be. I scanned that and I sent it to you and I said, make sure that the contours of the crown that you’re going to make me, or onlay you’re going to make me, overlay is no wider than this.

Because if it’s no wider than this, I know the retainer will still fit. And so similarly to Mahmoud’s question, how easy is it to copy scans that we give you? Is it a really tricky thing or is it a super easy?

[Graham]
I mean, it can be super easy and it can be super tricky. It just depends on your prep design also, because at that point you have to switch to a digital restoration. I can’t hand wax that to the same, what you’ve given me basically. So I have to go digitally. So then we’ve got the margins to try and keep integrity. And if you haven’t designed your prep as such, then it’s very difficult to get something out of the mill that hasn’t chipped or just any little discrepancy around the margin.

So that can be quite difficult to get right. And that’s just like, before we even look at the actual function that you’ve given us. So, and then we’re at the mercy then of the milling tools. Are they sharp enough for the job? Are they actually going to trim it back to the correct accuracy that we need?

So sometimes things can be left a little bit proud and you’d find that your retainers just a little bit tight and where’d you go from that? So I would never guarantee you that I can make it fit perfectly, but I can guarantee you that I’ll conform to what you’ve given and that I will put the function back in if it turns out just a little bit high out of the mill, once I’ve gone ahead and kind of almost sintered the material.

I can then grind back in if it’s high, the function that you wanted with the shape that was there before the shape that the patient’s comfortable with and their tongue is not going to be like on it all day, every day. So yeah.

[Jaz]
And then in the case of the anteriors that Mahmoud mentioned, imagine you’ve got some anterior provisionals, the patient’s wearing these anterior provisions for three months, and you’re really happy with the shape.

In that case, you copying via, and then you’ve got a scan, for example, that Mahmoud sent you, for example, in this hypothetical scenario, how are you trying to copy the shapes exactly in your ceramic? Are you taking like a palatal putty stent and then hand waxing from there? Or what are your strategies that you’re using? Or are you relying on digital for that kind of scenario as well? Mahmoud, that’s your question, right? That you answered for like anterior provisionals. How do we copy the shapes?

[Mahmoud]
Yeah, essentially A, how easy is it to get the shape that I designed in terms of the palatal surface? And also if you could later on to give us some tips about, okay, look, if you want me to be able to copy this guidance, make sure the guidance is on a flat area.

That’s like a couple of millimeters wide, not some funky, cool, cusp shape just so that the milling machine, all that sort of stuff, the backend stuff. What can I do to make your life easy so you can give me back what I need?

[Interjection]

Does occlusion confuse you? Do you feel like you need a taught in a way that actually makes sense? Whilst we have got a great online course, we totally understand that some people learn better from in person and hands on programs. Our Basics of Occlusion Face to Face Course will be too enlightening and fulfilling days with nine hands on activities.

We cover crowns on dodgy occlusions. No other course in the world covers this, and so it’s important because you know what? None of my patients have a perfect occlusion. We often have to work to a non ideal occlusion, but we want everything to work for the longest time possible.

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[Graham]
You can ask your technician, basically, especially when it comes to palatal function. I find that a lot of clinicians generally. They don’t prep enough. They don’t give enough space there. And a lot of the space that you give is around 0. 5 to 0. 8 mil. 0. 8 mil will generally get you what you want, but anything below 0. 5, 0. 4, all of a sudden, When you put it in the mill and you’ve wanted to conform to that shape that you’ve given us, actually the minimum thickness of the material then overrides. And then I’d have to then go in and hand trim everything. And then next thing you know, you haven’t got what you’ve given me, especially if you’ve got multiple areas where I need to do this adjustment.

[Jaz]
So top tip number one is if you’re trying to copy shapes intricately, especially when there’s functional pathways involved, let’s say palatal is uppers, make sure there’s enough space so that you don’t have to go back and then hand recreate it, it can be then milled into the correct bite. Is that a fair way to summarise it?

[Graham]
Yeah, that’s right, yeah.

[Mahmoud]
And this is a, you’re milling a wax pattern, right?

[Graham]
So you mill a wax pattern or you can just mill straight into lithium disilicate if you’re going to do an Emax or GC LiSi block. Well, same with Zirconia as well. It’s just having enough space in order to recreate what it is you wanted without the parameters of the mill machines and getting everything out of there in one piece because you can encourage micro cracking, you can encourage lots of things by having thin areas and then that goes straight into thick areas.

It comes out of the furnace and instantly you’ve got thermal shock. You don’t notice it in the laboratory, for instance. I then go through a few more processes, send it out to you, you fit it in the mouth, patient bites down. Oh, it’s cracked. So yeah, just prepping everything appropriately is pretty paramount to the shape that you’ve given, being able to conform to what you’ve given and give you a restoration that is actually fit for purpose. So maybe if you’ve got the wax up to start with as well, an idea would just be try that in and prep through that just to make sure you’ve got enough room as well.

[Jaz]
But do you often also take a putty palatal index to then when you’re checking and verifying to make sure you’ve got those shapes right?

[Graham]
Generally I’ll take that mainly for the tips and the length of the teeth. I can never, if I’m doing any feldspathic adhesion, I can never give you 100 percent what you want. Or what you gave me to start with. So I would prefer to do that in a monolithic. And then I’ve got much more chance of getting sort of like 9, 800 percent of what you gave me. As long as you’ve prepped accordingly as well to give me that shape.

So when you transfer into hand layered, felt spathic, you’ve got lots of variables involved here, and you’ve got shrinkage of the porcelains that go onto the substructures. And that can be quite a challenge. And the next thing you know, you add in little bits, and then you can overfire the materials as well, so you kind of got to make compromises.

[Jaz]
There’s so many parameters, there’s so many complications that can happen that go against you.

[Graham]
Yeah. So, yeah, it’s all about compromise at this point. Is this patient a stickler for that shape? And if the patient is a stickler for that shape and wants that shape and nothing else, then should really look at monolithic if possible.

And if there’s a little bit of give and take and the patient wants some additional aesthetics and translucencies in the teeth, then obviously you’re going to have to go for the feldspathic route. But you’ve got to let the patient know that there might be a difference in the shape when it actually comes to be made by the technician and in lots of laboratories as well.

Different technicians have got different ideas. And molds in their head, there’s go to shapes that technicians have and sometimes it’s hard to get away from that and give you what you want. So you might have made something on your digital design that was quite ovate, but the technicians used to making triangles and you’d get something like in between. So yeah, best way to go.

[Jaz]
I think the first major takeaway, Graham, that you gave is shim holds. The second major takeaway is every technician, just like every dentist does things differently, every technician will do things differently. So if you’re looking to do a case whereby you want to try this out and you want to make sure that the guiding surface is exactly how you want it and you give a prescription, or you’ve got some anterior provisionals and you want to copy the palatal contours, i. e. the functional contours, as closely as possible, pick up the phone, speak to a technician, and find out what records your technician wants to help facilitate this. And also when Graham, when you next get that case in, it’s like, Oh yeah, I had a chat with Jaz about this. And he told me he wanted to copy these for this reason. And therefore, you already have a bit of context when you’re treating that case, right. I’m sure it’s nice to have that.

[Graham]
Yeah, it really does help. Helps me to give you what you want. And especially if you give me what I want. And when you don’t, then that’s when it makes my life difficult in giving you what you want.

[Jaz]
And one thing that we touched on, which is the third key takeaway, Mahmoud, you said that you mentioned the functionally generated path technique, which we have a podcast on, so I encourage everyone to check that out. But essentially, I just want to just describe the sequence here before I get you to chime in here, Mahmoud, as well, is lower right molar if it’s broken down.

Okay, like a cusp fractured for example It’s broken down and you would like this tooth to be involved and contribute to the patient’s occlusion in the guidance what I typically would do is get some composite. No etch. No bond Just a dry tooth put some of this mock composite expired composite on, just finger shape it get the patient to bite together vaseline on the opposing tooth by the way vaseline on the opposing tooth bite together tap tap tap grind left to right, tap, tap, tap, start chewing, okay?

And then with my flat plastic, just trim away all the messy bits around the edges. But now you’ve got the shape of the opposing tooth beautifully carved in, right? So you know that it’s going to be perfect now in the excursions and the function. And then I cure that, I scan that, and I send that to you, Graham. But Graham, again, is that something that you don’t like, or you’re indifferent, or you like to have that?

[Graham]
I mean, I’m indifferent, really.

[Jaz]
Just try your best.

[Mahmoud]
I love it. I love it.

[Jaz]
Mahmoud, you were going to say something, sorry. Sorry.

[Mahmoud]
Yeah, no, I was going to say is that I think in, certainly in my head, at least at one point, it was like, okay, I’ve got a scanner now. So if I scan something and I send it to the technician, any technician, yeah, they’re going to plug it into this machine and it’s going to spit out either a copy if that’s what I want, or basically they can do anything. What I’ve come to understand, and hopefully Graham can maybe say that either I’ve got this right or wrong, but you can send that to 10 different technicians and they might have 10 different bits of software, 10 different machines that mill with different types of burs, different settings. And you can get completely different outcomes with the same data put in and the same instructions. Is that sort of correct, Graham? Is that true or false?

[Graham]
Well, it is true to an extent because all softwares and all like 3D printers or mills, they all have to be dialed in together. So if you haven’t dialed in your settings to how your clients actually like the work done or how you like the work done for your clients, then you’re not going to get the result that you want.

And some labs are more meticulous than others at actually getting everything right. And to perfection, where some laboratories are just like, oh, that fits quite well, and then they’ll just roll with that forever. I’ve experienced that in like labs of all levels through my career. Some are happy to accept lower levels of this, that, and the other to make things easier.

So, but you’d probably find that those laboratories have got a different business model and they charge less for your work. So, you kind of get what you pay for sometimes depending on what laboratory and yeah, it also just depends on the type of person that’s running the laboratory as well, whether they change their burs often enough, it just comes boils down to a lot and the quality control at the end, does it go through that lead technician, does everything leave by that lead technician?

Lots of other laboratories have got like five, six, good technicians, but each one of them have got a different criteria of how they check everything. So, they’ve probably got written protocol that says you’ve got to do it this way, but actually everyone’s different and everyone’s got their quirks. Everyone likes things done certain ways. So it’s an interpretation. Basically, given on, being given to you by a human, it’s been made by humans and everyone’s different.

[Mahmoud]
Just a little tip for people who do work with a technician regularly is when it comes to contact points between teeth and your crowns, it’s sometimes it’s not necessarily that you need to give them a specific wording to get what you need.

It’s about consistency. And this is how I got myself to a point where my contacts on my crowns are almost always perfect. And I’ve used the same wording every time. So I will say. Please give me, I use the word good, but that’s not the point. It’s a good interproximal contacts that tug shim on a solid model.

Okay. Wording is very deliberate. Not because if I give any technician holds the models and says, yeah, this tugs. I don’t think every technician is going to get the same thing. But what’s happened at the beginning is when I said that, I got some crowns that were too loose and I let them know that this was too loose.

So they will remember what it felt like and they will know that it’s loose. So now they will adjust and adjust until I get it right. So now they know what it feels like to them to tug shim and having it work in my hands, right? So then now it’s, it’s very consistent. So it’s not necessarily the words, but if you just give them the instructions as to what you want them to check and then give them feedback as to how it feels like in the mouth. And then eventually they will calibrate themselves to what it is you want. Does that make sense? I don’t know if I can-

[Graham]
It makes perfect sense. Cause that’s how I try and teach my technicians as well. They asked me, how is this supposed to be? It’s just like, I can’t really tell you it’s all about feel. So, once we get few right, then you’ll know how it feels. I can.

[Jaz]
Graham, what are you feeling for when you’re checking contacts? Cause I’ve said your contacts are very, very good. I’m very happy with them. Small percentage times I’m adjusting contacts when it comes to you. So when you are checking the overlay or the crown, let’s say, what are you aiming for on your models based on your printed models and your workflow?

[Graham]
The contact paper that I use is actually a 12 micron. I will just aim for it to be restrictive as I pull it through. But it’s a light restriction. Like dragging? Yeah, it’s a light restriction on both sides. If there’s anything less than that, then you know you’ll probably, you’ll get away with it, but you should be adding to that crown again. Send it through another cycle if you can, if you don’t feel like you’re-

[Jaz]
If you really miss the mark, how do you fix that? So let’s say you’ve got a zirconia, and you’re like, oh, oopsie, we’ve got an open contact here. You have to-

[Graham]
Add some ceramic and then go through that process again.

[Jaz]
Is that easy to do? Is that time consuming?

[Graham]
It’s quite time consuming. If you’ve got a lot of work to get out the door, if you’ve got a big case on that you’re under pressure with, and then all of a sudden you’ve got this single crown and the contacts have gone wrong, you’ve just got to go back through the furnace. So you add it, put it back through the furnace, and then you wait in, It can be frustrating. The life of a technician is frustrating. Sometimes.

[Jaz]
I can totally imagine a life of a technician with five kids, man. Honestly, I, I salute you, sir. Right guys, just a little summary. So far, we talked about what is a guiding tooth, the tooth that’s involved in excursions, let’s say, and why we should recreate guiding surfaces where we want to conform.

Well, we want to add to the function, and in some cases we might not, in some cases we will. That’s a patient by patient decision. We’ve talked about the lab, i. e. Graham, just looking at the adjacent teeth inclines and being for single teeth crowns, it’s like, you know what, I think it should go like this, because that’s what the opposing tooth is telling me, but it’s also what the adjacent teeth are telling me.

We also talk about the functionally generated path technique, i. e. using some composite and getting the patient to grind in the function and chew in the function so we can copy that. We talk about articulator are not being necessary for a single unit, but as units increase to help the technician get more predictability, like for example, if you’re doing quadrant, you have less landmarks and therefore you need to recreate the patient’s jaw movements on the desk.

So that’s when a facebow and articulator may actually be more useful. Is there anything else we need to cover to make sure the Protruserati go away listening to this episode thinking, you know what? I’ve got a little bit more predictability in my mind now. I’m going to start prescribing a little bit more in my lab prescriptions. I’m really going to be careful when it comes to the shim holds. I’m really going to make sure I pick up the phone to my technician and have a chat.

[Graham]
So anybody who uses articulators, obviously try and get yourself something that’s fully adjustable, but when you check everything on the articulators, you check.

[Jaz]
Are you sure on that? Fully adjustable is a big step. We usually recommend semi adjustable.

[Graham]
Yeah, a semi adjustable, anything that you can kind of get as much of a movement on as possible without the articulator breaking on you like a, don’t get yourself a Denar. That’s my own, that’s my opinion. They fall to pieces in my hands, it’s got to be a KaVo for me.

So yeah, you check everything on your articulator, and then my suggestion is, and it’s a good tip, is take it off. Check everything by hand. There’s a lot more movement you can gain with your hands that the drawer actually does than your articulator can actually transfer to you. And yeah, it really helps with things like Michigan splints to any sort of like shared guidances and helps you just get rid of those additional interferences. So yeah, maybe you wanted to say something.

[Mahmoud]
Yeah, no, I was just going to say that, just for the sake of people listening. I know we went through a little bit in terms of what, why are we doing this? And I picked this up from you, Jaz, which is fantastic. And stuck with me is that sometimes to know what something is, you need to understand what it isn’t, right?

So let’s say we’re talking about preserving the guidance on the tooth. Now, what happens if you don’t, there’s only really two other possibilities, right? Either you’re going to make the guidance on that tooth shallower, so you’re going to decrease the force on that tooth, which is something that you might want on a really compromised tooth, but remember that force is going to go somewhere else.

So at your examination, this is a good chance for you to find out where might it go? It’s going to be difficult to tell 100%, but if the patient generally has a well maintained dentition, then you’re not necessarily too worried. If they’ve got post crowns everywhere, you’re then that might be time to start thinking a bit more comprehensively, get some records, and maybe figure this out in advance.

The alternative is you’re going to make the guidance too steep, right? Which is something again we might want to do. For example, we do it with canine risers. But again, you’re going to choose a canine that is unrestored, probably, or has a small restoration, and you know it can take it. However, for example, if you do that on heavily restored tooth, again, it’s going to accept, it’s then going to take more force.

So is it more likely to fracture or frustration? Is it more likely to be in the way of how the patient wants to function? So that’s the reason, that’s really the reason.

[Jaz]
Function or even para function. Like sometimes the function would be and it’s happened to me before where I gave an upper left premolar crown and if I look back at it now, it was way too steep compared to the adjacent teeth.

Like it just didn’t fit in that arch and the patient came back a few days later saying every time I’m chewing I’m knocking against his tooth. Whereas if it’s, it was also be too much in parafunction so that in patient’s parafunctioning, it’s only on that one tooth, which is negative consequences for the tooth, the PDL, the muscles, the TMJ.

[Mahmoud]
So sometimes it isn’t, oh, you should copy what the patient has, right? Like, it’s not like me and Jaz are saying, if you don’t, you’re a bad dentist. It’s just sometimes that the consequences of not doing that could be problematic.

[Jaz]
And a lot of times, it won’t be problematic and you’ll get away with it, but that’s not the kind of dentistry we want to aspire to. We want to aim high and do precision dentistry, and Graham, it’s great to have your input to help us all achieve this. Graham, just tell us about where you work, what kind of work you are happy to accept. I know you’re super, super busy, but if you’re happy to accept any work, I can match for Graham’s vertical crown.

So if anyone’s doing, vertical preps, you’ll have to probably send him a case to check your preps first, because he’s very particular. He wants to make sure he gets good preppers on, send him a case, try one of his vertical zirconias. His overlay ceramic work is brilliant. His wax up stuff is fantastic. Graham, tell us about how we can get in touch with you.

[Graham]
It’s best off. Give me a call, find my number on Instagram or on the website. Just give me a call. Tell me what it is that you enjoy doing most or do most of. And we’ll see if we can fit you in. I can’t take on any cosmetic works, and I can’t take on large cases currently, because, yeah, I’m pretty stacked. But when it comes to generic crown and bridge works, and biomimetic dentistry, we’re kind of, we’re there. And we can provide that service for a few more.

[Jaz]
I’ll put that in the show notes for everyone. And Mahmoud, the work you’re doing as always, you’re a veteran in this podcast. You’re very much part of the podcast foundations, but I’m loving your contributions, not only on Instagram, but also on the Protrusive Guidance app. Please keep them up.

[Mahmoud]
It’s such a fantastic community we’ve got there. So it really is awesome.

[Jaz]
But tell us how to follow you, mate.

[Mahmoud]
Yeah, best place is either join us on Protrusive Guidance, please. Because there’s such an amazing group of dentists, so open, people are sharing cases, asking questions. It’s really thriving. So that’s awesome. Otherwise just follow me on Instagram. That’s where I post most of my stuff. Just stick my handle on the show notes.

[Jaz]
I’ll put the handle in the show notes. Chaps. Thanks so much for a geeky discussion. Awesome. Graham. I know you’re having Legoland next week. So I hope that you’re able to get through today’s work, probably finishing at eight or 9 PM tonight. So that you can actually enjoy that Legoland experience over a couple of days. I hope you have a fantastic time with your family. Keep fighting the good fight, mate.

[Graham]
Take it easy, Jaz. Thanks, Mahmoud.

[Jaz]
Thanks so much. Great to speak with you. so much, guys. Mahmoud, thanks so much.

Well, there we have it, guys. Thank you so much for listening all the way to the end. What did you learn? What are you going to change? What are you going to implement? Could it be the protrusive pearl of using the wedge? Or could it be the way you’re going to think about the next time you do a crown, and more than likely that posterior crown is actually involved in the occlusion?

Are you going to pick up the phone to a technician and just have a nice little chat about occlusion? Like I said, this episode is eligible for CPD on the Protrusive Guidance app. You’ve come this far, you listened to these episodes, you watched them, you enjoyed them, I hope. I’m hoping the value for money is absolutely amazing and therefore you should join Protrusive Guidance and get your CE quiz certificate as well.

We’ve got a lot more stored for you in Occlusion Month, so make sure you’ve hit subscribe if you haven’t already. And as always, don’t forget to give us a thumbs up. I want to thank Team Protrusive as always. Erika, our fantastic producer. Mari, our CPD queen. She’s also the one that lets you into the community, so make her life easy. Send her the evidence that you are indeed a dentist because we are a exclusive private network. I also want to thank the support team of Krissel, Nav, Emma, and Gian. My friends, I’ll catch you same time, same place next week. Bye for now.