In this episode with Dr. Carlos Sanchez, we’re going to take a look at the concept of additive equilibration as a way of managing tooth wear. In other words, it’s an occlusion-based technique that involves adding composite or ceramic to achieve the ideal restorative results and we’re going to try to help you understand what that is. There are also some themes that are discussed in the same way as the Dahl technique.
Protrusive dental Pearl: Keeping PTFE tape secure – a straightforward trick I found to keep the PTFE so it doesn’t get sucked away is to floss the PTFE through more distal contacts. It gives the PTFE some security and resistance to being sucked away. So it’s not going to make that horrible sound and you get to keep that PTFE in the stable place!
If you want to improve your skills and your understanding of occlusion, I’ve set up a free monthly resource for you starting this August! Just head to www.occlusion.wtf to sign up for monthly occlusion goodness.
Highlights of this episode:
- 2:40 Protrusive Dental Pearl – Keeping PTFE tape secure
- 9: 43 Fundamentals of Additive Equilibration
- 37:28 Journey of Additive Equilibration
- 44:22 Additive Equilibration workflow in generalized wear cases
- 1:00:37 Restoring lateral and central incisors for aesthetic reasons (after canines)
- 1:06:36 Anterior coupling in class two increased overjet cases
Check this Easy Peasy technique that Dr. Jaz mentioned: The ESIPC Jig
If you liked this episode, you will also enjoy Basics of Occlusion
Click below for full episode transcript:Opening Snippet: Hello, Protruserati, I'm Jaz Gulati and welcome back to your favorite place to grow as a dentist. In this episode, we're discussing ADDITIVE EQUILIBRATIONS for managing tooth wear.
So, this is an occlusion based one. Dental students and young dentists, it’s a lot of things that we discussed that might stretch your mind a little bit. So, if you’re new to the world of occlusion, you might have to listen to it a couple of times, you have to hit the books, you have to speak some mentors. It’s okay to listen to something that might be a little bit beyond your depth at this stage. Certainly, when I was learning occlusion, I had a lot of that. And I slowly, slowly, slowly, you know, gained more knowledge, spoke to more mentors, gain new perspectives.
So, just because we cover some themes that you might not understand in this episode, doesn’t mean you shouldn’t give it your best shot. Now on that note, if you are looking for some basic, but powerful, impactful, actionable, and practical occlusion tips, then I’ve set up a free monthly resource right to your inbox. Starting from August, it’s worthwhile just joining now, if you head to www.occlusion.wtf, that’s right. It’s www.occlusion.wtf. Listen, I’m on a mission to demystify occlusion. So, with this very practical gem that I’ll send you every month, I’m hoping to go a long way to help our peers. So do check it out, sign up, and I look forward to sending you some occlusion goodness.
In this episode with Dr. Carlos Sanchez, from North Carolina USA, we discuss treating the worn dentition with something called the ADDITIVE EQUILIBRATION TECHNIQUE. So people think a equilibration is usually when you get to a bur and start drilling teeth away. Well, this is additive equilibration, we are creating the “ideal occlusion” or “ideal occluding” scheme by adding for example composite or ceramic or whatever it might be to get to our ideal restorative results. So, it’s not so much equilibration as you may know it before, it’s additive. It’s restorative. There are some themes discussed, similar to the DAHL technique, which is quite refreshing because in the USA, it’s not used as much so it’s nice to hear it in American dentist, Dr. Carlos Sanchez talking about the DAHL technique and the way he did so I know you’ll enjoy this perspective.
If you listen to the last few episodes with Dr. Javier Quirós. You know how much I love the CaSi instrument, well, actually Dr. Sanchez invented this instrument. So it’s something that’s distributed by Cosmedent or Enlighten Smiles in the UK, and I’ve raved on about it already. I’m not gonna go again. But I want you to check out all the other instruments that Carlos has made. They’re really amazing. I’m gonna show them off in the clinic. The other thing I found on Dr. Carlos Sanchez’ website is the Vacu-Grip. This is like $10 for five of these little things. And let me tell you why I fell in love with it, because I’ve got one now. So, you know when you’re washing your ceramic, so you’ve etched your ceramic, maybe with a hydrofluoric acid for 20 seconds, like your Emaxs, for example. And then what I usually do what I hold the crown in tweezers or my glove, and I’d wash it, and make sure that I wash it over the sink, and that the sink has got some wet tissue paper inside. And the problem with that is it’s over the sink and it’s away from where I was initially, and it’s get a little bit messy.
So, what the Vacu-Grip is, is a little insert, little plastic insert that’s got foam inside, that fits nicely into your suction. So, I try this by putting the crown into the Vacu-Grip which goes in your suction, it’s like a little tiny black bit of plastic piece. And now I’m holding the Vacu-Grip that entire unit upside down and my crown is not falling. So, it’s like extra gravity, it’s sucking the crown so that it’s not going to fall out. So, I can even turn it all upside down and the crown will not fall. So, you can imagine that when you’re washing your ceramic, now you can do it into the Vacu-Grip and the Crown’s not going to go anywhere. And it’s a nice and safe way to do it. So, check out the Vacu-Grip and all the other products that Carlos Sanchez has on his website, that’s aesthecon.com. Again, I’ll put the show notes on the website protrusive.co.uk, and on the YouTube watching there. So, you can see all the awesome instruments including the CaSi and a Vacu-Grip and all the other lovely brushes that he has on his website. There’s some really brilliant instruments that Carlos has invented. So, he’s a true innovator when it comes to instruments in dentistry. And I hope to share some of those with you.
The Protrusive Dental Pearl
Today’s Protrusive Dental Pearl is HOW TO USE PTFE. So for example, we use PTFE in so many different scenarios, and one of the most annoying scenarios is when you are preventing the etch and the bond from contacting the teeth that you don’t want it to touch. So, it’s a great way if you’re doing onlays, bonding onlays or resin bonded bridges or veneers or whatever, you know, I like to floss some PTFE into the contact so now the etch won’t hit that tooth, but the issue that we have in this scenario is that unless you are with your finger and thumb holding on to the PTFE it gets hoovered into the suction. It makes that horrible noise which is not very pleasant for your patient and gets very messy and it’s not so nice. It might even pull off your PTFE or just make that horrible unbearable sound which I absolutely hate.
So, there are a few ways I’ve seen some dentists manage it. They often get some liquiddam or, some flowable composite, and they sort of tack cure the composite onto the adjacent teeth to keep the PTFE there so it doesn’t get sucked away. But what I found really easy trick that many of you probably already do is once you’ve placed your PTFE, and then you manipulate it onto the more distal teeth, either will then floss that PTFE through a more distal contact. If you’re watching the video here, great, you get the idea. If you’re listening, just imagine you’ve put some PTFE through some contacts, and now you’re extending it.
So, let’s say you put it between the premolars, lower left first and lower left second premolar, you put it there, and now you can extend it on to the first molar, maybe even to the second molar, so that it’s long enough to cover all those teeth. And then you’re gonna floss it between the first molar and the second molar. Now that you floss that PTFE in that area, it’s no longer gonna get sucked into your suction. And it’s not gonna make that horrible noise. And it gives your PTFE some security and some resistance to being sucked away. So, it’s not going to make that horrible sound. And you get to keep that PTFE in the stable place. So whether you keep the PTFE there the whole time, or you remove it after your etching and bonding, it’s up to you, obviously, how you want to do it, but it’s a great way to keep that PTFE stable. So, hope you liked that little pearl.
And let’s join Dr. Carlos Sanchez to talk about all things, occlusion and additive equilibration technique. Dr. Carlos Sanchez from North Carolina, USA. Welcome to the Protrusive Dental Podcast. How are you?
I’m doing great, Jaz, what a pleasure, man. It’s a pleasure to be here with the Protrusive Dental Podcast. So it’s a joy. [Jaz]
Well, it’s great to have you and it was amazing again to find out that you’re also someone who listens to the podcast. And as we had a zoom session a few weeks ago now just to catch up and learn about each other’s interests and stuff. I mean, your occlusion background really interests me, your sort of reflective practice that you’ve been doing in North Carolina, I think you said you’ve been in the same practice for many years. Is that right? [Carlos]
27 years. [Jaz]
Well, tell us about yourself. Tell us about your practice. And tell us about your journey within dentistry and occlusion? [Carlos]
Absolutely, I’m going to disclose my age, been practicing for 30 years. I’m a general dentists but I’m a geek. I love all facets. I’m not into the academics, but I definitely like to get in there. And you know, as I do my stuff, I’ll make sure that it is a science base. But, I was in the military for about three years. That’s where I got my experience in everything. My wife is a dentist. But long story short, we were able to settle in Kannapolis, North Carolina, love the environment, and from there, I journey into different intrapreneurship with practices and so forth. And interesting just leading to the occlusion. You know, you get out of school. I was very fortunate that I went to University of Iowa, shout out to Iowa. But I feel comfortable with giving me a pretty good foundation. Not perfect. Not perfect, but a good foundation.
So I thought when I got out there, it’s like, Okay, I’m gonna get out there. I’m gonna rock and roll do this and that, three, four years into it. Guess what? I got burned, man. I got burned. I learned my lesson. There was a particular case, did some Crown Lengthening on top and bottom. Nothing that posterior. The gentleman left, long story short, it was a journey. A good year with the insurance. I didn’t get sued or anything like that. But I learned and I learned and I said to myself, You know what, I don’t want to catch myself in this position again. And so that propelled me, that’s how I started in this journey as far as occlusion.[Jaz]
What happened in that case that made you think that okay, I need to go back and and do further learning in occlusion. What was it? Was it a failure? It was a premature failure. What was it? [Carlos]
Two things actually, lack of my communication with the patient. That was another words, I just assumed. And I didn’t explain myself well enough. And I’m just being candid with you. That was so- [Jaz]
It’s very humble of you. [Carlos]
No, I mean, that was one. Second was that I think that was the big picture. The second one was standing in touch with him because he moved, so basically what it was, worn dentition, top and bottom, missing from, I know the nomenclature is different from the US and in Europe and everything but from the canine bags, he was missing those very short, efficient, like so and so naturally back then you do crown lengthening, build him up and so forth. I didn’t pay attention to this angle right here. That needs a coupling and the disclusive angle. Looking back, I made it too steep like this. So, I didn’t pass- [Jaz]
Too steep of a envelope constriction? [Carlos]
Yeah, the envelope of function, I violated the envelope of function, I constricted it. Rather than open it, I constricted. Absolutely. And so he moved to the beach. And that’s where I got the letters saying that, you know, this whole case needs to be redone and so forth. But long story short, there were some good colleagues. That’s why you know, as colleagues, we have to be attentive, you know, help each other out. And there were two gentlemen over there that evaluated the case says, ‘Carlos, you haven’t done anything wrong, everything. The only thing was, you know, the posterior we needed to build them up and so forth.’ And my thing was that since he left, there was no way I could do it. I even propose to the gentleman, ‘Well, come over, whatever you need to do. I’ll do it.’
So long story short, that was the big aha. It’s like, okay, I got to make sure that I side move in progressing my evolution in my field, that I don’t do this. You know, you don’t want to make the mistake again. Make it more predictable. And so I started my journey with Pankey. I remember Pankey for the whole week. I again finished the whole Pankey because it was such a long process. Did the Peter Dawson, listen to Spear, let’s see who else and then I was very blessed to meet that to be on my chorus. He’s a gnarthologist, this is how you know what I call them as they’re the ones that foundation for prosthodontics and so forth. You know, those are the guys that say you had B.B McCollum, you had Stuart and Skyler. They started the whole, this whole journey of occlusion.[Jaz]
You mentioned some real big hitters that in the field of occlusion and dentistry in general, a question that I get a lot is how do you pick, now I really admire like many of my guests who I’ve had on, what I admire is that they haven’t just listened to one’s growth or and then ran with it, which is fine as well. There’s nothing wrong with that. But a lot of the guests I’ve had on very privileged, okay, the done Kois, but they also did Pankey. And then they listened to Dawson, and they respect Spear and they listen to everyone, you know, and they develop their protocol that works in their practice. How does a young dentist choose which path they will go for first, and you think it matters so much exactly, you know, between Spear and Kois, who they ended up going for first? [Carlos]
No, you know what I think and this was the hard part, I think in dental schools is understanding the basics. You know, the anatomy and the physiology. That’s the most important part. Because if you look at, you know, there’s different, you have the CR camp, you have the LVI, neuro-musculature, you have those. And we can all agree that you know, you want simultaneous contacts, guidance that’s both, but where they vary is where you start, which is joint position. And among those is those positions, how to get there. And to me, doesn’t matter how you get there, just get there. You know, once you get there, just get there, you know, if you want to use a Kois deprogram or use it, use a leaf gauge, get use a cotton roll, just get there, make your diagnosis and move forward, right? And then how do you put stuff together?
Well, you know you got to respect that, a Kois is mentor, was that to be on my course. We had a long talk and everything. He was from the Air Force. One is an incredible clinician, but, you know, he has a certain way of where he likes to start on the Posterior. There’s nothing wrong with starting the posteriors. I like to start in the anterior because I think the actual, I do more, get more from the, as far as the aesthetics, phonetics, I test the joint, if I started the front. But started the joint. once you get your diagnosis, then it’s just a matter of what you have in your toolbox to implement the final result. And always start from the end and look back. You know, look at my nice picture and look back, don’t get intimidated.[Jaz]
You’re very much Carlos, you’re very much echoing the same thing that you know, we did a two part episode with Dr. Bill Supple. He’s the president of the AES. Have you been to the AES before? [Carlos]
But one of these I have not- [Jaz]
I’d love to go, maybe 2025. I kind of sounds crazy thinking so far ahead. But I’m a family man. And I’m just thinking kids and stuff. So I’ve been I’ve actually emailed 2025 Bill Supple with that. I said, Okay, I kind of told him at 2025, I might see you in Chicago, for AES. But anyway, well, what he said in the episode was very similar to what you said, like look, the endpoint between all of them is very similar. And they all care for the patients and they will all, if you follow one of them to a tee, you’ll get a good result. It’s just how you get there. And the little micro steps will vary that little squiggle from the point A to point B will vary.
But the point A and point B are invariably the same, ie getting the correct diagnosis and being able to communicate that to the patient and then getting something that you’re proud of and the patient is going to be able to get longevity from is the same. So I’m glad we covered this again, because it’s important to remind ourselves we get very worked up about Oh, but you’re Kois and you’re Pankey, it doesn’t matter.[Carlos]
It doesn’t matter. It really doesn’t matter. You know, I was one of those back in the DNS. And I try to, you know, talk to, it’s like politics and religion. You cannot convert anyone, you just can’t. But no, with occlusion, it’s the same thing. You know, the occlusion and here’s one thing and I’m gonna say a couple things about gnarthology that I’m a little bias, little bias. I want to keep things simple. Well, you know, joint position. That’s what we sell. We do our diagnosis, right? But as far as finishing the cases, we’re not worrying about the lateral and the central, we just worried about the coupling and the anterior, you know, the envelope of function. So I’m like, for example, of course, a lot of the viewers know this, your traditional Pankey Dawson and so forth. You want 28 contacts simultaneously.
Well my friend, it’s hard to get freaking 28 contacts especially in the anteriors, and it’s hard, I mean, there’s just no way. Okay? Now, I’m not bad, and I’m not gonna bow my head, there’s no way you can tripodize a full mouth in gnarthology. There’s no way but the beautiful thing about this, if you understand the big picture, understand the stabilizing the tooth, it doesn’t matter, just stabilize in that tooth. Then, with that, first of all, if there’s instability against with the patient and everything, if you start stabilizing one or two teeth, it’s amazing how the body starts saying, oh my gosh, I think this guy knows what he’s doing, the body does, right? And then you start seeing some progress. So what I’ve learned in my 30 years is not the big picture. But you then you can pick and choose, some patients don’t have to go to the nth degree, you only need to do one of a couple things, you know, just a man working in offense here and there.
And bam, they do well, another person and the other one you may do is before you get started you and I know this is before you start on upper posteriors, make sure where the first point of contact is because if you change that, depending on how that patient react, some people have wide zone, some people have smaller or you can put a rock on me and I’m fine. My wife, you put something oh my god, what have you done? So you have to be able to have that in your toolbox so you minimize your problems, right? Right. That’s what the thing is we want to minimize it and we want to look good, we want to look good in front of the patient and so forth. And so with gnarthology was, the way and the right time when, I’m a liberal gnarthologist and I’ll explain why I’m liberal gnarthologist because yes, I understand the tripodization, I understand this for what up disclusion. Yes. But hell, I can’t do that all the time. But what I realized if you can do it one or two, bam, it’s amazing how that patient does. Now-[Jaz]
So really, just to really make it clear to those listening and watching our dear listeners, the Protruserati, when you say stabilize a couple just, what do you mean by stabilize a few teeth, like just make it really tangible, like, describe what you mean by stabilize? In that context. [Carlos]
I had a patient that came in and I have a document and so forth, woke up with a pain on the right side, lower right side, came to me and just was distraught. Let’s just say, I’m hurting, the muscles hurting me and the whole nine yards. So my thing was, okay, let’s take a look at this. How am I going to start with this? I’m like I said, I’m a leaf gauger. So I owe a medical history and so forth. Because that you know, that’s another topic we’ve met with the medications increasing muscle activity. So naturally, there was a reason why she was having an issue, that tooth was some in the way of her function or whether it was clenching, grinding. So it was instable.
So I come in, go to my leaf gauge, to check out how to joint, the muscles and the teeth. I get the teeth out of the way, check the inferior lateral pterygoid to deprogram and see where it is in position, right? And then from there with the warm compress, figured out how she does and I also use pressure point readings. I think we talked about that earlier. It’s a modified dry needling, I’ll just go straight to the source, and just put it in, put that breaks up the lactic acid.[Jaz]
Well, so using a like- [Carlos]
I’ll just use a 27 gauge needle. I just take a wipe it down with alcohol. And I’ll tell, ‘Mrs. Jones, you’re going to feel a little pinch, I’ll find where the tight contact is.’ She has a leaf gauge, she’s pumping out muscle. I’m checking it, I go in one or two, warm compress, wait five, six minutes, go take a cup of coffee, do whatever you need to do, come back and you’d be surprised. You’d be surprised how the patient, so naturally on this particular case, that on the right side was number 31 was had a distal buccal fracture. And wants it stable now you had one, having tried this back in the day, well you can put it, you can add to that too. So I need to do that.
But my thing was this I went to the front, stabilize with the canines, I added that was my first point of contact. There was about a millimeter or two, went ahead, use the leaf gauge, created my vertical, use my restorative adhesive, place a composite and immediately she was able to respond. Why? Because no longer was she coming in straight lateral enough The non working interference are already removed, because you have the anterior.[Jaz]
Essentially, you created a more harmonious occlusion as I say in the textbooks by removing the posterior “interference”. So that, that tooth was no longer taking all the brunt of the parafunctional forces. And then you recreated some form of anterior guidance, right? [Carlos]
That’s it. That’s it. That’s it and and I used to Canine. Now bring it back again to the gnartholical is what the beautiful thing about it, all I got to do is worry about the canines and back for you know, equal contacts. And for the anteriors, what is the purpose, the function of the anteriors are there for disclusion, they’re not completely touch, they’re ready and set for disclusion. So as soon as you move boom, you get the disclusion, left and right, you get the disclusion. That creates a labor three system, it’s the least mechanical offensive. Right there, is anytime you have a posterior interferences, a class one, that’s a seesaw, you have the joint and the muscle, they’re going to be sold.
Especially remember, you have you ever seen a patient comes in, and they have wear on the canines and you wonder why they wear in the canines, you know, this happens at night sleeping postures. So if you see, if your left eye sleeper, you’re gonna put your head like this, it just goes this way. And you’re going away this what’s going to happen, this joint is going to be the painful one, that mall or back is gonna be a fulcrum, like, you know, you’re number 14, 15. And you’re going to see canine where the opposite side, now the person toss, in turn, you’re going to see on both. And what’s beautiful, I have documented cases that patients in the back, you barely see a little bit of wear in the front, because the teeth, a very revealing, let me put it this way, the teeth are very revealing. They’ll tell you how stressed they are and everything. Just think about it. Because you know what 24/7 goes deep, and so forth. So leading to the knock knock-[Jaz]
Before you progress on, and that fluctuates, I just want to make a point that I actually posted an Instagram story maybe a few months ago. And it was just like my nurse who’s been working with me for almost two years now in this practice, I joined this post pandemic, or just middle the pandemic, I guess. And she has been amazed exactly at that finding that you suggested whereby you can predict the sleeping posture of a patient based on the wear patterns on the teeth. So my success rate in getting this right is about 95%.
So you would think that if I guess left, the right would be 50%. Right. But it’s that 95% Even then I think some patients just get the left and right confused, really. And I actually know which how they sleep. And they basically might start one way, but in the middle night, they go to the other way. So essentially, if they got more wear on the right side, they’re probably sleeping on their left, and they’re grinding away from the mattress, too. And it’s amazing when you start picking these things up is so the patients start getting freaked out.[Carlos]
And you just tell your significant other, if that patient comes in and you have an issue, because a lot of time 80% of the issues with the muscle, it’s all muscle induced and so forth. We don’t have to do a lot of stuff, and that’s another step you have to do. But you educate the patient, you know, you take a walk to oxygenate, you give them a little deprogram on the front, it doesn’t matter what if the cotton roll, you can put a cotton or you can use anything. Warm compress and sleep on the other side and have your mate sleep on the other because you don’t sleep facing each other. Right. So anyway, so yeah, and so you know, going back to the, as far as the gnarthology Yeah, the occlusal scheme is I don’t have to worry from the canines back. So that’s beautiful. I don’t have to worry about you know, getting this perfect. Don’t get me wrong. Do you want to have in an hour? I can show you all share videos later on? [Jaz]
Yeah, sure. Whenever you want. [Carlos]
You can take the articulating paper. And once you do the canine guidance, you slide it, you automatically create that half a wing. And that minute disclusion or no contact that is necessary because just think about it. If you put all the teeth together, it is hard. If you have a little interference, mesial incline of the upper one against the distal a little, is going to push forward and guess what happened? Teeth are going to spaced, your lower teeth are going to be sensitive. So it’s important to have the little neutrality that little space in there because we’re not perfect that inevitably we have that means you’re drifting when we’re born in teeth setup. We have a means you’re drifting that with the teeth are not perfectly nobody’s walking with CRS and MIP equally no one it is so inevitably you’re going to keep going forward and you’d get this thing like this. What’s beautiful is when you get mobile teeth and you add to the canines and so forth, is how things start torquing knob, hygiene improves, it’s insane now this is not an I will lead slowly to the canines.
My thing through my process of Peter Dawson and all that, you know, they said okay, oh, I remember Tanaka, Terry Tanaka. Great, incredible if anybody wants to go see him, the guy’s insane. But I remember he’s saying that don’t ever make non-working interference or adjustments when you mount them unless you have canine guidance. And it makes sense, it makes so much sense because you’ve been too aggressive. You know, anytime you start cutting away, that have an interior protection, you cutting away teeth to structure. So that’s stuck in my head. That stuck in my head, too, when I would build my chorus with the leaf gauge, and he’s a big leaf gauger. And he’s the one who made it popularized and now it’s now unfortunately, when Peter Dawson passed away, they’re starting to use a little bit more into camps, Spear, as you know, one thing with this-[Jaz]
It’s great tool. I’m a huge fan of leaf gauges for about six years myself now. And it’s great. [Carlos]
You know, when people say to me, you know, people, oh, you’re gonna posture most of your life did they join or- [Jaz]
Distalise the condyle, or whatever. I agree. [Carlos]
You can. Pass the relaxed length for the inferior lateral pterygoid. That’s a partial go. You can’t go any further than that. [Jaz]
And also, the vector, the masseter and anterior temporalis. The vector that is made, it won’t allow your condyle to go all the way back. Now, in a very deep class 2 Div 2 you’re probably a little bit more mechanically disadvantaged there. So it’s gonna be a bit careful, right? But yeah, on the whole, in most cases, it’s very safe to use. And for a lot of dentists, that what they told me is that their occlusion, their journey in occlusion became a lot easier. And they were able to progress in their journey. Once they were able to get a leaf gauge, because a lot of dentists when they’re starting to think full mouth, they really stumble on, you know, the lucia gauge and then checking and verifying the contacts.
Sometimes, CR is like what Ian Buckle teaches one of my, he teaches Dawson in the UK, so it’s a buddy of mine, a really fantastic dentist, great communicator, and he says, centric relation is like playing golf, okay, you’re never gonna get a hole in one every time. Okay, with the leaf gauge, you get like 97. There, right? And then you get your temporaries. And then you get a little bit closer. And finally, you get in the hole, basically. Okay, so the leaf gauges is that first swing that gets you almost there. And sometimes you get fully there, if the patient’s relaxed enough. But if there’s few engrams, and their muscles are upset, it still gets you closer to where you need to be, would you agree with that?[Carlos]
Oh, my God. 100%. And here’s the thing going back to the diagnosis and the muscles now, you know, and the engram you mentioned is, you know, naturally we have this normal stimulation that our muscles develop this pattern. And with the leaf gauge, as say you separate the posterior teeth and and the 8 teeth will in contact and so fort. They showed that you don’t use, you don’t shut down but you reduce the electrical component of the masseter medial pterygoid, you know, climb down and so forth. But what you also do on loading the joint right you load him by putting everything in the front loading the joint you test them that joint is during inflammation is that capsule on the lateral side and everything. And I want to say one little thing about the joint because I’m a geek, I want to share this with everybody.
Let’s remember that the capsule is made of dense fibrous connective tissue. And what that means is it has mesenchymal cells and it has the ability to reshape, reform itself, all we have to do is create the right environment. So, what do we do? We do the diagnosis and then we create the environment. Okay, so that’s the patient has a dislocated disc and so forth. You put the leaf gauge, within a minute or two on their try-in, you take cotton rolls, put it in the back, because remember this, the center point of here is your first molar. What’s the first tooth that comes in the permanent is the first molar. That is that weight. That is your center point. That creates you guidance and mixed dentition you guidance is your first molar. Anything back of the first molar, you’re decompressing the joint and I don’t care what people say, you can decompress with my experience with 30 years I put something back there that feel better is good, right? And if I put anything in the front anterior to that you load in the joint okay? And in a lot of times is the medial pterygoid or the inferior lateral pterygoid that is thight. That you do is a we lose it releases what you have released. We released this what you have to do is be patient with the leaf gauge especially somebody has comes in as symptomatic and so forth that you pumped up muscle you pump it five to six seconds like Rocabado said.
There’s something magical about six seconds pumping and release that makes up muscle finalize the contraction, it releases and so if we understand that disk, man, we don’t need to go surgically, and they’re just provided by the environment. Okay, so somebody has this problem. However, take the full apply. Here’s the other thing, you take a full mouth guard, I don’t care whether the segment or just the full, create the most pivot in the back, don’t go. In other words, don’t bring the jaw forward, you bring the jaw forward. We got two parts out of position, you got the jaw forward, and you got distal position, you have two parts. I don’t want to mess with that and stay home, just decompress, wait, monitor that patient, monitor that patients so that that pivot is in the back, nothing’s in the front. And I’m telling you, the younger that patient is, you get remodeler this is beautiful, and then you can rock and roll then you know a lot of times they need ortho as the other thing is we don’t utilize ortho that much. Orthodontics is underutilized. And it’s unfortunate. But that’s the thing about the disc, I want to make sure is it everybody can get that pay attention to this. All you have to do is make your diagnosis. And then it doesn’t matter what appliance you use psychology. Well, I used this appliance all the time. And in my mind, I said hmm, really?[Jaz]
A lot of the studies Carlos that I’ve done on appliance type and generally TMD and conservative care, giving, you know, educating the patient home therapies, analgesics, and occlusal appliance, physiotherapy, they all show consistently 80% Plus success rates as not so dependent on the appliance type. So, I completely agree with you. A lot of appliances will you know just disrupt the system, disrupt the neural links and help the muscles heal. And it’s great that you mentioned the muscles because yes, we talked about the disc but the superior lateral pterygoid attaches into that disc so a lot of the issues are muscular based so once we can calm those lateral pterygoid superior inferior down then the disc has an ability to potentially return to where it wants to be. [Carlos]
Yeah, remember the disc seats here and the front, the disc gets a superior head or lateral pterygoid is the top right. And the posterior of the bilaminar is on the elastic connective tissue and it’s made to go you know it is a component that goes down and back and so forth. When you’re treating like TMD you treat him, you’re targeted the inferior lateral pteyrgoid. It’s the lateral pterygoid that you’re trying to get those are the only muscles that are- [Jaz]
They are the troublemakers. [Carlos]
Yeah, they’re the troublemakers. And that’s what you have to gear your therapy. And so if you understand this, this mechanics is very simple. I just everybody, you load the joint, you put something back here you decompress. You make your diagnosis however you make it, if it’s joint problem, target your therapy to be in the back, if it’s muscle target your therapy to be for that. And that’s it. You know, people say oh, you use them, what use one use one orthotic. And based on that you make the adjustment. And remember the joint always trumps the muscles, it always says what happens is you get a cold a combination here and there. But what happens isn’t a true joint that I’ve seen in my cases and everything, when in doubt start in the back, when in doubt all your plans start in the back.
And then what’s going to happen is if the appliance is too thick, the anterior portion of the temporalis it’s going to it’s going to you’re going to find out this and then to the muscle are going to be tight, but you can load the joint and it’s gonna be fine then you said, ‘Mrs. Jones, I got you covered.’ Now we’re going to move everything to the front use the same one you cut the back, you put the front and said go home, come back because all that was pretty good. There you go.[Jaz]
So essentially just to make it very tangible for for listeners watchers, in this primary joint patient, you decompress the joint use an appliance that is thicker or, or more involved posteriorly than anteriorly until you get the joints to make some sort of healing and then you convert it to provide some sort of anterior guidance to relax the muscles. So, as you said joints first then than muscles- [Carlos]
And I’m sorry to interrupt Jaz, but on the posterior, what you have to do is use one the most posterior tooth, the palatal use as you pivot. So in other words, what’s going to happen is you’re gonna use the maxilla. So the bottom, you’re going to use an upper appliance, most likely I use lower appliance, I use pivot. But if you say for example, if I was somebody came in with TMJ, I use a full appliance, I want to make sure that the most buccal functional cuspal, the bottom one just hits my top, the posterior, just one little point right there and just skate on that. All you want to do, you don’t want anything in the front because anytime you hit anything in the front, you load into joint and you’re gonna put pressure on the joint. That’s why- [Jaz]
Wow. This reminds me, Dr. Andy Toy epsiode I think was 38 or 40. We talked about the PGO, posterior guided occlusion. So it’s very similar the concept of the PGO appliance to what you’re saying just to those my listeners who remember that episode, very similar, and I use the PGO appliance occasionally for primary joint patient, but it’s great that you say that in the interest of moving forward I’m Carlos, anything you want to add to this before we now talk about additive equilibration? [Carlos]
And yeah, let’s so no, not that we can get another word now, in my evolution with mythology and so forth was I started noticing, you know, how am I going to treat this patients that have worried and impatient people that come in. And so when Tanaka said don’t do not working in offense and so forth, and then thought to build my chorus, he’s using the liftgate. I said to myself, well, first what I did was I started putting composite where it was worn down. That was my first time without using a leaf gauge. And it was a failure. It was a flop. Why? Because I didn’t have a reference point. I didn’t know my vertical, I will just add him. Patient will come back to knock it off. It was a mess.
But I didn’t give up. I didn’t give up and then I had an epiphany. So why don’t you just leaf gauge, the first point of contacts. Ah, that’s not truly there that you know that it’s an actual point is and then I evaluated the anterior overjet, I started evaluating and this I just started slowly make sense, you know, this way too much like this is going to be an ortho case. That was another thing and I’m going fast. I had this lady for five years in ortho, poor thing. She comes to me and she goes, ‘Can you see- and I’ve been in four years I want to get my teeth corrected and so forth. Can you help me?’ So I put the leaf gauge you know, she’s already like this she went home like that. And I said dear, you’re-[Jaz]
That’s a surgical case. Exactly. [Carlos]
Exactly. So, I called the orthodontist I called you and I said you know what you’ve done I know that but you know, if you really want to, you want to present it in such a way if you want to be this will be orthodontics. Just remove everything and let’s figure this thing out. Okay, here’s a little tip Pearl, no one can afford you know, the correct this. What you do is use plastic, use a segmental appliance and a knife, you create your ramp so that when you sleep, you get disclusion. I learned that from my course. So not everyone has to be crippled and 24/7 you use your posterior teeth. So if somebody is like this, you stabilize the back and I’m jumping, [Jaz]
So, just to make- because you’re doing visuals, I just want my audio listeners if someone has a very large overjet in their centric relation, so if they got a very large horizontal slide, how would you with issues and who may not be able to it’s not the right time in their life to consider surgery, what are you suggesting for that? [Carlos]
Make them six through 11? Making a segmental, six through 11, a little plastic splint? And acrylic, yes, and you create your ramp and and you just adjust it. And that’s it. [Jaz]
But that’s for nocturnal use only right. That’s for sleep use. That’s for nocturnal. [Carlos]
Yeah, right. Yeah. Because yeah, you’re nocturnal, not during the day. Because you know what, how many times a day, if we use our teeth are functioning intended, we weren’t needed during the day their teeth don’t come together only when you swallow, in phonetics, you don’t so you really don’t- [Jaz]
Those patients who have, who are parafunctioning because they’re clench and grind things that you shouldn’t be doing. So I’m not we’re very much cut from the same cloth. I completely agree. [Carlos]
What I do some of those cases I’ll do tell him use it for about an hour or so in the afternoon. Dependent, you get the segment applies. But you have to make sure you adjust it to the vertical, the posterior don’t leave them open. Because some people love this thing. If you wait 24/7 Guess what the posterior teeth are gonna supra-erupt. So make sure you have you worked out the occlusal scheme on that. So canines, I had no success with just adding. Then I had an epiphany using the leaf gauge. So there, that’s where everything just changed. Go to my leaf gauge, find my first point of contact, evaluate my horizontal. [Jaz]
Call us, I mean, I just want to stop me because I’m loving the drill. So now we’re talking about a journey of additive equilibration. And a common question again I get is when you’re using the leaf gauge and you’re so advanced in your journey now that you’ve been doing for so many years, the beginner dentist, the first stumbling point they get believe it or not Carlos is how do I know how many leaves to use, right? I’m like, it doesn’t matter just stick enough in to disclude the posterior teeth. There’s no magic answer depends on obviously the skeletal stuff but just put enough in to disclude the posterior teeth is any guidance they want to give on. [Carlos]
I’ll give you a couple tips. Yes, that’s very good because it’s so dependent on what you knew by the 0.1 millimeter in thickness. Each one is supposed to be point one so you know 10 is supposed to be a millimeter with that said is arbitrarily arbitrarily you select the amount I usually go from 20 to 25 That’s my starting point. Usually 20. Depends. Now you put them if you haven’t put them in, you have a slide forward, slide back just just to just to keep it in place. And then you’re going to have a squeeze for five seconds, relax for six seconds. Why? Because if your inferior lateral pterygoid is tensed, you’re going to start you’re going to be working on you’re working on that on the inferior lateral pterygoid. [Jaz]
It’s the masseters and temporalis and the medial pterygoid by contracting, which then should give the cue to the lateral pterygoid to say, ‘Hey, you guys are needed here. You guys need to relax.’ [Carlos]
To relax. Yes, yeah. When I think of the leaf gauge, because I’m always thinking of the inferior lateral pterygoid., but yes. The electrical activity anterior temporalis medial pterygoid slowing down. And then also the inferior lateral pterygoid is also relaxed, because remember, the inferior head works opposite of the superior head, as the inferior head contracts the superior head, relaxes to allow this to come forward and back. But anyways, so you do that. Now what’s going to happen? Here’s the pearl. After five minutes, let’s assume you use it for five, let’s say you five minutes to patients some leaf gauge, going look, I tell him, if you feel contact in the back, add some more leaf gauge, because my experience has told me that what happens is yeah, as the inferior lateral pterygoid relax and the condyle seat, you get the posterior contact, more noticeable. [Jaz]
As the condyle is sitting further distalising. Distalising is the wrong word. It’s just the lateral pterygoid seating- [Carlos]
It’s going home, the doors open he’s getting home. But so that’s important, because what happens is, if you’re too quick with the leaf gauge now, if somebody’s not having any pain, and so forth, yeah, within five minutes, but if you have somebody suspecting that muscle problems, and you really want to work on this mountain, the case and so forth, then my thing is pay attention to the thickness after five minutes, if the patient is not hitting in the back and, go back and check with articulating paper that your photos are in here. And so I’m not hearing you go back there they are hitting.
So go back and check. I like to look in there, it’s the second game before I start second again, you know, I think this patient is gonna hit on the left side first, you know, or depending on the rotation. So I’m making a game for me, you guys, which is going to be the first but here’s the thing is after five minutes, check and see make sure there’s no plans. Now, once you had the first[Jaz]
Make sure there’s no contact, make sure there is sufficient posterior clearance. [Carlos]
Exactly, just posterior tooth. So muscles are quiet, everything is good. You look at the canines, and then that’s why you have to make for me four millimeters is the maximum for the novice then I’m going to start adding composite. But let me also regress a little bit with the leaf gauge. And for those that are don’t feel comfortable, and you want to get in there, there’s nothing wrong with the patient, putting the leaf gauge get behind the patient like Peter Dawson has said and then just get a feel for it and get views I’ve had the assistant older and you get a feel and that’s how I develop my sense of manipulating the joint because I remember going to Peter Dawson over there you know romanting the joint and so forth, you know, you need a talented dentists and you need a patient is very cooperative.
When the leaf gauge get on board, I use both up and then now you know it’s just alivio sometimes you can get them right I’m not gonna go there. But you can get somebody in this remember what is centric relation, it’s a muscle induced position. You don’t put the patient in centric relation they go there the inferior lateral pterygoid has to relax and wherever the condyle goes? The centric relation. Now, the question is-[Jaz]
I think Pascal Magne uses the term passive deprogrammation. So, it has to be passive like you cannot lead them there, you cannot definitely not force them there is a- [Carlos]
Centric relation should not be fortunate, it’s a muscle induced, you get the teeth out of the way with the leaf gauge, the inferior a lot of target relaxes your home. And wherever that that condyle is, that’s where it is, you know, people get, oh, talking about the joint and everything well, you know, anterior posterior, I don’t care where it is. I don’t mean, as long as I know that I’m there and I can load it and everything. That’s all I care about my clinical part, and so forth. [Jaz]
Right, one of my mentors, Michael Melkers, he says that, you know, we get very worked out about exactly the seven o’clock 12 o’clock, all that kind of supposition. Well, you know, the only way you can verify is by getting a scalpel and cutting and then peeling it back and say, ah, I’m there, it knows how to do that. So therefore, you go with your signs from the muscles, and again, it’s your first record you’re taking, you have an ability to verify and refine in the future. [Carlos]
Yes, absolutely. Absolutely. So, you know, with the leaf gauge, don’t be afraid to use it. You’re not going to cause and here’s the thing, and I’m going to give another tip if the patients as using the leaf gauge. You tell the patient, ‘Mrs. Jones, I’m going to split this deprogram on the front. This is what’s going to happen you’re going to feel some tightness what they do, they’re going to feel some tightness. It’s going to be okay after five or six minutes, it’s going to go away if it doesn’t, we’re sure if it’s a TMJ or capsulitis within three or four minutes, they will like to hate it and then and then what you do kidney stones you know what? Okay, I got you covered. Take cotton rolls immediately put them in the back don’t have any squeeze just relax and guess what? Pain goes away. Now you just made the diagnosis you got you got some some type of capsulitis, synovitis, muscle and treat that first before you go doing, measure twice cut once and you work with that. So okay, so you use- [Jaz]
You described the leaf gauge beautifully so I think a lot people got value from that so very common question I get Carlos now let’s talk about it you have a generalized wear case maybe and you are using your diagnosis, you’ve got your leaf gauge in, you feel as though, ‘Okay, I’m gonna start adding to the canines here as you’re gonna say to to recreate some sort of anterior guidance and coupling anteriorly.’ Do you have the leaf gauge in place as you are doing your bonding or do you get a wax up first? I feel as though you’re you do a lot of freehand stuff, tell us your workflow. [Carlos]
So let me let me let me walk you through the procedure. So the person will go ahead and of course dependent after six the patient has the leaf gauge, find my first point of contact, that takes time to find the first point of contact and that’s critical because if you get sometimes when I get a little bit too quick and everything and if I don’t pay attention to that then I’m having to adjust a lot so pay attention to the first point of contact and once you get that nail in and everything, you look at the verdict you look at the horizontal and there is going to be as such then you do your restorative protocol I use I’m a fourth generation opti bond and microetch canines, air abrasion . Air abrasion, etch. [Jaz]
This is again, this is with the leaf gauge in place or is this-? [Carlos]
This is out but I don’t have any close to the- [Jaz]
Teeth together again because- [Carlos]
No, you activate anything. No, you have to stick your hand in there and you work with your system, but you don’t have to close down you don’t do that. Once you have you’ve done you’re setting up your restorative your teeth you’ve gotten in prepare, etch, bond. Here’s the key is what I what I’ll do then is I’ll take a piece of plastic, this is the most expensive part. I’ll take a piece of plastic, layer it over when I put the composite, I’ll put the composite, put the plastic over it like that. And then I put my leaf gauge on top of that, have the patient now here’s another pearl have the patient bite on the back teeth. Because inevitably if you say bite down they’ll go forward, they’ll go back. Practice- [Jaz]
Like rehearse and coaching. You have to coach your patient. [Carlos]
Coach and guide him through coaching. Now I also use cotton rolls I have three cotton rolls buccal and he’s shy and on the lingual bandit and I’ll put the corner just to try to contain the moisture then I’ll put this, put the leaf gauge, have the patient bite on their back teeth imagine binary bite they’re gonna bite down, leaf gauge on, plastic in place, my assistant is going to come in and light cure [Jaz]
Now, but just to just to verify because I’m kind of seeing where there’s going because I’m trying to visualize this way of doing it because it is new exposure to this exact way of doing it usually I’m led by a wax up and stuff so I appreciate the freehand the A) the complexities of it but B) I’m loving where it’s going so but you’re not planning to add composite where you’ll have the- This is we’re talking specifically the canines here- [Carlos]
Just the canines. [Jaz]
Okay, and the piece of plastic, for the guys to describe it at home.. It’s like thick cling film. It’s just like clear mylar. It’s like a piece of wrapper. It’s like a candy wrapper or something. [Carlos]
Very clear plastic. Yeah, that’s the most expensive part. It takes a lot. [Jaz]
Okay, so do you have composite on both the upper and lower canines? Like uncured? [Carlos]
Good question. Yes, it varies. Usually, let’s assume an easy case. The overjet is not that great. So I’ll just use the most of the time. 80% of the time, I’m just adding to the lower ones. Very seldom our to the lingos of the posterior unless you have a really steep you know a big overjet Alright, so most of blindsides send the represent all the actions in Psalm 22 and 27. Just the canines. Those are the canines. Well that’s it. So what happens is- [Jaz]
And the reason for using the wrapper is so that the upper and lower composites don’t stick together. It’s just some spacer- [Carlos]
And also for saliva. control, even though try to get by my environments, I don’t want to lie they get in a lower. So what this does is it protects, it doesn’t allow this a lot to get in there. It minimizes, let me put it this, it minimizes the contamination of deposit. I know, I know there’s people that does that without this plastic thing. I like the plastic and and however you want to do it, let me put it this way. But the key is this Yeah, here’s the pearl is based on the thickness of the first point of contact the vertical. That’s how much composite you’re going to use in the front. So you don’t have to put this glob in there. So say for example, you have about a millimeter, just stick about a millimeter millimeter of composite. Now also pay attention or how that canine is. Because just the same thing is you don’t want to put say, if you put it on the distal side of the of the canine, it’s going to push your jaw forward, if you put it on the music on the bottom one. So pay attention to the position of the canine Where do you need to put the composite, that’s another advantage.
But when in doubt, just put it over use a CaSi instrument that has the instrument becomes so easy just put it in, left right left, right, put the plastic bag down like your now when you remove it, you’re going to see a blob of material. And you’re going to see a little edge on the side. Before you do anything dried up, put some flowable composite, put a little bit of flowable composite, then if you’ve done your homework and is and you’ve done your vertical correctly, have the patient bend down and what the patient is going to fail. I tell the patient Mrs. Jones, as we do this procedure, when you first close, you’re going to feel two boulders, I’ll tell them you feel two boulders in there, you got two rods. And then now we’re going to go into the back and see how it is. So if you’ve done your homework, you take that in checking the back and you still have the first point of contact, which is usually the means you’re in kind of the top one against a disability plan of the lower one that pushes you forward. Okay. So I’ll go back there, and I’ll adjust it and guess what? Everything drops back.[Jaz]
Okay, are you adjusting the posterior interference? [Carlos]
The first point of contact of interference. Now some people are gonna say, Oh my God, that’s heresy. He has mounted the article, you know, have mounted the case. And what’s going to happen that my experience of 15, 10 What I’ve been doing this, I’ve yet to cut in anything. So you know, for those that don’t feel comfortable, that’s fine. But what I’ll do is I’ll just that and then what happens is the jaw drops back. It just dropped back a little bit. And you said Mr. Hyde, it’s not perfect. They still feel kind of a little heavy. And then what you do is you come in and you just shape it, you just reshape it, reshape it, make sure because you don’t want to because of the plastic, it gives you some irregularities. So just shape it, polish it up. [Jaz]
So using the Soflex disc and that kind of stuff, right? [Carlos]
Do you want to do it? Yeah, however you want to do it. Now. This is interesting. I will probably say 40% of the cases. This is crazy once I adjust this, everything because remember, the muscles are like your shock absorbers. Everything’s we settled in a lot of time. Guess what? Everything is balanced out any material because I have the spacing. I already have but right. Boom, you ready to go. I mean, it’s it’s amazing. It is amazing. I other cases, other cases, you’ll get a unilateral everything is contact, and you get an opening here, right? Unless you have bridges and so forth. That’s different but but I tell the patients who said I’m going to have to come back in two weeks. I usually follow them up in two, four and eight. By then by the eighth week if one tooth has not settled and you choose what you want to do, you can put composite you can just leave it alone. You can leave it alone you no one wanted me now. Now what happens is you asked when did [Jaz]
You call us just to complete the visualization here. You’re sending the patient home now absurd compared to their preoperative state? You’re sending them home with four canines, a polished- [Carlos]
Four or two. [Jaz]
Yeah. Agreed, four or two, you haven’t yet done anything to the incisors. And other than maybe just gently adjusting their posture, first point of contact, you haven’t really done much to posteriors. So this is kind of like we spoke about on Zoom about this before. This is kind of like the start of a doll concept doll technique. And then when you see them again, at two, four and eight weeks, he said, What are you checking for? And what’s the next step from there? [Carlos]
So what I’ll do is the following is I’ll check a document and say, Okay, let’s, let’s, let’s, here’s the worst scenario, one scenario, just canine guidance, and I’m not getting anything. There’s space in between them. Okay, that can happen if you don’t pay attention to the first year. So what I told the patient a lot of times is I’m going to put you in a diet. I’m going to, I’m going to put you on a diet because we’re gonna be hitting on the canines, right? You’re gonna go home, you’re gonna defend a diet. I’ve only had one patient that came back and says Carlos, you got to take this thing down.
And I did one page, I remember though. But most of the time we told, ‘Mrs. Jones, you’re gonna go.’ And what’s interesting too is within 48 hours, maybe maybe three days, most everything is just feels fantastic. So sometimes when they walk out by the office, because when they come back there, ‘So yep, Carlos, as soon as I left, I felt good.’ But so I’ve told the patient, you’re gonna feel the bullish, you’re gonna leave, you’re gonna come back. And when you come back, I’m documenting really well, where they, where they feel the where the space is and where they contracted. So let’s assume there’s no contact at all. And two weeks they come back, they may say, ‘Oh, I feel a little bit snug here.’ Let us know-[Jaz]
Usually, very posterior, usually second molars, first molars, right? probably be the last ones. [Carlos]
Yeah. So I feel that now what I’ll do is this is subjective, it is very pronounced because depending on the height is in a submission or missing part of the apple elicit this stole it, I may take it off. I may, I may remove it. If not just leave it alone. Okay, check the other ones, then 100 Come back, like I said, and a month from there. So it’d be two, four and eight, then you may, on the other side, pick up conflict. Why, because of the dog principle, thanks, we’ll go to the path of least resistance. The only thing that will keep you from keep coming together is what you cheek, your tongue. And I’m working in offense, sometimes not working in offense, that can that can hold that two things in place. Or there’s a study that was done a long time ago is because of somebody told me because of growth hormones, when you stop at a certain age, growth, hormones can change.
But that’s besides the point. But so you might you’re monitoring the disserve equilibration that is occurring, and at the end of four, four months, four weeks, then what you’re going to do is figure out if everything is stable, do I need to add, sometimes you just leave the patient alone, my case has been this is a case insane, like half half of my cases, and so forth. They’re within two weeks by the fourth second lesson. They’re balanced. Now, what you do have to pay attention to is how far how fast were these canines? Because this is not a procedure that is that a one time dependent on the patient just that you want them. You know, nothing is more stronger than you enamel. So you have to tell Mrs. Jones, Mrs. Jones, this is not a one time deal. And you know what’s beautiful? After three or two or three or four years? You said Mrs. Jones, you know, you won this game, I’m ready, let’s let’s put some work in and you don’t have to do anything, you have to sell this. Yep. Now that’s for a certain population.[Jaz]
So just just to rewind, for this group of patients, essentially, you have done utilize the dial technique, right, essentially, these patients have dialed in, there was probably a degree of further joint seating that assisted you as well, in this case, and the dial effect taking place. And then when you actually achieve those posture contacts, here’s something that’s not seldom discussed with the dance technique. And there’s a there’s a guy called Professor riazi are are one of my mentors in the UK. Carlos he’s doing some amazing research behind dog like he is doing the module. He’s doing a T scan at the time of doll placement. And then he’s following up every month and doing a new T scan a new module, and he’s seeing exactly which teeth at what interval come together what percentage like it’s amazing the level of research is going into in there so I cannot wait to turn it I know you’ll appreciate this as well. But here’s a question for you is that as the teeth are coming into contact posteriorly Are you worried about the quality of the contacts? Are you worried that okay, there is an inclined contact here or- [Carlos]
You want to tell me the truth? I’m gonna be honest. No. [Jaz]
Okay. Yeah. And you know what, that’s what a lot of my colleagues told me as well because then I know what to say next. You’re gonna say as long as they still have smooth anterior guidance, Kanaan initiated guidance known anterior, but the posterior the way they come to get as long as there is a contact is good enough is it would you say that’s the philosophy that you follow? [Carlos]
Yes. And then and then few concern is you know, with mythology we believe in Tripodizing and so forth. Tripodizing, you know, you know, when you look at centric relation and Tripodizing that is, in an ideal, so ideal worldwide, you you can have no non interference free occlusion and a talented clinician, you know, teeth, teeth are variable, they change in anything, but what I will do and I think you had a mark one of the gnarthologist or Chow, in here a while back, but what I’ll do is I’ll put a little bit of composite at the floor at the base of the fossa. So if there’s, if I need a little compact, I’ll just add a little bit of flowable composite and that’s actually to get a little bit of stability. What I look for, when I’m working in offenses when they go left and right and remember in you know, the So when you do when you check you for non working interference don’t both have the patient know what you do is you go out and you put pressure to come back, you go out pressure, because that’s why you’re activating the masseter medial pterygoid. When you go like this- [Jaz]
When you tell the patient just grind it through, right, they wouldn’t recreate what they’re maybe doing in parafunctional at their worst, so yes, get them to do it for us. And also when they get stuck, when they feel locked in you, you guide them. Yeah- [Carlos]
You got to get masseter involved. Because when you clench, and grind is the masseter medial pterygoid, those are the bull dogs, those are the ones that are destructive. Those are the ones we’re trying to naturalize. When we do the interior ones, we’re trying to neutralize those things, you know, because they’re the bad. So, this scenario, that’s one. Another scenario is when I’m done with the additive procedure, a lot of times your balance, their balance is insane. Their balance. Okay, go, I’ll come back one more time and check. I’ll use this to check my diagnosis of the joint. I’ll use this to face dentistry. And other words, somebody comes in, they want an interior and I have cases in shot, I’d love to show him but why they want anterior teeth, aesthetics and so forth. Well, what I’ll do is I’ll go to the canines in centric relation, I go in and figure out that overjet, overbite, because you never believe a door like this, there’s something that is unless you’re a true class three skeletal position, but inevitably, there’s something that is pushing them forward.
And is what is it like? What pushed you forward? Three things, inflammation here, inferior lateral pterygoid or the mesial incline of the upper one against the distal pushing you forward. And you just slowly work your way back, you know, through your diagnosis. And that’s what happens when you use the canine, you’re testing the joint right? You loading the joint, you test it. Testing the aesthetics and phonetics is testing the aesthetic for him. You check in the muscle, the tongue so you’re doing a lot, you’re doing a lot of work, like just confront, you know, taking care of the interior teeth, and everything. So-[Jaz]
At what point do you then start restoring the laterals and incisors and the lower incisors for for aesthetic reasons? [Carlos]
That’s a good question. It depends. Usually I’ll have patients because I do like this as the occlusion the aesthetics part of dentistry. And so and I do a lot of composite, direct composite even though it’s harder and everything I enjoyed. But with that said, then I’m really rock and roll with the interiors, I’ll do you know, the laterals canine. Once I have the canines, it’s up to the patient. The other thing too, is you can do face dentistry. Once you get to stabilize, you can do the top to bottom with composite, I do a lot of composites in the front, even on a class 2 Div1 railroad, I’ll build up the composite first. And then on the top, I use Emax, whatever, however you want to do it. You know, that’s, that’s a personal thing. But I’ll- [Jaz]
Pick your poison. [Carlos]
Exactly. I’ll use this to stabilize and do face dentistry. Because not everybody can afford a full mouth rehab, no one care but this what was beautiful about this is it gives the patient also the sense of confidence. Because especially when they come in with symptoms here and there and you stabilize him, and it’s like yeah, this is what happened the right direction. And then you can start building your relationship and do what you know, whatever you need to do with the patient and so forth. So with the additive equilibration, it gives me a I have control in helps me my diagnosis a lot. It really does. It really does and I think it’s something that’s reversible, why? Because the patient out to me as a clench and grind and so forth here start adjusting it off and everything you do have to pay attention on your recalls for the non-working interferences and so forth, you do have to pay attention and so forth. But all you do is this- [Jaz]
And what are you doing when you find a non-working side interferences? Are you just adding more of steepness into the canines? Or are you happy to just adjust the non-working side interferences and if so, any guidelines to help a novice dentists when they’re adjusting those? [Carlos]
Here it is, if you are novice dentist and I remember choices, what you want to be careful is make sure you have canine guidance before you make those non-working interferences remove it because what happens is you could open up a Pandora Box by start adjusting in the back without having any any stability. So- [Jaz]
You got to make sure that the patient has enough potential for because there’s some patients that they don’t even have because they have an anterior open bite or severe cross bite or whatever, they don’t have the potential to have it and therefore you shouldn’t start to adjust posteriorly when you haven’t planned that, okay, what’s going to happen anteriorly. [Carlos]
Right, if you’re not coupling, anterior coupling, or canine guidance, do not make any, on a class to open bites and so forth. Here’s one thing I’m going to also share with my experiences. I gave you the anterior night guard, what I’ve noticed even if you don’t do anterior night guard if you balance thing, I know you had a T-scan tube and I love that, it’s fantastic. But and the posterior, if you can balance out those that first point of contact equally, you’d be surprised how well they do it. It’s not to say you don’t mean interior guidance, please, please, please. But you know, just to get them stabilized, you’re having issues and so forth and you can’t get it, you start with with flowable composite and with this and just having bite down, like you’re not adjusted, just balancing this back from Canon back, you doing that patient, a lot, a big service.
And then after that, you can start planning on you know, doing new restorative part, crowns, which what have you, but I am now I’m not afraid to tackle class two give one posterior for stabilizing them. And then also to remember, remember what the mechanics of the lower job, the key here, as long as we keep the junior how a muscle behind the canine so that means I can go to the pre molar. But as long as you’re behind this, you have a class Leverage System three, and you can use it. So, you can use that as your guidance, you can use the upper first premolar, this lower canine remember, as long as you’re using the lower canines is behind the muscle, you understand? So you can use a premolar for guidance as long as you’re using the canines, use the canine you still behind the muscles behind the canine. T 22 and put in Saturday. Remember that this is JR How is this a turbo? That’s a total Gina Holly is the most interior muscle that is similar that the pulls down. Okay.[Jaz]
So what you’re saying is that as long as you’re on lower canines, you can be on upper premolars against lower canines, and a class two div one for example, because you’re still encouraging a class three lever with the muscle. Fantastic. Okay. [Carlos]
Yeah. Now think about this. Remember, you know this about orthodontics? I know I’ve jumped around all over. But you know, when you take extractions and that’s why I’m not big on extracting baby teeth for ortho. Because what you do in extremely narrow and and not only you’d narrow for air space, but mechanically you put the patient at disadvantage, you move and everything closer to the muscle tissue here. That’s almost like a class two class three system. So you know, back and they don’t do it that much now, but the last thing you want to do is don’t take teeth out and bring back.
No, you want to always expand. Why class three people don’t have as much problem as class one, class two? Because they’re further away from the back there. Come on. So the mechanics, that’s what it is. And if you understand that, then you open I mean, everything is just like you’re not caught in this little thing you understand the whole thing is it always is the mechanics, the mechanics, that’s all it is.[Jaz]
Carlos, you’ve given us a lot of think about. I loved it. No, it’s been amazing. I’ve enjoyed this journey. Now, just on a point, before we start talking about the other side of your dentistry, the very inventive side about instruments and stuff. So I’m gonna discuss what this is about that. And tell us about some of those cool instruments and whatnot. But before we get to those, I just want to check one more thing. Last question. On those class two division ones, increased overjet and you’ve got your leaf gauge in and they might become, the public will become a little bit more class two. In that case, yes, you can maybe use upper premolars, like you said, and get some sort of class three leverage that in a way, but how do you maintain or achieve anterior coupling in those class two increased overjet cases? [Carlos]
First of all, you can because by definition, you don’t have an class two, div one, the spaces so far. So to get a copy, you have to do it indirectly with plastic that’s the first thing you have to deal with plastic, either surgery ortho, bring it forward, or you have to do the plastic. Now okay, that’s the idea. And for some reason you want to go you know, for you cannot physically get you know, they’re going to look ugly. So, you just go to the canine and a night you protect them with that segmental appliance six right now, one thing about class one div one, they have a narrow angle, it’s a very narrow, they cannot tolerate stuffing in night guard, they can’t tolerate that.
So, they’re very notorious for popping and clicking too. And those are the ones that you have to be very careful with, you know, class two division ones, those you have to be very careful when you go in there and doing restorative. Measure twice, cut once. And that’s for another side that you really have to be careful with those. Because you can get in trouble. They have a lot of clicking and popping, they have a lot of muscle and it’s just because they’re narrow, they’re narrow, they’re coming back, they’re back to where the muscle sources like I was telling you earlier, so you have to be very, you know, be careful with those but you can help them, you can really help him out.[Jaz]
For sure. And I send you an email that if you got a chance to read this but did you get to read about the ESIPC Jig that I sent you? [Carlos]
Yeah. Yes, I liked that. I did. [Jaz]
So I’m gonna shout out to Dr. Gurmit Hothi another dentist, I met a BDA Study Club once and he’s been such a great person to know over the years and we email each other, I’m gonna share, I’m gonna put this in the show notes, this PDF. So what Carlos has described so brilliantly with so many different facets was the leaf gauge technique and how you can get the anterior coupling, first point of contact. So there’s that kind of revision for this episode. But a different way to do it would be to use we call the Easy Peasy jig, which is a great name, there’s a whole you know, aesthetically, whatever is a full name, I’ll get it out for you, but essentially, is using some bis-acryl material anterior, and then that becomes kind of like what the leaf gauge is doing in a way, and then that really makes you a stop, so they can then rebuild the anterior teeth.
Just another way to think about it. So I’m gonna add that in the show notes. But I want to jump to Carlos, tell us about how you became so inventive. Like, where do you find the time when you’re active, your father of three, you’re very geeky dentist, how’d you invented the CaSi instrument, which by the way, I have talked about before. I talk about how much I love the CaSi instrument, I literally before I wouldn’t hold it, I used it. For a broken incisor, I love how it can, instead of using my finger, my gloved finger, I’m now using the CaSi we’ve got that you know, the blue, reduced sticking sort of surface mystic resurface and the correct contour, whether I’m building the palatal, or if I’m doing composite veneers to shape the anterior with the three planes. Amazing. And you also got some brushes that you made as well. Tell us about your instruments and stuff.[Carlos]
Well, I want to talk about that. No, yeah, basically, you know, I do my own wax ups and everything and so in my lab at home, I had an epiphany with the instrument if I could, you know, create this angle, have these angles with the instrument, and so forth, you know, make my life a whole lot easier. So, that’s how I started my journey with the CaSi instruments. And then of course, Cosmedent and was very, they’re very nice to take on the instrument, and they’re the ones that they’re selling it for me and so forth. And then, you know, being on the artistic side, I was, you know, Newton, Newton fall, you have Dr. Denny, a lot of people use brushes.
And so being influenced by the brushes, you know, there’s a way we can come up with a brush that is a handle that it’s not disposable. And then also with disposable tips that would, you know, could help out and so I have an handle basically, it as sturdy as you can get, you know stainless steel, and then with different tips on both angles, they’re gonna see here, it’s like, I’ll show you. So you got on both sides. And I think but for those viewers that can’t see it, you know, just the brushes. And hopefully, I’m working with Cosmedent if they go ahead and pick it up, you’ll be on the market for everyone. So but that’s our, I mean, just I’m very intrigued, I just-[Jaz]
It’s great that you do that and you find the time to do that. And it takes a lot of time and effort to do these things. And I’ve got my CaSi and you very kindly sent me some more. So I’m going to start using some videos because to help dentists to see how useful that is, as well as the brushes, I’m going to have a go of them and stuff. So I really appreciate that. And I will share with everyone how I’m getting on with that. But yeah, it’s great to have the design of it. And to usually the stumbling block I had with these brushes in the past that becomes very expensive habit to use his brushes, but the way they have the autoclavable handle whatnot, and how it reaches in the back. And how you can very easily create the right angle of the cusps, as you were saying, will reduce your appointment time and occlusal adjustment stuff. So it kind of makes sense. So I’m looking forward to using that and sharing that journey with the Protruserati so thank you so much Carlos for making that possible. [Carlos]
Well, first of all, thank you for you know, for the plug and everything. I appreciate that. And I hope you know people like it. But you know, I’m always I can share, I’m passionate about occlusion I think you can see as we go. And so you know if anyone has any questions that I’ll show- [Jaz]
I was just gonna say because you’re so easy to chat with on Instagram and stuff like. Tell us your Instagram handle. So if someone’s doing their first case and stuff and want to send some photos maybe like, I’m sure you’d be happy to help them. [Carlos]
I would I would Yes. And then with you, Jaz, I’ll send you, I have videos now to have videos with as far as I do have videos with the CaSi instruments also have with the additive equilibration start to finish. I’ll give you- [Jaz]
Send us everything. I’ll put it on the Protrusive Dental Community Facebook group. I’m gonna stick it on the show notes. Please join us. Are you on Facebook, Carlos? [Carlos]
I’m on Facebook, none other but on Facebook. Yes, sir. [Jaz]
I’m gonna invite you to the Protrusive Dental Community come and join our little community. It’s somewhere where I don’t invite people because the problem with these big groups that invite people is that you lose control of who’s in. This is very much a club that you have to do the your own work, you have to find the link, you have to click it and then you get accepted inside. So what that breeds is a community who self select themselves. You know what, I’m so geeky. I’m going to be part of this and you will be a great addition to this. So come in Join the Protrusive Dental Community. And then you can see it’s the kind of stuff that we talk about. And we’d love to hear about your experiences and your mentorship would be very much valued on there. [Carlos]
You know, I want to share because I want to make left. I love dentistry so much. It’s a great profession, you know that. And if we can make it easier for those young lads that are coming up and everything and help out that, you know, that’s to me, that’s rewarding, so [Jaz]
Tell us your Instagram handle and your website, Carlos. [Carlos]
Just put the Cosmedent. [Jaz]
But in terms of reaching out with you, how can we reach out with you? [Carlos]
On Instagram? Yeah! [Jaz]
I got it @carloscanchez_casi. But yeah, join us on the Facebook as well. And it’ll be it’d be great to have you there and learn from experiences. I think a lot of my listeners are yet we’re global but lot of the UK and in the UK and also in Scandinavia, we’re already very intertwined and very experienced in DAHL, we are the leaders of DAHL in the world, right? So what you had to say, will really really catch the interest and capture the sort of different ways to approach it. So again, thanks so much for coming on today and sharing all that. It’d be amazing if they weren’t kept up, I might to break this up into two part episode. But again, thanks so much, Carlos for coming on. I really appreciate everything you did for us. [Carlos]
There we have it guys, thank you so much for listening all the way to the end. So a few different unique perspectives shared there, which may be familiar to you already in terms of how you might be doing your tooth wear techniques but it’s always great to hear how other dentists around the world are managing their patients. As I said to you in the intro, I’m introducing a monthly email for free with some videos and occlusion tips to help you be a practitioner of occlusion. So why don’t you head to www.occlusion.wtf to join that free newsletter andI look forward to email you. Thanks so much again, and I’ll catch you in the next episode.