Adhesive Full Mouth Rehabs Part 2 – Wax Up and Temporaries – PDP106

Jaz’s Introduction: Hello, Protruserati. I’m Jaz Gulati. Welcome back to another episode of Protrusive Dental Podcast. In this episode, we’re going to go through how to plan your full mouth adhesive rehabilitation, including the wax up stage and actually putting the wax up into the mouth using a bis-acryl mock up and how to even send the patient home with that mock up so they can test esthetics, phonetics and function. If you’re new to the podcast. Welcome, it’s great to have you. This is a part 2 of 3, so you need to rewind to Episode 103. For the part one of adhesive full mouth rehab. The concept here with Dr. Devang Patel, is we’re going to cover the 11 appointments, the traditionally 11 appointments from the very first time you see the patient for a comprehensive examination, all the way to reviewing them with an occlusal appliance at the end, and all the stages in between of how to get a full mouth rehab done using adhesive approach. This has been one of the most anticipated episodes ever, like the amount of DMS I get saying, Jaz when is the part two out? I really enjoyed part one. So here it is, guys, I’m so excited to share with you. And Dev. I mean, shout out to Dev for getting so much value, giving so much away to the Protruserati, it is really, really great to have educators like you who are all giving, right? That’s what we want, we want to share with each other, share knowledge and improve our daily workflows.

[Jaz] Now, before we get on to today’s Protrusive Dental Pearl, I want to talk about emails, right? Yesterday, I sent an email and the subject was like ‘Why you need to start charging more for your dentistry?’ And this email has absolutely exploded. I’ve had huge open rates. And it was like an essay type email, but I just jam packed it with some reflections that had. So basically one of the delegates on the Splint Course, he had my stabilization Splint module and his feedback, five out of five stars, by the way, and then he gave me some feedback. And he said, Yeah, I need, in capital letters. I need to start charging more for my splints. And like yeah, hell yeah. So I discussed this with my Splint Course group like yeah, we started charging off splints, but then I took a step back, and I thought, You know what, we need to start valuing our Dentistry more, we start charging more for dentistry. So there’s four main reasons why you might not charge enough your dentistry. And I suggest four different fixes. Now, if you’re not on my email list already, and you want to be anyone check out that email that I sent, then go to protrusive.co.uk/emails, that’s protrusive.co.uk/emails, and on that page, you will access some of the more popular newsletters I’ve sent that I made public for you. So if you don’t love me enough to see me in your email inbox a couple of times a month but you love me enough to actually check out this email, then go on that website.

[Jaz] I also want to share some an announcement with you about the course that I’m doing. So I’m doing an occlusion one day course, hands on and theory for the Kana Dental Academy. It’s on Friday, the sixth of May. And the Kana Dental Academy is one of these diploma programs over 12 days. And the cool thing about it is that you can pick out like 15 or 16 different options and make, you can custom make your own postgraduate diploma. The full name of the diploma is a PG diploma program in Aesthetic and Restorative Dentistry. And I think it’s a cool concept one that’s quite popular nowadays to actually design your own diploma because you might have already seen one speaker, or you’re pretty confident with one aspect of what’s offered in the diploma so you can actually customize it to your own learning needs. So this is like a diploma cohort that you do for several days and you sign up for 12 days, you can do a standalone course as well. But I think there’s a lot of value in doing the entire 12 days. If you’re looking for an all encompassing course that has a bit of perio, bit of communication, bit of aligners, bit of occlusion, bit of treatment planning, a bit of everything to set you up ceramics composites, I mean some of the speakers are brilliant and I when I was reading through the list of the speakers for this diploma, it made me smile about how many alumni of the Protrusive Dental Podcast ie previous guests that we’ve had on this diploma like we’ve got Shaz Memon teaming up with the singing dentist and they’re talking about communication. Shaz came on episode 37 about personal branding. Koray Feran, I mean I’ve got so much time and love for Koray. He did a equilibration with us on episode 94. If you haven’t checked that one out and he’s doing treatment planning and consent, a whole day on that which is a huge, you know, contemporary treatment planning on the diploma program. We’ve got Shiraz Khan and Harmeet Grewal, who did the rubber dam Episode, episode 26. We’ve got Nick Sethi that episode 59 on ceramic onlays, which you guys love so much. You know, so many of you listened to that again and again, and you send me photos of the notes that you make, so that’s epic. Chris Waith on sectioning and elevating teeth. We had him on episode 85. And so you know, we can call this a Protrusive diploma if you want to. But you know there are some other amazing speakers. I’m just gonna just show the image on screen or post on the blog of this website, protrusive.co.uk about who all the speakers are, so you can see some great names on there. So do check that out and if you want to check out the website is kanadentalacademy.com based in Milton Keynes, that’s Kana, K-A-N-A, kanadentalacademy.com. So you can check out all the dates and all the speakers and see if this is gonna tickle your fancy.

[Jaz] The course I’ll be presenting for the Kana Academy is no nonsense occlusion, pragmatic principles and a risk based approach. It’s gonna do exactly what it says on the tin. Dentists were able to carry out occlusal examinations on each other, as well as muscle and joint evaluations and be able to take that through onto the examinations on Monday morning. It’s about identifying the high risk patients, the ones for which the occlusion is a super sensitive issue and how to tread carefully with those patients. As well as the daily skills that you can use to improve the longevity of your restorations. It’s occlusion made pragmatic because the best articulator is the TMJ.

[Jaz] And finally, the Protrusive Dental Pearl that you’ve been waiting for before we joined the main meat and potatoes of this episode. So the Protrusive Dental Pearl, following on from what I covered last time about how I communicate an oro-antral communication, I’m going to share with you a few pointers, I’ve picked up myself about how to communicate an RCT risk. And what I mean by that is, I actually dread and obviously, I’m learning to manage it more now. I’m gonna share that with you how I manage it now in terms of communication, but I used to really hate treating deep caries lesions like, I kind of want them to be not very deep, so I can restore them and tell the patient you’ll be fine, don’t worry, or I want them so deep that I know the answer is a root canal. But most of the caries that we treat nowadays is like, oh, there’s a higher risk of root canal. It’s quite close to the nerve. It’s not in Interpulp, but it’s, it’s quite close. And therefore you to have that whole conversation with the patient that, okay, we’re gonna do this restoration or this temporary crown wherever. But there’s a chance that you might need a root canal, do you know what a root canal is and explain what it is. And it’s messy. It’s annoying, it’s stressful, and no one likes it when you do a large restoration. And then six months later, a patient comes back in pain, because if you haven’t communicated it to the best of your ability, or some patients, they just don’t get it, okay? Oh, my tooth wasn’t hurting before you started drilling into it. And you did this big filling. And oh, you know, you hear this all the time. Oh, my dentist, I think my dentist drill too much. And now I need a root canal. But we hear this all the time for our patients, so they don’t get it. So how can you make sure our patients get it. So some patients will be just fine with look, there’s a risk that you might need a root canal treatment explain because that YOUR decay, Remember I always say YOUR tooth decay (in YOUR tooth), YOUR filling was very deep. And that’s all they need to know. But if I ever get like a bad vibe, or if I just feel that this is a troublemaker patient, or they are just not getting it now to really make this consent process crystal clear to them. I will say the following, Okay, remember, we treat all our patients differently, okay, because everyone is different, they have different personality. So certain groups of patients, I will say this too, I will do the whole thing, you know, YOUR filling, YOUR tooth decay, etc. But then I will say that, if we do nothing, then your tooth will eventually be in a worse situation. And you may lose your tooth. And this could be a painful process as well. If I do something, then that involves drilling your tooth decay, drilling the soft bits of your tooth away, drilling away the old filling that’s leaking. And drilling is not a nice thing. Your tooth was never designed by God revolution really believed in. Your tooth was never designed to be drilled. So even the drill is damaging to the tooth. So by drilling, I’m damaging the tooth. Okay, so there we are, I’m being very real to the patient. Okay, so an endodontist called Steven Godfrey taught me this, and I always stuck with me. So by drilling, I am damaging your tooth. But if you don’t treat this, you’re gonna lose a tooth anyway. So I’m going to try and help you. But your tooth is in a very bad condition. And I’m drilling it and I’m hoping that your nerve will make it and survive this drilling procedure. If your nerve doesn’t make it, you might need something called a root canal. Explain that. So the reason I like that for certain patients is that you know, I just put my cards on table and say, okay, yeah, what I am doing is destructive. And I don’t want to be doing this, but it’s your, you got yourself in this position, your tooth is messed up. So yes, you might need a root canal, okay? Do you want the risk or not? What do you want to do? So again, it’s makes it very clear that it’s a very real eventuality, and they might need root canal. And if and when they’re the patient that, you know, a few months later, a few years later, they end up having an abscess, or they end up needing a root canal treatment, you know, they’re gonna be one step closer to remembering that, Oh, you know what Jaz did tell me that, you know, the drill is damaging. So I know this is not everyone’s cup of tea, but for that certain type of patient it really drilling into them, excuse the pun, so that it sticks and it’s memorable. And like I said in the previous episode, the whole point of consent is that if they decide that they don’t want this treatment anymore, then that’s good. Okay. Then that’s the whole point of consent. You know, you don’t say, Oh, if I warn them too much. Then there’ll be scared and they won’t have the restoration, well, that’s the point of consent. If there is a real risk here, communicate it. So that’s one way to do it. So let me know what you think, email me, message on Facebook Protrusive Dental community tell us other ways that you communicate it there, which are innovative, or useful or memorable for the patient. And remember, this is what I was sharing with you is not the best way to do it. It’s just sharing a way that for certain patients I like and that was taught to me by an endodontist. And I think it really sends a message clearly to the patient. Anyway, let’s join the main episode with Dr. Devang Patel. And I’ll catch you in the outro

Main Interview:

[Jaz] Dev. Welcome back to part two, we had a really jam packed full of information, part one. And it’s good to talk about the next step because everyone’s now eager to know, what do I do next? What do I do next? So Dev, just recap for us what we spoke about last time, and where we’re going to pick up from today.

[Dev] Well, I’m glad to be back. Jaz, thank you again for inviting me. So we discussed about the mindset, which is really, really important. Mindset of full mouth reconstructive dentist, very important investment, investing in yourself. We talked about appointment one, the mindset was appointment zero, if you remember. Appointment one is really when you’re doing examination, you gathering all the data, you’re really discussing with patients what are you planning to do? You’re doing full mouth assessment examination, you’re kind of discussed about conformity versus reorganized approach, how we can do and how, what are we going to do? Appointment two now is really records. So you need to take good set of impressions, you need to take some sort of a Facebow record so you can mount your model. And you would have decided by now that whether you want to restore the case in MIP, or CR or CO for that matter. So most of the time, you I do not mount models in MIP, I would mount model in CR. And even if I’m restoring in CO or mount model in CR and if my mounting is correct, if I drop the pin, it will..

[Jaz] I’m very anal about CO, you’re using CO as a definition as an MIP. Yeah?

[Dev] No, CO is..Correct definition of CO.

[Jaz] Yes. The Centric Relation Contact Point. Okay, fine. I just want to clarify that because people listening maybe they haven’t listened to some of the early episodes and like, Yeah, fine. First Point of contact. Perfect.

[Dev] Just to recap, because as you quite right to be honest, if you pick up Glossary of prosthodontic terms of 1999 CO is equal to MIP. If you pick up you know there’s different time, different definitions, but my understanding is CR is your relationship, [overlaping conversation] hinge axis, and teeth apart relationship. So it’s quite reproducible. CO is when you are, when your conduct is nicely seated, and you’re now closing your jaw and first point of contact is centric occlusion. And then MIP is when you have the slide or shift or if you don’t have a slide if you don’t have the case, then you..

[Jaz] We have the same language, Dev. This is the first time in occlusion. Two people are speaking the same language

[Dev] Very good. Yes, because to be honest, you made a great point. Because when I do the course I first start with terminologies because there are so many different terminologies to different I mean, in UK, we use RCP, ICP. But however I stopped, I use CRCO and because that’s more generally use terms. But if you’re in UK, if you’re reading some UK journal articles, then RAP is equal to CR. RCP is equal to CO and ICP is MIP, which we know anyway. So what I was saying that I would mount model in CR almost all the time, because I’m not going to restore, if I’m doing one arch or full mouth reconstruction, then I’m not going to restore patient in MIP, for me, it’s just not ideal. So I have..

[Jaz] Often increasing the OVD henceforth, the traditional way of working in a reorganized centric relation, sort of position or centric relation contact point or beyond the centric relation contact point like we talked about last episode about sometimes when you can open up just exactly what how much you need. It gives you a playing field where you can get complete control and I liked that when we discussed that. Remember that everyone and also just want to just check out just for those dentists listening they think okay, articulator, what type of articulator just briefly, what?

[Dev] Articulators, I mean, I do quite complicated full mouth reconstruction, I don’t use fully adjustable articulator, I mean I use a semi adjustable articulator how many times I’m changing condyle inclination, I don’t know I mean if I do 500 cases, maybe two times so if you even have an average value articulator with a set of values I use Denar I’m biased because I was trained on Denar articulator. I use it, it works for me, but you can use you know different articulators, if you want. So I use Denar, slight Facebow and Denar articulator, again, I use semi adjustable but you can use average value to save money and also, if you starting your journey, you’re not going to use any setting of semi adjustable articulator and actually you’re risking, if any of the screw becomes loose, then the settings will change and you will notice and then all the mounting will be wrong. So just use, just buy average Value Articulator where all the values are set, which is 25 degree of inclination, seven degree of sides, sort of progressive shifts and zero degree of immediate side shift. So, that’s all set up so you don’t need to worry about that your calibration is much easier for those articulator as well. So, I use that. Now once I’ve done that now, we haven’t really talked about digital and we can talk about sometime later because I’m more analog person to be honest, but if you let’s say if you’re doing digital while in your and you’ve got a scanner, then you need to take obviously scans of upper and lower jaw, you still need to have some sort of a jaw relationship and scan the patient in that jaw relationship to mount model on the articulator, which is digital articulator really. So you still need to use a Lucia jig, or leaf gauge in order for you to get that CR position. And what I tend to do is I would have bite registration material squeezed on the back teeth, I would take one side of the bite registration material out, scan the bite, put that bite registration back, take the other side out and scan the bite. So then I have a stable occlusion when I’m scanning the bite and patients not moving around too much.

[Jaz] So for those who are watching this on the like YouTube or the app which is coming soon, I’ll have a visual of exactly what this looks like. When you take a bite, digital bite in CR and you have all that lovely space. So I can share that with everyone, those listening, Dev made a good point about using bite reg left and right. I personally just use a leaf gauge at the front. And that stays at the front. And then I makes the patient stays in the position I want them to stay. And here’s the magic bit, at the desired vertical dimension I’m roughly aiming for to reduce the error in opening and then I’ll just scan left and right and yes, exactly. So this is the digital way to get the same information as analog. And I’m glad you mentioned that because some of our colleagues are digital now. So we need to please both groups.

[Dev] Yeah, exactly. So now the model gets mounted. Now at this point many times what everyone does is they would send the impressions and the records to technician and say Look, mount the model, do the wax up. But in my case, I mean I personally met all my models myself, because I’m just I like it. So I would mount the models, I would then assess it because I want to really assess the occlusion I want to assess the plane. So when I’m planning the treatment, this is when more confirming my treatment plan which I already planning patients when patient was there because as I said last time, use patient’s mouth as an articulator, it’s the best articulator you can use because you’re going to use that, you know, treat the patient in the mouth. So make sure that you plan most of your treatment then and then and then what you’re doing is when you mounted the models, you reconfirming your planning because there are some views you cannot see in patient’s mouth, you know, so articulate helps to look at in the various angles. Now, there are five things I’m looking at when I’m planning any treatment not particularly just on the looking at the articulator, but just overall. So there are five things which I’m planning, the first one is, which we briefly touched upon, is assessing patient. Patient himself or herself, right? So my first criteria is, if I don’t get a good vibe, if you’re not getting on with each other, I will not start the case no matter how simple it is, I will not start the case. It’s different when you’re doing NHS dentistry and you don’t have a choice, you know, you have to treat patients before those main needs, you know if they have broken tooth and you need to fix it. That’s different

[Jaz] Basic health needs.

[Dev] Sorry, yes. Whereas we are doing we’re talking about full mouth reconstruction, we have a choice because this is private, it’s beyond NHS remet. Anyway. So, I choose who I treat and I choose very carefully now as I mature over the years, because I have been bitten before. So my criteria is first thing is, am I going to get along with this patient right? Because once you start doing full mouth reconstruction or even single arch, you kind of start with that patient for some time. So that’s one thing.

[Jaz] One thing I want to sticks in people’s minds, Dev, Ian Buckle when he used to make the same point, he’s used to say very simply, date them before you marry them. And I love that because it is pretty much when you do a full mouth rehab. It is a marriage. You know when something happens in the future they’re gonna come back to you and whatnot. So date them before you marry them. Because sometimes that actually means…

[Dev] Yeah, especially doing full mouth implants upper and lower. That’s it, they kind of end.

[Jaz] Exactly. Sometimes it just means that you need to see them for a couple appointments just to go over hygiene and do that filling in the lower left six, which they need because it’s caries to suss out. Okay, can they? Are they a suitable patient, both in terms of their mouth and in terms of their personality profile that matches you going forward. So that’s a fantastic point, well made. Thank you.

[Dev] Yeah. So basically, yes, I would assess patient. And the other thing I would assess is what they want, you know, the expectations, but I can match the expectation. We are very grateful to be honest, in UK, our patient match expectations are quite realistic, to be honest. So I never had a patient, well I would say never maybe once, maybe I had a patient where I could not match the expectation because it’s just unrealistic. So but otherwise, we are quite good. But you need to make sure that in your capacity, you have your capacity or skill level to match the expectation. Because once you start these cases, you can’t really go back. And we can argue day long about the you know, composite versus porcelain and composite is, “reversible treatment”, I don’t think composite treatment is reversible. Once you bond the two really nicely, or once you want the composite to really nicely, a patient doesn’t like it, you can’t really undo it, you can’t really take it out in patients on you know, there is no way

[Jaz] You’ll never go back to the exact same position they were before.

[Dev] Cannot. Yeah. So but it’s very easy to adjust. And if you’re doing full mouth reconstruction for the first time, I would highly recommend start doing adhesive sort of composite buildups, because it’s very forgiving especially if you’re bonding skills nice, then you know, you can, occlusion you can adjust here and there. So that’s what something I assess. The third thing I assess for the patient is non compliance. So some patients, they want to have nice teeth, but they don’t want to put an effort to have those nice teeth. So they don’t clean their teeth. They don’t want to do good hygiene. They don’t, they miss their appointments. I really don’t, I look at their history. And I tell them from up front that you know, you need to do all this record, I think because patient will say on that appointment that yeah, we’ll do everything. You know, I’ll stop smoking. I’ll you know, we’ll see hygienists every three months. But it may or may not happen. So you need to really suss it out what happens because, again, I’ve been bitten before. There, you know, there are patients who FDA before, their general dentists and I can see their history is quite patchy. And they need a full mouth reconstruction. And you know, it’s nightmare because they missed the appointment, they canceled appointment, there won’t comes first, which is I understand the problem is we are also working, so we can’t really, I have three hours appointment and the patient a day before cancels, I mean, I can’t fill that whole gap within 12 hours. So we need to understand whether this patients priority to fix their teeth or not. If patients priority is not that, then it is likely that they won’t take care of it. So that’s the…

[Jaz] It might be not their priority right now. But, you know, a year down the line, I’m sure you’ve had patients given treatment plans before and they come back some years later, because again, and then they’re ready. So it doesn’t matter if you lose the case. Because if you lose the case, it’s a good thing. Because you know, you’ve decided this isn’t the right patient yet. Yes, being the key word and in the future, they might be your ideal patient.

[Dev] I mean, I had a patient who, when I used to do normal checkups and everything, I proposed a full mouth reconstruction to him. And he literally laughed at my face and what how much, you know, I can do three holidays to Spain or whatever. So we discussed, we literally discussed four checkups, same thing and he laughs. In the fifth checkup, he said, Yeah, I want this done. Because things changed. You know, he broke couple of teeth during that two years time. And you know, he’s like, look, things are deteriorating, and I get it what you wanted, what you were saying to me two years ago, let’s get this done. Okay, so obviously he paid more because now it’s more work two years later on and the prices increase and make sure that you give that example to patients and other patients as well that you know, they may not realize. So that’s one thing. The second thing is I assess while I’m doing records is load test. Load test means is really checking the health of your TMJ whether you are assessing whether there is any intracapsular problems so keep it at around the TMD if there is any problems and for loas test, I used to make Lucia jig all the time, but I find leaf gauge very easy quick to use for load test. For mounting I’m still old school so I still use Lucia jig for mounting because it gives me a nice vertical stop and I lock them their bite on my Lucia jig so when I’m asking them to close their mouth, on the Lucia jig I know that they’re closing at the right point because bit leaf gauge, you cannot tell whether the patient’s going further back right by when you put your bite registration material or not. And I don’t like to push their jaw, I just like them to move their jaw forward come back comfortably. And that’s how you…

[Jaz] With the load test. I just want mentioned if we go to the fifth one with the load test is for those people who don’t have a leaf gauge is A) get a leaf gauge. So it’s a very valuable solution, many scenarios. Exactly, it’s not expensive at all right? 20 pounds. And then for those who don’t have one, I mean, do they need to load test a patient right now, the other way they can do it is get a wooden spatula on one side, let’s say you want to load test the left joint, you put the wooden spatula between the right molars, and then you get the patient to clench on it, and then you assist with your hand by pushing the angle of mandible up. So you’re pushing the condyle into the fossa. And that’s another way to do the load testing for that one joint then obviously got to do the same thing for the other joint. So it’s important to have these baseline measurements including like when I’m doing more complex work, I need to know exactly in millimeters, the range of movement, I want to know the pathway. These are all things that you said you record in a very comprehensive check. So you need to have all this information. Because if something happens later on, you need to medically know exactly what situation your patient was in. So please do not take these measurements lightly. These are little details are important.

[Jaz] Yeah, and one thing though, you can get false positive results with the load testing if your lateral pterygoid are a bit stressed. So what I tend to do is if I have patients it is bit painful around jaw joint area, I give cotton ball rolls, asked them to bite on both molars tight squeeze, release, squeeze, release, and then do the load test again. Sometimes the pain goes because it’s just that the lateral pterygoid are tense and then just relaxes

[Jaz] So you just make sure that you check to get a true positive is quite rare thankfully, so to get a true positive load test, and that means that they got severe intracapsular issues. Thankfully,

[Dev]Most of the time patient knows when you have true positive, patient would know that they have some issue going on with that TMJ. So make sure, so that if I do find true positive, or even some f alse positive, and I’m not really sure I would give them Michigan splint to start with to make sure that you know the occlusions, they can tolerate the raise OVD. A) their compliance is good. And there are lots of reasons why you should use Michigan splint before your full mouth reconstruction. But it doesn’t. When I was taught, I was taught that you need to do Michigan splint for 100% of the cases, full mouth reconstruction, 100% of the time, which I don’t feel necessary to be honest, in my opinion, if patients has got sort of load test is positive, you must give the Michigan splint and you make sure that you don’t start treatment until that pain goes, so you need to keep checking. If I’m doing load tests, everything’s fine. Patients not in pain, muscles are not tender. And I can really relax that jaw nicely and they go back into CR very nicely, then there’s no point in giving them Michigan split, okay? So I will then crack on. Especially if you’re doing composite reconstruction, you got plenty of time, even if you’re doing indirect reconstruction, you will have plenty of time to check because you’re going to do a mock up, you’re going to do your provisionals. And then you’re going to do final, so you will have time to sort of test it out as it were. So that’s that and then if there are some patients who are genuinely cannot, you cannot relax their jaw at all. In those cases, you can give them some deprogrammer, you know, and your course is really amazing. So you know, you can get some deprogrammer to use, I give them I make a bit larger version of duralay sort of lucia jig, which they can use, but you can get different types of deprogrammer. Give them to take it at home. Bring them later next time. So use it for a few days and then come back.

[Jaz]
What percentage of your patients would you say would have a splint therapy before doing a full mouth rehab? Just interesting to note.

[Dev]
Yeah. Very, very rare. I mean, not that many percent. So I would say, I don’t know, 5 to 10%, maybe? So not that many.

[Jaz]
And some clinicians are doing it in a much higher percentage. And that’s fine. You know, that’s part of their philosophy and it’s okay. But I think you’ve given us some good guidelines about when to consider it.

[Dev]
Yeah, I mean, I was taught like that, and I don’t see any issues with that. Having said that, it does increase the treatment time, first of all, but also by giving the Michigan splint, what you’re trying to do, you’re trying to relax the jaw, right? So if you feel that you have their jaws relaxed and you know you can go to CR and this is all about feelings. Remember I’ve been doing this for 10 years so initially all my cases used to get Michigan splint. So whether you when you start getting more experience, you know that this patient got really tense muscles, you don’t want to start the treatment, you want to get a Michigan splint first, make sure they’re nice and relax. And then having said that patient who are bruxist, past parafunctionist, they will always do that. You know, we know that Michigan splint 24/7 is not a good idea. So you know, for all the time. So you know, you need to take everything with a pinch of salt, and modify your treatment according to your experience. But in the beginning, when you’re starting, not sure, if you’re not sure, just give them Michigan Splint. That’s the best, safest way to start full mouth reconstruction.

[Jaz]
And again, if you’re not sure, then again, it’s another way to check the patient’s compliance to check the patient has really committed as well. That’s sometimes the reason I do it purely just to check their compliance. Very rarely, if they are severe Bruxist but I still get their muscles relaxed, then it’s fine. But sometimes it’s important for them to understand that what they’ve done to their own teeth, they destroy them, they’ll probably put the restorations under the same stress unless we can somehow switch off that trigger that they have for their bruxism, which is very difficult. Therefore, in some cases, you might give it for a secondary reason to also check their compliance.

[Dev]
Yes, because for those bruxism patient, I want them to wear Michigan splint after I finished the treatment. So if they think the CR convert this, then that’s the best point I would say, Look, I can’t treat you because you know, you’re going to break things. I mean, I tell all my patients who are treating cases that you will break might whatever I’m doing to your teeth, you know, 100% chance, at some point, you will break something. It may last 10 years, and you will break it or it may last you know two years. I mean, it’s very difficult to tell. Obviously, we’ll do our best to give you the best treatment, but you know, you might break things. So that’s that. Once I’ve done the load test, I would then check the type of wear. So how many teeth are worn down whether and that will allow me to decide where the patient needs single arch reconstruction. I just posted a case sort of late December. But I’ve just done single arch, upper arch, it’s erosive case, patient had, she had a sort of fizzy drinks issues, drink a lot of fizzy drinks and everything. So she has one, just her upper teeth quite massively, and the lower teeth were almost not too bad. So just single arch reconstruction and lower arch levitating up. So depends on the wear, you’re going to decide whether you’re going to do single arch, we’re going to do full mouth reconstruction, or you’re going to do just anterior reconstruction and dahl the patient into the posterior teeth in. Dahl means, you know, orthodontic movement of the teeth without putting braces on. Right? So you put in, you’re doing just anterior buildups, and you’re allowing anterior teeth to intrude and posture to extrude. Having said that, it’s not very well utilized in the sense that if the very strict criteria, which cases you can use dahl, I mean, if patients got posterior wear, it’s a complete No, no, I mean, you increasing this, you creating this nice space to restore posterior teeth, why not just restore there and then, why just dahl the patient and most of the time it’s easy to communicate with patient and dahl technique because it’s cheaper, right? So you know, it’s full mouth reconstruction is much more expensive, because posteriorly, you’re going to involve more onlays more you know, until you can just do composite, dahl, quick done.

[Jaz]
Because if you have like you said, if you’ve got a significant posterior wear, restore it. Planning for restoration, don’t leave it to dahl. It’s very much a interceptive treatment for localized anterior tooth wear. That’s the way I think about it. And for those who if you haven’t listened to Episode 16, and 18 with Dr. Tif Qureshi, he really goes into full detail of a couple hours about this, beyond the limit of what we’re talking because we were talking about the full mouth rehab now, but great point, not every case that you see, needs to be treated a certain way, you got to have different tools in the shed. So some cases may be amenable to a dahl. And that’s a point well made.

[Dev]
And also don’t try to fit you know everything into the tools you have. Just because some people just comfortable to dahl there just to dahl everything. They dahl all the cases which is not ideal, but anyway, so now if you have posterior wear and anterior teeth are completely intact, and I’ll show you the case, at some point where I have treated case like that, where you just want to restore posterior teeth. Now how can you do that? You can do orthodontic movement of the posterior teeth, braces, intrude the teeth create the space or restore the posterior teeth and have braces to close the anterior teeth down because when you restore the posterior teeth, you’re going to almost increase the, decrease the Overbite so you know you’re going to sometime can create open bite interior If the patients come through the very edge to edge almost occlusion, and those patient who are have quite heavy posterior wear, they don’t have very deep bite unless they go into CR and grinding their teeth, okay? But if it’s localized one or two teeth posteriorly, then orthodontic treatment helps a lot in managing them. So again, how many teeth are involved helps me planning what I’m going to do, also the type of wear. So if a patient comes with wear, how would you know whether you need to increase OVD or you need to do crown lengthening, and restore the patient in the same OVD, because there is envelop of compensation and patients have already worn up. So patient actually hasn’t lost any OVD. But just the two teeth have overerupted because the idea of compensation, and one of the quick way to measure that is asses patient’s smile. If patient’s smiling and all the teeth are on display, you can’t really increase too much OVD because then you’re going to give them horse teeth, okay? So then you need to think about also you need to think about Crown Lengthening, other things apart from increasing just increasing OVD, okay? So that’s a few things you need to keep in mind when assessing wear.

[Jaz]
Just a point on that Dev. So now I’m going to continue because I think you’re gonna come to it, go for it.

[Dev]
So the fourth thing I assess is Curve of Spee. So I want my occlusal planes flat-ish if I can, okay? I don’t want very steep curve of spee on the lower. So when I’m assessing my models that will help me in assessing Okay, how much I’m going to add on the lower arch and how much I’m going to add on the upper arch to get that plane flatter, okay? It’s not always possible without orthodontic treatment, because the teeth have may have moved so much. But keep that in mind. Because sometimes what happens is you have, again, every the compensation of the lower anterior, lower anterior’s come up, the posterior is quite lower down. And now if you’re building the lower anterior, you’re really increasing the steepness of the curve. So to make it flatter, you need to really have quite thick posterior onlays to match up with the level of the incisors. Now, that’s when you realize okay, this really case needs orthodontic intrusion, and then treatment rather than just building everything up or a crown lengthening or not build too much length out. So,

[Jaz]
So the models or your 3d scan will give you so much information to be able to assess the occlusal plane all that information

[Dev]
Yes,, exactly. So 3d scan will help you a lot, patient’s mouth, you know, you just look at patient’s mouth again this articulator so I really assess a lot when patients they’re in the chair, it helped me a lot with planning. And then the rest of it is just literally confirming what are planned. And it just gave me a little more time to think about and patients there. I don’t want to just have pause and lots of you know, silences where patients like wondering what’s going on. So I will do what I need to do, I need to assess what I need to assess and then thinking time will be after patients left. So that’s that, and then we assess any limiting factors. So you need to make sure that what are the limiting factors for me if I sometimes receive cases, I, right now, I mean, I don’t do much checkups, I see patients on referral basis. So I get consultations patients come to me. And sometimes they refer to me for single implant and dentist has done some crowns and some veneers and I think okay, now this patient kind of needs a full mouth reconstruction. The problem is they’ve just done a new crown or new veneer, can I fit my full mouth reconstruction within that, without changing it, because the crown veneers really nice, it’s really nicely done, don’t want to really disturb the tooth too much. And put patient to extra cost. So that’s something is not a limiting factor. But something you need to be you need to I need to make sure that you’re aware of it. Another limiting factor, which I believe is quite some time with patients who have all dentistry done is posting core crowns with very poor endodontic treatment. Now, when I raise OVD, we kind of committing to at least doing one single arch reconstruction. So if the post and core crown is falls within the arch, which I’m doing reconstruction for, then I need to change that crown and it’s much higher risk when you removing the post when you’re doing the crown. Because if the endodontically treatment’s not done very well to need to remove the post, do the proper endodontic treatment and then put a new post in, new crown in and the cost of seeing a specialist having all that done, and then it just increases increases, increases, and then you thinking, Okay, why not just take it out and do an implant. Because even though you do all that, the tooth is going to be very weak because it’s already got post in there, you’re doing a lot of things in the root. So that’s something, I always need to have a constant sort of discussion with patient during my treatment planning discussion. The other obviously..

[Jaz]
You’re right, so I’m just trying to pick you on old dentistry. So I’m just probably a bit further with old dentistry, that is a real challenge. When it plans old dentistry really gets in the way, it’s much nice to treat those erosive cases where they’ve just haven’t got many restorations and you got, you can do what you want in a way. But when you got old dentistry, you have to be a little bit smarter. Now one question I have for you is, what about those cases of wear, I’m sure you’ve seen loads of these, because of the nature of the clientele you see, that they have so much wear on the anterior is that the anterior teeth were root filled at some point, and then they continue to wear and now they’ve got a GP exposed, you know, 3-3, What are the guidelines that you suggest in terms of doing a re-RCT for every one of those teeth before then restoring it defensively? Because again, it’s another factor, which can significantly increase the cost of a plan by several thousand of pounds, because you’re doing now so many re-RCTs and lots of time commitment. Any guidelines on that?

[Dev]
Yeah, well, for me, I mean, for me, it’s clear cut, if the GP’s exposed, that means there is a contamination. And if I’m doing something to that tooth, that tooth needs to be re-treated, I wouldn’t feel comfortable doing I mean, if I’m doing direct composite buildup, maybe I’ll take a chance, if I know the patient very well, and I think but I haven’t taken that chance yet. I’m just saying maybe I’ll take a chance. But I have not taken that chance yet. Because I just don’t feel comfortable. Because we know that one of the main reason why root canal treatment fail is because of the leakage of your corporate restoration. Now, if the GP is exposed, you see a lot of bacterias going in and you know, maybe yes, patient doesn’t have pain. But when you do something, you’re going to change that by sort of a fluora anyway. So patient might then start getting pain. So any indirect restoration complete No, no, I mean, I will not even, if the root, there is no periapical pathology, but the root canal treatment is short and is not great. I do not feel comfortable doing any indirect restoration on that tooth, I would always send patient to a specialist, or I’ll do a specialist because specialists endodontist incentives, they are busy, you know, at least the area where I’m working. And if a patient needs to have wait for months, then I will just do it myself. But I’m trying to shy away from root canals as much as possible.

[Jaz]
Wise man, but not that I think that’s a nice clicker answer. If you have GP that’s exposed by time that comes and seen you, it’s probably exposed for a long time, it’s probably contaminated. So although it might raise the cost of the case, overall, it’s based on sound principles that you should before you put the indirect on it. Treated textbook. So that’s the answer, clearly,

[Dev]
Yeah, I think it’s a textbook. But also, I’ve seen a lot of exam because I have associates approaching me all the time with the planning and also approaching with me when they have done something and hasn’t worked out. And I’ve seen a lot of cases where they feel trapped when they have done that kind of treatment without being re-root canal. And now patients turn and say, look, it wasn’t painful before. And they completely forget the discussion you had with them that you know, it may get painful, it’s completely out of there. They don’t remember that because you know, a lot of things goes on. And it’s very difficult to remember every single thing you tell the patient for the patient, for you it’s easy, but for patient that gathering all the information, so yeah, I don’t tend to take chances. So then the other clear cut limiting factor is existing implant, which are good. So if doing reconstruction and implant is in the right position, then it’s fine, you just change the crown, you’re done. But if implants are not in the right position, you want to do ortho, you want to move the teeth, then you are kind of limited by the position of the implant, if it’s in the molar area, maybe it’s easier, but if it’s an anterior area a few degrees can change the implant restoration from screw retained to cement retain. I personally don’t prefer cement retained restorations. But, you know, it just changes the method of how you’re going to restore the implant. So implant is one of the reason you need, it’s the limiting factor. The other limiting factor which is supraerupted teeth, which you will see a lot if you start restoring cases which is heavily wear, edentulous areas some of the areas where teeth starting supraerupt so much so that even if you’re increasing OVD you can’t get occlusal plane to flat and especially the posteriors, you start Getting sometimes this big slice because of those supraerupted teeth. So in that case, you need to have a discussion with the patient whether they’re happy to have intentional endodontics, chop the tooth down and then do an onlay on that or extraction implant or orthodontic moment, obviously. So that’s what we discussed before as well. So it’s these things just nuances you need to really be keep in mind, there are lots and lots and lots of them. I’ve just stopped touched upon

[Jaz]
Just a real world sequencing question there. But I mean, these important considerations and important discussion that you have with a patient, you’ve obviously seen the patient for a comprehensive evaluation, you’ve given them an idea, you’ve gained some sort of commitment for them, you’ve probably charged them some degree of money to do some planning. And now you’ve got your articulators. You’ve done your process, you’ve done your load testing. In your mind’s eye, you know, you’re limiting factors, you know about the implant curve, some compromises, but these sort of a next lot of discussions that you figured out based on doing your articulator analysis and you decided, actually, I need to discuss this further with the patient, because there are some decisions, the patient’s needs to make, should we extract this? should we do ortho? Are you inviting the back and then presenting an ideal plan and having those discussions again? And so how long does that take?

[Dev]
100%. So this is so first, when I do the treatment planning, I would have said about most of the limiting factors to them anyway, because this is quite obvious factors. So you know that so patient would have almost 80% idea what to expect, when they see me 85 to 90%, I would say. And the only reason the treatment plan might treat them in a manner when I’m planning is 90% 95%, 90 to 95% there when patients first appointment. And the only reason it changes a lot sometime is because I’ve forgotten to put something in like whitening, or you know, and I need some time and you know, you just came away with things. So that’s why I never tell patients that this is the final treatment plan, I will do mounting, I’ll assess everything, even when I’m doing mounting a man might put some wax here and there just to have an idea to whether I will be able to achieve what I want, and how much opening and everything. For all direct cases, I do all my wax up myself. Because it’s just easy, because then I’m building that in patient’s mouth. So I know the anatomy, I know exactly the shape how I’m going to get the shape, especially when you’re doing the interior. But now with, you know, injection molding technique or smile fast, you can you know, you can avoid knowing too much about the anatomy and all that but I’m still old style. So I will do wax up myself and do direct build up myself. So, after this appointment, patient comes back again and I will give them the full analysis, full treatment plan with still ifs and buts because you know, you never know when you remove all amalgams what you’re going to find underneath it, sometimes the cusps goes and you’re planning to do single simple MOD restoration and now it becomes a non lead because one cusp just flew off. So you need to let patient know, you also need to let patient over the root canal treatment for those deep old amalgam fillings. Having said that, using adhesive techniques and adhesive onlays I’ve done 1000s And I could probably count five or six patients which got pathetic after treatment. So you know, many dentists get scared of removing this big amalgams. It’s pretty safe because the nerve has already created that tertiary dentine, you know, protection around the thing. So, you know, you’re quite alright, unless there is active caries, and you’re now taking the caries out. So, because you’re doing adhesive restorations, even the sound amalgam comes out in my cases, so I remove old amalgam out and replace them with composite. So, I have checked with patients, once patients happy. And once I’ve got the plan, that’s when I would send either I do the wax up or out send models to technician to do the wax up. So that’s when the vaccine is going to happen. Now, of course, if…

[Jaz]
At this point, Dev have you presented any sort of imaging, like some people like will give them an image of their face, and like a digital mock up of what their smile could look like? There’s something to motivate them or something to show them to something for them to go away with and make it more real for them.

[Dev]
Most of my cases, I showed them previous cases before and after. So they kind of can imagine. I sometimes what I do is I take photos, and I’ll send it to technician because although I’m quick at doing analog, I’m quite rubbish and takes time to do in digital. So I’ll send to technician they’ll do digital kind of wax up on patient’s mouth. Do that sort of before and after and send it to me, and I’ll show them to patient, if patients quite aesthetically driven. But otherwise, or sometimes what I’ve done is I’ve taken quite large have expired composite, just literally direct, quick mock up in patients there and then well on the model, and then show them how it looks like you know how it’s going to look before and after. So if you want to do…

[Jaz]
The pro tip is to use expired composite on the models and not actual compositet. And the reason I mentioned this Dev is because you’ve got all these bank of cases that you’ve done, you’ve got all these cases that you can show to a patient, but to the dentist is perhaps new in full mouth rehabilitations, and taking that next step, they may not have cases that they can show. So at that point, you can do some sort of like a 3d imaging, send to technician, you could do a wax up, you could do an intraoral mock up or even better do on model just using some expired composite. Perfect. Yes.

[Dev]
100%. Expired composites really helpful. If you ask your boss, you know, I’m sure they will have some expired composite laying around, you put it on a model, and then quickly so you avoid the cost of paying for wax up before patient says yes to the treatment plan, right? Because you don’t want to have a full mouth wax up done sure your patient pays like I’m not interested. So I would present the treatment plan. Sometimes if I’m not sure, I will charge them for wax up, I would charge them for full mouth wax up, everything, and then present the treatment plan, they would have some sort of estimate before, but I’ll do the wax up and then present them the proper treatment plan later on. And that happens a lot of times, because I need to rely, I need to make sure that but mainly it’s because whether they want veneers on the interior, or they just want edge bonding on palatal. So you want full functional reconstruction or you want some aesthetic component to it as well. So if they want a veneer and if I put, if I do two type of wax up so technician can do not putting anything on the buckle wax up, and then another model, duplicate that and do another with the buccal last sort of and wax on the buccal and then we can do trial on both and show it to patient to show a difference and mock up is the next step, so next step number three or appointment kind of number three is a mock up, right? So now you decided what you were going to do, plus or minus veneers on the buccal. You asked technician to do a wax up so patients, technicians done the wax up. And then now you’re going to take that wax up, use Putty indices, bis-acryl or acrylic whatever reason you have and transfer that into patient’s mouth. I have a video of that demonstrating it. And then also video on YouTube to be honest, but I have a video if someone’s interested, I can provide you link.

[Dev] You need to score the model so then there is less of the access coming through the putty. You just pick up the bur and just below the sulcus, so i’m just going to score it tiny bit. Need to extend too much maybe one or one and a half tooth either side is fine. So it needs to be thick enough to hold the rigidity. Then when patient comes in we’re just going to squeeze the material in there, temporary crown and bridge material in here and seat it in patient’s mouth and let it set. Take it out remove the excess and show you to patient how it will look like. Okay so that’s your mock-up. So this is just temporary to show you how it would look like when we finished.

[Dev] It’s very, I mean it’s good for single anterior tooth you know when you’re doing wax up, so you must must do a mock up in patient’s mouth. So mock up is something you do in patient’s mlouth, wax up is on the model. Yeah, so that’s the difference. So the mock up, when I’m doing the mock up, I would make sure you wet the model, make sure it’s wet because when you put the putty on the model, sometimes it gets stuck if models really dry. So I wet the model, put the putty on there then cut the putty so then it’s not too much access when you’re making that putty indices or any PVS indices, make sure that’s thick, so you need around five millimeter good thickness so that when you pushing it, it doesn’t bend. Okay? And then I’ve done both ways I’ve used light body after the putty set and put light body in there, put it again on the model, squeeze it really hard to make sure get nice finer details and I’ve done it without and they both work if your impression’s accurate. So the main thing is your impression needs to be accurate and model needs to be accurate. I tend to put, on the model take a very sort of a medium small round bur and put a small notch around the crevices so that again that’s shown on my video but small crevices on the model, so when you put the putty compresses, it goes into the area and then when you put it in the patient’s mouth, it compresses around the sulcus area so that it’s a clean cut. And you know, you don’t get too much access and it’s easy to..

[Jaz] So it’s like a little groove, just it’s like a little groove that you make and some people even use an old ultrasonic scaler, an old one, little tip they can run across something just to create that demarcation.

[Dev]
Yes, just don’t use a new ultrasonic scaler, your boss won’t be happy. So just make sure, the round bur was quite easy, it was, the only thing is just it’s very easy to drill really hard and the stone is very soft. So you have to have very soft light hand to just do that. In the mouth, I would depends. I’m going to put the Vaseline on the teeth which I’m not going to put the wax on, the mock up on. So then it’s easy to flick things off, if they do go. I’ll put a ptfe on every interdental area, which is long ptfe, which comes through the puttu indices. So then when I see my putty, I can pull through that ptfe through the putty so that into proximately patient can still put the tepe brushes because remember, I’m going to leave patient with this wax up or at least the mock up with for at least a week, because I want them to assess, I want to assess their TMJ, I want to assess the muscles, I want to assess the speech sound or to assess for the breaking anything. So a lot of things I’m going to assess. Now if some teeth are added little bits, very little wax, then I will spot edge that before I would put this mock up in patient’s mouth to give a little bit more retention. Okay, no bond, just a spot edge in the middle of the buccal surface or whichever surface you put in the resin. So it just holds it a little bit better. But if you shrink fit, which means you putting this in patient’s mouth and leaving it until it completely sets and you take it out, even if one part of the area is a bit thinner, the other parts will hold that thinner area. So usually it is not a problem. Once that comes out, I would use either a bur or I tend to start with a blade, number 12 blade to remove the excess material. And then if I think I need to do bit more then I’ll use a bur, if you have a void which you will see in the video there is a void, then you can literally use the same shade composite and just fill the void, you don’t need to repeat the whole thing. If the incisal edge is hasn’t come across really well then you can just build incisal edges, I tend to then polish them really well because they tend to stain quite easily especially bas-acryl, if you using the nice resin, acrylic resin. You know the ones we use like PMMA based acrylic

[Jaz] Unifast or

[Dev] Yeah, exactly. They are very good, right? So but if you’re using bis-acryl that leaves this gooey, sort of a surface, on the buccal surface out to end a patient drinking tea or coffee straight away, then it will stain quite badly. So make sure you polish them really nicely. And then give the patient hygiene instructions, how to clean them make sure they know that they can floss between because they connected, how to clean them. At this point, I would have only done interior mock up, I’m not doing the full mouth, I’m doing anterior mock up with if I want to look at the arch the posterior then the buccal cusps of the posterior teeth are done. So then I can have the occlusal plane idea and I can know that but anterior wax up is the more important one, if you don’t full mouth, that’s fine, it’s just a little bit more tricky and more take time consuming to doing full mouth wax up in FASCO. So anterior wax up…

[Jaz] Just to clarify then Dev here, you just when you’re loading up the putty with the bis-acryl like integrity or protemp for whatever, you’re only doing it on the anterior teeth so the patient will go away and the patient will look like as though they’ve had a dahl, because they’ve had upper 3-3, lower 3-3 or lower upper 4-4 whatever, or you’re actually doing the lower full arch?

[Dev] Not 4-4, upper and lower 4-4, I would asked technician to just do 4-4 and duplicate the model so that your putty seats very well, because if they have done the full wax up when you take the putty indices from the full wax up, then the putty won’t seat very well. So you need to (overlapping conversation). Yeah, so but if you’ve done the full mouth, then that’s fine. You know everywhere there will be and that’s a good way to check. But for me to check the occlusion is much easier if it’s just a 4-4, to make sure my mounting’s correct. And that’s what I’m going to build first anyway, if and again, we are discussing about the steps of adhesive full mouth reconstruction mainly because that’s much more easy and practical. If you’re going into full indirect restoration, then it becomes a bit more complicated, a bit more complex, shall I say. But I’ll go through indirect steps in a minute as well. But for now, I’m doing 4-4 upper and lower to give myself some idea as to how my mounting was. So when I’m at this point, I’m checking patient’s occlusion. So patient bites, I want to check whether the occlusion patient’s mouth is the same which is on the articulator. If it’s not, then we have a problem. We have a problem, which means that somewhere in the process things have gone wrong, right? So if the occlusion in patient’s mouth doesn’t match up in the articulator, 90% 95% then there is a problem. I mean, you will be surprised how many times it matches up 100%, if you’re really methodical, if you do a really good job, it matches up really, really accurately even though using semi adjustable articulator or using older Facebow, which many people think that, you know, is useless, and it’s not proven that it’s useful, still using it. But it’s still, for me, it gives me sort of reproducibility. So I’ve checked the occlusion, make sure everything’s fine. What if occlusion’s not fine, right? So what are you going to do if the contact’s not great. So, first thing I would do is I will start adjusting them on my provisional or on my mock up, and see whether I can get them right by doing adjustment. If I’m going to do a lot of adjustment, and everything’s changed completely, then it’s going back to drawing board. But if I’ve done a little bit adjustment, but it’s more than sort of 5% kind of ish adjustment, then I’m going to, but patients happy after that, then I’m going to take impressions of that. And I’m going to duplicate the model, because I will then use that as my indices to use for my indices when I’m doing the buildups. Okay? So, two scenarios, two ways you can work out either you repeat everything start from the scratch, but what you don’t know which process things gone wrong. And there are things in place, you can check every single step, but you know, for me if I adjusted because I’m going to do composite it’s easier. And also even if you’re doing indirect, if you’re there about 5%, then you can still refine it in your provisional stage. So that’s, I’m checking all the F sounds and you know..

[Jaz] If patients got gone away. And then aesthetically, they’ll show their family and stuff and looking gray and they come back and you check the occlusion. Where do we now go from this situation where you got anteriors, pretty much waxed up, you haven’t yet waxed up the posteriors by the sounds of it, or have you done also a full mouth wax up?

[Dev] No, I mean, I would assess the posterior whether I have enough spacing for spacing to make sure you know, if I’m not sure I would wax up the posterior to make sure I have enough space. But you can measure different ways whether you have enough space for posteriors or not, but no, I tend not to wax up posterior. I used to do everything full mouth. But this is now I’m following this for especially for adhesive reconstruction. So I’ll do that. And then. But if you’re not sure about patient aesthetics, and everything, by all means, ask technician do duplicate and do full mouth wax up, you know, so there’s no harm in doing that. It’s always better to have more information than less. So now the patients come back in one week time, I’m assessing same thing again, I’m assessing whether the occlusion’s changed, because it could be that my patient changed to CR, right? So the patient’s gone, more relaxed, and the jaw has gone for the back. And now patients off my ramps which I made. By the way I can again, this is very important for you and technician to know what type of palatal shape you want to create when they’re doing wax up. And most of the technician gets it wrong. Okay? Because they’re trying to create a natural palatal shape, which we’re not trying to achieve. The shape which I have, which I get is very artificial. It’s a nice perpendicular. So I want lower incisor to touch almost perpendicular to that platform. So that you get quite a good force, you’re not getting angled force on the interiors. So in particular shape again, I have a nice photo showing that if you can remind me and I’ll share that with you, or now at some point we can share, I can share that. So with regards to the secondary patience for that I’m checking occlusion again, checking in breakage of the temporaries I’m checking the TMJ, making sure the patient not having an TMJ pain, muscle pain or anything like that. And just checking making sure patients happy with what they want to do. Now once that’s done, I would then take everything off. Okay? The reason being that the gum becomes quite although they’re doing their best, I want my gingiva to be healthy perfect when I’m doing my bonding. Okay? So I’m taking all the mock up out when you’re doing that just make sure you tell patient you know I use sickle scaler to just flick them out, hand scaler you can if it’s quite thick, sometimes you can use a bur and then just flick that like crack them and then take them out. If they have a lot of undercuts, then what I tend to do sometimes is I would fill those undercut first with either putting some sort of I don’t know if you use, you can use Cavit or like on you know, sometimes you get really big copings on the rare cases on the incisal edges make huge copings and then if you put your mock up in there, it gets locked in there. And then it’s very difficult to take it out. So for those, I will preempt them. And I will put reuse a temporary filling material. So we call it TFM. So you put that on there and cure it, so that it’s quite soft. So it’s easy and then put them on.

[Jaz] This is obviously a resin base like Telio? I imagine like

[Dev] It’s the same thing. TFM is, you know that, Telio is

[Jaz] I think maybe it’s Voco?

[Dev] Yeah, that’s fine. So same thing. So I would you put that to block the undercuts before I put my mock up in. So make sure because then it makes your mock up quite easy to take it out. Otherwise this nightmare patient like

[Jaz] To touch on means we’re going to be wrapping up the this episode, before we then re record for the final part to go into the nitty gritty details. But what just one thing to check is at the time of adding your bis-acryl, did you do any preparation to teeth? A) to make sure that your bis-acryl will be a bit thicker? Because it’s very thin in some areas is going to be a big issue. I know you’ve got some thickness from other areas and B) to remove any thin sharp bits, which you know you’re going to be losing in the future anyway, maybe with a sof-lex disc. Have you put any consideration to air just doing some adjustments before you send them home with this bis-acryl test drive for a week?

[Dev] I try not to. The reason being that this is still a test drive. Okay? Patient can still go out from the answer. Look, I don’t want this. And I want that opportunity for me to say look, I haven’t touched your teeth. And you know, if you don’t want any treatment that’s done, no harm done kind of thing. If I’m now changing something that patient you put a drill into my teeth, you know things I prefer not to but yes, if there is a very sharp edge, I would tell patient. And by this time, my rapport would be really good anyway patient like yeah, do whatever. So you can just nicely made them smoother edges. But generally the edges are sharp, because you have coping. And what I tend to do is I fill that up with or some sort of temporary material rather than drilling them. Okay, and no, I don’t drill the buccal surface of the Comp because remember, I want freshly cut surface for my bonding. So I’m going to do that anyway, when I’m going to do bonding, so I don’t want to drill the, remove that a prismatic enamel now get contaminated, and then have to remove again some of the enamel for my bonding. So my aim would be to try and keep this, I’ll tell the patient that little chip and break anyway. So patients aware of it, just may warn patient that is it may chip or break.

[Jaz] Brilliant. Well, I think what we’ll do then is take a little break, a little fresh and break and then we’ll come back for part three, which we’ll release next week. And in part three, we can now go from Okay, now they’ve had their mock up, you’ve test driven it, you’re happy to occlusion, aesthetics, and then how to now actually make it into the final form, ie full mouth form through adhesive rehabilitation. So stay tuned for that, everyone. Thanks so much for listening. And we’re gonna catch you in very shortly next week.

Jaz’s outro: Well, there we have it, guys, thanks so much for listening all the way to the end. Always really appreciate you guys coming all the way to this bit. And part three, that part three of three of this adhesive full mouth rehab, as you get more and more gritty, the sequencing or you know how to place which composite, the different stents to use, the different techniques to use, that’s all going to be covered in the next part of this series, which probably be two or three weeks away. I’ve got so much coming your way, including a Top Gear style review of all the different IPR systems like how do you do IPR with a bur versus a strip versus a disc versus an oscillating handpiece and showing you videos of how to, you know, 4k videos 30 gigabytes worth of videos of how to do this, all coming on the podcast very soon. So stick around and subscribe to the emails if you haven’t already. And I’ll catch you same time, same place. Take care guys.