Are Class I Molars Important? – PDP007

Jaz’s Introduction: Hello, everyone, I’ve got a really good episode for you today. There’s some useful links and resources that if you want to access them, you can download the show notes from www.jaz.dental That’s Jaz with one Z. That’s jaz.dental. And under this sort of episode title, it’s like a blog post you can download a PDF version there’s quite a few good links that Dr. Mohammed Almuzian shares today. So you can check those out on the website. So some of you know already I’m doing a diploma in orthodontics with ACE which is Academic and Clinical Excellence orthodontics. So it’s ACE orthodontics, based in Manchester, and the specialist and the educator or mentor for this diploma is Dr. Mohammed Almuzian, who has been just a beacon of energy. He’s been a fantastic educator, and I really wanted him to appear on the show, so he can share his orthodontic gems, and I thought just where a better start. Then one of the pressing questions I always had when I was student or with my restorative background and mindset to ask why our class one molars important. Why are orthodontists dare I say so anal about class one molars. Now if you’re someone who’s listening to this, who is an orthodontist, or someone who is well versed in orthodontics, you’re probably thinking, what the hell is jaz all about? Isn’t obvious why class one molars are important? Well, actually, not quite, I don’t think is that obvious. And I think some of the points raised today is actually I’m hoping will help a lot of people, a lot of gdps. And maybe students think, oh, that suddenly makes sense, I want something to click, I want the penny to drop. So for example, in my restorative background, my previous sort of rehabilitations or veneer cases, I wouldn’t actually always look at the molar classification. If I’m only working anteriorly, maybe slightly increasing of the occlusal vertical dimension, I wouldn’t always like record or mentally note the molar classification. And I think that’s a mistake. And then now obviously, after doing this diploma, I appreciate the molar classes, much more due to reasons that it will shed some light on why that is today. And also I appreciate faces, I look at faces long face, short face. I really look at that much more now as well. “Do they look brachyfacial? Have they got large masseters? So really learn to appreciate faces after doing the diploma as well. So what me and Dr. Mo cover in this short word valuable chat is, what’s the deal with class one molars? Why is this classification so important? Why do we need to sort of appreciate the molars? What does it actually mean? How can you mathematically calculate the overjet once you align the teeth based on what the molar classification is? So it’s pretty cool thing that you know, once you get confident, and you can tell patients, okay, if we just simply align your teeth, you will have a seven millimeter overjet. This is what this looks like on your models. Is this an acceptable compromise fro you? So and that gives you another sort of consent point. And it makes you look very clever that you could actually predict how the teeth will change. Some of those who maybe use a 3d conject software can have already got accustomed to this now. And interesting. We also discuss in which cases can you accept a compromise result in orthodontics? Give me some feedback, let me know how you like it. And before we get into that, I want to share with you my Protrusive Dental pearl for today. And basically, it’s one of my favorite sayings. And it’s a great quote, and it is basically ‘how you do anything is how you do everything.’ That’s how you do anything, is how you do everything. Basically, once we qualify, our standards can drop so sharply, so quickly without us even realizing it’s scary. And I think we all know what you mean, there are standards, the little things that, you know, we’re sort of strapped for time, you’ll leave something, you know, a restoration high or when you’re placing a matrix band, and you know that, you’re getting a little bit of seepage anything, it’ll be fine and you know, just restore anyway, so our standards can drop so quickly, patients will be fine, usually 99% of time, restorative work can be quite successful, even if it’s done poorly, unfortunately. And something that you know, you can get away with, but in the long term, you know that that’s damaging the patient or it’s not an ideal result, or it’s not the way that we were taught at dental school. So what you could do is if you focus on one thing, just one thing per week to increase or up your standards, so that by the end of the year, you have made, you know, a monumental shift towards working at a highest standard of care. So how you do anything is how you do everything. Remember that when you’re cutting corners, try and be as textbook as possible where you can. We are all learners we are all students, but our aim is to get through dentistry fall in love with the real minutia and the details of dentistry, and that’s one thing that’s, I think it’s quite important when you’re passionate dentist, falling in love with the very little details and getting satisfaction from mastering those. Hope enjoy the episode I’ll join you for a debrief at the end.

Main Interview:

[Jaz]
So firstly, I would say, Dr. Mohammed Almuzian, thank you so much for joining me on Protrusive Dental podcast, I’ve been wanting to have you on for a long time because to me, you’re one of the best educators I’ve seen not just in orthodontics, but but generally I mean that genuinely honestly, you know, me and the other doploma students were very raving fans of yours. And I needed to get you on the show. Because I think the way you explain certain things will really, really empower and help gdps and that’s what today is about. But before we get into the meaty bit, just quickly can just introduce yourself, tell us about yourself, what’s your interests are and where you working now?

[Mohammed]
Thank you so much, Jaz. Well as it’s my pleasure to meet you. You are one of the brightest students, the diploma, one of the smartest one. And then pleasure to and it’s my pleasure to be with you here. My name is Mohammed Almuzian. And people call me Mo. I’m a specialist orthodontist. I’m on an electronic University of Sydney, research fellow at the University of Edinburgh. I work as a specialist orthodontist, in London and in Glasgow, and also I teach civil diploma across the UK. And also I teach and supervise some postgraduate students overseas in the Middle East, Australia, and in Germany as well.

[Jaz]
One of the things that you’re quite famous for I mean, there’s, you’re famous for lots of things, especially you’re heavily published in peer reviewed journals. One thing that you’re really famous for amongst MO Students or orthodontic students, is you’re famous Almuzian notes. So if you are interested in learning delving deeper into orthodontics, I mean, I know Mo teaches on lots of taught diplomas and courses, but even just to read around all these notes that is simplifying for learning, how can people access the famous Almuzian notes?

[Mohammed]
Well, it’s accessible for free online, they are available on the Facebook, on SlideShare. It’s took around seven years for me to write them up. And I post them for free and to share it with our colleagues. And now I’m at stage of condensing them, rewriting them, proof editing them and make them in a free book, which is accessible through Kindle app. And it will be kicked updated, as shown. And just let you know, that’s because I have an access to the statistic of slideshare. And I can see how many people access and like or download the notes. I found that in the last month since 2013. Until now, they have been downloaded almost 350,000 times.

[Jaz]
You can’t see this right now. But my jaw literally dropped when he told me this.

[Mohammed]
I can’t see that.

[Jaz]
That’s huge. Congratulations. That’s very good. This is exactly what I want to have on the show. So let’s get to the meaty bit. Okay. I’ve been on a few short orthodontic courses before, okay. And, you know, I’m still in the very early stage of my journey of learning orthodontics, I think orthodontics very, very complex, I think personally, and I think Dr. Mo has helped to simplify a lot of the aspects and make me into a safe beginner who can use the evidence and come up with reasonable treatment plans that are safe and effective for patients. And that’s the

[Mohammed]
and this is why we developed the safe more technique for treatment plan, which is an chronium help that specialist orthodontist or dentists, to structure their treatment plan and come with very structured and thorough treatment plan,

[Jaz]
Can I put a link to that on the book?

[Mohammed]
Yes, absolutely. Actually, I already developed the beta phase of an app where the clinician can go through and add questions and answer and after that, it will give them a treatment plan. It’s not ideal. It’s not a place wherr you

[Jaz]
It’s a guide.

[Mohammed]
It’s a guide, it’s a set templates.

[Jaz]
If that’s available, I’ll put it whenever it is available. I just put it on the show notes and then you can download that. So one thing I want to ask is why and this is a question that gdps might be embarrassed to ask okay, but why are class one molar so important? Right? Because I’ve asked some few questions on a few courses, especially if you let’s say STO or anterior alignment orthodontic courses. And we think oh, if he sent an orthodontist it’ll take two years course treatment they’ll get within class one what’s the point? Why the midline have to be coincident? But I think when I when I came on this course, and I realized something I don’t want to ruin it by saying because I think you’ll say you’ll get more justice, but class one molar Okay, so someone says, oh, why is class one molars important? What’s the point? Okay, how can you simplify the understanding for GDP?

[Mohammed]
Well, we as a specialist orthodontist, we are not looking to achieve a class one molar all the time. But the molar relationship for us is a guide to guide the anterior teeth occlusion. So by achieving a class one molar relationship in a case where you don’t extract teeth, I mean, that’s in theory, you will get a class one incisal relationships. And in cases where we have a class two, for example, class two molar relationship, this and missing tooth in the upper, in theory, you will get our aligned teeth. So it’s very complicated to explain it in this short interview. But the molar relationship, whether it’s class one, or class two, or class three doesn’t make any difference in terms of stability, in terms of aesthetic, or in terms of that function. There are actually a guide for us as a clinician, whether we are a specialist orthodontist, or dentist with enhanced skill in orthodontics to guide the anterior teeth. So it just give us a view how the teeth will look like at the end of treatments,

[Jaz]
Perfect. And for those who are very simple minded, like me, the way I when Mo taught us, and he went to much more detail than this, obviously, what’s possible in this short audio show, but basically, if you’ve got someone in the way that if you’ve got someone in half a unit class two Molars, okay, and they’ve got a, let’s say, a class two div two and you know that they’ve got a bit of crowding anteriorly, you can tell the patient, why it might be a good idea to treat, to get treated more comprehensively, because you could say already that because they’ve got a half a unit class two molar. That means and please correct me if I’m wrong. So we’ve got half your class two molars bilaterally, then that means that both molars are ahead, by half a unit, which is roughly about two and a half four millimeters, right?

[Mohammed]
Yeah, assuming that you have full set of teeth and

[Jaz]
So therefore, you know, that your overjet if you were to simply align everything, and level in line, everything would be four millimeters more than the class one. So it’d be you’d say to patient Listen, you wouldn’t even say it this way. But you would be able to show them that your upper teeth would be ahead about six millimeters.

[Mohammed]
Yes, because our aheads by four millimeters

[Jaz]
The whole set.

[Mohammed]
The whole set of the teeth are aheads by four millimeter. This means that after you straighten the teeth and align the teeth, then the anterior teeth will reflect what’s happened posteriorly, and will sit forward by the same amount as the upper teeth are sitting forward in relation to that lower teeth. I’m trying to use non jargon words here because maybe we’ll have people who are not dentist or hot Angeles in dentistry. So when you have half the class two molar, which means that the upper molars are sitting four millimeter ahead of the normal position, then when you align the teeth then the anterior teeth will become four millimeter ahead.

[Jaz]
And it sounds really simple when I look at it now now that I’ve been through most of your diploma, but at a time when you explain this, it just clicked and I think all GDPs and a lot of GDPs probably in haven’t thought about it this way. Actually, it’s the molar being in class one is not the what we’re aiming for. We’re aiming for a pleasing appearance in a good occlusion with good cusp to fossa relationship with good overjet, good overbite, these are the things and these are guided by a molar relationship, it’s not the fact that we’re chasing after the class one molar, it’s because we’re chasing after a good stable pleasing looking smile. And that is led by the posterior.

[Mohammed]
And just to remind you know, and the molar relationship, it’s one of the first key of occlusion and Andrew’s six keys of occlusion. So achieving class one molar when you have full set of teeth is essential to achieve incisal relationship. Assuming that you have full set of teeth, and to simplify it in another way, if you have two upper teeth are missing, then ideally should your molar relationships should and in full unit class two what’s called therapeutic class two in order to achieve the class one incisor and if you have missed two missing teeth in the lower then your molar relationship should be class three in order to achieve class one incisor relationship and just small comments about half units well as orthodontist or as a dentist who has enhanced the skill in orthodontics and a good educational background in orthodontics. This is our aim achieving class one, class two or class three if there is a missing teeth or not, but half units or flexion. Class two or class three is not an ideal because this means that the patient are biting cusp to cusp and this is not stable in terms of occlusion, it might affect the long term prognosis of the health although the evidence are weak. It might effect that TMD although the evidence are weak, but we try to eliminate these even if there is a small out or weak evidence

[Jaz]
When you see class one, a perfect class one case study models. You see that how everything intercuspate so nicely.

[Mohammed]
Absolutely and this is why they are locked together I’m guessing that the teeth will get stable

[Jaz]
Yeah, but even in a class two, full in a class two things actually intercuspate nicely as well. So in these full units, they meet well, but half units, like you said it’s not quite well into intercuspated.

[Mohammed]
Absolutely.

[Jaz]
So which leads nicely onto GDPs Okay, a lot of times get this in, especially in the UK where dentists, GDPs can practice orthodontics, in some countries, they can’t. And I know in Singapore right now, given me some news that in Singapore right now, they’re going through a lot of appeal at the moment the GDP are upset, because the specialists on to suggest that GDP is need to limit their scope of practice, that they may not be able to do orthodontics anymore, they may not be able to do a lot of what they do like implants, root canals, that sort of stuff, which is crazy. Let’s not get into that too much. But in this country where we can practice orthodontics, where is the place for compromise? In which case if you think it’s okay to compromise what I mean by that is, in which cases it might be okay to compromise within reason? And which count cases must use simply always try your best to get a comprehensive result? That’s not too unfair a question?

[Mohammed]
Yeah, let me let me rephrase the question. So you’re saying in which case we can accept a compromised result, well, always our aim is to achieve an ideal result, an ideal or normal occlusion or ideal occlusion and this means that good intercuspation of the teeth class one incisor relationship. When you say compromise occlusion it’s mean that you are accepting slightly imperfection in the occlusion may be increased overjet, may be reduced overbite, may be increased overjets or

[Jaz]
Yes, so all those things that you just said, except things will be aligned and the patient might look a little bit better, however, at the expense of overjet, at the expense of potentially overbite, at the expense of fraction class molar. So fraction class two fraction glossary, whatever, but it’s basically the social six are happy in that case. As an orthodontics, opinion and educator, in which case Do you think okay, it might be more acceptable, it might not be in the real world?

[Mohammed]
First of all, you should know that orthodontic treatment is most of the time is an elective procedure, it’s cosmetic procedure. So the evidence that is reduce the risk of developing Achilles has added a new paper has been published recently. And they said that there is no difference between straight teeth and a regular teeth. In terms of the straight and get in terms of the function, mastication, it has limited effect except when the patient has difficulty in mastication and chewing or incising food in anterior open bite. In term of the effect on their TMD and other factors has been proven by Luther Cochrane Review that there is no correlation between strated and good occlusion and and TMD in most of the cases. So what I’m saying is that’s why I said that orthodontic treatment is an elective procedure. Sometimes you need to waive the risk and benefits. And if you find that the risk of achieving comprehensive treatments or let’s say, a perfect occlusion class one incisor, class one canine and perfect intercuspation is higher, the risk is higher than the benefits then I personally as specialist orthodontist, and most of my specialist orthodontist colleagues, we do sometime and accept a compromise treatments when, for example, the patient has some periodontal problem or I’m not saying you should actually not treat a patient with periodontal problem, let’s say the patient who have a slightly short root. And if you move the teeth significantly to correct the overjet, significantly, this means that or two that you want to collect the object to the ideal. This means that you will expose the patient to a higher risk of root resorption because there are at least a systematic review by Cochrane that if you move the teeth over a long period of or long distance, and over a long period of time, you’ll expose the patient to higher risk of root resorption. Okay, so maybe we’ll accept just aligning the teeth accept compromised overjets and pleasing the patients and assess.

[Jaz]
As long as it’s an informed discussion with the patient. This might be a way to go because it might mean that might be less issues with the you know, your teeth breaking down, root resorption, losing your teeth, or reducing the prognosis of your teeth base. I wouldn’t say like that to a patient but in terms of a lot of dentists, listen to this. So in those cases, where the risks may be greater than a benefit of being completely comprehensive getting complete overbite and overjet reduction, but at the same time you still need to meet the aesthetic goals because it is an elective procedure.

[Mohammed]
Absolutely. But if you are going to achieve a compromise treatments and if you are whether you are a specialist or you’re dentist with enhances skill and it is your obligation according to the GDC requirements or GDC advice, which is actually a Montgomery is to offer all the patients all the treatment options including not treatments, compromise treatment and comprehensive treatment and you should be able actually to provide all of these options in case the patient decides to change their mind during the treatments okay? And secondly, if you are going to offer a compromise treatment you should discuss the side effect of having compromise treatment. You will tell the patient Listen, I am going to tax your teeth I call when you do orthodontic treatments, I call taxing the teeth. Okay and every time you tax the teeth that it will become, the road will become shorter and if the patient decides to go through the compromised treatments, they will have, their teeth will be taxed once, if they change their mind after a couple of years, then the teeth will be taxed again and they become shorter. Plus, you should inform the patients about alternative options achieve treatment plan with the risk and benefit of the alternative options. You should also inform the patient that there might be, the teeth might be unstable if you are not achieving a good intercuspation. If you are accepting a compromised overbite and overjet you should make sure that you have a good retention strategy in this case, because you know, stability, good intercuspation, a comprehensive result sometime help according to evidence to maintain the result. In your case when you have happen class two molar or when their teeth are biting cusp to cusp or when the teeth are not meeting in a good intercuspation. They are free, they are they can slip forward. They are not locked down. So you need to inform the patient about all the risk but there is no harm. I do a lot of compromise treatment. I don’t call it STO, I don’t prefer to call it short term orthodontics because it’s not a science. Okay? It is alignment phase of anterior teeth. And this is of course, if the risk is higher than the benefits of achieving a comprehensive result. Of course it should involve the patients in this decision phase.

[Jaz]
That’s fantastic. I really loved the taxing. The taxing was great gem. So we’re running out of time. So I’m just gonna just do one more thing. What do you think about this last bit? What do you like this phrase about children to treat them idealistically, adults treat them realistically. Who said this you know? Otherwise that is I always hear it I really think it’s a nice thing

[Mohammed]
I think we should be, see Jaz when I finished my first orthodontic treatments, orthodontic training 19 years ago we our treatment was a clinician centered treatments. So we want to please ourselves more than pleasing the patients we want to achieve everything perfect class one incisal, class one canine and we move the teeth you know behind their envelope and it’s took ages for the patients Okay, we spend a lot of time achieving something minor. Now the treatment has been moved and become a patient centered so instead of for example, if you have buccal impacted canine why I will be bothered of extracting the premolar or bringing the canine down, the canine I will come with a receded gum which will take ages and the patient doesn’t care about having a canine or premolar as far as they have well aligned teeth and nice a smile. So what I am saying is is that you should we should actually aim to achieve a patient treatment that please the patient first within reasonable justification okay and we should be realistic rather than idealistic and maybe just another comment about why we sometimes we can be a idealistic in children is because we have a lot of options in children. We can expand the jaw, we can move the mandible forward, the teeth not the jaw actually. We can do a lot of things, teeth move faster. Okay, a study 2018 and show that the teeth move faster and patient’s compliance is better. Okay?

[Jaz]
Distalization

[Mohammed]
Distalization. A lot of options. Okay. We can move the teeth in the 3d in bigger envelope than in adults.

[Jaz]
Profits envelopes?

[Mohammed]
Yes. Well, profit envelope is a wonderful and good. But for children the envelope of doing orthodontic treatments on razor is bigger. Yeah, so we can achieve a lot while in adults. You know, the discontinuation of treatment in adults is 30% compared to children, which is 12% because adults are decision makers, they can stop treatment now, because their pain is higher than children because the pain releasing factor is higher end adult children,

[Jaz]
I didn’t know that. So 30% of adults discontinue to finish a bit earlier maybe

[Mohammed]
Yes 20 to 30% a day there’s discontinuation of treatment at some stage where they’re changing the plan to get shorter treatments or just abandon the whole treatment plan. And this is because they suffer from a lot of pain, the tooth movement is faster so their compliance is dropped after a couple of months and because the pain is higher and because we are decision maker we get bored you know if I put fixed appliance now I’m sure that you’re using an Invisalign. And you start now complaining last time when it drove me you start complaining about your treatments. If you are a 12 years and you are my son, I will force you to use fixed appliance okay? Because their motivation in children is external. An external and internal in adults is main internal and you can make a decision and this stop the treatment now.

[Jaz]
Brilliant.

[Jaz]
Well, thanks so much. Thanks. I really appreciate. It really helped all the GDPs

[Mohammed]
My pleasure, Jaz. All the best. And all the best for the gdps as well.

[Jaz]
Thank you

Jaz’s Outro: Okay guys, I hope you enjoyed that. Let me know if you did. And also if you like my episodes, then please tell a friend and also sign up for their newsletter on my blog jaz.dental, so that any episodes that come out can get email notification as well. I’ve got some other really cool things lined up and lots of guests and some solo ones as well. So I’ll catch you next time. Thank you so much for listening.