I will reveal a little ‘trick’ that might ‘recapture the bite’ on a patient who develops an anterior open bite (AOB) after wearing a nightguard/splint/occlusal appliance.
There is a degree of risk and uncertainty when we prescribe occusal appliances as it hinges on patient compliance and factors that are out of our control. There are certain risks that come with treatment that we should consent for, and this includes bite changes.
Occlusal appliances are not an exact science – the evidence base is not high quality. That does not mean they do not work, it just means that we need more data! We don’t even know the mechanism of HOW occlusal splints work as that is yet to be proven.
Hello Protruserati! Welcome back to the third episode of #AskJaz where I answered three main questions from our Protrusive Dental Community – 1) developing anterior open bite after an occlusal appliance, 2) how to scan/bite register at a desired OVD, and 3) what should the occlusion look like on composite veneers or edge bonding?
Dr. Mahmoud Ibrahim and I are currently working on a huge project called OBAB, Occlusion Basics, and Beyond – it will be the best occlusion resource in the Milky Way…and that’s our mission! We want to finally demystify Occlusion and make it Tangible AF!
Join the waiting list HERE!
Highlights of this episode:
- 1:51 Risk of having AOB after an Occlusal Appliance
- 15:48 Trick to recover an AOB that has developed
- 26:49 Bite Records for Stabilisation Splints
- 30:25 Checking the Occlusion after Composite Veneers
- 37:02 Occlusion Basics and Beyond
Do join our Protrusive Dental Community Facebook Group. It has so many great gems and pearls shared in our little community – ONLY FOR LICENSED DENTAL PROFESSIONALS.
If you enjoyed this episode, check out this episode with Dr. Barry Glassman – Do AMPSAs cause AOBs?
Click below for full episode transcript:Jaz's Introduction: Occlusal appliances can be scary things. When we are given to our patients, we're at the mercy of their compliance. We don't really know if they're going to get along with it or not.
We don’t really know if it’ll help their pain. If pain is the reason that we are prescribing in occlusal appliance, and a lot of times we are taking on a bit of risk because there are certain bite changes that can happen after occlusal appliances.
And despite what you think, you know, you might think, oh yes, anterior only appliances, they’re the big culprits here. They’re the ones, those shifty devices, they’re the ones causing all the bite changes. But actually, you can get a bite changer. A patient can get a bite change from any type of occlusal appliance.
So, I see this quite frequently on the Facebook groups from dentists and also lots of dentists message me and share some of the cases where they’ve had some bite change. They’re trying to get their head around what exactly happened. So, in this Ask Jaz episode, I’m going to cover three main themes.
The main, the big one. The first one is, a patient who develops an anterior open bite after an occlusal appliance, and I’m going to teach you a trick that you can use if this happened to your patient to recover their bite. Okay? So that’s number one. Number two and three, a shorter one. The second one is how to scan or record using silicon bite registration paste, the patient’s centric relation record at the desired vertical dimension for something like a Michigan splint, for example, and the third one.
What should the occlusion look like on composite veneers? These are three questions, or the last two are questions that were sent in by you guys. The first one’s something I promised Professor Paul Tipton, that I would do, which is reveal this trick.
If you’re new to the podcast, welcome. This Ask Jaz series are kind of in their infancy, but I’ve got hundreds of questions that have been sent in by the Protruserati and just find time sometimes to just go through some of these things. And if you are a regular listener, thanks so much for always coming back. Let’s hit the main episode.
So my friends theme number one, your patient gets an anterior open bite after a partial coverage appliance. Or actually, you know what, any appliance. You may have had a patient or nova dentist who had a patient who was given a soft bite guard or stabilization spin, or an NTI, SCi or something, and the patient came with some sort of a bite change classically, an anterior open bite, and this can be a little bit scary for dentists.
And what happens that the dentist passes on this fear to the patient. And really, you know, I talk about it in other episodes, but this isn’t a huge deal, but it’s certainly an inconvenience if you didn’t warn the patient that this was going to happen. So that kind of makes sense. So, when this dentist colleague on one of the Facebook groups posted about this, about how she gave an SCi appliance and the bite changed and she was really upset, I wanted to help.
So what I did was I said, listen, you can PM me. And I’ll talk you through a little trick that you can try to recapture the bite, which has worked well for a few colleagues. And so, professor Paul Tipton, THE Paul Tipton messages saying that he would love to know my little trick to solve an anterior open bite that doesn’t position the condyles in any other position than centric relations.
So Prof, this one’s for you. I got you. And some of the other comments from our esteemed colleagues were along the lines of, unfortunately, whilst the incidence remains low, so that’s an incidence of a bite change or an AOB. After a splint is very difficult, if not impossible to resolve. So guys, I’m about to share with you the impossible.
Allan, this is for you. Akhil, this is for you and for all the others that messaged me. Let’s do this. Let me show you the trick. But before I do, let’s just talk about what this dentist shared with us. So just want to thank this dentist for raising this to the group. And she said that a patient developed an AOB after a few months of wearing an SCi.
So, for those of you who are unfamiliar, SCi stands for Sleep Clench Inhibitor, and it is the same thing as an NTI, which is the American version. So the British version is SCi, American version, NTI, right? So it’s those little appliances that cover like lateral incisor. You can get variations.
But essentially a small appliance on the front is classically what we think of. When we think of an SCi or an NTI. You see, I was told at the school, never, ever, ever to prescribe a partial coverage appliance due to the over eruption that’s inevitably be going to happen, et cetera, et cetera. Fast forward many years and hundred appliances later, guess what?
Over eruption hasn’t happened. It doesn’t happen. It can happen if the patient wears it for a prolonged time and all those things. But the AOB risk, the anterior open bite risk is a real one, but NOT FROM OVER ERUPTION. And that’s kind of the theme of the first part of this Ask Jaz. Now, this dentist on the group went on to say something very interesting.
She said, ‘How unlucky, because the studies show a 1.6% occurrence of an anterior open bite.’ So she’s referring to the study. By Dr. Blumenfeld, right? So Dr. Blumenfeld’s survey, was a 512 dentist, right? And these 512 dentists gave 78,711 NTI splints. So those little ones, and of those 1.6% developed an anterior open bite.
Now, what you need to know is that Dr. Blumenfeld isn’t a dentist. He’s actually a neurologist and he works in a headache center. And so he was fascinated when this appliance was being talked about by dentists as being able to help with headaches. It was natural for a neurologist who’s really into headaches to be interested in this field, and I really commend Dr. Blumenfeld for really integrating medicine and dentistry together.
Because what they found is that when he incorporated the NTI protocols using a dentist, so James Boyd, they found that 50% of their migraine sufferers were now significantly better so that they didn’t need to rely on medication anymore.
Let me say that again. Half of the people with migraines responded positively to the extent that they did not need medicines anymore. So I actually read a lot about this and Dr. Blumenfeld said that, now in his protocols in his neurology practice or for his headache center, is that patients will have an NTI and only those that don’t respond will then go on to have these heavy duty medicines.
I think that’s absolutely fascinating. So there’s a lot of benefit for headache sufferers with this kind of appliance. But when we give someone an appliance like this, are we really facing this unlucky dip scenario that like spontaneous combustion, any one of these appliance like Russian roulette, you’ll get an AOB.
Is this really how this works? Well, when I didn’t know much and I was like fresh off the course and stuff, and I didn’t really know and I hadn’t been experienced and I hadn’t really put much thought into it. I said this to my patients, I said, look, the studies say that there’s about 1.6% chance that you are going to get an AOB.
And patients accepted it and I made peace with it. But just like, when we say about wisdom teeth, right? When there’s a surgical wisdom tooth and the tooth is impacted, then we say, okay, there’s an X percentage chance that you are going to get a numb lip. But for some patients, that’s a 0% chance. When their roots are like way away from their inferior alveola nerve canal, you know that this patient is not going to suffer from that fate, therefore they’re ultra, ultra low risk or no risk.
Whereas other people, the nerve is intertwined with their roots and therefore they are pretty much, definitely going to get some sort of numbness or paraesthesia after having their wisdom tooth surgically removed. So we can’t use a blanket percentage figure to all patients.
But you see, when I went on the course and stuff, they said that yes, your patients may get AOB and understood the mechanism i.e deprogramming, which I’m going to touch on shortly, but it never taught me the features to look out for in patients, which I’m going to go through again with you that will help you to recognize who is high risk and who is low risk for developing a bite change. And so if you want to learn more about this, well over a hundred episodes ago I was talking about this episode 41 of the podcasts was on anterior midpoint appliances. And I did another one, I think it was 58, where I did the continuation of that.
And so within those two episodes, I go really deep into anterior midpoint stop appliances. And the cool thing now is that with my patients who are high risk, who I deem as high risk, I’ll actually put my leaf gauge in and I’ll take a portrait photo of them with potential anterior open bite that they could have from wearing an occlusal appliance.
I.E I’ll take a portrait photo of them with the leaf gauge, their back teeth separated to roughly their central relation contact point. And I’ll show them this photo and I’ll say, listen, if you get a bite change, this is what it might look like. You might find that fine chewing at the front, like having a sandwich.
You might miss the lettuce or you might miss the ham, for example. So you gotta talk about, in real terms for patients, you might not be able to bite your nails anymore. You might not be able to bite sellotape anymore. These are the ways that the patient will be affected. Thankfully, only psychopath smile with their teeth together.
So really, aesthetics and stuff isn’t affected. It’s just those little things like that. But like I said, now with my protocols, I’m able to really consent my patients properly to the highest level. So hat tip to Dr. Michael Melkers, who taught me all this. And just as a way of revision, if you already listened to those two episodes before, or if you haven’t before, and this is all very new for you, the three main risk factors of someone getting a bite change or an anterior open bite spontaneously after an anterior appliance or any appliance.
Any single appliance, okay? If the patient has these three features, we should warn them that their bite could change or they could have an anterior open bite. So they are in order, a minimal overbite to begin with. I.E, they kind of already have an anterior open bite. They have an anterior open bite tendency.
They just maybe got half a millimeter of over bite or that’s it. And so all it takes is a little bit of a shift to reveal an anterior open bite. And so if you really do your homework and you go through all the Facebook groups and you find the previous ones, and you try and find some pre-op photos and models, you’ll find that a lot of these patients had minimal over bites to begin with.
And it kind of makes sense, right? Because orthodontists are treating deep bites and you ask them, how easy is it to treat a deep bite? It’s not easy. It takes time, right? Especially if it’s a severe skeletal deep bite. You’re not going to give someone an appliance and turn someone with a true deep bite into an open bite, right?
So, a deep bite is like ultra low risk for an AOB, but there could be a risk for a bite change. But let’s not get into that. So we’re specifically talking about anterior open bites, someone with a deep bite is not going to go from a deep bite to an anterior open bite from wearing any type of splint, right?
Whereas the patient who’s already kind of got an AOB is more likely to develop one. Now, the second feature that informs high risk is having a large slide from the centric relation contact position to the maximum inter cuspal position. So basically your retruded contact position or rcp. So your first point of contact within centric relation.
If these are all new terms to you, then maybe listen to episode 90, Basics of Occlusion. But essentially when your condyle is seated anterior superior in it’s snug position, the first tooth or teeth that touched together in that position, right? So that place and how different that place is to the patient’s comfort bite where all the teeth meet together and you bite together day-to-day bases your comfort bite, your bite of best fit.
Now, if there’s a big difference between those, then it puts you at higher risk. How large is large? Well, people say that a 1.5 millimeters in an anterior posterior direction is considered large and half a millimeter transverse i.e. Left and right is considered like a large slide. So if your patient has got a minimal overbite, And they’ve got a large slide, they’re at higher risk.
Now, why is it that someone with a large slide is at higher risk? Well, think about it. This large slide exists because there’s a difference between where the condyle wants to seat in this stable musculoskeletal position and where the teeth want to meet together and the way they meet together. So if any point the muscles want to relax or the teeth get worn, they kind of want to go back to that position.
If that position is really far back, then that will change the bite. The patient will notice a change in their bite. And the last feature is a lack of posterior stability. Now this is explained really well by, imagine you’ve got two study models and upper and a lower, and naturally we want to put them together.
And for most patients, we can put our models together and they fit together really nicely, right? We don’t need a bite registration because they just click together really well. But have you ever been this scenario where you’ve got these two study models and you just have no idea how they fit together? It’s like five different positions.
This patient bite together in one position. They have an AOB, another position. They have a crossbite, and they’ve got like three other positions, which are class one. And it’s just, you can’t figure out, you need that bite registration. You see when you have someone who’s got very cuspy teeth and the teeth just sit together like a key and a lock, like a jigsaw puzzle, right?
That’s good posterior stability. Whereas when you got really flat teeth, warm teeth and there’s not really good meshing of the teeth together, that’s poor posterior stability. So if the patient’s brain is kind of struggling to remember this bite, any hint of getting deprogramming, so relaxing the muscles, can you see the potential in the patient just going to any other new bite?
Any other position because that previous position was the brain’s best guess. And it wasn’t even that good. It wasn’t even that comfortable. And so now when the bite changes, the patients kind of forgot the old bite because it wasn’t stable to begin with. So if you have someone with a minimal overbite to begin with, a large slide and quite flat teeth or lack of posterior stability, you can’t really tell instinctively how they should be biting together.
Then that is a high risk patient. That is an ultra high risk patient. I think if you have two of these, you are high risk, but if you have all three, then you’re pretty much going to say to the patient that this will change your bite. And at that stage, you’re probably wanting that bite change so that you can restore them to that position.
Now that dentist on the group again. Okay, now, and I’m coming to the trick. Don’t worry, I’m coming to the trick. Okay? I promise you, with a few minutes, you’ll know my little trick. Okay? So this dentist felt horrible. She felt like a little shock to her system because she felt as though it was her fault that the bite had changed.
And she wishes that she just went for the Michigan splint, which apparently he didn’t get used to wearing. So is it really her fault? I don’t think so. Okay. I don’t think it’s your fault. I really, really don’t. And I was thinking of some analogies, like, how can I explain this right? Now, this analogy isn’t very good, but let’s run with it.
Okay. There’s a film called Room and it’s pretty good film. It’s got like 93% on Rotten Tomatoes, and there’s a spoiler alert coming, so just run with it here. Okay. Room is about a mother and a son and they’re trapped in a room. And so the person who’s like captivated them or kidnapped them, just locked him up in a room and you know, they live his food and medicine.
That’s about it, right? And so this kid was born in this room and raised in his room, and I don’t know, he’s like five or six years old and he’s never left this room before, right? So you can imagine he’s got very pale skin. He’s probably deficient in vitamin D and he’s not a socially normal child because he’s never ever seen another child before.
So then, and here is a spoiler by the way. He makes a break for it with assisted by his mom. And so they make an escape, and they succeed. And so now this kid who sounds like the first five or six years of his life, in this room is finally now let out to the real world. And the real world has different conditions, different environments, better environments.
Right now, he gets some sunshine. He’s going to get a tan. At the very least, he’s going to develop these social skills to see other children, see other people. And you see what happens to this child is that, as a response to this new environment, he changes. And I really think that in a similar way when it comes to our scenario that we’re talking about, the patient’s bite in a way was pathological in a way.
And so when the muscles were able to relax, when they had an opportunity to relax, when you improved the environment, that’s when the bite changed. Because something had to change. Now the patient’s occlusion was out of this room and it got to experience a much more favorable environment. So that’s how I like to think about it anyway.
So as a consequence of changing the environment, the bite changed because the bite i.e. The way the teeth come together is controlled by the muscles and the condyles. I guess the only issue is that we should be able to warn our patients that, yeah, okay, this is going to happen. And so the issue is not that the bite has changed, is that you didn’t anticipate that the bite has changed.
So hopefully now you’ve got a few features to look for, to know when someone’s bite might change. But I’m going to teach you guys a trick. Right, the trick. Okay, prof, you’re listening. This one’s for you and everyone else on Facebook group who want to know my little trick. Okay? So you can use this trick anytime a patient has developed a irrecoverable anterior open bite.
Now what I mean by this term, IRRECOVERABLE. Now, for those of us who wear anterior only appliances or even Michigan splints, for example, when we take it out in the morning, do our teeth go together straight into MIP? Maybe, but you know, sometimes you might hit your centric relation contact point or the bite might feel a bit funny and eventually, oh yep, I’ve got my bite.
And then your teeth mesh together normally. And so that is someone who has a recoverable anterior oven bite. Someone with an irrecoverable anterior oven bite is kind of like the situation we’re talking about now. i.e. the reason the dentist posted that case on that group to get some advice. The patient removed the appliance.
But they weren’t able to remember their old bite. Their existing MIP is now out of the equation and they’re biting in a new position, which is an anterior open bite. Now, by the way, I forgot to mention, I reached out to the dentist and I was helping her. I was coaching her about how to do this trick, and then she showed me the photos kindly of the pre-op situation.
I can tell you now, it definitely wasn’t posterior over eruption the mandible had just shifted to the left, and by shifting to the left, it was now hitting an incline of a molar, and that resulted in anterior open bite and someone who had all those features, including a minimal overbite to begin with. So what’s the trick that I advised her?
Well, those of you who are watching right now, you’ll see this, but I’ll describe it to those who are on their commutes listening on Spotify or on the Protrusive app, right? So let me make it really tangible and show you another case where we actually applied this trick to recover an open bite. One of my colleagues who’s a delegate of the splint course, she gave her patient a Michigan splint.
This is before she became a delegate, and the reason she gave a Michigan splint is to deprogram the patient. I e relax the muscles, relax the lateral pterygoids, and test drive the vertical dimension. And then on the day of the fit of the Michigan splint, all the teeth are hitting. We’ve got the dots and the lines.
The front teeth are hitting, the back teeth are hitting and excursions. We’ve got anterior guidance. Now, four weeks later, the patient comes back and what do you think has happened? Well, it’s worked. Okay. We’ve got some de programmation. So what that would look like is that the mandible slides back a bit.
Distalizes, and now we’ve got a few dots to the back and no dot to the front. So i.e., we went from a complete of a bite on the splint to an incomplete overbite on the splint, and now we have a bit of overjet. So what do you do here? Well, you adjust it all again, you remove all the high spots, and then you achieve the even dots to the back and lines at the front, which is classic for a stabilization splint.
So what this dentist does, rightfully so, is eight months of monitoring for whatever reason, I don’t know why it was eight months, okay? But there were no changes seen on the splint, and the patient was happy to proceed to a full mouth rehabilitation. So had lots of crowns and a treatment for his worn dentition.
But this is where the interesting thing happened. This is where the anterior over bite might happen. So it’s very interesting. I’ll just read it out loud. So I’ve done a full mouth rehab for a tooth wear patient two years ago. In the diagnostic phase of his treatment, I made a Michigan splint for him. He wore it for deprogramming for eight months when his bite on the Michigan splint did not change anymore.
So kind of recapping what I said already. Now, after his treatment was finished, I provided another Michigan splint for protection in his bite. At this point, his MIP was equal to centric relation, so i.e. He’s in his seated condylar position in the musculoskeletal stable condylar position, all the teeth were touching together.
Occlusion is just so confusing. Does occlusion even matter? Wait, don’t you just grind away all the blue marks, right? You mean like plant it low, let it grow or leave it high and let them cry? Listen, what are these interferences even interfering with? Is it safe to lengthen teeth? How much can I raise my patient’s bite?
How can you stop your composite restorations from chipping? Can you raise the OVD on a patient with clicking TMJs? Is canine guidance always better than group function? Why can’t I just use the DAHL technique on all my wear cases? Can I stop my patients from grinding? What the bloody hell is crossover? What should the occlusion look like after orthodontics?
How and why do you check for fremitus? What on earth is a custom societal guide table? How do you use a leaf gauge? Do you always need to use a facebow? Does everyone really need a perfect occlusion? What is the difference between edge wear and pathway wear? Is it naughty to adjust the opposing tooth? What the is centric relation?
Occlusion is coming. One does not simply just open the bite. May the force mitigation be with you.
To make sure you don’t miss the crucial update about the launch of our occlusion course, OBAB head over to occlusion.wtf. That’s right. It’s actually occlusion.wtf. It’s almost released and you’re going to love it.
Now, she saw him six months later to find that his mandible had distalised and only had contacts to the back with three millimeters of overjet.
And so those of you are watching, I’ve got the photo right here. So we have an incomplete over bite and I would actually probably disagree, I don’t think this is three millimeters of overjet. This is five millimeters overjet. Remember, the overjet is measured from facial of the lower incisor to the facial of the upper incisor.
So the patient actually probably went from a two millimeters overjet to a five millimeters overjet and a loss of anterior guidance. So how did this happen? Well, you know, sometimes patients deprogram more and for whatever reason, the patient wasn’t fully deprogrammed. That’s the most common thing. The other cause for something like this is a change at the condyle level.
Think of the disc going out of place, or think of some resorption, which is rarer. And so anything at the condyle level, any changes, any pathology could change the bite and we can confirm it was muscular because our little trick worked. So what was the trick? Well, if you want to see it in action, you can actually go on the Protrusive Dental Community Facebook group.
It’s kind of the same trick that we do when a patient is high risk. So you’ve identified a high risk patient. I would make one of these devices, which I’m going to share with you now to prevent an open bite so you’ve got a high risk patient and you make them this device alongside their splint to prevent their bite changing.
It’s the same thing that we can give to someone who’s developed an open bite to recover that bit old bite. Now, at this point, you’re probably a little bit confused, but don’t worry, I’ll make it crystal clear, right. Now, this concept of positioning the mandible in a different way is actually borrowed from those who are treating the airway, because what you find with mandibular advancement splints for, let’s say sleep apnea for example, or sleep disorder breathing, is that because you’re holding the mandible forward, you get contracture of the lateral pterygoid muscles, and the risk is a patient will develop a posterior open bite because their jaw has come forward.
They’re now protruding forward, their front teeth are meeting, they become more class three and the back teeth aren’t meeting anymore. So what they started to do is every morning when the patients wake up from wearing their mandibular advancement splint, is that they wear something like on the screen now, where I’ll describe it is an MIP bite, basically, is that it guides their jaw back into their MIP in the morning, so hopefully it prevents this shortening of the muscle, basically.
And so this is AM aligner and it’s got indentations in it to really guide the patient into their MIP. So it’s kind of like an MIP bite registration, but I wouldn’t want to send a patient home with a normal PVS silicone bite because it’s very fragile, right? It’s going to break. So let me explain the trick now, right? So you have a patient and their teeth meet together fairly well, and then after the occlusal appliance, the teeth don’t meet together well anymore, and you have an anterior open bite.
Now, if we accept the fact that it’s not, because of posterior over eruption and it’s just that it’s a change in the muscles. Then what we can do is this, okay, we get the models and we have to do this on models because if you try and get the patient to bite into their normal bite or their MIP, they can’t do it because they’ve kind of forgotten.
That’s the whole thing about deprogramming. They’ve been deprogrammed, right? How can we reprogram them? Well, the way you do it is get the study models. You now squirt some Memosil or Exaclear. Clear silicone materials, right? They’ve got their resilience, they’ve got their bend ability in them, right? Bit of flex in them.
That’s the word I was looking for. You then squirt it all around as if you’re doing a bite registration, a full arch bite registration. You then seat the models together by hand and you are basically creating the patient’s old MIP i.e. I used to bite like this, that bite, okay? You actually do it by hand and ideally you want to rely on some photos or some scans to help you.
Because remember, the whole reason that this mess happened is that the patient probably had poor posterior stability. So you really want to pay attention, look at the photos, and as the material setting, you bring the bite together in the desired bite. The bite you want to go back to, right? And you let the material set.
So now you have a bite registration of the old MIP using the study models, you now transfer that to the patient’s mouth, okay? And you get them to guide their mandible into this bite registration. So let me tell you how this dentist did it after I advised her, okay, so this is what she said. When the patient came, I got his previous models out.
I showed him his previous bite and explained that it was changed because his muscles had relaxed. Before his arrival, I made an AM aligner with Memosil. So just like I described guys after the explanation, I fitted the AM aligner and asked him, and here’s the magic thing, because you know this is something that we make up because there’s no evidence that I’ve seen about how to recover someone’s bite.
So we’re kind of making up. So, this dentist was smart. She advised him to bite into it for 20 minutes. Okay? So, the patient has an AOB but is now got this Memosil bite of his previous MIP and he’s biting into it for 20 minutes. So after 20 minutes, he then removes it and when he closed together, he was able to bite again into his old MIP straight away, and he recognized the difference.
Okay. Without any pain, without any discomfort. Okay. The fascinating thing, which I absolutely find crazy is that the patient was unable to protrude his mandible before, but after this exercise of biting into his bite registration, he could. Isn’t that fascinating? This is the complete opposite of deprogramming.
This is reprogramming, and it just makes sense because if the muscles have forgotten, why don’t we give the muscles some help and remind them? So those of you who are watching, here’s the photo of him biting onto this Memosil, which was made on the study model and moved to his mouth. Why it wasn’t this bite record using Memosil taken in his mouth?
Because he couldn’t bite there. He couldn’t physically get into his old MIP again, he just had this distalize bite with a larger overjet. But this is now guiding him into his old MIP. This dentist went on to change his appliance from Michigan to something else, which isn’t so relevant.
But he preferred this B-splint or this Dual Arch Anterior Scribe Appliance to his Michigan splint. And those who are watching is a para functional pattern that you see. So a big fan. Coloring these splints with a sharpie marker. And the patient gets to see their pattern. It’s like a gothic arch tracing that you get on these splints.
So the patients see that they are still bruxing every night. Because some patients they think that they stop bruxing just because you gave ’em a splint. Whereas I tell our patients, listen, you’re still going to para function, but now you are para functioning on this piece of plastic then on your teeth. And so there it is again.
The trick is reveal. So those of you are listening, it is essentially an MIP bite using the study models in the old MIP, and this can really, really save you. Now, I can’t offer any more guidelines because this hasn’t been studied and we’re kind of making it up, but it helped my colleague and it can help you too, if it ever stuck.
This is worth giving a go because what else have you got to lose? This is a simple and a cheap way to attempt to recover the bite because what’s the alternative, right? Either the patient lives with this AOB, which is totally cool, I think, or B, they consider orthodontics or restorative to try and get their old bite back or something similar to their old bite.
So I think it’s a really handy little trick to have up your sleeve. I hope that made sense. And if it didn’t make sense, and if you’re listening, then maybe you want to just go to the app or YouTube and watch this bit. But in a nutshell, it’s reprogramming the bite using the patient’s own MIP bite record using the study model.
So it’s not deprogramming, it’s reprogramming, it’s trying to make that irrecoverable AOB into a recovered AOB. And if any of you use this, do comment, let us know. Let us know how you get on. And maybe we can do a study one day in terms of recapturing these old bites. So Prof Paul Tipton, I hope you found that useful.
And anyone else who thought it’s impossible, maybe this is a way forward. Okay, so that was a long one. I’m actually exhausted, but we’ve got time for just two more questions. And these are much shorter, right? There’s question number two before we talk about occlusion on composite veneers. The question is, when recording at your desired vertical dimension in centric relation, how do you record it?
Do you gun in some bite reg around the side when they are in their retruded position? Okay, so let’s talk about this and let’s really clarify and make tangible what this dentist means. Let’s say you are making a Michigan splint or a Tanner splint or any type of stabilization appliance. Classically, you would make this splint at centric relation.
So the condyle is in a musculoskeletal snug position, superior anterior against the posterior slope of the articular eminence. Because like I said, it’s a snug position. It is a good position to be in. It’s not essential position to be in, but if the muscles relax, that’s kind of like where the condyles can easily find.
Now classically, when I was trained, I was taught to take a centric relation bite record, so just beyond the first point of contact. And then a face bow and then what the technician would do is a technician would mount everything on a semi adjustable articulator. And then because the bite registration was pretty much at the point of contact, we now need to open because we need a minimum thickness of splint material of 1.5 to two millimeters.
So the technician then opens the bite on the articulator, but remember the articulator, although a very useful tool, does not a hundred percent accurately mimic the patient’s condyles. So by opening the bite, there is a degree of error introduced, so we can be a bit more clever because if at the point of doing the bite record instead of recording it at that very first point of contact, or just beyond it, why don’t we record the bite at the required vertical dimension.
i.e. Record it in a position whereby we’ve already respected that 1.5 to two millimeters of minimum thickness. So what this looks like for me is I’ll have a leaf gauge in, because I like to use a leaf gauge. It’s very, very convenient. It’s not suitable for all patients, but it’s a very, very handy tool.
And so as I have the leaf gauge in, and I’ve set it now so that there’s no back teeth touching, I’ve got the patient in centric elation, grind forward, grind back, squeeze together the muscle seat the condyle so I don’t have to do anything. It’s a hands off approach, the muscles seat the condyle, and because I have that space now, I’m going to scan the left bite and scan the right bite at the centric relation position with my desired thickness.
Already there, or you can actually gun in the bite registration material as this dentist suggested. The beautiful thing about this is that now the technician uses the bite registration at the increased vertical dimension, but still at centric relation. And the scenario they have now is that once they’ve mounted the models, they’ve got the space ready, they can just start waxing up for the splint.
They don’t need to open the bite or close the bite anymore. They pretty much fill in the space with wax. And this is where the magic happens. Now, whether I’m doing, DAHL composites, full mouth rehab, or a Tanner splint, or a Michigan splint using this trick has been really brilliant because when the patient bites together after I put my temporaries, or put my resin or put my splint in, I found much less adjustments to do.
So, I think this is a wonderful thing to do. Anytime you’re aiming for a centric relation record, give the bite not at centric relation, but your desired vertical dimension, which may be at centric relation contact point, but if like for a splint, you want to give them some space, don’t let the technician open up the articulator.
You give them the perfect space, and now their error of opening and closing the articulator, which is not the patient’s mouth is removed. So thanks for sending that question. I would name you, but I didn’t ask your permission to name you, so I don’t want to offend anyone. So, that’s that. Now question three and the final one, I think we’ve gone on for far longer than I anticipated, but checking the occlusion after composite veneers.
So the question from this dentist on Instagram is, ‘Hi Jaz. Would love some advice on an occlusal question. After placing composite veneers on upper anterior teeth, should the incisal edges of upper incisors will be in contact during lateral guidance? What about in protrusive movements? What markings am I looking for on the articulating paper? So all from the articulating paper, right? Thanks in advance.’
Right? Great question. Okay. I love it. Let’s just boil it into his fundamentals. Okay. So first part of the question is, after placing these veneers. Okay. Should the incisal edges be in contact during lateral guidance? I think it totally depends on what the starting situation is, because if you start with our friend, the anterior open bite again, and you put some veneers.
On someone with an anterior open bite, then the edges will never touch, right? Because they have an AOB. And if you’ve maintained that AOB, maybe you’ve lengthened the teeth, but and reduce that AOB, but they still have an AOB. So no matter how much lateral excursion they do, there’s going to be no articulating paper mark on those edges.
Now, on the opposite side, if you’ve got a severe class two patient, right, they might not even go all the way to the edges because the amount of movement they have to do to go on the edge is significant. They might go there, right? But they might not. So for that kind of patient, again, they might not go to their edges of their central in incisors, in lateral excursion.
So really that eliminates a few groups of patients. Would your patients who’ve got a normal amount of overbite, you know, 10% or more, then there is potential for those teeth to touch. So should there be contacts or it depends on the overbite.
If there’s enough overbite for anterior guidance, then eventually the lower incisors may and get onto the centrals. So there isn’t hard and fast rules out there, should they? But it’s rather will they? And if they will, why don’t we optimize that environment? Now, in an ideal world, it should be canine guidance to start with and then swiftly and smoothly, right?
And I don’t mean smooth, like shiny, smooth. I mean like the mandible finds it really easy to move left and right. What we don’t want in a scenario is that the patient’s bruxing, for example, right, and they’re going left and right and they’re bashing against this composite. And this composite, it’s so steep.
It’s not letting the mandible move. And by not letting the mandible move, it’s putting a lot of stress and strain on those restorations. But instead, if you shallowed out the guidance, the mandible can just move freely and not put all that pressure into your restoration. So let’s recap. You go canine guidance, for example, in the classic scenario, because I can’t cover every single scenario because the question you’ve asked really is case by case by case.
So canine guidance, for example, transitioning onto the edges of the centrals, okay? And if they go into crossover, crossover is when they go all the way to one extreme. And I’ll show you an example of this in a moment. For those of you who are watching, the patient who goes into crossover may well come onto their central edges quite regularly.
So in a nutshell, should the patient contact on their edges? Not necessarily. It depends on the existing occlusion, but when and if they do, make sure the transition to them is nice and smooth. So whether that is from the protrusive or left and right, you don’t want ’em to be canine initiated and then suddenly have a jerky movement towards a distal incisal of a central, that’s not going to be good.
Right? You want everything in harmony. And sometimes that means having nice, straight lower teeth, or at least not these sharp jaggedy edges of lower incisors, which are doing no one any favors. So always have a look at the opposing and see sometimes you might optimize the environment. I tell the patients I’m doing a manicure for your lower incisors and they love it.
It feels much better and it reduces the harmful forces and pressure on your upper anterior composite veneers. So before we talk about, the next case, which is protrusive, for those of you watching the video, I’m showing you a patient who’s a severe bruxist. He destroyed one of my small splints in a matter of six weeks.
So I’m showing after his dialed composite restorations what his excursions look like. So they’re nice and smooth as they come onto the edges. They’re really smooth, nice contacts on the edges and as we go to the other excursion. Now we’re going nice and smoothly, transitioning to the centrals and now into crossover.
And there’s no jerky, there’s nothing hitting prematurely. The mandible can move freely left and right, and this is what we’re aiming for in Protrusive. It should be the same thing. It should be no jerky movements as the lower incisors bite onto the upper and it come protrusive. I want to see nice, broad, even Marks ending on those edges or even beyond.
But I want them to be nice and even I don’t want one incisor to be taking more load than the other. And I don’t want like a thin marks. I want nice, thick, broad marks. Okay. Why do we want nice, broad marks onto nice broad edges because it reduces the pressure. Okay? Because ultimately pressure is force over an area.
So if you’ve got a thin little chicken scratch of a line, then there’s going to be a lot of pressure, right? That broad line has more area, so that force is spread over more area. So it’s a bit like, if someone’s going to walk all over you, , do you want them to walk all over you in high heeled stilettos or wearing flats?
Right? So I think we all know the answer to that one, and that kind of is a crude way to explain the kind of marks we’re looking for. So to summarize that, we want nice, even strokes that go from the MIP contact all the way to the edge, and I want nice even contacts on the edges. So the lower incisors, upper incisors come together, the edges are unchipable.
And that’s really important because I’ll show you now for those of you’re watching, but those, you’re listening, there are these group of patients, okay, who just love coming edge to edge then. Even though they’re class two and they’ve got like, you know, five millimeters over jet and you think, how on earth do they go there?
But as soon as they bite together, things fit together perfectly because they like to bring their edges of their teeth together. Couple of reasons I think one could be airway, right? They could be bringing their jaw forward during stressful scenarios to bring more oxygen in to improve their airway. And the other theory, which actually is supported by some weak evidence is that by tapping on your front teeth, you reduce your corsol levels and you reduce your stress.
And so regardless of the reason, it’s important to identify who spends a long time on their edges and who doesn’t, and those who spend a long time on their edges, please, please, please double triple check these excursions and make sure the edges are well accounted for.
You don’t want any sort of uneven edges or sharp bits or fragile bits, okay? You want nice, thick, broad composites. If you’re doing composite veneers on someone who likes to be. Edge to edge. So hope you enjoyed that. It was very much an occlusion theme today sparked by that Facebook group, and we’ve talked about taking bite records at the desired vertical dimension and a little bit about occlusion on composite veneers, if you like this kind of thing, then me and Mahmoud have put together around about 30 hours, can you believe it, of content that’s ready to come out in March, pre-launch deal coming.
So the way you can get involved with that is www.occlusion.wtf. Well, there we have it. Guys, thank you so much for listening to this Ask Jaz. I hope you found that stimulating and interesting about how we can recover someone’s bite.
And for those of you who want to learn more, maybe listen to those episodes that I referenced about those anterior only occlusal appliances, part one and part two that I did way back around about a hundred episodes ago. Can you believe it? If you are looking for an occlusion course, then me and Mahmoud Ibrahim have got some very exciting coming up.
So on 7th of March we’ve got a pre-launch deal coming. So if you want to be in the know when it comes to this pre-launch deal, you want to head to occlusion.wtf. That’s right. occlusion.wtf is an actual website, I promise you. Enter your email address and first name and I’ll email you when we have that deal ready for you.
It’s something that we’re super proud of. Worked really hard over the year. In fact, have a listen to one of our beta testers had to say. Hi, my name’s Marwa. I’m a general dental practitioner. Occlusion Basics and Beyond does exactly what it says it’s going to do. It takes you from the very beginning, the very basic principles of occlusion, and as you go through the modules, your knowledge just gets built upon and built upon.
So much so that by the time I reach the end of the course, I felt like I finally understood topics that I just struggled to wrap my head around for years. And that’s purely down to the way in which the contents delivered. Mahmoud and Jazz, walk you through things in such a clear way that things finally make sense. So I’d really recommend this course to anyone that’s looking to lift that cloud around the dreaded topic of occlusion.
So, once again, that’s occlusion.wtf. If you want to stay in the loop and talking of in the loop, that is exactly what the next episode is about. It’s about Karl Walker-Finch’s book, it’s called In The Loop. I’m very excited to speak with him, to wet your appetite for this fantastic book, which is dedicated to a very important dental charity. So I’ll see you next week for that episode.