After the cliffhanger from Part 1, Dr. Sandra Hulac is back to share more information about Frictional and Constricted Chewing Patterns (CCP) with cases shared and explanations given.
The Protrusive Dental Pearl: Overjet is King. We don’t want tight bites. We want a bit of overjet that gives chewing space – this will reduce the chances of a functional attrition and avoid ‘too much anterior guidance’ or locking the patient in.
“It’s important to know why things fail and try and avoid failure the next time”
Highlights of this episode:
- 0:28 PDP141 – Stop Blaming Bruxism Part 1 Recap
- 6:34 The Protrusive Dental Pearl: Overjet is King
- 6:56 The role of pre-restorative orthodontics
- 9:24 Case #1: Extremely traumatic deep bite
- 14:10 Case #2: Crowding of the lower anterior segment
- 19:41 Case #3 Lot of wear on the front teeth
- 23:54 Case #4: Chipped and worn front teeth
- 27:06 Case #5: Worn front teeth
- 32:41 Case #6: Patient had an extraction ortho
Dr. Mahmoud and I are also excited to share the occlusion that we learned over the years – in a way that you have never seen before!
Occlusion: Basics and Beyond is the most tangible, real-world, and comprehensive occlusion training on the planet.
LIMITED DELEGATE SPOTS DUE TO STARTER KIT STOCK – AVOID DISAPPOINTMENT! Occlusion Online Course
Click below for full episode transcript:Introduction: Hello, Protruserati. I'm Jaz Gulati and thanks so much for coming onto the app for part two or what was quite a brilliant part one with Dr. Sandra Hulac. Her energy is just absolutely amazing.
Now, just a recap, we left you on a bit of a cliffhanger last time. We talked about, I asked Sandra about orthodontics. You know, how often does orthodontics come into it?
Is it every single time? And the answer she gives is really pragmatic. So you’ll hear that or see that in just a few minutes. But I just want to do a bit of a recap, what we talked about last time, right? So, a constricted chewing pattern is someone who really wants to bite here, but the teeth meet together here, so the condyle gets sort of pushed back, if you like.
Right. So for this patient, the centric relation is actually further forward. So who’s at risk? People who’ve got upright or retroclined upper incisors, right? And their jaw wants to be further forward, right? Maybe cuz of growth, the jaw wants to be further forward, which is why Sandra said that people who’ve had orthodontics and upper pre-molars extracted.
The maxilla gets smaller if you like, and mandible start continues to grow and those patients may be at risk. So if you see those kind of traits, then maybe we shouldn’t be using like a leaf gauge for centric relation on those patients. We should be using like a deprogramming appliance Lucia Jig or a Kois deprogrammer.
If you fancy that one because that’s what Dr. Sandra does. And what you find with these patients with a CCP is yes, their jaw gets shifted back, but you might get more wear on their edges. And that’s not from bruxism. That’s because the outside in movement. Right? Their jaw wants to be further forward.
Now, this is similar. The cousin of this is the frictional chewing pattern who their condyle isn’t getting forced back, right? Their MIP is okay. It’s just that as they’re chewing the outside in is causing this. So, let’s say that’s normal, the incisal edges are not worn here. Can you see?
They’re a bit jaggedy over here, right? It’s just, to over here and over here. We see this all the time and let me show you some photos actually on the screen or what this might look like in a 75, 80 year old person throughout their life. And you’ll notice here, the upper right central incisor in this patient is actually more worn than the left one.
Why is that? Because the upper right central incisor is more palatally positioned, right? It all starts to make sense, okay? There’s not enough chewing space. And we also see this glassy thin structure of tooth. We see this glassy thin enamel. Now, in bruxist, we don’t tend to see glassy thin enamel because their side to side teeth grinding destroys it, right?
So if they’re destroyed their canine, then they’ll come onto the centrals and they’ll make it really flat. So, it’s a clue that, okay, maybe it isn’t so much bruxism, maybe it’s more functional. And we call this pathway wear. We see it on the facials of the lower incisors. And the lingual of the upper incisors. The problem though is, in dentistry, there’s always different opinions.
And so whilst I respect this opinion, the other school of thought that we need to consider is, This patient, right, who we’ve decided that has got a frictional chewing pattern. Their upper incisors are more retroclined, and when they bite together, maybe they’ve got a bit of fremitus, a bit of vibration, right?
They’ve got pretty much too much anterior guidance, right? There’s not enough space, there’s not enough overjet. So when the patient bites together on their retroclined upper incisors in the lower teeth, come together. Now, imagine this patient also happened to be a bit of a bruxist. A bit of a bruxist, because Sandra, she introduces term that true bruxism, you know, your heart starts racing is generated centrally mediated, which is true.
But there is something called rhythmic masticatory muscle activity, right? So, we know that bruxism is a muscle behavior and there are normal bruxist, right? 60, 70% of us will grind for a couple minutes every night. About three minutes on average, and that’s normal.
Okay. Three minutes a night based on some evidence that we’re just going to be grinding left and right, three minutes a night, even grinding. This is a cool bit. Okay. Even bruxism or muscle movement without tooth contact. So imagine someone’s opening the mouth and going side to side that counts as bruxism. So the bruxism that we are concerned about is people who are clenching their teeth together and grinding at the same time, right?
So moving to the side with their teeth together. So imagine someone’s doing that for three minutes. That’s different to a patho bruxist. So kind of what Sandra is doing to these patients may be patho bruxist. They’re grinding for 18 to 20 minutes per night. They’re doing significant muscle contractions. They might be in different phase of sleep when they’re doing it.
So these are the dangerous beast, basically. And I completely agree that for those patients, yeah, you get this flattened appearance, but think to the normal grinders, or even a pathological grinder who seems to have a lack of overjet, right? So yes, the outside in is affected, but as soon as this patient wants to grind left and right, the front teeth will get in the way.
So what I’m trying to say is, yes, there is this functional attrition happening, right? The outside in, but it’s not helped by at any time in this patient’s life if there is any bruxism or parafunction happening as well. So just think about that, right? Sometimes one compounds the other, and what I’ve done is, I’ve often taken photos of my patients who’ve got this pathway wear, or this frictional chewing pattern.
I’ve seen photos of them and I put article in paper and I just get them to grind left and right. I don’t get them to do the test that we’re going to show you with the blue paper 200 micron. Yeah, we show that in this video. Sandra will show that, and I’ve got videos of that as well, which I’ve put on occlusion basics and beyond.
But let’s think about checking the inside out. Let’s check the left to right grinding. The color, the ink that’s rubbed off kind is similar and matches the wear pattern, which we say is from outside in. So really my argument is, do you really need to get into the semantics of the diagnosis?
What’s causing it? Is it bruxism? And this is, they just have too much anterior guidance. Is it bruxism on a really retroclined upper teeth? Or is it this functional attrition that’s happening? So is it function or is it parafunction? My argument is the treatment for it is actually the same, right?
The treatment for this is actually the same in the way that we open the OVD. We procline the upper incisors, we gain some more overjet. So it’s important to consider, okay, this could be a friction chewing pattern and plus a minus bruxism, but the way you treat these two conditions is very often the same.
The only thing that might differ is if you truly believe that this patient is a frictional chewing pattern, and you think a night guard is going to solve that. Then yeah, it’s not. Right? So just some food for thought and I hope I didn’t lose you there. I want to, I’m going to crack onto part two with Sandra.
Protrusive Dental Pearl
So Protrusive Dental Pearl is, overjet is King, overjet is your friend, right?We don’t want tight bites. We want a bit of overjet, gives you that chewing space. And also if there is any grinding left and right, it gives space for that as well. So Overjet is definitely your friend, and that means orthodontics is your friend, which leads nicely to the episode where we pick up from the cliffhanger.
So let’s join Sandra Hulac for that right now. The role of pre-restorative orthodontics, because what you’ve shown there is a wonderful case where this was managed purely restoratively and finding this new joint position, which is going to be in her case, slightly further forward because it’s now no longer distalize.
And by increasing the OVD you now had some space. Tell us about, what percent of cases A) would you like to, in an ideal world. You know, have a wand and say, okay, this patient’s going to have orthodontics and go through the pain and misery of that and B) what actually happens in terms of what percentage actually get on board with that and what is your cutoff point? At which point you say, you know what, if you don’t know ortho, no treatment.
Okay, so my answer to this is what, like I told you before, not enough patients will accept the pre-treatment orthodontics, and there are cases where I will say, absolutely, I’m not going to treat you unless you agree to this. Okay?
Which, you know the case I’m going to show you now, I said to the patient, no, this is absolutely not possible in your way in without pre-treatment orthodontics and, you’re going to break your teeth very soon. And he said, well, I’m not willing to have this orthodontic treatment. He started breaking teeth, so he had the orthodontic treatment.
In that case, took from start to finish about two years because it was very complicated orthodontics. Now what I have is really, it’s like very often, is the juice worth the squeezing. So in this case of the last case I told you, whatever I did, even if we had pre-restorative ortho, her teeth are actually in the right position in her face.
What are we going to do? Are we going to intrude her lower front teeth? Now we can’t do that either, right? Because, you know, we can’t intrude the teeth so much that we get them away from her palatal surfaces and have enough restorative space. Plus, we do know that, you know, lower intrusion is the most difficult treatment of all orthodontic movements, and it’s also not very good for the teeth.
And let’s not forget that the two of these teeth actually are have to have implants anyway. So, and it’s very complicated ortho and she needs restorative dentistry anyway. So I will not go and go and say like, if a patient has a bombed out posterior occlusion and needs onlays on everything anyway, and I can’t achieve the same by just opening the occlusion vertical and I don’t need to put them through orthodontic stent, the patient will not even get proposal of orthodontics.
So what is my biological burden? I will say, and I will show you a case, for example, where I found the biological burden acceptable. And the first case where the biological burden was basically that there was, you couldn’t do it without, so maybe now let’s just go and have a look at the first case, which I’ve treated a very long time ago.
I saw this patient, I think for the first time in about 2010, that’s when we started and he came to me and you can see it here. Beautiful case. Obviously we have an extremely deep overbite. It’s a traumatic deep overbite. The patient had these crowns fitted by a prosthodontist in boston four years prior, and you can see that already.
I’m expecting for the next slide to show me like completely bombed out, lower incisors.
I will, I will. But I also want to show you how the right canine is already broken off and see how the canine tip has broken off of the right canine. We also can see even just by looking at the patient at the picture, that there is a significant cant, and this was obviously the times before DSD and before everybody was Christian Coachman’s best friend when, you know, people really did dentistry without looking at the faces whatsoever.
And obviously Christian has changed this, but I like, I would like to say that John Kois created, facially generated treatment planning 25 years ago. We just didn’t have a smart tool like DSD. We had to do it with, you know, a face bow and levelers and literally water weights on the face bow to get the stuff straight.
But you know, he made sure everything still was straight in the face. Anyway, so here we have this and yes, we have totally bumped out front teeth, lower front teeth. I’m going to show you that more in the next slide, but we also have a completely mutilated. You know, occlusion, you can see there’s over options there, teeth missing.
And you know, and the patient comes to me and like, I want you to just treat my lower front teeth. And I’m like, you’ve got to be kidding, right? Yeah. But they’re so warn, can’t you just put veneers on them? And I’m like, no, we cannot. And I said, you my friend need comprehensive orthodontic treatment.
And if you don’t, You will break your upper front teeth pronto very soon because all these teeth were root canal treated and many had large posts in them. And you can see, I don’t know if you can see that under the right side of the screen, but you might see when you look at that right central, you can see how the porcelain is cracked in the cervical area of this tooth. Can you see that? The porcelain fracture in the cervical of the one one?
Not so clearly from my screen.
Okay. So there is little crack lines going through that porcelain on the cervical, and that shows you the enormous amount of torque this teeth gets. These teeth get, from the constant banging of the lowers against it.
So I said to the patient, so you’re going to break one of the teeth off very soon? And he’s like, okay, well I don’t want the orthodontic treatment, so goodbye and two weeks later. He came back in and this had happened and I’m like, ah, gosh, I hate it when I’m right. So when, then he said, okay, so we have a broken tooth there.
He is like, okay, well I understand what you’re saying and let’s do the orthodontic treatment. So first what we did, we actually put him in long-term milk provisionals because we needed to open up the vertical for us to even get to those lower teeth. Cuz I mean it, it looked so bad. And so these are actually long-term milk provisionals, which were already big, big, improvement.
And most importantly looked at were actually straight in his face. Then we did comprehensive orthodontic treatment for two years, starting in the lower and then going to the upper closing the spaces. And this is the case in 2012, so that’s 10 years ago, finished.
Now I don’t really would say this porcelain work is something I’m very, very proud of. I certainly, you know, but the patient wanted a very American look, very bright. And this case is holding up beautifully. We’ve lost one lower tooth because it was so bombed out and had a large post. So he has an implant there now.
And one of the upper canines also, pain subsequently became an implant. But the patient knew this was going to happen, so this wasn’t entirely surprising to us, but this case basically is, you know, you must have orthodontic treatment, otherwise I cannot do the case. Okay.
So was this upper and lower orthodontics or was just lower?
Upper and lower.
It’s impossible to do with lower? Yeah. Mm-hmm.
The upper also had it, because, you know, there were all these spaces, the teeth had to be moved in the right position and that once we were finished, we basically just, you know, went into very, pretty poor, not very pretty white person work. We’re done this case is holding up beautifully.
So, it’s quite a successful case. So the next case is a case also where I did ortho. This was much, much less comprehensive ortho, but we can see for example here that the patient has a little bit of crowding of the lower anterior segment, particularly on the lower right hand side.
And we can see subsequently that there is a lot more wear on tooth number one, one and one two, because these lower front teeth are coming out a little bit more now. So again, to this patient, I say, if we want to do this right, we have to sort of, do a little bit of aligner therapy first.
We are going to do a bit of stripping here and get those teeth a little bit down and back, which is exactly what we did. So at the end of the treatment, you can see the teeth are slightly more intruded, everything is much more aligned, and we can do 10 beautiful veneers. And this was done without any, you know, opening of the vertical or anything like that.
And this is, and again, you know, looking now, there is no contact on these teeth. We’re just doing all that. And that’s also a successful case, you know, with a tiny little bit of aligner therapy. Now here’s a case where I didn’t do-
Can I just ask you, Sandra, on the previous case, just cuz some dentists might be thinking as they’re listening and watching is for, so we don’t have a maximum intercostal position contact and definitely, as you could describe, it will not be holding shim anteriorly, but how do you account for it in, from the in the inside out? Do you still want to have your lines at the front and dots the back in your inside out? Or are you not so fast about that?
No, I don’t want any lines on the front teeth. Ever, particularly not on my porcelain, you know? In the final position and I don’t want any shim shock on the central and laterals. Okay. Yes, in my final position I can have a little bit of a spot, you know, but I don’t want that on the edge of the teeth.
Okay? I don’t want them to come in a fully seated position. Yes, I can have a occlusal contact, but I don’t want them to come into an occlusal contact and rubbing over the teeth while they’re going into the-
You don’t want a line being formed outside in.
That’s right. That’s right.
But what about the lines inside out? So what if this patient decides to become a bruxist?
Now remember that real bruxism, they don’t decide that. It’s a neurological thing, you know? There might be clenching a little bit. Okay. But there’s a distinct thing, but real bruxism is lateral and posterior. They don’t go over, therefore, they will be going over their canines maybe, but they don’t go over their front teeth. In the 30 years that I’ve had that I’ve been in this profession, I’ve had exactly one person bruxing anterior posteriorly. And Dr. Kois said the same. So people don’t brux forward and backward.
I agree. I do a parafunctional analysis all the time, and I see it’s always left to right, yet to find that unicorn going forward to back. But, I guess because you have treated these patients in a position where you’ve given them that space, even if they were to go left to right, the anteriors are not getting in the way.
Correct. They’re not getting in.
Because of the setup. And so essentially it’s in harmony. They’re in harmony. Essentially all these people, you know, Kois, Dawson, they all teach. Everything should be in harmony. The inside, out and outside in, yes, outside is very important, but often it’s in harmony. When you treat one, you almost help the other.
Well. Yes and no. I mean, as I say, you know, you always will have people that clench their teeth a little bit. Okay. But this is not bruxism. They go like, they don’t go, very rarely. Yes, yes. You will have the odd patient that does it when they really have a lot to drink, for example, because then it’s again, it’s up in the brain, but your average patient doesn’t really brux. Only the real bruxer bruxist and the real bruxist gets a mouth guard.
The pathological bruxist, absolutely.
They get a mouth guard, but a patient like this doesn’t get a mouth guard. No. Why? He doesn’t really brux. So, I’m a lot less generous with my mouth guards. If I suspect that the patient, so if I, and this can happen, this happens all the time, you know, when I have not so much in chewing constrictions because chewing constrictions are actually, I don’t want to sound blase, but if I have a constricted chewing envelope and a patient’s that willing to do treatment, this is my ship has come in.
Because this is actually an occlusal problem, which in my honest opinion is a little bit easier to get right. What’s really hard to get right is a proper chewing dysfunction, because some people, they just chew all over the place. And to find, to get now you have to be a real visit to fine tune those occlusions. And sometimes you can’t cure him. Even John Kois and he is probably the best equilibrator out there, will tell you that sometimes some patients you can make it better. You can’t cure them.
And these patients will continue to maybe clench around a little bit at night, constantly going around and looking, you know, very often then if they’re under stress, this kind of throws them out and puts them in an episode where everything, you know, can’t find my teeth, blah, blah, blah. Everything is terrible.
Yeah. And these people, you need to definitely, if you treat them a mouth guard needs to be part of that, because it’s a security, it’s like the belt and suspenders thing. You know, you just do it for every option.
Oh, thank you. I’m going to explore your philosophy there. Please we’re going to show one more case, I think.
Okay. So what I wanted to show is here’s a case where we should have done ortho really. It would’ve been so much better, but the patient just didn’t want it. So there was a small biological price to pay here, because the only way we could get this right was by opening the vertical. So this is the patient that I showed before. So we have a lot of wear on the front teeth, and you can see the palatal surfaces of the upper front teeth are worn out. So this patient, I again, was one where, you know, I actually used a jig. Or like a bonded platform. I’m not a jig person.
I like to bond platforms and I took a centric bite like that because some, I have a lot of patients, you know, Hong Kong is kind of, you know, a city of professionals or used to be, and these people say, I’m not going to run around with an orthodontic device in my mouth for best part of the day, I need to be able to talk.
So we do this. And in this case, I’m also a secret waxer. I actually like to wax up these kind of cases myself. So this was, you know, what I wanted, again, a case done before DSD, this is what I wanted to be, this teeth, you know, like on the top. And then what we did, we put the patient in long-term provisionals based on my, not long-term, but into provisionals for a little while based on the wax, the bite that we had that we wanted to do, and we find to the occlusion in that this is like, you know, my wax up temps, which, you know, are nothing to write home about, but at this stage they’re all additive.
So these teeth actually haven’t been prepped at all yet. Okay. I want to make sure that everything is okay. Before I actually start prepping the teeth. So, and then, you know, you can use your temporaries as a prep through guide, which, you know, this whole Galip Gürel concept. I mean, typically when we do veneers we always use now an additive wax-up as a prep guide because you want to make sure you are maintained as much enamel as possible.
Begin with the end in mind.
[Sandra] Exactly. And then here what you can see is how much I had to prep the back teeth in order to get the minimum thickness for these pressed emax, which in those days, I think now they say you can press it to 0.3, but you know, not really. So these were like 0.5 thick or something like that.
Wow. Still very thin.
Very thin and we-
But you got a lot of enamel there which will help cuz you’ve got so much enamel there that which is the key indicator really.
Yeah. So apart from the seven and funnily enough, because the seven had quite a bit, I had a composite in there that one actually broke and I had to redo this one and I had to make it a bit thicker.
But you know, the others have held up very nicely and this is the case. These are, this is a German patient. These are German hyperrealistic teeth done by a wonderful dental technician of mine in Hamburg. And you can see this is actually the case a couple of years out. I only restored the lower front teeth with a little bit of composite and there’s a little bit of chipping of that lower composite because it’s so thin.
Because it’s less than a millimeter in thickness there. But other than that, that case has held up very, very nicely. And yes, we had to do eight more teeth that we wouldn’t have to do without ortho, but with a minimal biological cost. But yeah, so ideally this would’ve been better off with ortho. Some patients don’t want to do it, so, and then if they don’t want to do it, then they have to do something else.
I mean, I have to get the restorative space and I have to get the right restorative position. And if they don’t worry, then they very often it happens that they just don’t want to do any treatment. And then they just want some, they just want prettier front teeth, right? So what are you going to do it? You’re going to let them go to the next [unclear] who’s going to basically drill these teeth down and slap, slap on 10 veneers that then break and the patient comes back to you crying, but now can even afford you less. Or, what are you going to give these patients? You know? So, and this is maybe what we can talk about next.
Yes. Oh, I’d love to. I was going to say, you’ve covered a nice range with ortho, which showed a great case. Without ortho opening the bite link, the mandible will come forward. So what about that patient who is unable to go through the whole hog? What is a halfway house that is going to make you happy and hopefully save the patient some tears.
Okay, so what a halfway house, for example, is a patient like this, you know? So here we have her. She comes and she has these kind of chipped and worn front teeth with a fair amount of palatal wear.
Now, I don’t know, the patient had orthodontic treatment and then she is Asian. And very often when you have Asians patients after orthodontic treatment, they end up with ginormous, black triangles. And she had some composite work done on these teeth to correct the black triangles, and it was obviously done.
Done quite poorly. The teeth are not the right proportion and the composite heads aged very badly. So she really wants to do something about the front teeth. Now when I examine her, she, I see like, you know, I’m like, hang on. This is all very tight and very weird and do you know how your teeth fit together?
And she’s like, yeah, I’m not really sure. So I said, really what you should have is a comprehensive occlusal analysis that we actually know how your teeth going to fit together cuz you can also see, obviously there’s something going on here. Is she bruxing to the left hand side? She says she doesn’t brux.
There’s a lot of wear on the left canine. Is that because she has an enlarged chewing envelope? So, but the patient is like, no, I don’t want to find this out. I want pretty teeth. So what I then say to the patient, okay, here what I can do. We forget about all that, but the only thing I will give you is four composite veneers.
I’m going to remove the old composite of those teeth, and I try and pretty-fy the teeth a little bit. I make them a little longer, and most importantly, I’m going to build the edges out. So I want these edges out of any kind of functional envelope that can possibly get into. Now, can she still break them? Of course she can.
And that’s not my problem. So we have a clear understanding that I recommended something else. But I understand that the patient wants pretty teeth, so I will do this pretty teeth at zero biological cost. I will not touch these teeth whatsoever. Okay? You will get four composite veneers that are going to give you a cosmetic improvement.
They’re not going to be as wonderful as porcelain would be. But I’m not going to hang porcelain off those teeth and ruin them. Forget it. So here is the composite veneers done.
For composite veneers doing, trying to get a little bit better, a more kind of nicer shape with rounded edges, with classic Asian two shape, and just making it look all a little bit better and it does look better.
It’s not ideal. But it does look a hell of a lot better. So, I have these kind of patients all the time, so this is another one. You know, he has been-
Just to share under a key lesson before you share that. Okay. The key lesson, in case anyone missed it, everyone was multitasking, they didn’t hear you is, you did the veneers, the composite veneers at minimal biological costs. But the main thing there is that you built them out. The incisal edge was slightly further forward to not exacerbate this issue. So again, it doesn’t interfere with the outside in. So if anyone missed that, that was a real important gem there.
It’s super, super important. So very often I will actually wax these cases up beforehand and then make my lingual matrices like that. But here I have another case. So this is a patient that has worn front teeth. He wants them to be longer. He doesn’t want to go through, that’s actually stable wear.
He doesn’t want to go through the process of occlusal analysis. So I’m like, okay, let’s do four composite veneer. So I look at these edges, I go like, okay, well opposite at 2-2 the left lateral has been built up for a very long time with a lot of composite, and that’s still there. Nothing’s chipped there.
So I’m quite happy to leave that edge in exactly that position. The rest, I’m not leaving like that. So here what we do, we do a very, we do a quick and dirty intraoral mockup, and you see how much I actually add to those edges in length, but also how much I built them out facially. Okay. And then we just go through the process of removing the old composite whatever is there.
And first, as this is just, I like to build my cervical outlines first because it makes the placement of the rubber dam so much easier. So then we put the rubber dam on, and then we start the process of four composite veneers. And it certainly does look a lot better.
And I haven’t seen him. I’m a fellow of the American Academy of cosmetic dentistry. And we are also known as, you know, the Academy of Pretty Composites, so we do. If I’ve done something a lot in my life, it’s composite veneers, it’s like, ugh. I love doing composite veneers. It’s my favorite day in office.
Yeah, it shows.
I really like that. So, yeah, and this is a very nice way and here’s the fun thing with a case like this. If you have a patient like that, this can actually be a diagnostic restoration at the same time. Because if this patient comes back now in a couple of years and he hasn’t broken anything, I’m like, let’s do veneers.
We’re just going to copy this. We’re just going to copy this incisal plate, this exact incisal position. We are doing exactly this, and we say to our technician, under no circumstances are you going to go back here? You know, you’re just keeping it where it is or if anything, you know, if you want to, you can go even a little bit more forward because we liking that position, we know that works.
So if the patient wants that in a couple of years, and I do that a lot as well, that people will then go like, oh, I like my composite veneers. But you know, they stain a little bit and they will stain even if you do everything right. You know, I do all my composites under rubber dam and I pay a lot of attention to the polish, but it stains.
I mean, and that’s patient dependent. It’s not your fault. We have to stop always going like, oh my God, I’m such a bad dentist. Your composite has stained, you know, oh my God, I’m such bad dentist,
It will stain as you say. And you’ve noticed that it’s the smokers, the coffee drinkers, that kind of stuff, who’s going to be affected more. So it’s part of the aftercare and the warnings that you give.
Exactly. That’s one. It’s like, this is an upkeep restoration, okay? If you want something that’s not going to stain, then you have to go for the porcelain, but for various reasons, you’re not going to get it in my practice unless you do X, Y, and Z, you know?
And because I’m not going to be that person. So, and if you do the composite and you break it, it’s not on me. I can repair it. I can easily repair a broken composite veneers, and I certainly, I won’t do it for free. If you break the edge. I told you, you know, this is a classic, what we call the red dot scenario not being on my forehead.
You know, literally, I mean, this is not an Indian reference, but at Kois we have a green dot, yellow dot, red dot, and red dot means there is a big problem, but I’m not going to have that dot on my forehead. It’s the patient’s problem. It’s not my problem. You have to stop making patient’s problems, our own problems.
Oh. Preach. Preach it. Absolutely.
There’s so many people out here that are just so, they’re like, go home. They’re so depressed. You know? And you know, I will say that it’s good. I very often go home and I’m still very depressed if things don’t go my way. And I will wake up in the night and I’m like going like, oh my god, what have I done here?
It’s like, because stuff like that happens and that makes you, I think, a good and a conscientious-
Because you care. Because you care so much you care, but you don’t want to care too much more, especially more than the patient.
Exactly. And it’s the patient problem. The patient has to own it.
I think everyone must rewind two minutes and listen to the exact spiel that Sandra gives to the patient and how she just said it to us now. If you break the edge that’s on you and to make it clear that yeah, guess who’s paying for it? Yeah.
Not me. It’s going to be you. And it is just very clear that you are rehearsed in saying that to the patient, your patients, and the clarity in which you convey your message of patient’s understand and they get it.
And, let me tell you, I’m not just saying that once, I will say that in the initial appointment when we make the veneers, when we decide that we’re going to do composite veneers, I will say it after we’ve done the composite veneers, and I will say it at third time when the patient comes back for a shade check.
Make sure everything is okay, just checking the occlusion one last time. So these are, you know, three appointments where the patient gets told it all the time, and guess how many, like, oh, I wasn’t aware that this could break. And I’m like, are you fucking kidding me?
You knew that but yeah, so, I just quickly want to, I mean, show you how important it is that you, when you do restorative dentistry yourself, that you check the position of these edges. And it’s, and as I say, I’ve been doing this for a little while now and it happens to me still. So here I have a lovely lady, she is a work colleague of my husband, and she had, you know, basically she had extraction ortho, and it’s so the kind of the classic ortho, which just the upper arches get way too trunked.
And the anterior posterior position of the centrals can’t be maintained. So these teeth basically fall back in the patient’s faces. And in her case, there was actually a shitload of composite on these teeth. And still, you know, they weren’t really visible. You can see, I mean, maybe you can see the step here in the right picture.
You can see the difference in the buccal corridor width, particularly on the right. So you can get an idea how much composite is on those teeth. And this lovely patient, she hated it. So I’m like, okay. Now let’s do some proper veneers here. And then everything was wonderful. And then she wanted lower veneers as well cuz she didn’t like, so I’m like, okay, let’s do the lower veneers. And then this happened. So-
Oh gosh, yes. Upper left central.
And this is, I didn’t do anything. I was just chewing. And you know, if you look, and you can’t really see this now, but you could see that if you could blow up the picture, you can actually see that there’s a tiny little bit of black marking on the right lower central, and this is the classic porcelain friction.
You actually get little black marks on the porcelain. So when you see something like that, you go like Uhoh. and guess, I mean, I did check this for friction. I thought I had adjusted it enough, but clearly I didn’t, you know, so here I am, you know, doing two more centrals free of charge, because once you have to, you can’t just redo one, you know, and these are done by a porcelain technician in Australia, and he’s not cheap.
And I have to pay for that because I did not do my job. And obviously, you know, I’m then 100% sure and see what’s happening. See now you can see actually on the, you can see \ on the edges here, you can see the little bit of black hair. And that is what’s happening. She’s coming in still way too forward.
So I actually had to also adjust and you can see here that there’s way too much. Smudging on these edges, you know? And I need to get rid with all of that. I need to get rid with it. Now. I can keep the big contacts on the bottom. Okay. When she goes into full seat, I can keep those. But anything that’s on my way in, I need to eliminate because that’s what’s going to lead-
And in this case, when your decision making, would you be adjusting those areas on the upper or would you be now looking to the lower, facial to try and not have to compromise so much.
I actually, in this case, because the lowers were veneers already, and you know, they were just pressed emax, and I can’t polish this back up. I had to do both. Okay. Because I obviously don’t want to hollow up my edges too much. And this is like, I mean, there she is. She’s a very pretty girl. And I mean, as I say, I don’t want to do this one more time and luckily she hasn’t broken it since then. So, you know, we are not fairly happy that this is not going to break anymore, but, you know, happens.
Happens and happens to me too, and then no, if it happens, it’s my mistake. This is my mistake, I’m going to pay for it. If the patient breaks a composite veneer that I did, telling them that they should do something else, that’s not my mistake. I’m not paying for it.
I love that because you’ve shown both sides. Sandra, you’ve shown the side where you know what, actually, it’s on the patient, but it was so much humility and you’re so humble to share your own mistake and say that, you know what, when I cock up, it’s because I did cock up. And then that’s when his ears is on me. It’s so refreshing to have that.
And I love clinicians always value clinicians who share their mistakes and failures. And actually you actually blew it up in front of us and showed us. Exactly. And that for us, the learning is just so, so, so much here. So thank you. I also now learned that you spent some time, you did time in NHS, which is, wow.
I can’t believe that. That’s amazing. So there’s hope for us all. You showed so many signs today and so many great cases that you showed as well.
Thank you so much for having me. I have to say I’m on one hand I’m jealous that at the younger generation that there is so much out there and you have this, you have this amazing choice and you can see everything on the internet and everybody throws stuff out there.
I mean, you can learn more these days that, but looking at somebody’s Instagram for a little while, somebody good, obviously, and following them, you can learn more. Probably then you could have learned until like in one month in dental school. The disadvantage of you guys, what you guys have is now obviously to distinguish yourself, you need to have a rocking CV with a lot of continuing education. It’s so much more competitive these days. And yeah, it’s got them hard.
And there’s so much, it’s information overload as well? Like, you know, there’s from every angle? There’s this, who do you listen to? You know, how do you form your own philosophies? Who do you pick as a mentor? So it’s almost like too many mentors out there available. Yeah. So who, you know, you got to pick your best.
It’s too many, too many chiefs, not enough Indian scenario. So I would always go, I guess it depends where you are. I just felt 15 years or 14 years in that I just wanted something that was very comprehensive, that really started at A finished at Z and wasn’t ever done.
Because you know the Kois Center as well, one of the very few facilities where we go and we have an annual symposium where we have continuous, you know, updates on treatment planning, on everything. Cause John will actually read all the stuff, all the literature that has come out. So he reads about 25 articles a day, every day without fail.
And if there’s an article in the last 30 years written in English, he will have read it. Okay. And he has a, when it comes to that, he’s like a little bit like a rain man. He can really get all this information out and he will very often change treatment. Not the system, but he will tweak it.
It’s never dogmatic. So it’s not like, oh, we have to do it like that, because that’s what I told you 10 years ago. We actually do many things completely different now.
Because the evidence is better. And the case come back absolutely.
Because the science has changed and because nobody is infallible. And actually, if you want to see, if you want to see treatment, taught and philosophies is taught, showing failures. That’s where you go cuz he can show you failures up to a zoo and then he will explain why it failed. I mean, the most frustrating.
Just like you did as well with that last case. It was so good.
I know why it failed. And that is what’s so wonderful is because you will still have failures. Okay. And some failures are your failures. Many failures are patient failures and failures. And patients have to understand that even with the most meticulous planning, there is never a hundred percent guaranteed there can be undesired treatment outcomes.
And so what’s the most frustrating is to see something fail and fail again, because you don’t know why it failed. That is really what’s soul destroying, and that is when dentists just give up and will actually not prescribe any treatment anymore. Cuz that’s your classic, you know, dentist that’s just not even doing fillings anymore because they don’t want to have post-operative sensitivity.
And you will go, like my dentist said, everything was okay. You know, I guess that’s where you get to, because you simply can’t take the failure anymore. But, nothing is without failure. Nobody is infallible. It’s important to know why things fail and try and avoid failure the next time by changing your bonding protocol, by doing this different, by doing that different, you know, by knowing also that despite your best efforts, you can have a postoperative sensitivity.
You know, typically the worst 40 hours after the procedure. So very often if I do large composites. Big cases, these patients go on painkillers for three days afterwards. Best combo would be, you know, 800 milligrams or 400 milligrams of ibuprofen with a thousand milligrams of paracetamol on top as a nice cocktail.
You know, get them over that post treatment inflammatory bump that happens on day two by day three, typically they’re gone. They’re good. You know, so, I mean, it’s going to happen, you know, but you just, you need to know how to deal with. Okay.
Absolutely. I think it’s some such great real world advice for a lot of the young dentist listening who have that fear in them. Sandra, I know you do the demonstration at Kois, do you do and you run any courses in Asia or Australia or anywhere. How can we learn more from you? Please share with us all the channels we can connect with you because I’m sure you’ve inspired so many dentist today to start looking, taking a step back and instead of blaming bruxism.
Look out for these constricted patterns and frictional chewing patterns and maybe to now think that actually maybe the knowledge that we have wasn’t enough and we need to learn a bit more.
Okay. Let me just see if I can, so this is just a lecture. I do online lectures. I’m part of the Australasian College of Dentals, so, but I do online lectures for them. and my Instagram handle is here. It’s @sandrawholikedentistry because my Instagram is private. If you want to connect with me, you have to send me, you know, you have to ask for me to accept you, and I will, and then you can ask me stuff. I’m very happy to answer it, you know, so-
It was so refreshing that a superstar, like your staff even replied to me. So again, thank you so much and like, the amount you give away, the amount you share, you know, you don’t hold anything back. And that’s what we love about educators like you, you know? Thank you, thank you so much for all the time and the expertise and the humor and everything today.
Well, I’m very happy to share this with you because I think if you’re at some stage in this profession, to be perfectly honest, It becomes a little boring. So you need to find something that that helps you recreate the passion. And I constantly, and during Covid, I haven’t been able to go and go on continuing education. For me, I find this is very, very important to avoid burnout. I need to constantly, I’m a bit of a CE junkie. So the next best thing is if you can actually share something you do know.
I’m a wet glove dentist, you know, I’m not really a teacher, but I do like to share whatever wisdom I might have to share, you know, and I’m very happy, you know-
And there was plenty of it today. Thank you so much.
That’s very nice of you to say.
You not only met my expectations, you exceeded them greatly, and it was so great to learn about your journey as well. Sandra, thank you so much. I’m going to put the Instagram handle on the show notes well, so people can connect with you, expect a barrage, people reaching out to you, and hopefully they’ll keep your dms too busy.
Okay. No, I’m looking forward to that. So, as I say, I share copious fashion advice and dentistry on my Instagram. So there’s a lot, there’s a lot of, so I can tell you everything about shoes and handbags and, you know, teeth.
I’m specifically going to tell my wife not to follow you. Thanks so much. Well, there we have you guys. Hope you found that really helpful. I really enjoyed speaking to Sandra. So do give her a follow on Instagram @sandrahulacdentistry and do tell her that you heard about her from Protrusive and send her some Protruserati love.
That’d be great. If you’re watching, and it’s March, 2023 and it’s before 21st of March. There’s a few days left probably for you to join the pre-launch deal. I know I’m banging on about it, but look, this is the most important thing I’ve done in education and I’m so proud of it. I just don’t want you to miss out on a really good deal.
So if you want to check that out, otherwise afterwards, it’ll still be a bargain. It’ll still be worth it. But if you’re going to catch it at the best time, it’s part of the pre-launch deal. Anyway, I’ll catch you same time, same place. And if you’re new to the app, you know, have a little look around and let me know what you think. Thanks so much. I’ll catch you around.