Stop Blaming Bruxism! How to Spot Frictional and Constricted Chewing Patterns (CCP) – PDP141

OBAB:
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Jaz’s Introduction:
In this episode, we are gonna discuss a type of wear, a type of attrition that would not benefit from an occlusal appliance. There is no place for a splint in this type of wear. Now the way I got the guest Dr. Sandra Hulac on today is, I was on a Facebook group for dentist, I believe it was DPR, and someone posted a photo of some anterior wear, and so many people suggested occlusal appliance, splint, occlusal appliance, or something of that nature. But you see, this type of wear was not due to parafunction. The type of wear exhibited was functional, and therefore, in these patients, we need to stop blaming bruxism and start looking at different etiology of the wear. And this is what Dr. Sandra Hulac will break down so well. Some of the key themes that we really cover well in this episode.

Hello, Protruserati. I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. This episode will change the way that you see the tooth wear that you observe in your patients. We’ll go on to describe the terms later, like frictional, chewing pattern, et cetera, but not only does sandra describe it.

We show a video as well of one of our patients who exhibited a constricted chewing pattern. So all these terms might be new to you, might be familiar with them, but essentially it may fool you. It looks like bruxism. It almost, you know, you look at it and think, yeah, yeah, that’s bruxism, but it’s not bruxism.

So it’s really important for your diagnosis so you can start getting predictability in your treatments. I was really stoked to have our guest today, Dr. Sandra Hulac. She is just absolutely brilliant. She’s so giving and she’s so passionate, so, so good to have her on the show. This is one of those really big episodes, which might take you a while to process because we do go into the deep, dark world of occlusion.

My favorite place to go to, and there are two ways that this episode may just twist your mind a bit. One is with a whole, you know, think of bruxism as something else and a frictional chewing pattern as another thing. So, functional wear versus para functional wear. We’ll talk about that. And that itself can take a while to wrap your head around.

And the other thing which is really crazy, and for me it took me years to realize, only when I saw it in my own patient or in occlusal appliance, that I realized the following, right? Which is that centric relation is not always more retruded, or the other way to say is centric relation is not always more distal to MIP. Centric relation is not up and back in the joint.

And there is a case whereby some patients, their centric relation is actually anterior to their maximum intercuspal position. So for those of you who are new to these terms, are getting a bit confused, we go into it a little bit, but not so much. So you might wanna check out some of the more foundational episodes of Protrusive or check out OBAB.

Protrusive Dental Pearl
But let me just explain this concept, because this concept is your Protrusive Dental Pearl today. Every main episode, I’ll give you a Protrusive Dental Pearl. So the Protrusive Dental Pearl is to acknowledge and to understand and to believe in the fact that sometimes your patient-centric relation is not gonna be more distal.

It can be anterior, and the mechanism to think about it is imagine the mandible is a foot, because a foot can move, right? And the maxilla is a shoe, the shoe doesn’t move, it’s the foot that moves, right? So the foot fits inside the shoe. So, in our case, the mandible fits within the maxilla. Now, if you are wearing really tight shoes, right?

So your foot, you say it’s your normal, usual foot. So you go through the shops, you buy some shoes, and the person gave you the wrong size of shoe. They gave you two sizes too small. So you try to put it in and you’re really having to force your foot within your shoe. So imagine having to force your mandible within the maxilla and the maxilla is too small, right?

And so to make it fit, the mandible might have to go back a bit in the same way that maybe you’d have to curl your toes in. You have to really force your toes and curl them to allow you to get inside this shoe, and it’s not a comfortable position to be in, but you can still walk in it and over time you might even adapt.

The shoe might stretch a bit in a way. The foot may adapt chronically to that scenario. But the drive home point is that sometimes the shoe is too small, or rather the maxilla is too small for the mandible and the resulting bite means that the condyle actually goes further back in the glenoid fossa and therefore it’s no longer in an anterior superior position.

And that’s the whole point of centric relation. It’s no longer in centric relation. So for that individual whose condo is further backwards for them, their centric relation actually is further forward. So I hope that made sense and maybe you have to listen to it a couple of times. But basically, these patients do exist and so we do mention that as well.

And that is your Protrusive Dental Pearl. We’ll talk about how to diagnose that through occlusal appliance therapy or a jig, or, as Sandra describes it, the Kois deprogrammer. Now enough for me, blabbing will join the most wonderful Dr. Sandra Hulac.

Main Episode:
Dr. Sandra Hulac, welcome to the Protrusive Dental Podcast, longtime fan of yours. Welcome. How are?

[Sandra]
I’m good. Thank you. I’m glad to be here. It’s such an honor.

[Jaz]
It’s so great. I mean, today’s a very cool day for me. I’ve got yourself, just about an hour ago I had Gregor Slavicek, from Europe talking about some really cool occlusion things here. So today we’re talking about a really important topic and I’m just amazed that I’m with you recording right now because, you know, you look at your heroes and you are very humble on Facebook, and I messaged you.

You’re so incredibly humble, but it’s amazing now. I know there’s so many negative things about social media, right? About, you know, mental health and where it is too much. But one of the greatest things about social media is for young dentists to be able to message anyone in the world. Anyone, they look up to for mentorship, for advice.

And we connected because on DPR Facebook group, someone had posted a photo of a particular type of wear, and about 80, 90% of people, were like bruxism, you know, watch this, para function, et cetera. But you are the first one. And I was thinking, wait, why has no one mentioned the ccp? And then you’re the first one who mentioned it.

I was like, oh my God. It’s Sandra Hulac. So, I was like being cheeky. I was like, you know, I, I don’t think she’ll reply to me, but I messaged you. And then you replied. So, God bless you. Thanks so much. And now here we are to spread some knowledge to share with our colleagues. So for those of you who haven’t heard, and guys, please check out the work of Sandra Hulac, online contents.

Amazing. Tell us a little bit about yourself, because I know you’re in Hong Kong. You’re my first guest from Hong Kong. Where you trained, what inspired you? All those things, please.

[Sandra]
Okay, so I actually come from a family of dentists. So my father is a dentist, my brother is a dentist, and my cousin is a master ceramicist.

And both my father and my brother actually also started out being dental technicians. So it’s kind of a family thing. And I knew fairly early on that it was a profession that I really wanted to go into. I was, you know, not the least bit surprised in dental school. Like many of my colleagues that had thought it would be something altogether more different and more glamorous.

I was like, okay, well that’s just how it is. And yeah, I never regretted the choice of becoming a dentist. Now what I regretted is when I got out of dental school, although I knew that, you know, you’re not done learning and-

[Jaz]
Where did you do a training? Because I know you’re in Hong Kong, but where did you actually do a training?

[Sandra]
I went and studied in Germany and I studied at a very, very small dental school in the north of Germany, called the University of Witten/Herdecke. And it was at that stage, one of the very few private universities in Germany, but it wasn’t fee paying. You had to apply and you got in and, you know, so I actually decided to go there because my brother had gone to a very large state university, Erlangen, which is one of the foremost dental schools in the country in Munich, sorry, in Bavaria in Germany.

And I was close to home. But it also was quite brutal because they accept about twice the amount of students they can have in pre-clinic, and by the time they’re going to clinics, they need to get rid with 50% of them. So my brother, because he was a trained dental technician, much of the stuff they have to do in pre-clinic, like, you know, the waxing, all that kind of stuff, that was, you know, nothing for him.

But I didn’t have that training. I didn’t wanna go into a large dent like where this could happen to me. So one of the things that Witten had was that it much moral in the kind of, you know, American way that they went into clinical training much earlier than your average university where you wouldn’t really see a patient before you’re in the fifth term.

Now, we started seeing patients in term three already. Our whole thing was like, the whole patient. So you, when you were doing your cons assignment or your prosth assignments or your, I mean, you had to treat the whole patient. You had to go and develop a treatment plan for this patient. This patient needs this to that, and even for your finals patients, you know, we had to do, by the time you do the finals, you had to do like X amount of crown preps, X amount of this, X amount of that.

But that all had to happen in a patient that you had started from start to finish. So finding your final exam patient was really, really, really challenging. Because you had to do a fixed prosth, you had to do a removable prosth, you had to do crown preps and all that.

[Jaz]
Very comprehensive.

[Sandra]
So very comprehensive. So we’d say, I’d say I’ve come from a comprehensivity kind of training. We were incredible. It’s just like we didn’t really know why. I mean, well, our course coordinator, Dr. Reynaldo Ramirez also would say like, any monkey can learn how to drill a tooth, you need to know why you do it.

So, but still, you know, when I came out of dental school, it was 1993 and I knew that, I knew nothing. This was another one. You know, nothing. You know, nothing. You know nothing. I knew that I knew nothing. So we certainly weren’t a dental school that trained you very well in the art of Dunning Kruger. So it was-

[Jaz]
Just to get perspective. How many classmates did you have, Sandra?

[Sandra]
We had 20. We were 20. Max 20.

[Jaz]
That’s amazing because one thing I really resonate with there is, the book by, I dunno if you’re read the works of Malcolm Gladwell. I’m a huge fan of his. There’s a book he wrote, David and Goliath.

And he talks about it’s sometimes better to be a big fish in a small pond than a small fish in a big ocean. Kind of thing. And I think with your training, I think I definitely hear those vibes that you had a lot more smaller class sizes and therefore perhaps a better learning experience.

[Sandra]
Well, you know, I don’t know. When it comes to, one of the things that we had a problem with is that there wasn’t that much time for theory, so to speak. And because it wasn’t like big established university, yet many of the lectures we had weren’t really lecturers. There were people that worked in the field, so they knew how to do, but they didn’t know how to teach, or they’re taught with a lot of passion.

But there was, it was a lot. It was quite chaotic to be perfectly honest. I know it’s not like this anymore. I noticed the university has come heaps and bounds, but in my time, boy, it was, it was so chaotic. And we suddenly got a new dean and it was, ugh. Anyhow, it was like five years of lovely chaos, seeing a lot of patients.

And so one of the things that I always find when it comes to like knowledge, for example, particularly when it comes to removable prosth, which I know nothing about, you know, material science and stuff like that. So I’m sometimes sitting there scratching my head and people go like, yeah, it’s like blah, blah, blah.

And I’m like, how come I don’t know this? Yeah, because nobody ever taught you that in university stupid. On the other hand, because we were doing pre-clinic with the medical students, you know, it wasn’t separate. Because it was big medical faculty there as well.

It’s actually much, much more famous for its medical faculty. And so I can still, you know, run circles around many, like when my partner ask me something medical and I’m like, well, it’s because of this and this. It’s like, how do you know this? And I’m like, because I went to university, you know, the same thing you did.

But so my training was great in some aspect, totally lacking in other aspects, but the most important thing is that you gotta understand when you do dental school, you come out and it’s very good to know that you know nothing. You know nothing because, and you know, you can do dentistry for years and you still know nothing because you’re never done learning. Never.

[Jaz]
Sandra a hundred percent agree. But the difference now, Sandra, is that yes, we still know nothing when we come out, but the danger and the real sad thing now is not only do we do nothing, We have done nothing. i.e., we’ve done, like, you know, we’ve done like one root canal.

[Sandra]
Exactly.

[Jaz]
In my class, in my peers. You know, the amount of the volume is not there. Sounds like you had a bit more comprehensivity as you called it, and a bit more volume behind you, which I think is a real danger or a real worry about new graduates.

[Sandra]
Yeah. So, no, and it quite right, so, and I think actually, so it’s a double-sided sword on one kind. Well, I think when you’re coming out as a fresh grad out of university, you know, in most countries you paid an extraordinary amount of money. Not in the UK, but in the US you have, you’ve received, or what you think you have received very comprehensive training because that’s obviously what they tell you.

That you know, you are the best trained and then you go out in the real world and nothing is like how it was, you know, for once you find out, you can’t take the teeth out of the patient’s mouth like it could do in the phantom head. And you can’t sort of pull the cheek away when you have a difficult cavity and all that stuff, so, and if you haven’t done it, then I think it’s very hard.

You just have to then many people make the decision. It’s like they stop even trying and then, or maybe they try and do their best and they still clinging onto a notion that they were so well trained. Or they realize that they have to go a completely different way and become extremely conscientious and really then look at, for example, my God, on Instagram, what’s available, and these people tend seek out mentors.

I mean, I did not grow up in the time of the internet, so for me it was, it took me a little while to, I always had an inkling that I needed to know more. But then, you know, I started working in London. I actually worked in London for nine years, and I worked first in the East end. That was pretty rough.

Like, Four months in bio next to the Royal London Hospital. Whereas, I mean, in a full on NHS practice, you know, where we had-

[Jaz]
No way.

[Sandra]
Where we had portable suction units, you know, the ones you rolled around, which you had to empty at 10 of today. Yeah.

[Jaz]
Wow.

[Sandra]
It wasn’t an-

[Jaz] I would never have thought that you spent time in (beep) NHS Dentistry

[Sandra] No, totally. And the building I was working at, the Bow Dental Surgery on Bow Road, naturally was allegedly once owed by the Kray twins. So, it’s like, and it had no heating in winter. It was just miserable. So I worked there. But you know, I saw volume, you know, I saw volume again.

And then I started working in a kind of semi-private practice and I stayed there for a little, I stayed there for four years and then I opened a private practice for Bupa in Tower Hill. But I always felt, you know, I needed to know more. And when I then started working in Hong Kong in 2001, it was the first time that I worked in a big group practice. And I suddenly had-

[Jaz]
I just want to know, what took you to Hong Kong? Was it family? Was it love? What was it?

[Sandra]
Yeah, it was my husband’s job basically. So he got offered a job with Citigroup to go over to Hong Kong and we thought we were gonna stay for like maybe three years max.

And I was gonna go back to the university and I wanted to do maybe a master’s in endodontics, believe it or not, which I really loved at that time. And now I haven’t done a root canal in years, obviously and, but so that didn’t pan out. So I took my licensing exam. I passed my licensing exam, and then I started working and this practice was suddenly, you know, there were so many good dentists there.

They were all like, they knew so much more than me and I was just, and I knew, they knew much more than me. And then I started working there. Then I had a couple more children. And finally in 2007, when it comes to big decisions, by which time I had been working for 14 years.

Which is one of my biggest regrets that I didn’t start this earlier, but 2007, the time was right. My youngest children were just two years old. I could finally, literally leave them and I took myself off to Seattle, to John Kois. Yeah. So I went to Seattle to train and I started taking the whole curriculum of John Kois.

And when it comes to post-graduate education, I still think, oh, I think it’s the best in the world. If you want to have a comprehensive program that teaches you literally the alpha to omega of dentistry and gives you, you know, I don’t know. And also puts you in touch with a bunch of great people and mentors.

And it opens really, it opened, it opened the world to me. I am so grateful to, to Dr. Kois and everybody in the Kois Center. And you know what happens when you are finished, then that Kois center, typically you start mentoring other people and eventually you become a mentor and eventually become a clinical instructor.

And that’s what I am since this year. So I will go back in September and actually, you know, be clinical instructor on my first course, which doesn’t mean I really instruct, but I’m just really there to help Dr. Kois to facilitate the best learning process. I mean, it’s really amazing.

[Jaz]
I mean, everyone who’s done Ko is said such wonderful things, is a gentleman and a philosophy and a camp that I respect so much, so much time.

And I’ve got, behind the scenes, those who are listening. Can’t see the screen right now, but I know you’ve got the checklists and stuff, which is so comprehensive and thorough that they put out and it’s just great that we are, it’s lucky in dentistry to have the institution.

[Sandra]
And John Kois will be the first one to acknowledge that there are many, many ways that lead to Rome. What he has just tried to do is to give everybody an easy entry point. You know, it doesn’t mean that this is a cult, and you have drunk the Kool-Aid. He doesn’t want you to stop thinking, but what he wants to do is give you a system. And systems are not recipes. Systems create foundations. Recipe creates ceilings, you know, so there is no recipe to this.

It’s just a system of record taking, a system of diagnosis. Because if you don’t have a diagnosis, what are you going to do? And when it comes to wear, it’s not a diagnosis and you don’t need to go to dental school to tell somebody, oh, Mrs. Brown, your teeth are worn.

Yeah, I know that doctor. I can see it, you know. So you don’t need to, you need to know what is the origin of wear. So what is the wear, it’s a symptom of an underlying occlusal disease or-

[Jaz]
Which leads so perfectly to the exact issue I wanna talk about. You time that really well. That was, you know, you rehearsal this. So it was wonderful. So, we saw that photo on that group. And so you identified it and so did I, but I was surprised that no one else did that you suspected that this wear was a CCP or a constricted chewing pattern.

So now for those listening, what are, and they may also have looked at it and say, oh yeah, bruxism, we see some wear automatically assume it’s bruxism. So this episode’s called Stop Blaming Bruxism, because there could be some other diagnoses that we can make. So what guidelines can you give to equip dentists listening and watching to be able to now change their perspective and facilitate them to make such a diagnosis.

So what are the classic features? What are the classic signs that we see that may lead to us? So just give us a, the background on this type of wear.

[Sandra]
Okay. So I wanna start out with to tell all our listeners that bruxism is the most overdiagnosed disease in dentistry because everybody will immediately jump to bruxism as soon as they see any kind of wear. Now, real bruxism is actually an extremely rare beast because it’s a neurological issue.

It’s an above the nose problem. So it comes from the basal ganglia and what the patient will do he will go sideways. So in my bruxism is always lateral and posterior. And if you give these people a mouth guard, you will actually see, you can read that mouth guard and that mouth guard looks like a Zamboni machine has gone over it.

You will see the tracks on the mouth guard. This is your classic bruxer. What people then, very often they see anterior wear and they say like, oh, this person is a bruxer. Now, anterior wear will only happen in bruxism if the patient has flattened the posterior so much that he will or his canine so much that he actually can get onto his anteriors.

Okay? And the wear in the anterior wear in bruxism will be flat because the patient goes over the surfaces all the time. Now, if we see anterior wear, solely anterior wear or anterior wear that looks different like little spicules, little thin wear on the palatal where you know the enamel, where you really, patients are hollowing out this palatal surfaces.

This is never wear from bruxism. This is where that happens in function, and this is what people don’t understand that wear can happen if the function isn’t functioning properly. So if your occlusion, if you can either have, you know, something called occlusal dysfunction where your chewing envelope is so large where your envelope or function is so large because your brain can’t find a back teeth.

And, this is a completely different pattern, but, we call this occlusal dysfunction, or you have something called constricted chewing pattern, or frictional chewing pattern, which are two different things. Whereby because of dentistry, or very often because of orthodontics, by the way, or because the patient grew wrong.

You have just during chewing too much contact between the facial surfaces of the lower anteriors and the palatal surfaces of the upper anteriors because these teeth actually in function should never touch. And one of the things and that’s why, for example, unfortunately many of these problems are, or you see many, many constructed tune envelope patients that had previous orthodontics because orthodontic cases are very often finished in the growing patients, say 14 to 16 years old, we’re done.

The young orthodontist is, or the orthodontist is taught in orthodontist’s school that the front teeth have to touch. The facial growth isn’t finished, particularly in the male. If your growth pattern is somewhat brachyfacial.

These people literally grow through their front teeth and destroy them. And so this is why, my orthodontist and I always like, leave me room there. I don’t want any touching on the centrals and laterals. Never ever do I wanna see a extreme stock contact on a central or a lateral ever.

If I’m doing restorative dentistry, I check this out in static and, you know, in functional, I don’t wanna have much contact on these teeth because they don’t have to. And even, even, you know, you can go and look at all kind of occlusal concepts, but there are certain things we have decided to unilaterally own.

And even Dawson writes, you know, in the big book that one of the biggest mistakes a restorative dentist can make is to constrict the envelope of function. Okay? And very often this is also done with restorative dentistry, you know, your bulky surfaces of anterior crowns and so on. But the technician looks at it in the articulator.

It goes like that looks fine. Lots of room, but he doesn’t know how does patient choose. And even you can have all the functional analysis, you can do all the anterior incisal tables in the world. Still, it’s probably different in the patient’s mouth and you gotta check it out in the mouth first.

[Jaz]
So it’s fair to say that bruxism is inside to outside. And then when we see the type of wear that you described. Now it’s function, so it’s outside to inside. It’s the hollowing out of the palatals of the upper, against the facial of the lower.

[Sandra]
You have said this, this is a very important outside, in an inside out. So this whole thing, when we are sent, when we are checking the envelope of motion, so the limitations of the chewing envelopes, right?

Working, left, working intrusion, you know, I’m just doing this for our listeners so people don’t chew like that. This is an inside out movement. It’s completely useless. I mean, it’s great. You know when you do it on the patient and you go like, oh, now move your lower jaw to the right, to the right.

And they go like, which jaw do you want me to move? Because actually, they have no idea what you mean because this is not a natural, this is not a natural movement. So the only people that know how to move their jaw to the right or the left under tooth contact immediately are dental students or bruxists.

So this is, by the way, very interesting. So when you have somebody in the chair that knows immediately what you wanna do, like that’s somebody where I go, oh, this might be a bruxer. It has the memory-

[Jaz]
Muscle memory.

[Sandra]
The muscle memory for the movement, cuz this is a difficult movement, means like you have to contract like two muscles on one side, release, three muscles on the other side. So yes, but chewing doesn’t work that way.

Chewing is an outside in movement. So it’s causing a completely different wear pattern as you will ever figure out. And left working, right, working, and so on and so forth.

[Jaz]
Could you now show us some photos because you’re sharing screen. Do you have any photos to show us this type of wear? And then perhaps just describe it for the audio listeners in case we do end up having to spin there for the audio listeners as well.

[Sandra]
Okay. So let me just do my share now. This is what I’m showing here is a classic test now, for constriction. So this is for our audio listeners. This is a patient that has very thin and worn upper front teeth, and they’re also quite short.

And when we look on the inside, we can see distinctive wear on the palatal surfaces of those upper front teeth. And what I’m doing here, and I do this a lot when I see anterior wear, I let actually people chew on a piece of 200 micron thick horse shoe paper, because that’s precisely the amount of space we wanna have between the teeth during mastication, between the anteriors, during mastication.

And during any kind of functional movement, like talking or swallowing. So that’s the minimum amount of space we need. And if this paper shows us a lot of tracking marks on the anteriors, very often we know that there might be a problem. Now, it’s not solely that. This is a CCP now, or a functional chewing envelope.

This could be also a dysfunctional chewing envelope. That is why we need to have more diagnostic tools. But very often this is first thing we see when it comes to how we show it to the patient.

[Jaz]
But before you come to that, Sandra, can you just explain the difference between a constriction and a frictional chewing pattern? What are the key differences?

[Sandra] Okay. Actually that’s why I wanna quickly show this video, but basically a frictional chewing pattern means that, okay, the teeth are hollowed out, but the mandible doesn’t get distalized in full MIP which is, you know, basically maximal intercuspal position. So when you close fully, the mandible doesn’t distalize in a CCP, in a real constricted chewing pattern, in an active chewing pattern, the mandible is actually pushed back when you close.

And that is, you know, now we’re getting into the whole thing. But centric means the mandible is always going backward. No, it isn’t. Because very often in centric, the mandible actually wants to go forward because the mandible is for reasons-

[Jaz]
It’s being forced by the maxilla. There’s no space.

[Sandra]
It’s actually, yeah, exactly. It’s being trapped by the maxilla. So it’s actually distalized in full seatings. So what I have here, just quickly show that for our people that actually are. So what you see here, you need to look at the, you can see the constricted chewing pattern, how the patient is first when he goes in hitting on the front teeth and now distalize.

And you can see what happens to the disc as well, that, you know, the disc actually is anteriorly positioned when the mandible is fully closed because the condyle is pushed so far back.

[Jaz]
Sandra, I’m gonna share my video if you don’t mind now actually.

[Sandra]
Oh yeah. Oh, wow.

[Jaz]
Can, can you see this?

[Sandra]
Yeah. Oh, yes. Okay.

[Jaz]
Let’s watch the video.

[Sandra]
That’s classic. Yeah.

[Jaz]
But then what I do is I make it in slow motion now and watch it in slow motion. I think it goes like this. This is really, and then it really gets forced back.

[Sandra]
Oh man. Yeah. That is unlucky growth here.

[Jaz]
Yes, exactly. And, but I think it’s a nice little clinical demonstration to supplement your animus.

[Sandra]
Did this patient have premolar extractions on the top? Just wondering.

[Jaz]
I don’t know. Yeah, I’d like to know as well. I don’t remember. So, back to you, Sandra. So I hope that was, would you agree that that’s exactly, that is a classic CCP?

[Sandra]
That’s exactly, that’s pretty much a classic CCP. And I would think that this patient because there’s actually not that much wear on the teeth. Okay. She’s probably very adapted. I would think that she’s completely off the disc and she might be a little, she might be quite symptomatic.

What we typically find in that, that females don’t really wear their teeth, their everything else hurts, but because the muscles are weaker than they will typically end up with a lot more pain symptoms while men, they just destroyed their teeth. You know, they don’t have any pain. The muscles are so strong, they’re just destroyed their teeth.

[Jaz]
Yeah. Very valid observation. Do you wanna share again, your screen?

[Sandra]
Okay. So the important distinction between a frictional envelope and a proper constructed envelope is that in a frictional envelope, the mandible isn’t distalized in full closure, but in a frictional it is. So we used to call a frictional envelope an adapted constriction. So thinking, and sometimes it is an adapted constriction whereby, you know, the patient has worn away so much of their front teeth that you know, they now they can seat into that no further wear will occur or whatever wear is going to occur future in future to the teeth won’t, won’t be due to friction, but will be due to chemical issues.

For example, because once you’ve worn away all the enamel from the pala of the upper front teeth, you know your dentin is going to erode. Once it’s exposed, that’s just gonna happen, but that’s not gonna happen because of friction that’s just happening because of mastication, because of acidity of food and so on and so forth.

[Jaz]
Well when you’re looking at these two different patients very similar, but different, diagnoses clinically. I think the key distinction factor is actually seeing that mandible, distalize and getting a hint that, okay, there’s a mandibular distalization happening, but it’s very difficult to diagnose clinically, right?

[Sandra]
Correct. And you, in order to diagnose it clinically, you gotta actually, you know, put this patient in. Yeah. You have to get a centric registration record and see where does this mandible actually wanna go, and where does it wanna be? Okay. And how far is it gonna come forward or, or backward or whatever.

And one of the problems, and this is where people, old school, gnarthology, go like, this is bullshit. This doesn’t happen. The mandible will always goes back, it’s a fully seated joint. It’s always distal to MIP, blah, blah, blah, blah, blah, blah, blah. This is where, for example, using a leaf gauge is gonna bring you, give you a big problem if this is a true constriction. Cuz the only thing, leaf gauge-

[Jaz]
I was just gonna say this exact point, Sandra, that I’m a huge fan of the leaf gauge, but when I suspect this diagnosis, I might then go to a acrylic jig.

[Sandra]
Yeah, exactly. You cannot, because a leaf gauge will always distalize your mandible or you are running in a big, big trouble to push that joint back even further. And so you don’t wanna do that. So what I do when I suspect this, and what I do with most of my patients is I put them in a so-called Kois deprogrammer, which is your acrylic jig. But it’s basically an appliance that can be worn, it needs to be worn for a very long time because particularly when it comes to construction cases are much easier.

But when it comes to occlusal dysfunction in a brain that’s utterly confused and has no idea where the bite is, where everything is, you need to let the what we call the motion generator, the general pattern generator. Forget, so to speak, how everything is supposed to fit together so that the joint can seat and that the muscles are relaxed.

And for this, you need time and patients cannot run around with a jig forever because I mean, it’s annoying. So here is where the Kois deprogrammer comes in and I’m just gonna show you a quick case. So now here for our listeners, we have a case here with a patient. I did that a very long time ago that kept breaking her front teeth and there was a fair amount of lingual wear on those teeth as well.

And she also had a fair amount of wear on her back teeth and basically no more occlusal home because of poor restorative dentistry. So I wasn’t gonna go and restore this case before I knew actually where she wanted to be. So on the left, we can see now this is a Kois deprogrammer in action, so it’s basically like a holy retainer.

But it’s got a tiny little, what we call platform behind the upper front teeth, so it can be worn during the day and you know, people can talk with it. It’s a little bit annoying these days. We can make them without the wires in the front and you just scan them and you just have an appliance that really just sits palatal.

But basically what. You have with this patient, wear this as much as possible, and they only take it out for brushing teeth and for eating. And you want the patient to wear this for a good solid week and get back to you. So every morning when they take it out, you want them to sit up, tilt their head back about 45 degrees and close.

And eventually you will find that when they say is, oh, my teeth meet in the same spot every time I take this appliance out. And that means that they are now deprogrammed. And that’s what you then wanna see when you actually mount the models in the bite you have taken with the appliance in place.

By the way, this is what’s so smart about it, because when you take a jig very often or any other centric registration, if you guide the patient into something, you have to remove the appliance. Okay? With jigs you don’t, but this has the advantage that it can be worn for so long, and in my opinion, is sometimes really necessary.

So when you then take the bite registration, you have much more security that the patient is really gonna give you the centric bite, and then you mount this and you analyze the model. In a constricted chewing pattern or a frictional chewing pattern, the patient will say, my front teeth meet first.

Okay? Or I have my heaviest frontal, and in a dysfunctional chewing pattern, the patient will typically say that the first contact happens on one premolar or so, or can be a lower seven or something like that. You very often have premature contacts on those. So, yeah. So this is how a Kois deprogrammer looks, basically a Hawley with a little platform, but, it’s my tool of choice.

[Jaz]
Do you use this like routinely or only when you suspect a CCP or a friction chew pattern, for example, do, is the leaf gauge still in your drawer for a more straightforward case for you?

[Sandra]
Abso-bloody-lutely. I love taking a leaf gauge, but only when I’m 100% sure and even when I use, I always look if I put my patients, cause I do a lot of quite complex, full mouth rehabilitations because I specialize, or I’m a specialist when it comes to, you know, restorative cosmetic and wear cases and stuff like this.

So I put my patients in temporaries for a long time. I’m not going straight into porcelain, you know. Because I wanna make sure that this does works before we do this.

So I’m these days, I mean, in former days, you know, I used to, I used to, let me just show you a case. In former times, I used to put people into milk provisionals, and these days I do everything. I do everything with injectables because I’m a big, so here I have a case I just did recently and for our viewers, you can see, you can have an extremely deep bite situation.

The patient keeps breaking a front teeth at all. Everything also looks pretty ugly, and you can see now in the middle of the screen how this patient is hollowing out. The inside of her upper front teeth. I mean, that’s like that Left central is about to break off. I mean, that’s, that tooth is so bombed out and this patient like pretty much everybody has no money and doesn’t really wanna do anything.

[Jaz]
So I mean, while you’re having a drink there, you could see how the central incisors there have not got so much talk. Right. And that’s part of the diagnosis part of the issue.

[Sandra]
Yes, yes, yes, yes. They’re like, you know, slightly upright.

[Jaz]
They’re slightly upright.

[Sandra]
Very upright. And the lower incisors will be very often pretty retroclined because they already have been trying during growth to get out of the way.

But, you know, not enough. So, in her case. So here we have a pretty much bombed out occlusion as well. And so here, actually here, I did take the registration with a jig that I bonded behind her front teeth because she wasn’t gonna, she’s a head hunter. She needs to talk all the time. She wasn’t gonna wear the deprogrammer.

Okay, so this is what I did. So I don’t know if you can see that, but there is actually a small bonded platform on the back of these teeth. This is how I take my centric registration. They sit in the waiting room for like 20 minutes and constrict chewing patterns. They did program very, very quickly because their lower jaw wants to come forward.

[Jaz]
They want to come forward.

[Sandra]
Yeah. What we then do, we wax these cases in centric, and I don’t know, is injection is the kind of ejection molding technique, is that a big thing in the UK already or has that not gone?

[Jaz]
Yes, it’s growing. Yes, absolutely. Using the gc injectable resins.

[Sandra]
Injectable, exactly.

[Jaz]
But it’s great to hear that you’re using it as I’m loving the direction, you’re going in is that you moved away from the mill crowns to this, it sounds great.

[Sandra]
If I need a patient if I need to get the patient out of this pronto. I mean, who can afford? We are talking about, you know, this is basically a full mouth case.

We are looking at about 150,000 US dollars worth of dentistry. Who can afford this? Just like that. But I know if I don’t get this patient off her front teeth pronto, she’s gonna make them unrestorable possibly within a year. I need to get her off her front teeth. So that’s where injectables are. Great.

So here we have the classic thing where we have a wax up and we duplicate the first wax up model, and then we knock off every second tooth because we’re using alternating matrices, two matrices per arch. And then we go and we start. And so I’m going here through this. This is this for me. This is a fun day. Took me six hours. But it’s basically all the teeth.

[Jaz]
And for those listening what’s Sandra’s showing essentially is that Sandra’s doing injection molded long-term, direct temporary crowns, like composite crowns is what you’re doing. Which is great. See?

[Sandra]
Yeah, exactly. And I know I give the patient, I said, look, I don’t know how long this is gonna last because it is pushing the material to its limits.

And if you talk to GC, they say, yeah, you know you can do it. But it’s also, yeah, we good for occlusion. But this is like, really pushing it. So I say to the patient, look, now I’ve gotten you off your front teeth. And you, and here we have, we do the same thing. You know, we make the patient chew and we see we gonna get rid with all those little contacts we have.

But you know, she’s not on those front teeth so much anymore. And now you have the finish case. Basically you can see that as a significant bite opening we have done, but we don’t just have open to bite by letting the patient, by rotating the mandible open and distalizing it more, we actually have allowed the mandible to come forward.

So this patient has been in these provisionals now for about eight months and she’s actually moving to the UK. So I’m gonna finish off her upper front teeth because I want, I obviously want to give her the biggest bang for the buck. I said, when you are in the UK, because she needs some implants down there.

Those two lower front teeth are toast. The ones that look a little bit gray, she is opposite. She needs a lot of dentistry, but the nice thing is now she has time to sequence this treatment out to a point, you know, where finances and time allow, because at the end, yes, she added a little bit of cost to the treatment, but it bought her the luxury of time.

And as I say in this case, although I know that this is most definitely a constricted chewing envelope, I’m much more comfortable in doing this just with a jig bite because, but I still would’ve never taken a leaf gauge with a jig bite because I know I’m gonna temporize her like this.

And so I had these kind of patients you then bring back for short appointments and adjust occlusion, you know, make sure there’s no streaks on those front teeth. Make sure when they chew that you know, their back teeth really crisp into a very nice occlusion because you don’t want them to chew too lateral.

Now this is a different topic, when it comes to occlusion equilibration, but you want despite to be like, where they go like, wow, this feels really good. And then you’re done. And now you can segment this case out because hey, I’m not Frank Spear. I’m not John Kois. I’m not gonna prep, I don’t know, 28 teeth and you know, do a jig bite and then do, I don’t know, cross mounting and stuff like that. Nah, no, no. I’m not doing, I dunno. I’m doing it like this.

[Jaz]
I love to see that and I think everyone’s gonna love to see this. Just a technical question on the posteriors, were the posterior temporary, PMA crowns or were they also injection molded?

[Sandra]
Yeah, that’s all injecting molded in that is stuff strong ass

[Jaz]
Yes. Yeah. So you got, that’s all pretty much posterior injectable resin crown.

[Sandra]
Good. Exactly.

[Jaz]
Posteriorly as well.

[Sandra]
Exactly.

[Jaz]
Amazing. Yeah. Wow. They look so great.

[Sandra]
Yeah, I mean that’s because it’s a nice wax up and it’s good matrices. So yeah, it’s pretty nice. And as I say, you can do this quite reasonably because the lab cost at least for me is not that high, and the material is not that expensive.

So you can do this for a fraction of a crown price. And what I very often say to the patient, look for me, this is also easy because now the only thing I have to do is, you know, I’ve obviously removed the decay. This stuff is also my core buildup already. I can just prep these teeth now to ideal.

So it’s properly bonded on there. So now, when I prepped her, her 10 upper front teeth there was a doddle. You know I just have to get the margins back to tooth and do my stuff. But I’m quite happy to leave much of this is core built up. It’s a very strong resin material. Okay.

[Jaz]
Restoratively, it’s a dream, this scenario, actually very good.

[Sandra]
It’s very nice now, but I have patients also with constricted chewing patterns and stuff like this for much longer. I have one case where I completely changed to occlusion. He’s three years out now, and I brought him forward and gave him the bite he was happy with.

Now, when the material wears in the ideal case scenario, your teeth are going to erupt into occlusion. You know, that’s the whole DAHL concept in, in many so to speak, because obviously you still wanna have a supported occlusion. What you don’t want is, you know, big pots. That’s why I personally never DAHL because I think it’s too much, it’s too many teeth.

But typically if you just one posterior tooth is out of occlusion, you still have a supported occlusion. These tooth should erupt in occlusion and to occlusion.

Jaz’s Outro:
Just a few different side questions. I wanna lead you down now based on the case showed me that one of the questions that we are going to discuss is the role of pre-restorative orthotics, because what you’ve shown there is a wonderful case where this was managed purely restoratively.

And finding this new joint position, which is gonna 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 percentage of case A) would you like to, in an ideal world, have a one then say, okay, this patient is gonna have orthodontics. And go through the pain and the misery of that and, 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. Well, there we have it guys. What does Sandra say? Well, we have to find out in part two because I’ve left you on a bit of a cliffhanger. Now, part two, it will be on the app, on the premium app and the free app. So, you know, download the Protrusive app if you haven’t already, and you could actually get it for free by the way.

You don’t have to pay. If you want to get CPD and watch the premium videos, then yes, you should subscribe to Protrusive Premium, absolutely. But you can watch the episodes for free as well. So this part two, because it’s so visual, she shares cases and examples and how she uses the articulating paper to diagnose these issues.

And even sharing a failure and how she rectified it. You always have to respect clinicians that share their failures. So the way you’ll be able to access part two next week is on the Protrusive app only. It’s not gonna be on YouTube, it’ll be on Protrusive app. It’ll be on free version as well. Part two will be a free version on the app.

That will be the premium version, which can get the CPD and the premium notes, but it will only be accessible through the app. So you can go on your browser, for example, www.protrusive.app, and you can actually check out all my content via your browser. You don’t have to do it on your phone. Some people don’t like the idea of learning on their phone. That’s totally cool. You can do it on your laptop. Thank you so much once again for listening. All the way to the end. I’ll catch you same time, same place next week.