A Story of Digital Occlusion – PDP057

Jaz’ Introduction:
Hello, Protruserati. I’m Jaz Gulati and this is episode 57 of the Protrusive Dental podcast. Thanks so much for joining me. In this episode, we will talk about digital occlusion and not the nitty gritty over complicated kind of stuff when it comes to occlusion. The really important stuff like for example, how to use digital photos and digital scanning to make sure that you do not get cans in a patient smile, how to predictably raise the occlusal vertical dimension, using these two techniques to make sure that when it comes time to fitting the provisionals, or fitting the definitives in the patient’s mouth, then everything will be much more likely to work and need less adjustments. Because really, that’s what occlusion is about, doing less adjustments and more predictability. Okay, so I’m sorry, not sorry that this is such a long episode, right? This is a mammoth episode, I really appreciate that so much to do it. Like in two commutes, or three commutes, or that’s a lot of onions, you have to chop to listen to this episode. But there is a reason for this, right? The flow was just too good. Like, originally, I was gonna do this as a two part episode. But I just loved in storytelling. So for those of you who know Ian Buckle, he was an educator for the Dawson Academy in the UK, which I don’t believe exists anymore. But I did all the modules of Dawson with Ian. And you know, what I hung on to his every single word. He’s such a great educator, great storyteller, I learned so much about occlusion from him, but also about communication. But to you my friend, I appreciate that this long episode is not for everyone. So if you are really hungry for that special knowledge, that hot tip for digital inclusion, and when Ian gives it away, then I’ll probably start listening from the 50, 52 minute mark onwards if you really, really want to, but you will miss out on lots. For most of us who are happy to listen to the journey and listen to the stories before we get to the sort of the sexier part, which is actual how to make Digital Occlusion work for us. Man, you are in for a treat in this episode in the beginning. I mean, let me just put this into context for you without actually ruining the story. The story is that imagine you or your your partner is pregnant, and the doctor tells you that the baby will have lots of conditions, disabilities potentially, and one of those disabilities or complications is that your baby’s teeth, the baby will be coming to the world. Your baby’s teeth will be malformed. Maybe they will not have any teeth. Right? So when Ian found out that this was going to be happening with his daughter to be, he was heartbroken, right? So what do you do as a dentist, right? If you’re told this, what’s the one thing you could do, what the one thing you could do is at least you can fix the teeth. And so that took Ian on this journey of learning and upskilling and making connections so that when the time comes, he can help his daughter, and he will have a team around him to be able to help his daughter, which I just think is so noble. Right? So that’s his story and listen to that and how that inspired him. But we also talk a lot about career decisions. Do you do specialize? Do you do a masters or what are the complications in going in a private route and just upskilling with courses. So we talk about these themes. So as loads of communication gems in there, which you would expect for an episode with Ian Buckle. Now, just before we joined the episode, I want to share the Protrusive Dental Pearl for this episode. So many episodes ago, I gave you a pearl, which I think is now false, right? So I changed my mind. And another pearl I gave you in the episodes was that there’s something very unattractive about someone who can’t change their mind. So I think it’s a beautiful thing that we can change our minds. And so the pearl I want to adjust is the one where I told you that how you do anything is how you do everything. So how you do anything is how you do everything. So there is some beauty in that. And I think there’s a lot we can learn from that. But let me tell you why I’ve changed my mind right? The time now right now is 5:50am I woke up at 4:15am UK time I did my beard which is a thing when you got a beard like this, you have to tame it. And I had coffee, had breakfast and now it’s 5:50am. And I’m recording this. And I’m telling you this not to gain your sympathy or your bravado or anything like that. It’s because last night I was supposed to do some recording. So supposed to do an evening session, my producer supposed to have it by now so I can start working on it. But I didn’t do it. Because my son was just, it’s such a great time. So my son is 18 months. His name’s Ishaan, he’s 18 months. And wow, you know, he’s developing this unique personality, he’s got so much energies, he’s bouncing off the walls. And last night, he was just, he was a comedian. He was being a comedian. He was just doing all these shenanigans. And I was just loving every moment of it. So I just decided that you know what, I will not be doing my recording, I will be spending more time with my son and I don’t regret it at all. I love it. And so because this podcast needs to come out there, and I value you and I value your listenership and our value podcast, I love podcasting. So much fun, right? So I am up early to do it. And I mean, yeah, I’ve got good energy about me. As you can see, hopefully, I’m not sounding like lack of energy or anything like that. So the lesson to be learned here is what do you value? Because whatever you value that should govern what you do care about and what you should give everything for. For example, on the Protrusive Dental community Facebook group, Sheetal Kharbanda, Sheetal buddy, what you posted was you said, “Is there a way to get Alexa to play the Protrusive Dental podcast?” And I sort of made a video saying, look, Google can do it. Siri can do it. I’m sure Alexa can do it. Right. So find out if Alexa can do it. If not, I’ll make it happen. And then when I post that video, I realized oh my gosh, my desktop background is so messy. Right. So who else has a really messy desktop background? Right? So I’ve got a very messy desktop background. And then Dami,` Dami Bakare, an old friend from dental school, he commented saying, “Wow, that is one messy background. You’re such a busy guy.” How’s it? Oh, gosh, he’s right. You know, it’s such a messy desktop background. And I thought, why is that? You know, I’m pretty organized, in my dentistry and stuff. And so why is it that my desktop background so messy? I thought about, I thought, you know what, I don’t value the desktop background. And I think sometimes we have to limit all the things we value, we have to write them down. And that’s what you will apply how you do anything is how you do everything, right, because there’s impossible to do everything at the highest level. So last night, I valued my son and I value my son, so I spent more time with him and valuing you, and I’m here right now recording in the morning. I don’t value the aesthetics of a clean desktop background. And also I don’t have normal person OCD. Obviously, as a dentist, I have OCD when I’m doing teeth. But normal person OCD I don’t have so I can live with a messy background. I know some of you probably can’t. So it’s all about that, what I’m trying to bubble here is that find out what is it that you value, make time for it, you’ll always make time for the things that you value. And things that you don’t value will get squeezed and crushed and move to the side. And that’s totally cool. Don’t be too harsh on yourself. If that’s the case, accept it, except that that’s the beauty of it, that you can value some things and really give it your all and everything else that you don’t value doesn’t deserve the best of you. So hope you enjoy that pearl, and let’s join Ian Buckle with the story of digital occlusion.

Main Interview:
[Ian] There’s still that it was very basic, it was pretty basic dentistry in those days. And then, you know, I sort of moved on to get a little bit more interested in dentistry. And the probably the first thing that we were able to get better at if you like, was endodontics when rotary just came out. And despite what many people might think about me, maybe you as well, Jaz, as I’m quite shy person and I bother going to six text. Well, you know, I I’d say yeah, you know, I was brought up in the generation with my grandmother saying children should be seen and not heard. So I knew my place. But, so I went to this section 63 meeting, and I was, I thought it was very interesting that I could get good at this. And I wanted to provide good care for the patients and also have an interest for myself, you know, there was a selfish part in there as well. And so I stay behind waited till the end. And I said to the guy who happened to be the dean as well, you know, I’d really like to get involved, what is it I need to do? And it’s just like, well, it’s a three year course, full time. If you don’t like it, you know, you tough luck. And, you know, I was extremely disappointed, you know, because, you know, I had a young family at the time, you know, mortgage like everyone else, all those things. And it was, it really just seemed like a massive obstacle and you know, I didn’t know how to get past that. You know, always like to mention my friend Mike Horrocks at this stage because Mike was round. He was a year older than me but he went and got on with it and did it. And what he’s done with his endo stuff, I think is fabulous. And the way he’s encouraged practitioners to, you know, say, look, you know, let me show you how to do a better endo, and then and then it gets people interested, when you get someone interested, then they start really getting into all the other stuff in the research and there’s different ways of doing it rather than traditional three years, study some stuff and then come out on the you know, everything. You know, I think there’s a great way of learning. I think a lot of us. I think a lot of us in dentistry have a practically based so we like to do something and then when we’ve done it, then we like to find out how did that come together? So that was, that was my first sort of thing, you know.

[Jaz]
I just wanted to stop and say that what you said there was very relevant to some of the themes that we’ve had with the guests on the podcast for whereby we’ve talked about the specialist route and actually doing the MClinDent in ProRes, or endo, whatever. And then there’s the the sort of the other, which is the one I’m pursuing. Now I’m doing external based courses. I know, my limitations. I’m using mentors as much as I can. And there’s a whole beauty of that side as well, which I think sometimes when you’re a new grad, you’re all starry eyed and you sort of map out your career path. I’m going to do Dental Foundation, then a core training hospital, then I applied for my MCAT. And then and then I’ll be a specialist and a lot of people about 50%, I think seem to be geared towards that. And then the real world hits you mortgages come, the time thing, comes children come and then you sort of think actually, there’s this whole other route, that it’s very fruitful.

[Ian]
Yeah, I know, for sure. You know, I mean, you got to be respectful of anyone who puts time into anything, you know. But you know, I think both have value. I obviously have experience more of one than the other. But dentistry at the end of the day is a hands on sport. It’s a practical thing and no learning while you’re doing the job, but it I’ve always seen dentistry as an apprenticeship more than anything else. I think I’m still in the apprentice. We should all be apprentices. But so I think there’s value in those. But I think because everyone does it, it doesn’t mean it’s the right thing for you. I think there are some some great opportunities in postgraduate education that aren’t along that MClinDent on. And I think there’s all Be careful what I say, you know, but I think there’s a lot of things out there, which is about getting a piece of paper, rather than actually what you need to know to be a really good practitioner. I think there’s advantages in having the piece of paper. You know, it’s too late in the day for me, you know, so, but I think there’s advantages to that. And I can imagine how that sits in the modern world. But certainly, the, I think the absolute key is what you just refer to, which is whichever it is, get yourself a mentor or get yourself someone who you can resonate with, get someone who has, you know, your best interests at heart, not theirs. Yeah, I think they know, we talked for years about having a teacher’s heart. And really what that is, is that whole idea is the purpose of teaching is to get your students to be better than you are, you know, I mean, I said I was quite late to the game in many ways. And I don’t regret it because I was busy doing very interesting things. So but, you know, I again, it’s, you know, that old expression, when the students is ready, the teacher appears, but to have someone know, find someone that you that you like, what they do, that you think is a good ethos, and, you know, is ethical, etc, and then ask them if they’ll help you. You know, I mean, there’s a lot of, we’re so fortunate in dentistry, that there’s a lot of great people out there, who will help you and guide you towards the things that will help you in your career path. I think, you know, one of the things that we talk a lot about in dentistry, but I think it’s, it’s just as important, if not more important in life and in your career, is to have very clear goals for what it is you’d like to achieve. I know I mean, my, it’s a little bit changed for me now because, you know, I talk about these things, and my son’s going to be 30 in a couple of weeks time. So, you know, he sort of lived that whole thing with, but what are your goals? Where are you going to end up and, you know, I can remember him saying to me, but you know what, but I don’t know where that’s going to be. None of us do. And but the thing is, if you don’t have a clear goal, don’t be surprised if you end up somewhere you didn’t expect, very often. If we try our best guess right now that’s what we’re aiming for. So if you’re not absolutely certain, don’t be shy. Don’t be afraid of that. Don’t be shy of it. It’s your best guess right now. Go for it. And you’ll be things, no fate will take it and you’ll see other things Along the way, maybe you’ll refocus your goals. But, you know, planning is really important. You know, I really like being a general practitioner, that’s what I want. That’s what all what I wants to do. This to dentistry is about people, it’s about the whole functional system, it’s about, it’s not just about teeth, it’s not about perio, it’s not about ortho. And certainly when I was taught dentistry, it was very departmentalized. And almost everything was competing against each other. On my patients just want me to look after them and look after them appropriately, and to, you know, to have the knowledge and advise them. So it doesn’t mean to say that you’re the expert at everything, there’s a lot to be said for being a great generalist, who you know, can do a lot of great things, can serve our patients tremendously well, but also just know stuff so that if the situation needs it, then we can refer or get involved with other people that help us I mean, I am incredibly fortunate. Now I have a tremendous periodontist, and orthodontist and all sorts of other people that helped me out when it gets beyond my range, you know, but we, we all have the same goals. We’re all looking to achieve the same things. And so..

[Jaz]
One interesting thing you mentioned about your orthodontist and the great team, but people need to know that you’re very unique in that. When someone when the right case comes along, and the best person for the job is your friend in San Sebastian?

[Ian]
Alberto?

[Ian]
Alberto. Yeah, so a lot of the places will come to you in the world. And as part of your comprehensive diagnosis, some of them will end up having orthodontics, am I right? And they will have a little jolly in San Sebastian and see, Alberto Is that right?

[Ian]
Well, yeah, you’ve got the theme, correct. You know, I mean, we again, I came across Alberto. Alberto was it in Barcelona, Domingo is in in San Sebastian, both are great cities to visit as well. So if you ever get the chance, it’s great. I came across both of those guys. As part of my journey, and it was, you know, going back to what I was saying that before, we talked about endo a little bit, I always wanted to know, the thing I liked was to try and make teeth look like teeth. It was just a bit of a fascination for me. And we came across, I won’t go into down that line at the moment, but came across very many dead ends as far as that was concerned. And, you know, the cosmetic stuff helped me a lot with that. But, but 20, almost 25 years ago, our middle child was born. And she was born with a genetic disorder called Incontinentia pigmenti. And part of that, when we, when she was six weeks old, we were told she might be blind, deaf, mentally retarded, and still might not grow. All these different things. But as part of that, and she might have missing and misshapen teeth. And I think many of us as dentist, we just love to fix things, you know. And, you know, obviously, when you’re told things like that you sort of takes a little bit getting used to, but I was afraid to go, Okay, so what can I do, and the only thing that I could do, because most it was just about waiting. The only thing that I could do was to try and get to know the people that could help her if she needed it when she was older. And I knew she might need ortho, I knew she might need implants. So my, you know, I as I say I personally I was much more interested in esthetics, cosmetics, whatever you want to call it, and try and make things look nice and make them work well. Because, you know, our American friends are very cosmetically based. But you know, with us being Europeans and British, we know that it needs to work properly as well. So I was fascinated about how to bring those things together. And that’s what led me towards Dawson and all those other stuff. But with this, it really brought me on that journey to try and find particularly orthodontists that would put the teeth where I needed them to go and as I was that whole Dawson thing, as I said it was more about being a designer, you know, where did the teeth need to go in the patient’s face to make them look great and work well and be biologically healthy? And that’s, what that’s about? It’s about design, and then how you get them there is really between you and the patient, which is about an appropriateness and what’s best for them. No, I mean, some of that cosmetic stuff got a little bit out of hand and you know, it was diamond driven orthodontics, you know, but I mean, that’s just misuses as often we do. But the interesting thing is and you know I if you look at Pete’s book from 50 years ago, no, it talks about treatment options. He’s talked about reshape, reposition, restore, and then surgical stuff. And when I first I saw that list, I thought, well, that’s great because they like restoring teeth. I’ll choose that one. But actually what he was talking about was, this is the most minimal way to do stuff, maybe we could just alter things a little bit, maybe we need to move the teeth first. And again, if you look in Pete’s book, he was using rubber bands and paper clips and all sorts of things to try and move teeth, you know, just to get them in the right place to minimize preparation, and the restoration was just about on the top. And certainly, if it’s going to be my daughter, you know, what would I want for her? Well, we need to put the teeth in the right place. So what I have to do is, is minimal to nothing. And then through that. So through all this I met I came across a group called the face group which was known in the States, more perhaps more as the Ross Williams group. But they actually practiced orthodontics with the same goals that I had in my prosthodontic. So they like the stable composition we like to to come together at the same time, we like a nice envelope of function and guidance, etc. So we had some people that were looking at the same thing, they weren’t just straightening teeth, you know. So, I came across those guys, I actually came across a guy called Carl Roy over in the States, who’s phenomenal and such a nice man and helped us tremendously. But he said, you know, in, you should go meet Domingo in San Sebastian, he’s much closer to you. And I’ll be honest with you, I at that stage, I’d had a lot to do with the states. And I thought, well, you know, I’ll go and meet him. But we’ll see I think we will be coming over here. And Domingo is just the most charismatic person that tremendous guy, Orthodontist, most motivational person you could you could ever meet some. And his right hand man was Alberto who like just that tremendous pleasure working with them. And so we actually, you know, with no disrespect to any of my countrymen or wherever, you know, my decision was that if I wanted to get these teeth exactly where they needed to go, then I was prepared to take it to San Sebastian every six weeks to have a treatment on which is what we did for almost three years, you know..

[Ian]
But do you mind, when he told me that, but it blew my mind even further that you’ve continued that relationship now. And you know, you send your patients, the right patient who is who has everything aligned, and it works out to get continued treatment, in this modality of referring, you know, getting a flight going to a very nice part of the world to get some orthodontics on a regular basis, it blew my mind. But it showed me so much about how much you care about the vision end result. And you found someone who a team that is so in tune with your philosophy.

[Ian]
Oh, you know, you don’t just we talk about this, and we talk about what do they call it, but they call it the daughter test? You know, so what would you do for your daughter? Well, nothing could be further if you’ll be closer to the truth, I should say, you know, for me, you do anything. So it was really just a case of if I believe it’s the right thing to do. misguided as I may be, then that’s what’s going to happen. So, you know, and so, you know, but through that, I’ve had some of my orthodontic friends take the face training courses. So you know, we’ve had, we’re very fortunate. We had our are working here for a while. And then we have also worked with other face trained orthodontists here, and, but we do get, you know, Alberto for me, and Domingo are sort of top of the tree with ortho TMD surgical things. And so, you know, I mean, for better or worse, in my practice, I see some very challenging cases now. And, you know, my goal and my duty, more than anything else that I do is to make sure that patient is taken care of as well as I can. And, you know, I think I said, I don’t wish to be to comment, I’m sure people, although other people have better situations than I do. But, you know, sometimes I’d send patients to the orthodontist, and the teeth would come back where the orthodontist wants them, not where I wanted them, and you send them to the implantologist. And the implant is where he found the bone, not where you wanted the tooth. And so for me, everything was about the design, the final design, and then we moved, we got everything into place to do that. And so I needed guys that were respectful of it. And that’s where my team was and when it came, particularly when it comes to it. I mean, I don’t think anything could be more challenging than ortho, orthognathic stuff. And so you need a great team of people who I know is going to take care of someone and Alberto has a phenomenal team in Barcelona. So, no until, you know, I’m hoping to find someone in thought and hope just up the road. But that hasn’t happened yet. So..

[Jaz]
Let me tell you what I’m hoping we have someone look. So you inspired me massively with that when I learned about that, then you actually introduced me to the face group. And I was actually at the time I was doing my diploma in orthodontics. And now a good friend of mine, who’s now a specialist orthodontist. I won’t embarrass him, won’t name him he messaged me, they’re saying “Jaz, I know, you know, into occlusion, you like that kind of thing. I’m considering to go to Seattle to do the Kois. And he’s an orthodontist. And wants a Kois, I said, hang on a minute, hold your horses. Have you heard of the FACE group. So I joined the Facebook group of FACE, I invited him and I’m getting his exposure in a little bit of selfish way. But hopefully, one day, I’ll have an orthodontist nearby who will have this whole same philosophy. So thank you, Ian, for introducing me to so much and something that’s so broad, and it was a great thing to be able to give him a sort of a pathway as well.

[Ian]
Well, the the fantastic thing Jaz is, you know, we talked about this, and then as they gradually sort of haven’t got down sort of like occlusion war type things, you know, which is all the little details that people know, debate about now that the best thing you can do is get with colleagues, and, you know, again, a lot of the reason why things don’t work out with orthodontist is you send the letter with no detail, and they do whatever they feel like, and then we wonder why we didn’t get the result that we wanted. Why is that? Because there’s no clear goals. So and no, the thing is to find an orthodontist to find people who have the same goals as you who want to listen, who want to work as part of the team, who have the ultimate goal to take care of the patient. And, you know, if we can do that, then I mean, then we can hopefully, point them in the right direction to get the training that they need to be able to do it, you know, so I commend you for that. And it would give me greater pleasure than, for all of us to have an orthodontist to touch up close by that could do these things, you know, but until then, I’m still going to advise people, this is what I think is best. And then it’s up to them, whether they do it or not, you know, we all make our decisions. So and, but I mean, that was a no big commitment for us. We believe we know, it was a, she got tremendous treatment, she unfortunately had me to finish it off. So she’s now, should be 25, in a couple of weeks time.

[Jaz]
I seen her smile. She come on the dinner. It’s amazing. So you’ve done great work and as a team.

[Ian]
Thanks, Jaz. But she’s, the most important thing is she knows she’s very happy. And it’s given a huge amount of competence. You know, I see, you know, through that I came across a lot of youngsters who had similar problems. And, you know, it’s just, I mean, I’ve got one, I mean, I’m sure there’s lots that are very successful. But you know, I just one that springs to mind. I mean, this lady should be having orthodontics for 14 years. And, you know, she actually had the same problems as Dorsi. But the reason why she’d been having ortho for all those times is because there was no real plan. And there was no real design. And I know it comes actually came back to your I was sent as a dental problem. Because when often when you don’t have teeth, there is this you have small Jaws, and x and y and z and all these other things following and we look at teeth and we look at Jaws, and we think about how we do that. And, the first question I asked him is what’s your problems? Amy, what can I do to help you? And she said that I really don’t like the way I look. And I said, both to that your smile look? She said no, my face? No, I really don’t like my face. And because she’s got small Jaws, you know, she’s got the nose and the chin coming in to your very small mouth. And she knows she was 22 years old. And she’s saying to me, you know what, and this isn’t getting better is it and no, but that she, that is you know, that’s an aesthetic thing. I think it’s a really important thing. But here’s another thing. So then when you do your complete examination, which is of course my happyhorse is like, Well, you know, on the rise if you sleep Okay, well, not very well. And to cut a long story short, she had severe sleep apnea. So doing she was actually, Jessie had surgery and ortho and implants and whatever else. And what she now breathes properly, she’s healthy. She’s Well, she’s got a beautiful smile. She’s, you know, she’s loving life, you know. So, you know, but it comes down to that. No, forget tha you’re a dentist, forget that you’re an orthodontist, forget what is it that the patients looking for, you know, if they didn’t come in, because we’ve just bought a scanner, they didn’t come in just because we’ve bought Invisalign, or whatever it might be. They came in for your valued opinion, you know, now, we all go on the internet these days, and we come up with these crazy things that Oh, all my teeth have fallen out. Do you do pinhole gum surgery? Yeah, but how are they related? That it was a patient this week. So, you know, and we choose, what we think is appropriate, our job, or my job is if my pal walked in the door, which he did yesterday, and he said, what can you do to help me? That’s what I’m there for, you know, I just got to use my knowledge to help them as appropriately as possible. So it’s not just about teeth, and also, it’s about the patient and what’s appropriate for them, and actually trying to help them be healthy for a lifetime, you know, that would be the best, the secret of a good job is that no one ever really appreciates it. So I’m hoping that in, in 30,40 years, when Amy’s there, she’s not even thinking about what’s going on, because it just worked well for her and she was been healthy and well, and she doesn’t realize what the other path might have looked like, you know, so. Yeah, so that’s, my…

[Jaz]
Philosophy. This is your own story. This is your philosophy.

[Ian]
Yeah, and you know, it’s just a bit, it’s just about taking care of people and trying to do the right thing. And we also get plenty people we talk about those things, but maybe it’s not appropriate for them or for whatever reason, and sometimes there’s other things that we can do for them, which maybe isn’t as optimal, but a compromise can be okay, provided that we don’t harm people, and that everyone understands the compromise, you know, we always plan for the optimal, but there’s this compromises life, full of compromises, it’s absolutely fine. You know, but we just got to understand this should also be a line at which we go, that’s, I’m not doing that, I wouldn’t do that to my pal, I’m not doing it, you know.

[Jaz]
I’m getting flashbacks from being on the courses with you in the world. And one of the most the biggest takeaways I had, was just the way that you communicate with patients and how you pass it on to us. And these little lessons that you know, you’ve burned your fingers, you’re not afraid to share the times that you’ve burned your fingers, you know, ask me how I know kind of thing, and you pass it on to us, and the quotes and the sayings that you had one of my favorites being ‘when all is said and done, more said than done.’ All the various things that you know, I sort of memorize what you say in one of the episodes I sort of talked about the thing, one of the pearls in the episode I gave was, is how I now start most of my new patient conversations, saying that the secret of success is to be thorough in what you do. And that is then my cue to do everything exactly A to Z comprehensively on every patient, every time so they get the best of me. And that’s like, that starts off. So there’s so many communication gems I got in there. So now we know your origin story and your philosophy. And now I’d like to go deeper into the part two into digital occlusion.

[Ian]
I just want you to know, I mean, those little sayings that I have, they didn’t happen overnight. I mean, I often think a lot of what we do is like comedy, you know, it’s like you tell a joke. Goes, Okay, you know, but you know, if you tell a joke, and it works, well you make sure that stays in for the next one. And it must have taken me 5,10 years to come up with that little saying that I’ve given you in five seconds. So I’m glad you’re using it and it just gets you started. And you know, and this is the thing about mentors and things like that. It’s like what your, my whole, it wasn’t always an easy 5, 10, 20 years. So the one of the things that eases the pain for most of us who cared about those things is is if I can get other people and share that with them. It makes it worthwhile and also and then eventually, you’ll maybe find your own little phrase which is better still. But it’s a good start so thanks for this. So now I’m going to talk about digital. There’s another word for that but I can’t use it on a play podcast like this But yeah, I mean our storytelling is interesting as well. I think you know, I’ve always enjoyed stories, I’ve always enjoyed comedy, I’ve always enjoyed communication. See a lot more about storytelling now as a way of communication. And which is a you know, I really like to learn about stuff. I suppose it almost like Don’t want to know because I was just doing it because it was me. And now I’m learning out why I do it. If any of you like Ted Talks and things, if you go on some of the TED talks about storytelling, there’s some as an amazing guy on and he talks about how as you tell the story, that the different chemicals that it releases, and how you can sort of basically manipulate people, which is, which is not my intention at all. But it’s a very interesting thing. But I think, you know, for not just centuries, but millennial, we’ve all been communicating through stories. And I think it’s a great way of getting the say, anyway, let’s move on to digital because that’s a fun thing, and will make me feel a little bit.

[Jaz]
That’s the bit I’ve been getting all these questions sent in about and that’s the direction we’re going to take the part two of this podcast now. So Digital Inclusion is essentially you know, the foundations of occlusion what I’ve done with you with Dawson. And we’ll come on to the end about, you know, the future and stuff. But it’s a lot of the analog teaching, and you gave you a few snippets of the digital stuff. But now that I’ve been using the trio scanner for about 3-4 years, and the itero. I’m loving the digital workflow. And I just want to learn from you and share with the listeners, a few tips and pearls, and some background information about how you merge building great, long lasting occlusions and beautiful smiles which go hand in hand in to the digital workflow. So you’ve been doing digital for a long time, tell us a little about how you got started digital. And what percent is that fair to say? What percentage of your work you do is pretty much digitally oriented. I mean, I know when I was there in the Wirral, you’re scanning and you’re printing your own B splints in the practice. So you’re very far ahead in you know, from what I can from compared to me anyway, tell us about your sort of digital experience. When I was at Liverpool University.

[Ian]
I say 35 years ago, I qualified. So a few years before that, we actually had a static machine, you know, and there was a guy there, Nick Cavitch and he was very, he was a dental geek. And so we loved all that stuff. And we were very dissimilar in lots of ways. But I had an interest in dentistry. And I really had an interest in computers. And I was fascinated by things like that. So it seemed like a good idea. My brother in law at the time was a designer, and he was really getting into computer aided design. And so I used to spend a bit of time with him and actually seen and what was, what they were doing. And I was thinking, this is phenomenal, what we could do now. But in those days, with the static machine, you take a block and you put it in the machine, it would be in there for about four hours. And then you take it out and carve it to fit the cavity, and pretend you’re doing something that was worthwhile. But it did seem like a good idea. And then over those years, you know, we have the red cam and the blue camera and all those things. And, you know, I mean, [inaudible] We’re sort of market leaders in those fields. And a lot of it was based around single tooth dentistry, you know, so it was about it was really more about in house milling than anything else. And so, over time, and as I got my own practices, then I came to a point where we were able to, you know, again, standard was important to me, so it was important that we could make good restorations, but I was doing a lot of inlays onlays and posterior crowns, which I thought I could do very nicely with digital. So we became very, very efficient, just with in house milling of single posterior restorations. And occasionally we’d fool around with anterior stuff. And you know, it was a lot more challenging. And, you know, there was people out there showing great things, but I didn’t ever really want to be a technician, I didn’t really know, I don’t know that I’ve got that skill set. But I try my best. And I know I’m in the right cases, I’d have a little go but it was, but that’s really where we used it. And it was a very useful tool. But then there’s really been a massive leap forward. And I think your history is important. And I’ve been using it for a long time. But as you say, I mean that was more about in house milling single restorations mainly posterior. That was one side of what I did, which would fit into a bigger treatment plan if that’s what I was doing. And that was for me to decide. But then as you know, as I really started to Well, I think understand the analog system of complete dentistry and examination and records and then how to treatment plan etc. You know, it sort of gets you a window and wondering about, you know, how could you do this in the digital world and no, because, you know, somewhat some of the stuff that we’re doing is a pain in The neck. And, so one of the cool things is I’m very fortunate as part of my teaching that has taken me to Scandinavia. And through that I came across 3shape, which is a Danish company. And, they actually, whereas Sirona [inaudible] from the clinicians perspective with in house milling, they were more a laboratory based program. And so they were coming at it more from lab design, and then sort of the scanner and thing was tacked on to the end of that. But because of that they had, for me, they certainly at the time, a much more powerful system, that they had an orthodontic program, they had a restorative program, they had all these different things and so then I became fascinated about how we could make all these things talk to each other. The problem, as I found out was that they were very departmentalized, as well at the time. And some of the programs are written in different languages, so they didn’t talk to each other. I was like, Oh, so the thing, the main thing that I have going for me is that I persevere, you know, I crack on, you know, and, so, whereas a lot of the time people get pulled off, I’ll usually have a little bit of a, I usually say a few bad words, and then I’d go right, well, what are we going to do to make this work or better? And, at the time, of course, you know, everything gathers pace and gathers pace, because you know, that people can spot a market because it helps a great deal. But then No, the scanners were getting better, the accuracy is improving tremendously, you know, and we’re thinking, well, how can we reduce this to look at some of these bigger cases? So, you know, very simple thing, taking impressions. Well, taking impressions is a no, you got to get a good impression. If you if you go to a lab and you see most of the impressions that are there, you’ll see that the at least a second molar is a missing, you know, an all are distorted in some way. Taking a good impressions is a difficult thing. But with a scanner, you get to see your impressions straightaway, there’s no escape. So you get to be honest with yourself about what’s the, so we could certainly make sure we got some great impressions with digital and I didn’t have you know, instead of having to duplicate models all the time, I could press copy. I like that.

[Jaz]
So much better. I love that.

[Ian]
So, there was so many things that even simple things like that, you know, I sometimes they forget now. And they made it so so much better. British saying a lot of the time I was printing models and then put them onto articulator and so we’ve bent on digital orthodontics was commented on. So we could actually start to move teeth and see what how these would look, which is, again, a deal better than then sorting teeth out and doing sort of casting setups, the way we used to in house restorations was going real well. Also, the fact that I could work with a lab was great, because I mean, I could scan a patient and they have the information in seconds rather than three days. You know, I mean, nothing was worse than the impression go into a lab, or to get a phone call to say, no, that impression you’re talking it’s not the best. Whereas now that if we wanted to if we weren’t sort of ads that the technician could look at it straight away and go, Yeah, that looks great. Let’s carry on, you know, so. So it was a great communication tool. So there was so many bits and pieces that were coming together, implants. I mean, if you look at implants, look at Digital, a lot of people associated with implant or work because we’ve got, you know, everything is driven from CB CT, and we’re gonna make this guide, we’re gonna do this. And, it sort of lends itself to that. That’s just one part of it, you know? So how do you make this big picture fit together? So now we come back to know, the sort of, you know, whether it’s Dawson, whether it’s Pierre, whether it’s Kois, it’s about this sort of complete care and looking at the big picture, and how, if you come right back to it, don’t forget the complete examination, you know, digital will not save you from being a good dentist. No, you got to know how to examine patients, got to know how to communicate with them. We’ve got to know how to do some basic things, you know, but then, you know, my training then is got Okay, this is a this is a complete patient. So, you know, I think you put an email about it being a full mouth rehab, let’s think about every case not being in a full mouth rehab, but a full mouth consideration, a full system consideration. So no matter how little we’re doing, we’re looking to go if I just do that tooth, is it going to be okay? And then you know, if it’s okay, great, let’s just do that. No, but so I want to be able to look at that. And the traditional way is you would gather records, and then we would so we’d have photographs, we would have mounted models and then we’d be able to look at that and work out, diagnostics, and then work out a treatment plan about where these teeth needed to go to fulfill the goals that we’d set out to achieve. So then, you know, can we start to do those things digitally? And of course, whenever we move to some sort of new sphere, we always try and just mimic what we’ve left behind. And so for years, you know, many of us and I being included, I can certainly say seven, eight years have tried to copy that system. Exactly. Digital brings new tools, and new ways a year or two ago.

[Jaz]
What are you trying to say is that you were using digital, but to try and to conform it in the workflows that you had within analog, right?

[Ian]
Correct.

[Jaz]
So where is it heading now?

[Ian]
So Well, what what you need to do is every so often, not very often in my life, but every so often, you get a moment of clarity, you know, and you think, what am I doing? And you get so obsessed, I mean, so obsessed with inventing a digital Face bow, you know, it’s like, so many hurdles And you know, get into that, why don’t you think, okay, and we’ll save this for a little bit. But what is it I’m trying to achieve? What is it I actually need to do? Those digital have new ways of being able to do that, rather than just trying to copy the old ways of doing it. And so there’s things that have made me rethink, and it’s about going back to basics, what is it about achieve? What is it I’m trying to achieve? And you very kindly sort of mentioned Pete and I say, in no way where they ever compare myself with humans, just the most amazing guy, you know, but when we, historically, if you look at the old mythological days, and, you know, all the way we would try and measure everything, and, you know, then we say how everything worked perfectly when it didn’t really, because patients aren’t symmetrical, they don’t have mandibles that have the same side, they do have a bit of flex in the you know, there’s then they’re not made of metal, you know, biology is horrible in all it just those dreadful things to us, you know, so but articulators put our best guess. And then as a younger guy, Pete came up with this thing, but he said, Well, you know, what, we do all these things, and it’s all great. But really, what’s it about? Well, what it’s about is, how do we work ahead of time, make sure that when we actually get the patients in the chair, what is efficient and predictable and productive as possible? That’s it. That’s the basic thing. And so, what Pete was saying was, well, you know, if I use a semi adjustable articulator and I use a face bow, and we do this, I’m going to be pretty darn close. And so it’s going to take me much less time upfront, but I’m going to save myself a lot of time at the end, maybe just as much as time as you did when you spent 10 times more time up front, you know, so, and that was the whole deal of that analog workflow, and certainly, you know, can call it awesome philosophy. It’s the spirit, of course, it’s all those things. It’s all those people came from Pete’s idea, you know, and, you know, if you if you read Pete’s book, you know, and I was fortunate to get these stories firsthand. But if you read Pete’s book, he talks about he’s one of his favorite things was called blood on the walls, where he was invited to the pathological societies meeting, you know, when, and to hear his new way of doing things. And there was like, 1000 dentists there and so Pete gave his presentation, and everyone’s very polite. And then there was a luncheon. And then the speakers were introduced at the luncheon, the introduce everyone, then the guy who was the the big methodological cheese, said, you know, and, of course, Pete we want to thank Peter Dawson for his presentation, but we will continue to do the harder right rather than the easier wrong and, you know, to be, you know, to be put down like that in front of all those people as a relatively young man would would see most of us off. Peter has a lot of self confidence and a lot of belief. And you know, that sort of just sort of Stephens his resolve a little bit and he was also fortunate, because the next guy that got up to speak, was one of the, again, one of the other big cheese’s and he came up with a big pile of papers. He says, you know, this is the, this lecture is the one that I prepare for more than anything else. He said, But after what Peter’s just told us, I think I just need to rip it up and start again. And so you know, so in this, So, for me, again, in no way a comparison, but I think we’re at the same point, which is, oh, well, that doesn’t work. This doesn’t work. No, no, no, no, it does work. It’s just different. And so what we’re trying to do is how do we spend time upfront, which is allows us to plan the cases so that when we come to put this into the patient’s mouth, we’re pretty close. And then what we have to do is a little bit of refinement. And when you start to think about it like that some of these digital tools are amazing. And there’s so much better than what we’ve ever had in the analog world. I just want to before I forget, before we get into details of stuff. There’s one part of it that people don’t talk about so much. It’s almost like a different field, which is this complete dentistry and full mouth rehabs, or whatever you want to call them only happen when the patient says yes. We as dentists are dreadful communicators. And we say things they Oh, Mrs. Jones, you know, you then need 17 crowns, or you need to have equal intensity contacts and posterior disclusion, and this, this of this, so when would you like to get started? And we wonder why they don’t do. Digital is a fantastic communication tool. Okay. So now, when we talk about digital, we could talk about ways that we can use it an examination, and we certainly use it as for, for intraoral scans, for getting models, and I think that’s a routine thing. these days. We take photographs. Photographs are, you know, Jaz, because you’ve been, did a great record of what we’ve done today, they’re a great communication tool, so that patients can see what we can see. And they’re also helped us in our planning our two dimensional planning. So photographs are still a real important thing. But we need to find ways of engaging with the patients. And it comes back to that to the story with Amy, which is right became which is, what are they here for? What’s their motivators? You know, because, you know, they often are motivated by they might be motivated by aesthetics. And we’re talking about biology. You know, now, if you’ve got, again, one of my interests was sort of personality types and things. But if you’ve got that sort of a personality party person, and you start telling them about, you know, the bacteria that’s causing their periodontal disease, it might be very correct. And it might be exactly the right thing to do. But it’s probably not going to stimulate them to clean the teeth. I need to find the motivator, I need to think to find the thing that’s going to motivate you to do this work. Not for my benefit, but for your benefit. So again, one of the great things about aesthetics is people want beautiful smiles, but they want a beautiful smile, it allows you to access the health benefits for. So it helps us improve their biology because nothing looks better than a nice, natural, beautiful smile. So and now we do nice things for people, then hopefully, they look after it. So that’s all part of that deal. So, you know, I use digital, you know, in the examination, but then I also use it as an engagement tool. It’s a real way of engaging with the patient. What’s their prime motivation, and I sort of divided it into three main groups, are they, you know, just because everyone’s like acronyms these days, are they functional patients? Are the aesthetic patients, or are they more of a biological patients? So it could be like a F.A.B. patient, you know, and very often, it’s a combination of all those things. But what you know, if someone’s motivated biology, that’s going to speed up vital part of strees, because we love biology, we love caries, and perio and things like that, so that’s easy enough that we can show them pictures, and we can tell them what it is that needs to improve that those things are great. But a lot of the patients that I see a huge amount of them are motivated by aesthetics, you know, even old fogies, like maybe like to look decent, you know, most of us want to look younger and healthier and whatever. So, that’s certainly a big motivation. And some people are motivated by function as well, because they can’t chew properly, they can’t eat properly, or maybe they’ve lost teeth and how are you going to make this work for me? So, we can use these tools to help the patient understand what’s possible, you know, and so much easier than ever we could so if we take, let’s take the aesthetic one because that’s the one that probably is the most common one now. And is also it’s sort of out there in the bigger domain. Now, one of the things I learned from cosmetic dentistry 25 years ago, you know, was the motivation of sort of smile design, you know, with digital smile design now, you know, it’s a reinvention of an old theme, you know, but emotionally, you know? Well, I’m always a little, I’m always a little wary of the emotional phrase, you know, because I know they call it that, but, you know, it’s like, there’s a thing called buyer’s remorse? No? So just be aware of emotions, you know, so, let’s call it motivational dentistry or engagement, or something like this. But, and, you know, maybe I just can’t help you in the dentist. But yeah, just be careful of the emotional side of things. No, let’s figure out what’s their motivation, and then talk to them in those terms. So know, one of the, again, in the, you know, and certainly back to Pete’s day, and people since then it’s like, well, we take all these models and things, and then we mount them up, and then we spend four hours doing our wax off. And then we show that to the patients, and they’re bound to say yes, and we all said, Oh, okay, that’s fabulous. You know, and that’s the most people were prepared to go along with it, because they never do it. And those of us that did do it, were so invested in it, that we didn’t want to say that we weren’t that good at it. So it didn’t always work out great. The honest truth is, and I know I’m a bit of a observer of humankind is that the dentist that I saw that were fabulous as it were, actually, they were good clinicians, but more than anything else, they were great communicators, and they communicated to the patient their problems, and they communicated the problems to the patients in the terms that the patient wish to receive. And so and that’s why they were successful. That’s why they got to do the work, you know, so. And the cool thing with the digital now is that we can do smile mock ups and things like this, we can share our vision because someone can walk in and just be arrogant for a moment. And I’m thinking, yeah, I know, I can sort of see what I could do for you. But you’ve always got to remember, they can’t share that vision, we’ve got to find ways of sharing the vision with them. So you know, and digital, whether it’s photographs, whether it’s a 2d smile, where we can show them befores and afters and we can do it, we can do a 2d smile now in 10 minutes with the great software that we have, or whether it’s like an additive mock up, we can, you know, I mean, the way that we do it is we will put down certain markers. I mean, I can I can do it myself, but I’ll send it to the lab, they will do the design, they sent me the STL file, we print the model, we make the stents, we put that in the patient’s mouth, you know, I mean, it’s so, so efficient. And, you know, it’s rather than that, for me, there was a hole that we all fell into, which was this thing, which is I need to do a wax up. I can either I can spend four hours, and it’s gonna look pretty average, or I can pay the technician but I’m not sure that the patient is going to say yes. And no..

[Jaz]
That’s the big debate.

[Ian]
Yeah. And so, and that’s the way I was brought up, because people always said yes to Pete, you know, because by the time they got to see Pete Dawson, it was a done deal, you know, but he was a different person. I was like I get patients, it’s like, they’ve got kids at university, they’d rather go on holiday, they just got made redundant. All sorts of things going on. I have lots of patients, as I’ve probably told you with booko syndrome, which means they’ve got lots of problems and very little money. No, and so I want to have solutions that can help them as well. And that’s why design is such an important thing. So being able to do additive markups, simply quickly and cheaply is a big thing. And we can do that now, you know.

[Jaz]
Are these digital wax ups significantly cheaper than like, for example, if you send a personal wax up to a good lab, you’re kind of looking at 25 to even 50 pound a unit of wax up in there, you know that’s significant. What has digital made it quicker, easier and more cost effective to turn around this model that you can transfer for a 3d motivational sort of a mock up you might?

[Ian]
Sure like, this is where there’s a really important part, Jaz. So let me try and explain this. So there’s a difference between what we might call incisal facial mock up just to show people the way it is, which, in with in my own sitting on my high chair judging everyone I would look down upon because where’s the function in this? So there’s a difference between that and a proper fully Functional Diagnostic Wax up. But there’s a big gap between patient fully functional diagnostic wax up. This additive mock up can be the link, I think, Well, I know it is, I said he is in my hands, in my practice. Because we can do those. And I’m working with some of the labs right now we’re going to be seeing some things pretty soon, where we can do those inexpensively, okay? For a lot less than that. Because that’s the problem, you’re sitting there thinking, I need to spend, let’s say 30 pounds a tooth on this. Now if it’s a smile, let’s say it’s a teeth, you know, and you saying to a patient, okay, it’s sort of, let’s say, 500 pounds to do this, just like, that’s a big leap for someone that’s not sure. Now, if you’ve got someone who’s totally motivated, that’s a different thing. But that’s, those are the easy ones, you know, but we have a lot of patients who aren’t sure and to spend 500 pounds, to do something that they’re not convinced about. So the journey, as far as I’m concerned with engagement is, you know, first of all photos, and doing all the things that we do, I don’t want to lose track of that, I think, a great code diagnostic examination, where we’re explaining to patients what the problems are, and how we can help them with what they’d like to achieve is super important. Photographs, real simple. And really, really important. And then we come to, we come to that decision is this a general patient, someone who just wants to deal with the biology, or maybe this is a complete patient in waiting, you know, I, one of my mentors, like is either tells me, don’t forget data before you marry them, you know, it’s not a bad idea to get to know someone, before you start doing big stuff, you know, and you know, Tif Qureshi as you know, was a big part of mine. And, you know, Tif talks about the same things, you know, this, these things don’t have to do this. You see all this stuff, I mean, on Facebook and Instagram. And as if the patient came in, we did that patient came in, we did that. There’s nothing wrong with getting to know people. And know, and know, if biology needs to be resolved, let’s get that resolved. But at the same time, again, to know them, we’re seeing whether to respond to they turn off, you know, do they pay their bills, so we can get to know someone before we move to that next stage. But let’s say we show them the photos and they’re showing interest? Well, you know, we can do a 2d smile design with some very simple software. I mean, we tend to do that for free, takes about 10 minutes, and it gives them an idea. And then if..

[Jaz]
What I’m saying about that, because I want to get tangible for those listening to this part you do yourself or is that something that you are now outsourcing to labs because labs offers sort of smile mock up service in 2d images.

[Ian]
So let’s just talk about that for a moment to try and keep my focus on the bigger picture, but let’s just talk about that for a moment. I’m really, really keen on our relationship with good technicians, you know, what it is that we’re doing. And, you know, I have a lot of tremendous technician friends. And so when I say this, I’m not trying to be unkind to anyone. But again, like, we talked about the orthodontist who has the same goals, we have to work with someone who has the same goals, you can’t just send this to someone and get what they think, you know, we need someone who is on the same on the same page as us. Unfortunately, I work with the [inaudible] over in the States, Shamek Vanek, who’s over in Sweden, you know, and we just communicate digitally, I work with Phil Reddington, a lot of you know, we’ll be those of tremendous, we do different things together. But we have the same goals and they know what my goals are, they know what it is that I’m looking to achieve. So, you know, we need to be able to do that. But if you’re as far as this is concerned work, we can get the technicians to do as much or as little as we like. So my journey with this is when the smile design software first came out, I thought it was a pain in the neck. So I used to get Shamek to do it for me. Now, it’s really easy. So I learned how to do it, you know, I’m a bit of a old fashioned leader, you know, in the I like to stand at the front where even Magon say and follow me. So it’s like, I would use it to start off with and I learned how to do it. And now you know, my assistance. You know, they’re not in their houses, because they’re so they do so much for me, you know, but my assistants are trained to do it. So they would do the smile design for me in 10 minutes or so. We Yeah, no, and this is the thing and this is the you know, so by all means you can take the pictures, send it to one of these great labs and they’ll do something for you no problem very often they’ll do that for free to see because it doesn’t take them long to do. But because we’ve got the software we’re able to show someone real well, and you know, I mean, as far as your staff is concerned, you know this, do they want to just stand there and, and suck, spit and mix eugenol or would they like to be taken photos, doing smile designs, doing all these things, and really making the most of their job, you know. So those are the people that I’m looking for so in our practice, we started off, the technician was helping me, then I learned how to do it. And now mainly the staff are doing it, I still do it occasionally try and keep my hand on it, but you can choose whichever of those is appropriate for you. What I’m hoping is that you just get involved. And once you get involved, you’ll see the benefits in learning yourself and getting your staff trained as well. Okay. So that’s the 2d smile design, the additive smile design, I think is something that you could probably learn. But you know, to be honest with you, I have guys, you know, in various parts of the world, who are amazing at doing this. And here’s another obstacle for us. All this stuff costs so much money. Well, why? Well, it costs money, because we have to buy the software. And then we have to spend lots of time learning how to do it. If I know someone who knows how to do it, and I can, if I can describe them exactly what it is that I want. They do it, then we go on TeamViewer. And I can say could you change this or this or this? They make those tweaks just to make it look as though I’m actually in control. And then they send me the STL file and we print the STL file. And now we have a smile design in no time at all, you know, really, really efficient, very, very effective and cheap. And a great way..

[Jaz]
How cheap we’re talking? Bacause I want numbers.

[Ian]
You want you will you would want numbers. So this is something I’m working on with some other labs at the moment. So I know no one’s listening, Jaz, because I know what I’ve learned from when your time which is the no one that listened to you anyway, say. So I know no one’s listening anyways, so it’s okay. But as you say, I mean, typically you’re looking 20, 30, 40 pound a units, I think we can definitely do these things. Because no, there’s two ways I was looking at this is if I said by the time I’ve got the patient to this point where I’m thinking of doing this, what’s the number that I think would be high enough to get rid of the cap, tier kickers, but low enough to have them do it? Okay. And I think somewhere between two and 300 pounds is a reasonable figure. So if we could do this for say 15, 10 to 15 pounds per tooth, it’s costing you, maybe 120, 150. And you said them? No, Mrs. Jones, we could do this when we can actually show you what this would look like in your mouth for 200 pounds. I think that’s a good place to be. And I’ve spoken to lots of other people about it. And you know, I think, you know, I’m not a great one for totally free. I think we do ourselves down by that. I think there’s lots of people out there who will take the mick out of you for it. And take advantage of you. And you know, I’m being polite right now. So but I think that’s a fair get that, if we could bring that additive smile design in for, you know, somewhere between 100-250 pounds, and you were charging the patient 200 pounds, I think that’s a good place to be. I think if the patient isn’t willing to invest 200 pounds at that stage, it’s probably not going to happen. So that’s sort of what I’m waking up to. But let me tell you this, it’s not just an additive smile design, okay? Because this is the thing because like, which is nice, we put this in the patient’s mouth, and they go Wow, that’s amazing. And then we have to start again to work out how to make it work. Okay, so let’s think about being able to use that additive smile design to really enable function, okay? So let’s think about the three main things that we talk about in function and treatment planning function, upper incisal edge position, lower incisal edge position, vertical dimension, okay. So if you think about it, if we do an additive smile design really nicely. We have the upper incisal edge position, we have the lower incisal edge position. And then what we need is a little bit of knowledge to work out the vertical dimension. And now we have everything in place to do the full diagnostic wax up.

[Jaz]
It feeds into the next part. That’s fantastic.

[Ian]
It feeds into the next part, and we’ll make the next part even easier still. So let’s take this simple one, people don’t think it is necessarily the simple one. But the simple one is generalized wear, because it’s easy because we’re going to, without going into the occlusion bit, open the bite to a little bit have some space. So if we add a couple of millimeters to the upper incisal edge, and maybe a millimeter to the lower incisal edge, then we can see how that looks in the patient’s face. And then we just got to think about where do they come together? Do we reduce at the back? Do we add to the front? Or is it a combination of those two things. And that might be the, it’s a big topic, as you know.

[Jaz]
Well that’s far behind a podcast episode, but it’s just getting the whetting everyone’s appetite for digital understanding or workflows Ian and already you’ve told us about the how easy it now can be to have that 2d motivational photo to the extent that now you’ve got your staff train, which is amazing. And then you’ve talked about going to the additive mock ups and how that can feed in to the next part. And that’s really great.

[Ian]
Though, let’s also think as well, Jaz about sort of how that whole thing fits together. Because you talked a lot about individual parts that you know, so. And that’s sort of the whole picture. So and you said to me, you’re one of the questions you asked or mentioned to me was about when I take advice at the right vertical, I seem to be very successful. And that’s absolutely one of the keys. It’s an old trick that we used to use with splints. That if we took the bite at the right vertical, we didn’t need all the face bow stuff. All the big articulator because we were playing with the arc of closure, it’s the same with these things. So if we’re just playing a little bit with that, maybe we don’t need the old style Face bow stuff. Now there are times and the key is to understand when those are when we might need a little bit more information. But but to come back and say okay, what’s your protocol Ian for records for smile designs, rehabs, comprehensive patients? Well, so we do our complete examination, we do photographs, we talk to the patient about what’s there in the terms that they would like to receive it. And then if they’re motivated from the aesthetic perspective, then we will show them a 2D smile design, and we’ll get them, If they’re then motivated to spend that, let’s say 200 pounds on their smile design, then we’ll move forward with that. Now for that, here’s what I’ll take is, I will take scans. Now for those of you. Because I was only joking before I know loads of people listen to you. So for those of you who are analog and would like to stay analog, you can still take impressions, and we can have those scan by the technician. Okay, so this, you can get into this whichever way you want. For me, the real power of digital is in wax ups, treatment planning, etc. So you can take that we can take an impression and have it scanned. No, obviously, again, I’m hoping that eventually you just say, Oh, it’s a waste of time that we should just get a scanner, you know. But we take the scans, we take a bite registration and the bite registration that I’m going to take, I’m going to take it from my place in a stable condyle positions, you can choose whichever way you’d like to do it, I’m going to choose a stable condyle position. And I’m going to choose the vertical dimension that I think is most appropriate for that patient. So now there’s obviously some thinking that goes into that, that we could maybe discuss another time. So we take a bite at that stage. And then often now we’ll take a face scan as well. And the reason why we take a face scan is because the photographs, we can set the patient up pretty well using the photograph. But with a face scan now, I mean, I can take my iPhone out, and I can take a face scan on this. And then we can use that and we can with things like Bellus 3d, we can incorporate the intraoral scans together with CB CT scans into the patient’s face. And we have a virtual patient and now the technician can actually see the teeth sitting in the patient’s face and what, I mean, that’s amazing, isn’t it? And when you think about it..

[Jaz]
And that essentially your Face bow then right then. So but before we get to that, I mean, this whole scanning, the source scanning the face something I’m not doing the moment it’s very new concept for me and you mentioned that some software that you can use for that. In terms of one of the questions I had sent in is that if you’re relying on your photographs to become your digital Face bow, is that a good entry point into transferring that information if you don’t mind Ian just for the listeners who are hungry, A lot of young dentists listening, what is the main benefit of Facebow in general cases? and Why would you, Why would I even bother? Right? And then how would you transfer that, using photographs to a laboratory along with the scan? Is that a predictable way or not?

[Ian]
So this is where you have to come back to basics. No, I think in the analog world, a facebow. You know, so where that came from, and the old pathological days was a hinge axis recording which your if any of the younger guys or girls want to go on and look at that, by all means do so. But it looks like something from the museum. And there’s still things that we can talk about with hinge axis, it’s quite interesting. Because I’m sad. But no, we then move to this Earbow, or Facebook or whatever you want to call it, there’s a few different varieties out there. And really, what we were using then is like, this is a quick and easy way of transferring information to an instrument, which in some way replicates the masticatory system. That’s what it’s for. So what did it do? Well, it went in the ears. So we said, well, let’s we related the top teeth, to where the condyles are, okay? Where also, then that’s going to help us with the arc of closure, because that’s important if we’re going to take a bite and open bite, open register, open vertical, or if we’re going to play with the vertical dimension. And it also we also then used it to give us some idea of the incisal plane. So let’s blow up a few sacred cows, you know, it’s just me and you.

[Jaz]
Has to be done.

[Ian]
But let’s think about that. Well, you know, I mean, don’t get me wrong, if you’re in the analog world, this is still a great way of doing it. Okay? Because it’s going to give you a lot of great information. And I’ve done it for years, and it works. So well. Let’s think about it. So we put it in the ears. Well, where are those? You know, we’re actually looking for the medial pole of the condyle. Unless you’re pressing real hard, you’re not getting there. So they know far too hard. So, you know, what has got the most Facebows do I think they allow, you know, excuse my lack of knowledge, but something like nine millimeters, because that’s where we think that is? Well look at my fat head. And then look at lovely slim Jaz. I think we’re probably a little different. So we’re making an assumption straight away. Okay, and then if we’re going to use it to get the incisal plane, what are we going to do? I’m actually going to fudge it round in the ears a little bit. Oh, that’s super accurate. Okay. And then it’s going to be the arc of closure. Okay, so you can see that it’s good, and it’s quick, and it’s easy, and it works better than the other stuff, better than doing nothing. But here’s the thing, if we think about all those pieces that we just said is, why do we need the art of closure? Well, we need the arc of closure, you’ve got to mess with the vertical. But if we actually take the bite at as close to the right vertical as possible. Maybe that’s much less important. Okay, which is why you’ve been successful with those things, as you mentioned is exceptional.

[Jaz]
I mean, the reason Ian mentioned this guys. I emailed Ian little bit about what we’re going to talk about and one thing I told him was my experience of digital so far is when I’ve recorded the vertical dimension near abouts where I want the patient to end up before I restore them. I found that once I’ve done there and typically as is composite my level experience a moment moving with ceramic but at my level at the moment quite Junior doing a lot of composite work and transferring the sort of digital wax up into the mouth, and then getting the patient to close together and this after usually I’ve deprogram them, we’re using a deprogramming appliance. And that’s a whole another section we’ve talked about, I found that when they bite together, I’ve got these beautiful contacts and the excursions are just where I want them. So it just needs a bit of polishing. And the first time I did it, it blew my mind. I thought I flipped it, then a couple of times of the day it was it became very reproducible. That’s exactly the reason why Ian just said you know, when you record it at the vertical, you remove that element of potential error of actually opening the vertical. So that’s what Ian has been talking about. And now going forward from that, the questions we’ve had is we’ve essentially answered it Ian the virtual Facebow is essentially what you’re using is a face scan incorporated but one thing I perhaps misinterpreted was that you said the CB CT but if you’ve got a comprehensive patient who does not need implants, but you’re doing comprehensive dentistry so you want to transfer that information, would you be taking a cbct to as part of your records to then be able to relate that to a virtual Facebow?

[Ian]
Okay, so let’s talk about relating, or so that virtual facebow thing and see if this answers the question for you, you know, one of the things that relates to that correct vertical, the correct vertical only works with a stable condyle position. So that’s, just let’s be clear about that. So if we think about what we just said about face bows and how we relate the teeth to that, and how do we do it, we can choose a photograph that will give, that will be reasonable. Now there’s certain things we put to 2d to 3d, we can use a face scan, which will give us more information still, we can use a CB CT scan, if we have one. Now, I think it’s grossly inappropriate to be taken CB CT scans to my models, and many of the patients that I treat, have joint issues, ortho issues, implant issues. And I’ve got good reasons to take full volume, CBCTs, but I also have a lot of patients more smile design. It’s inappropriate, you know. So we’re taking appropriate radiographs, appropriate radiation. And so if we have one, that’s probably the most accurate way of doing it. But if we don’t have one, perhaps a face scan is the most accurate way of doing it. And the next thing that we can mention, so let’s but there’s a reality to all this as well, a photo is quick and easy and cheap, we all know how to do it. A facecam these days is quick and easy and cheap. And it’s easy to learn how to do CBCTs if they’re necessary there. Then we have things like MODJAW which are more like jaw trackers, etc. And they can give us tremendous information. And we can combine that information with the intraoral scan with the CBCTs, and we can actually see, we can actually record the hinge axis, what used to take us hours would take five minutes these days, you know, so it’s amazing information that we can get from stuff like that. But there’s a cost that comes with that. And I, my goal with these things is to get the best treatment for patients, for my patients. And then if I can encourage other dentists to do the same, then I think I’ve spent a lot of time well. And my other goal is to get them to sufficiently interested that it makes the, want to treat patients well, but also makes the days more interesting, you know, because they we all spend eight hours or so here. You don’t you may as well have an interesting day. And, you know, no, but also as well, I think many of us over time have bought expensive pieces of kits that didn’t, we didn’t particularly get a return on the investment, you know. So things like MODJAW I think are great, I think there’s huge amounts that we’re going to learn from things like that, as far as research and education. And I think as far as you know, treatments concerned, it’s a really valuable tool. I think at the moment, it’s at the high end of cost, it’s not something that I would suggest go out and buy one, if you like stuff like that, go out and buy one, you’ll have great fun with it, it’s great fun, and you might be you know, you’ll be able to patients will think you’re amazing, all those great things. So I think it’s a great tool to have if you’re going to make use of it every day. Okay. And I think that going forward, these sort of technologies will get incorporated more into what into the other things that we’ve spoken about. And like everything else, they’ll tend to come down in price a little bit. And it will become part of what we do. I’m absolutely convinced about that. And at the moment, there are things you know, I think, in some of the cases that I do MODJAW is incredibly important. But for some of the simpler things that we do, it’s interesting, but it’s not as important. So I think if we look at that, so I don’t know because the people that MODJAW are fantastic, and I encourage you to look at it and to think about it and if it rings you, floats your boat, get yourself one and get involved. And you know, I mean I’m really enjoying working with it myself, you know. But it’s no good having something like that if you’re doing just a couple of fillings every day, you know, it’s not going to help you too much. So let’s just recap over those so we can use a photograph, simple, easy, cheap, gonna give you a decent result. Facecam simple, easy and cheap, gonna give you a pretty good result. CBCT if appropriate, so relatively simple, easy and cheap, if it’s the right thing to do, and super accurate. And then MODJAW, super accurate but a little bit more expensive. That’s the overarching thing. And then let’s compare that to face bow easy, cheap. And, you know, I’ve done have to take the Facebow, take the models, mount the models do all those things rather than a, lot of time, you know, I mean, now I can take my scans, take my bite registration and check my first point of contact in 10 seconds. Usually we’d have to cast the models, mount open model where the face bow, mount the low level with a with a bite registration. And maybe two days later, I get to check the bite. Yeah, I mean, I sort of forgotten about that until one of my pals it pointed out to me, because you do that right away. And yeah, so I can tell if I’m on the money straight away. So there’s so many things that help us predictability and efficiency, productivity. And that I think we just got to think differently. So that’s the, that’s my view on Facebows now. I think if you’re in the analog world, it’s still a great way to go. And But otherwise, I think we have other ways which are, let’s say just as effective.

[Jaz]
Well, that was the most common question that come up. So thanks for those who sent it in. Now in the interest of time we’re gonna have to wrap up so one of the questions which I think is I do want to learn about is Sid Gupta, if you remember from Dawson, I met them at one of the Dawson event. Sid, young dentist and when he put in one of the part of the courses that we did with you is that we get to present our cases and his photography, and his motivation was just fantastic, I believe he is in Wales, fantastic young dentist, really great work. He wants to know when your digital courses coming out? So if you’d answer that?

[Ian]
Well, as you may or may know, already, I’m probably about the worst salesman as far as dental courses out that is concerned. So they are coming soon to probably on 40 to a webinar near us. So but they’re coming to you and I’m working with the guys what we’re hoping to do. And I’m actually that’s as soon as I finished with you, that’s my afternoon is working on, on those digital courses. Because what we’re aiming to do, and it’s little bit related to this beautiful COVID situation that we’re all in, but actually, it was something that I was working on before, which is now the idea that we could have smaller groups in a location that was more appropriate for you. So, you know, say for sit down in town in Wales, because let’s face it, Who else wants to go to Wales, and I haven’t been rude about them for ages. Now for for those of you who don’t know, probably 50% of my patients are Welsh. So, you know, I always mean to the people who live next door, you know, so and I’m a Scouser. So I’ve got no chance at it. So but but the idea is that maybe we could have five is that we would do a little bit of located lecture, which would be centralized, and then in that smaller location, you would then do a hands on exercise. So let’s take, say, taking the extraoral scan, taking the bite at the right vertical, so we’re going to be rolling those things out pretty pretty soon, they’ll always be the opportunity to come here and, time me when I do it, but, you know, so that’s but you’re going to be seeing those things very soon. And you know, what’s great for me, you know, is you’re very kindly invited me to this sort of thing, Jaz, and I know you have a lot of listeners and people like Sid, you know, it’s what’s been very, very rewarding in recent times, is to have these young people who are far more motivated than I ever was at that age. I know, well, if we can just encourage them to do a little bit of learning every day, every week, every month, they’re just going to be so such great dentists, and get such payback from this, their patients are going to be so well looked after you know that spending our time doing these things will be well worthwhile. So the courses are coming soon. Jaz, by the time I’ll make sure that you’re the first to know and if you can let these people know that would be fine.

[Jaz]
Yeah, I want to put that up to people use swap me on Instagram for information where it’s always usually on the website protrusive.co.uk. So when it’s out, I’ll update the blog post associated with this episode. So we’ve covered a fair bit I mean, it’s impossible to get into nitty gritty detail bits that we all love in just a video over 45 minutes or so which is the aim but I think we’ve covered a good deal to everyone’s uptight about getting the mean you talked about communication, that’s so so important about how to actually communicate and find out what motivates that patients. That itself was just phenomenal. We talked about 2d smile, we talked about the additive mock up and how you price that. So we talk a lot about the business element as well. It’s like a lost leader. But it’s one way to get that patient on board with a vision and how you beautifully took it to the next stage with implementing it into the upper incisal, lower incisal and the vertical dimension. We talked about a few hacks with the vertical dimension in central stable condyle position. And it’s come beautifully to full circle now. So Ian, thank you so much for your time. Is there anything else that you want to put out there?

[Ian]
Ah, you know, it’s a big old subject, I think, you know, it’s a combination, I mean, of new ways of doing things digital is exciting. You know, I mean, as I’ve been doing this 35 years, my daughter’s just starting just about she’s with all this A-level chaos. She just got into do physio with Sheffield. So it looks like I’m going to be working for a while longer yet. And while we’re going to work, you know, I think we have a duty to our patients to do the best we can. And we have a duty to ourselves to as enjoy everyday as much as we can as well. So, and all these things help us to do that. And so I appreciate your time. And I appreciate your listeners time and listen to us go on about dentistry. But we spend a lot of time doing it, we may as well make it as fun and productive and beneficial as we possibly can. So that’s sort of what it’s all about.

Jaz’ Outro:
I really appreciate that. Thanks so much, Ian. And I will catch you at the Digital Course. Thank you. I hope so. Thank you. There we have it, I did tell you that you would love his stories. And I really hope you gain value from that. As always, I really appreciate you listening all the way to the end. If you could do me a massive favour and go on YouTube, hit that subscribe button and whichever podcast platform you’re listening from, please hit subscribe and please tell a friend. That’s how the podcast grows. Next episode is going to be awesome. It’s with Payman Langroudi all about whitening in a way that you’ve never thought about before. Like how can we do more whitening, why we shouldn’t be doing more whitening and few tips and pearls to get better successful teeth whitening outcomes. SO come and join me in that one next week. Same time, same place.