The best articulator is the patient’s TMJ, but you knew that already, right? As a dental student I was always confused by Facebows in Dentistry and their role. Lots of clinicians I respect used facebows….but many others do not! What role do Facebows play in relation to Articulators? How can we make sure that articulators mimic the human articulation as accurately as possible? I am joined by Dr Salman Pirmohamed to end our confusion with Facebows!
Protrusive Dental Pearl: If you’re planning to increase the occluso-vertical dimension (perhaps for multiple restorations or an occlusal appliance) and you know the final vertical dimension, try recording your Centric relation record (or whichever bite religion you follow) AT that desired vertical dimension and NOT at the ‘first point of contact’. This is because traditionally when we send the technician a first point of contact bite, they will open up the pin to give you the space that you need for the restorations and optimal aesthetics. The problem with this is that it introduces an error because the arc closure/opening of the patient is likely going to be different (even with the best Facebow in the world) to the arc on the articulator. Therefore, reduce that error by doing your bite registration, not at the first point of contact, but doing it at where you want to finish. Read that again!
In this episode we discussed:
- Implant cases in MClindent in prosthodontics at Eastman 8:32
- Microbrush Technique (Stickbite) 12:24
- The ‘Putty Bite’ technique 16:05
- When to use the ‘Putty Bite’ technique? 18:29
- What is the role of a Facebow? 20:52
- Benefits of a Facebow registration 23:41
- Communicating to the technician in terms of using an average Value Articulator 25:23
- Making Facebows a part of your Clinical Practice 31:02
- Kois DentoFacial Analyzer 36:40
- Guidelines for using a Facebow 38:34
Check out this papers as mentioned by Dr Salaman on the Podcast!
If you liked this episode, you might enjoy A Story of Digital Occlusion with Dr Ian Buckle
Click below for full episode transcript:Opening Snippet: So that makes the best type of articulator, which is the patient, the patient is the best articulator. Like when you have temporaries or mock up so you can try something, you know, you've got complex restorations, just putting temporaries in the mouth, but lab provisionals checking the patient, if it will make sense, cement them in temporaries, see how it goes and when you're happy, just take a copy and use that because that's actually the best articulator you'll get...
Jaz’ Introduction: Let’s say you have a patient in front of you and you’re observing their movements, you’re observing their left lateral excursion, their right lateral excursion, and this just a bite in general with their delicate, wear facets and now you’re planning some restorations. Let’s say you can do some crowns and veneers on this patient. Now, you send the case to a technician, a technician that you’d like to work with and what they will do is they will design some restorations. And what they hope is that as they are planning the excursions on the restorations, when they send you back that work and you try-in in the mouth, the movements that the lab was making is the same as what you’re finding in the mouth. So essentially, going from patient to the technician and back to the patient. Okay? So how can we make sure that this is as reliable and as predictable as possible? Well, that’s why we use articulators, right? So we use articulators to mimic the TMJ and mimic the upper jaw and the lower jaw and all the movement. So that’s essentially why we use articulators, but we know that the best articulator is the TMJ. So now we have tools. Tools that help to sort of supposedly help to improve the reliability or predictability of those movements on the articulator being the same as the patient. So essentially, the articulator is the best articulate in the world should it be ever be designed would have the exact same movements as the patient, so it’s like recreating the patient’s jaw movements but outside the mouth. So One such tool is a Facebow, and that is exactly what this episode is about. The Facebow is a tool which confused me so much for so many years, I had to go in so many different occlusion courses to get my head around the facebow and the different types. So I’m hoping this episode is going to give you some closure on Facebows, some idea and some understanding, some theories and philosophies and also how you can get away without using a Facebow where necessary. Welcome, Protruserati, I’m Jaz Gulati, to this episode with Salman Pirmohamed was a specialist trainee at the Eastman doing prosthodontics. Sorry for the short break in episodes. I was at the BACD conference with Pascal Magne, who’s agreed to come on the podcast and here’s a little clip and a sound clip of what he said. Or I said to him at the time of handing him this handwritten note inviting him very dearly, inviting my hero to podcast. So fingers crossed this is gonna happen soon but here’s a little soundbite of the magic of Pascal Magne. There we are. Pascal’s gonna come on the podcast, he just said it. The second most famous Dentist Ever After GV Black. Man, I’m such a fanboy there. The other reason I’ve been a little bit delayed is my son is a not great sleeper. He’s you know, he’s only two. And we go through good patches. And one stage I thought, Wow, I’m absolutely an amazing parent and I’ve got this whole parenthood thing. And this whole parenthood thing is easy. And I managed to sleep train my son and I felt like I was on cloud nine. And then you have a bad week of illness and suddenly your son becomes a nightmare at nighttime. So it’s a real struggle. You know, the parenthood struggle is real, but it’s a beautiful struggle. And so we persevere and we do the best we can. Before we jump to the main episode The Protrusive Dental Pearl I have for you is probably something I’ve shared with you before and I have no shame in sharing it again, if that’s the case, because I think it’s such a huge pearl. If you are going to be using Facebow or if not, okay? This is a bite registration tip. If you’re planning some restorations, or if you are planning a splint of any type, if you know the final vertical dimension that you’ll be working to, for example, you know that you’ve got a generalized wear case, so you know that you want to lengthen the incisors and you want to open up the bite and you know the final Overbite you’re finishing with, you have a pretty good idea of how much you’re raising the bite. So what the traditional concepts teach us is that when you’re recording your centric relation bite or whichever position your religion believes in, you want to do it at the first point of contact, okay? And traditionally what would happen is that the first point of contact recorded and then the technician will open up the pin to give you the space that you need for the restorations. Now, the problem is that and you’ll suss this out in the episode as well and we talk about this is, is something I’ve already touched on in the very beginning of this intro, which is the articulator is not the person is not the articulator, so if you change anything vertically on the articulator, then there is no guarantee, in fact it’s definitely not happening at all that the patient does also opens in the same arc, okay? The arc of the patient is likely going to be different even with the best Facebow in the world to the arc on the articulator. Therefore, why don’t we reduce that error by doing your bite registration, not at the first point of contact, but doing it at where you want to finish. So if you decided, okay, I want to go from here, and I want to open them up three millimeters, why don’t you take your bite record at that three millimeters, or if you know that your splint is going to be, you know, 1.5 to 2 millimeters at the thinnest portion, maybe in the molar region, that you get your bite record at that position. And you can use something like a leaf gauge, for example. Now, these are all foreign terms. This is the first time you’ve tuned into Protrusive Dental podcast, you’re a student something and you’re thinking What the hell’s going on? Don’t worry, okay? Deep breaths, okay? Occlusion is a journey. Okay? And for those of you who understood what I said, I hope you implement it. I hope you get some good success out of that tip, and I hope you probably philosophize early, think about it. Think about what we’re trying to achieve here. So just to summarize, when you’re taking your bite record, consider taking it at your desired vertical dimension and not at an arbitrary position, because your technician will not have to raise the pin or open the pin on the articulator, and therefore you reduce another layer of error. Anyway, I’ll stop babbling. Hope you enjoyed that pearl. And I’ll catch you in the outro after this stonker with Salman.
Main Interview: [Jaz] Salman Pirmohamed, Welcome to the Protrusive Dental podcast, my friend, how are you?[Salman] Yeah, thanks for inviting me. [Jaz] No, it’s great to have you on. And the story when you and me is we’ve been following each other on social media we’ve never actually physically met, I look forward to one day as we get more and more face to face, but my buddy Harjot, he spoke very highly of you. He said, You’re doing the pros program at Eastman, which I want to probe you a bit further about, but I’ve been seeing some really cool tips you’ve been sharing on Instagram. And one really caught my eye recently, which was a putty and you know, we’ll expand on in a moment because it was a putty and then you drew on the putty with, I can only assume with a sharpie pen to give the technician some more information about the sort of horizontal plane of the anterior teeth. And that, for me was genius, from an evolution of sometimes using micro brushes as a stick bite and again, if someone’s listening to this, and you have no idea what I’m talking about, we’re going to go through in this little impromptu episode on exactly that. So that was really, why why you’re here because you inspired me a lot with that. So with that, Salman, tell us, tell everyone where you are at the moment. What are you studying? What are your interests? And how you’ve been finding your program at the moment? [Salman] So hi, everyone, my name is Salman, very happy to join you guys on this podcast. Essentially, I qualified from King’s College in 2016. Spent a bit of time doing PT in Northwest London. And I’ve still been on my VT practice for the last five, six years. So I’ve never really left, asked my VT I did a hospital job for one year, I was lucky enough to be at decent dental hospital. So [?] job a bit similar to I think what Jaz has done in the past also, after that went back to practice because I thought I’d had enough of hospital and after a few more years in practice, I realized I need to learn a little bit more. So I’m now halfway through my pros specialty training program at EastMan Dental Hospital, which I’m really enjoying. It’s while I go through a bit more detail later, but it’s pretty intense. It’s very hard for me [?] Google of dentistry, it’s amazing. I love every day I go in [Jaz] That really shines through on your social media that you’re really passionate and you love it and you live and breathe this stuff which is great to see Salman, honestly it’s amazing. Now, just the first question that springs to my mind about anyone doing a specialty program is a lot of dentists listening there may be considering at one point in to do something like what you’re doing you’re especially MClindent in prosthodontics for example, how much implant training do you get? So for example, do all the trainees get to a certain level of competency with an implant? Or do you make what you want? Do you get what you put in that if you want to do more of implants in that you can be pushed in that direction. So how can you answer that one for us? [Salman] So in terms of implant experience issued implants is there’s no specific specialty on implants, everyone gets involved in it, we’ve got prostho, we’ve got Perio, and then we’ve got people in the restorative training program within us oral surgeons and everyone’s a bit of a taste of implants. And for me, when I first went for my interview, the supervisor told me that this is not an implant training program, it’s a prosth training program. And in pros teaches you the treatment planning that you need to know to give the patient the appropriate option. So I think I speak a lot of Implantologists and the kind of thing everyone says before you’ve got as a hammer, everything becomes a nail and everything that comes in implants and I think the one one question to ask first is when should we be placing these implants? What’s the right situation for them? In terms of my experience in implants, so the pros training program in the Eastman, the first day we had a few weeks dedicated to implant training from a theoretical perspective, and then a very much depends on your case mix. By the second or third year if you’re lacking in a certain specialty and you want to get more involved in it, then patients get this ?? accordingly. The difference with implant planning is the planning for these implant patients in the Eastman Dental hospital because they’re either cancer patients, or hypodontia patients who met the treatment planning, the kind of NHS funding criteria, they’re really complex cases. So the planning can take three to six months before getting to implant placement, the way I went along my journey, so I’m five, five and a half years qualified. I’ve done quite a few implants, but I did all my implant training before during the prosthodontic program. So I wanted to kind of short foundation courses together to kind of figure stuck in there’s a lot of mentor placements. And I think mentoring is just, I know you mentioned in those in your podcast, it’s so understated in dentistry. Initially, it’s gotten me to where I want to be now. And so when I came to the prosthodontic program, I’ve really placed quite a few implants. And that means it’s kind of like, on an upward slope already. And that means I can make the most of it. So Jaz is right. So you get out what you put in. And if you’re ready to put in a lot of work, you get another benefit from the program. [Jaz] I think that’s great. I think you’ve done it the right way, you know, to get some experience under your belt before you start a very intense program like that. And you know, just to mention, for those who don’t know you, you know, Salman’s got an eight month old baby, working practice, doing the specialty program. Do you find it, it’s like a really, do you find like, sometimes you’re like, Whoa, this kind of week just flew by and you feel like really stretched for time? [Salman] And I pump all the time. My supervisor thought I was a bit crazy in the program, because when I first joined us and having baby in a few months. In the first four months of pros training is like a ?? program, waiting long shifts in the lab, constructing all your restorations and then I had a baby along the way. But to be honest, I wouldn’t have it any other way. There’s no right time for a child. And to be honest, it just makes you, Jaz, you’ll know, when you’re looking at something just know, you know what it is you’re aiming for and what you’re working towards. In actual fact, it’s the opposite. It gives you the motivation to keep going. [Jaz] Absolutely. [Salman] That’s just not really a job. It’s for me, it’s like a career. So it doesn’t matter to me. [Jaz] And exactly that when I also listen to other people speaking on other podcasts and speak to other dentists, they always say that, ‘Oh, I just put my practice and we were expecting or I just bought my second practice and we were expecting or I just moved to Australia at the time, and we were expecting.’ So you know, there’s never a perfect time for a child to slot into your career. They just come and they’re a blessing and you take it in stride and you make the most of it. So that’s amazing. Let’s hit the main theme of this episode today, which is communicating Cants to lab so for those baby dentists listening right now, a cant is when something isn’t quite horizontal, when someone smiles they’re they’re off at an angle and you see maybe a lot more of the left side and not so much on the right side when they smile. Now, Salman, what are the different ways and we can go into each one of communicating a cant let’s if we start with the brush, the Micro Brush technique and then how your the way you shared or so clever. So if you start with a micro brush technique, if you don’t mind? [Salman] So as opposed to just like the reason I thought cants began so important for me is when I started at the Eastman and I got my first study models, study cast from my patient, and I put them on articulator and I got to the articulate and I looked at it and I thought, Where do I begin? Because there’s no starting reference points. And that’s where I got involved in the cant and figuring out how they work. So the micro brush, the stcik bite technique that people use, essentially, using silicone bite registration paste, you put it on the teeth, ask the patient to bite together, the little bit of excess at the front, and with that excess bite registration paste, you’re going to orientate a micro brush in, people use one or two, the first Micro Brush should be oriented to the interpupillary line. So a line connecting the eyes and you want that line microbrush to be parallel to that. For some people, you need to assess them before because their eyes might not actually be at the right horizontal level. And so in those cases, I use like the countertop behind the patient, the floor, I look for a horizontal references. [Jaz] Or the blinds behind the window, the blinds is too horizontal. [Salman] Yeah, my patient had a joke. He said you should bring a spirit level with you when you do this. [Jaz] I was always thinking about how to implement that because I know sometimes, I know some my colleagues who actually use a fluid level, spirit level on their facebow to make sure that you really are or this really clever Lukas Lassmann told me once that with some glasses and some patient sunglasses that they put on, before they take the portrait photograph, they put the sunglasses on the patient, just to make sure the fluid bubble is correct, then they take the glasses off, and then they take the photo. That was a pretty cool way to read. I mean, that’s a really high level detail, but you’re right. So you’ve got your micro brush in and now when you wait for the material to set, the lab gets that and then the lab is able to figure out that Okay, if as long as this Micro Brush is completely parallel to my countertop, I know the situation of the models is going to be closer to the real life situation. [Salman] Yeah, and then mounting, it’s important to know that they’re going to be mounting this cast at an aesthetic angle
than a functional angle. Since its we’ll talk about later anyway, I’m sure we”ll go in to it. But these microbrush, the issue I was facing was the fight. When you’re sitting right next to the patient, you’re lining up this horizontal line. And then you step back and you realize it’s wrong. You kind of restarting again, that’s the biggest issue of sets, and you’re done. And then the second issue is transport. Because things get broken into postings get distorted, and then it’s all off angle. A really good tip is[Jaz] It’s very flimsy, isn’t it? It’s very flimsy. So yeah, you had a tip with that? [Salman] Yes, take a photo of the first thing. As soon as you’ve taken your record, just take a photo of it. See, if you’re a few degrees off, when the technician sees that photo and mounds of bits on a computer, they can just really calculate and just as you need to, they’re just some kind of reference point that they need to begin with. [Jaz] That’s brilliant. And nowadays with the, you know, [Keno] and the different lines and the DSD sort of lines, and like I said, If anyone ever emails me message me, I’m happy to send you the ruler and the lines and whatnot. They’re really cool to have. And sometimes you can just verify on your laptop, okay? Was this actually done nail it, and if you didn’t, it’s okay. Just tell your technician, Okay, just make sure you shimmy a little bit, a couple of degrees clockwise or whatever. And they can accommodate for that. So tell us now about this really cool tip you shared about how to overcome this stick bite because it’s so flimsy. And I really appreciate because it was really clever what you did. [Salman] So when I started in the Eastman, there is two supervisors who really helped me out and give me a lot of tips of my cases. And two of them recommended that if you had some putty freehand, you place it over, you can place the teeth or even in edentulous ridge. And I mainly just go for the upper three to three, I roll it over. And then once it sets, you draw some lines to get a Sharpie marker. And the lines I drawn as a usual horizontal line, a drawn midline, we can even add in things like I’ve had people like messenged me on Instagram, they’re canine lines, full smile lines, resting smile lines, and because you can change it and adapt it, and the best thing is if you get the line wrong, you rub it out, start again and you just send it off and it doesn’t get distorted in the post, take a photo, some simpler. And that’s really helped me out a lot in practice. [Jaz] It’s an easy thing to do for all and it’s almost as though you’re creating a wax jaw registration, wax rim, right? And you know you’re able to draw on that. Now just because the nuances, obviously the putty can be a little bit curved, 3-3, we’ll have that labial curve. Any tips on being able to draw a nice line? Like you’re obviously looking at the eyes, assuming they got normal eyes, I guess, looking at eyes and you’ve got the ruler, or are you doing a freehand any tips and nuances? [Salman] You know, I’ve posted on Instagram, Harjot messaged me, he said you should have used the ruler. Because even the post is a little bit curved. But I think for me like draw in a pencil first and then just mark up with a Sharpie afterwards. That’s really the easiest thing to do. You give it a floss and bend it across the putty and use that. I think it’s nice that it’s actually on a curved platform. It’s actually better than a microbrush because your smile is naturally a curve. So a cruve may actually work better than doing a straight line. Yeah, this pencil is sort of the best thing that can be done. And as soon as you take that photo, you’ll know when you see that photo and you see what you’re sending to a technician, you spot straightaway what the mistakes are with it. Just today, you know, Jaz I work in NHS mixed practice, though, like half one day a week. And so I’ve been trying to figure all these tips I then I take what I’ve learned at the Eastman are very, very high level. And it’s applied this in a kind of practice setting. These are the kind of solutions that take away with me so much trying to figure out what will work for these patients and this time and financial constraints. Now showing you a business of the same challenges every day. [Jaz] We do. We have these challenges and we need something that’s quick and easy, quick and dirty to do these little tips are really helpful. Now, this begs the next question. Okay? When would you do, Okay, let’s so if we call the evolution away from stick bite to the putty bite, let’s call it the putty bite, shall we? The putty plane. The Salman’s putty plane, okay? When would you use this instead of your Facebow? Or are you often using it to supplement the Facebow? Either both in the real world. And in the ideal scenario in the most you know, ivory towers. [Salman] Yeah, ivory towers. Jaz, in terms of cant there’s so many I’ve got like nine or 10 ways I measure it within practice because there’s different situations I work with. So I’ll just share a few of them I fint it easy. So for example, I was prepping like an upper six unit 3-3 bridge a couple of weeks ago. And after I finished I looked in and said hey, I’m going to translate this cant to technician and I looked at the canine tips and I just held my ?? handle across the canine tips and looked at it match the patient eyes as like that looks about right. I don’t need to do anything. So when I send in prescriptions to one technician I just say you know what the canine tips mount it aesthetically according to that and that’s your cant stand for you right so if someone you’re going to go wrong, there’s an extra putty here to go over the top. And another way that I’ve started a temporary is amazing, I heard Basil’s podcast with you but by temporaries provisional restorations. If you’re happy to temporaries in your provisional cants, take an alginate ask for that copy. It’s a much easier technique and much more accurate than all of this that we talked discussing. And the last one is as I was prepping a 6 upper unit case again A couple of months back. And when I finished the preparation, my supervisor at the Eastman told me, what you can do is this with one of these teeth, just prep it according to the cant that you want. So the upper left one just shave off like point 2.3 millimeters, get in the right horizontal axis and just ask the technician to use that tooth as your reference points. [Jaz] Okay, that’s an interesting way to do it actually it and by that do you mean like a midline camt for that one? [Salman] No, even just even the incisal edge of the upper left one, just the way you trim it. And you’re done right? So that there’s someone who is doing this but the main thing is you got to think about the challenges that we give our technicians because I never appreciated it. And now I do the lab of my own patients, it’s blind if you think about it, the sooner the two cants and download the patient’s face in front of them. And then suddenly when work comes back and you complain, realize it’s our fault in the first place. [Jaz] Absolutely, I mean, you’re so right, all these challenges we face all the time and so the more we give our technicians the better so what point are you then supplementing these accessory techniques to communicate a cant with a Facebow and what are your views on always Facebow or let’s go very fundamental, Salman. And then we get this question all the time like when I was a new grad like I didn’t know anything about Facebows even though we had the module, it was just really confusing. You know, I didn’t really grasp until a few years afterwards. So what is the point of a Facebow? So some people listening are thinking, you know, why? [Salman] There’s just one thing like this podcast episode, I just like to be able to not be scared of the word facebow like, it creates so many, like random thoughts and mysteries that I don’t understand at all until I got to this Dental hospital. So the Facebow is purely just a way of measuring the relationship between the teeth to your jaw joints, okay? It’s just a utensil that we use, okay? Now, two reasons why we would use a Facebow, there’s aesthetic reasons and there’s functional reasons. So the aesthetic reasons to use Facebow would be to translate a patient’s cant to the lab. But that’s definitely not the primary reason of a Facebow. Because the old style Facebow, well, even the face was that we use that arbitrary Facebows, which means we use them in the ears as our reference points. And people’s ears are not necessarily parallel to the interpupillary line or to the floor. But it isn’t a majority of patients. So if you’re taking a facebow record, a secondary benefits will be that you get to translate cants to your pros technician. But if I needed to translate cants, my primary thing I pick up a that party and a Sharpie marker, rather than an actual Facebow record. [Jaz] That would be supplementary to your Facebow record to verify, right? [Salman] Yeah, because when we figure out when in articulator, it just our guesswork of what the jaw joint’s there, right? And when we put on maxillary and mandibular correspondence, we can either mount them in a functional relationship, which is how Facebow works. Or we can mount them on an aesthetic relationship, which is when I send my putty to the technician, I told the technician just mount according to the putty line. But I know that might not necessarily be what’s in the patient’s mouth. It’s purely just to give it a horizontal reference point so that the aesthetics for me come out correct. And so the question that people will then ask is, what’s the point of a Facebow? Why use it? Because if you imagine things not with Facebows and the workout fine, what’s the actual reason for this? And this is the, there’s a huge debate on behind the scenes in this for dental hospital about [Jaz] And just for you reveal the answer there. I mean, you’re totally right, I’m gonna echo those thoughts. So if you have a successful putty, with the line going across communicating the aesthetic plane, and the technicians able to mount that on an average Value Articulator without the use of the Facebow, and then you’re getting good results. And then therein lies the question, what additional benefits is the Facebow giving? [Salman] Well, this is the big debates, right? Because they’ll be things I say that people don’t agree with. So let’s see, we have just a [rigid] patient we’ve got upper and lower 7-7, which a sound and I take an upper impressions, and I thought a technician to mount it. Now when the patient puts, when the technician puts this cast together, and they might have an ICP that’s a static relationship. And me sending a facebow record to get that static relationship has no benefit whatsoever. Okay? But if I asked the technician to raise the OVD, will increase the OVD about one or two millimeters, increase a wax up in that position, I’ll have to go back to basics, Jaz, because I’m making sure that so there’s different types of articulators. The first type of articulator is a hinge articulator which just goes up and down. It doesn’t affect the patient’s jaw at all. He doesn’t need a facebow records [Jaz] I mean, even more primitive than that, Salman, is the old wristiculator. [Salman] You know, Jaz the evidence shows that the hand articulator is more accurate than the actual hinge articulate. In fact, if I’ve got like a six single unit crown, I’d rather my technician man sit on his hands and figures on the excursions rather than puts on a hinge articulator because that just has no relationship to what happens. [Jaz] Very true. [Salman] Okay, the second type of articulator, it’s like a fixed average movement articulator which has general averages that work for, like it’s multiple patients have been assessed or the angles of an articulator and your mandible cast on there. Now that articulators it doesn’t accept the facebow record, you position the cast on that either just randomly, or there’s certain prompts that you can mindset using, which I can discuss if you’d like to? [Jaz] While we’re on that topic. Yeah, let’s go into that. So you just we talked about the evolution, we talked about the wristiculator, which actually Salman said that evidence suggested may be better than a simple hinge. So therefore, let’s avoid the simple hinge. let’s skip that. And then now we’re talking about an average Value Articulator and then in that you, you know, you imagine you’re a technician, you get these cast through and you’re trying to put it in somewhere within the articulator, and here is lies issue, you’re just guessing. So what clues can we give to the technician, I think is what you’re coming to, to help them to almost be as good as what the perhaps a Facebow may give. [Salman] Yeah, so like, if you look at Denar for example, like the companies will sell a special mounting plates for these cast to go on top of. And there’s mounting plates that do this. And there’s ?? for features like there’s a simple one triangle, bond angle. And essentially, this is set parameters that is a certain number of centimeters, I think it’s 11 centimeters from the condyle to, like the mandibular incisors, and you know that this measurement is fixed. And so when you then put your mandible across on the articulator, you put it according to what we call [formulas] triangle, you set up there, and then you put the maxillary cast on the top. And you know which angle to put out because a bulk this angle, and there’s all these degrees that you can put on and start with that first. And then you’ve got some kind of average to begin with. So that when you then begin to move to that maxilla and mandible around, you know, that may be related to what was going on in the patient’s mouth. So that’s the fixed average artuculator. [Jaz] And I mean, the other thing that we can also do here to help our technicians and something that you know, you’ll be doing all the time is sending some full face photos, and also even the full face photo with some retractors so that when they bite together, you can see all the gingiva. And then a clever thing to do then would be to get that all, make sure all the planes are correct a little bit of tiny rotations and degrees. And then when we take our intraoral photos to make sure everything lines up and you can nowadays you know, on Photoshop, whatever, put your or superimpose your intraoral photo on the facial photo, and just make sure everything’s correct. And by giving that level of information to the technician, they can now as they’re about to set the model, on the average value articulator, they can look at your photos and be like okay, this looks look a little bit like this. And I’m going to do like that and then you can even have a side view, a profile view showing Okay, this is the best guess of how it’s going to be and that’s just it little things we can do to give our technicians more information so they can recreate the patient’s actual anatomy on the fake bit of anatomy that we’re trying to recreate with an articulator. [Salman] Some people might be asking, like, why do you just mount it in. So even the maxillary occlusal plane we know it’s not straight, right? ?? sphere. It’s like down the tools, even all these little things when you got new articulating plaster, if you’ve used it sets like this, like when you’re holding that model or suddenly moving in with a set, you’re stuck in that position. So it’s not an easy job that technicians have everything that we can give them makes it so much easier. Then we go on to the semi adjustable articulator. So these are the regular ones that we use at the Eastman Dental hospital for regular cases. And these are ones that accept facebow records. And so what that facebow record does is you take it and for those who don’t understand facebow, it’s the maxillary cast which sits on top of your facebow record, your facebow record inserts into your articulator and then that maxillary cast gets stuck into the articulator at the correct position. So the semi adjustable articulator has like a fake jaw joint on it. So it’s all kind of It’s looks like a jaw joints, and then your maxillary cast can stuck there and then you put your mandibular cast underneath as an ICP or an open jaw relation position. And that’s kind of more accurate than a fixed average Value Articulator [Jaz] Yeah, it’s good because when you are moving something on the articulator, we’re hoping that’s going to be closer, representing what’s happening in the patient’s mouth, compared to what the average value may give you. Because you’ve got that extra, it’s essentially getting I’ve got a diagram for this I can put it on at this point is like the different arcs that are made, that your the arc of closure is going to be more hopefully, more closely representing what the patient’s mouth is. But, you know, as someone who uses articulator or facebows very, very little nowadays, there’s more digital I go, the thing that really annoyed me, Salman is like, seeing some of these virtual articulators, right? And I didn’t understand the following, which is on the actual, you know, Denar articulators, for example, it’s the upper member that’s moving, but we’re sort of visualizing it as the lower’s moving but it’s the upper one that moves the way it’s designed. But even on the virtual articulator, they still design so the upper moves. I’m like, Well, why would you do that? Just make the lower move. Like, you know, why would you design it that way, even a virtual when we have the power virtually to change all that. So that was like, what the hell is this? [Salman] Yeah, and Digital’s coming into everything it’s like articulators, a purely our guess, our best guess of what’s actually going on in the patient’s mouth. And so the next articulator to semi adjustable is fully adjustable articulator and these articulators they’re complicated like that you take like full pantographic tracings of jaw movements in a patient’s mouth. You said they flap all of these, you translate all the information onto this fully adjustable articulator and has been shown that this does reflect because in the patient’s mouth, but is it really practical to use in day to day practice? I don’t think so. And we need to find the easiest solution. So that makes the best type of articulator, which is the patient, the patient is the best articulator [Jaz] Absolutely. [Salman] Like when you have temporaries or mock up so you can try something, you know, you’ve got complex restorations, just putting temporaries in the mouth, but lab provisionals checking the patient, if it will make sense, cement them in temporaries, see how it goes and when you’re happy, just take a copy and use that because that’s actually the best articulator you’ll get. And yeah, I’m sure it is for you, Jaz. [Jaz] I’m so glad you said that, because I was waiting for this. And then you said it. And I’m so glad you did. Because the best as Tif Qureshi told me many years ago, the best articulate is a patient’s own TMJ. And then you you raise a great point, look, the time as a dentist, we start using these tools, because all it is just tools, right? Articulators, Facebows, it’s just tools to help us to do less adjustment in the chair on the day of delivery. That’s essentially, you know, in a nutshell, it’s all it is, to help reduce appointment times to make sure that we and the technician can work together to do less work, make it easier for us, right? And then by having temporaries and IE doing complex work, and therefore we’re now having to use facebows and articulators, and therefore you’re probably going to be having a temporary phase. Now, this temporary phase could be in composite, in temporary crowns or a combination of both. And that is the time you work on it, you nail it, you Dahl it in you do your adjustments, you do your, you know, equilibrations within your temporaries because that’s what we’re doing essentially, we all are equilibrating temporaries and then you hit the nail on the head, when you said, we then get the in the future when we’re ready, when we’ve tested it, the environment, the human articulator of that patient, and then get the technician to copy the features. That is I think as as good as it gets and negates the need for any, you know, fully adjustable articulator would you say? [Salman] Yeah, the only big thing on earth is that this is not missing, your facebows at all because those initial temporaries have. This is the old school Eastern opinion I’m about to give you but those initial temporaries and we made from a wax up which you’ve had on articulated casts, which you’ve had an manage opening, closing the OVD, and you only get the accurate wax up and accurate planning and accurate diagnosis. But having a set of properly articulated study casts, you only get sort of the articulated study casts, in my opinion, with the facebow record so that you can open and close the pin properly. And so if you’ve got really great wax up, and then you make templates from that, and then you do this really minor adjustments to those temporaries, then you know, you’re almost perfect on the day of delivery. And I still have these even I personally, we do a lot of zirconia crowns nowadays, and like monolithic zirconia crowns should work amazingly well. But as you’re going to these kind of materials, the more and more difficult to adjust in the mouth. And for me, like the degree of precision you need is certainly going up and up and up. And so using things like Facebow and proper wax up, the first principle should always still be there in all of our minds. And the other thing to know the Facebows, there’s no harm in doing it whatsoever, you’re not reducing your accuracy by taking Facebow. For me, it takes less than five minutes to do a facebow record. It’s like when you start with an SLR photography, you’re like highly sensitive photos, you just keep it ready. And honestly, it’s so easy to just pick up and take that photo, just keep a Facebow ready in your surgery. And once you’ve done it two or three times it’s very, very fast, people overcomplicate it, undergraduate. So really, really simple technique. It’s not something only specialist prosthodontist should be using. It is something in every general dentist like [Jaz] Once you get slick at it and your nurse gets slick at it and your nurses in having to look for it. Which surgery is it in today and all we’re missing the bite for whoever and once you get you know, once you have, once you organize and you have it in place, and you rehearse it a few times, you know, I remember when I was in practice, starting to use the Facebow a bit more. And I was like on YouTube like refreshing myself or Dentinal Tubules watching these videos to remind myself so they’re like, I don’t know, like an idiot. And even like in the first few times I use it. The fork was facing, the actual fork was facing the wrong way. And the big pole was coming out on the left not on the right. And yeah, these little things you mistake you make it once and you realize oh yeah, that’s how it is. But you’re so right, it is actually a super simple thing. It literally is as easy as 123 and you screw and tighten everything up, obviously depending on which type you’re using. But eventually once you overcome your initial fear and you book extra 5, 10 minutes initially, it only takes up to five minutes. And then you can even take a photo when the patient’s got the facebow on as well just to make sure later you can look back and think Okay, then I have everything, did I nail everything? DId I get everything all correct? And this is all there to help you make better temporaries for less adjustments, and then when you got everything right in the temporaries we could transfer it to the mouth and Do the least amount of adjustment as possible to so you’re not drilling away your precious zirconia ceramic restorations. And that’s the way to think about it, what you’d say Salman? [Salman] There’s two or three like the other benefits of facebow we discussed earlier, you get this functional benefit and yours can be aesthetic benefit to the technician that is cants on that same articulator set of study casts. And then finally, for me like something I’ve learned at Eastman as the way we stage appointments, we’re not planning tooth surface loss cases is we will not take all our records in one visit and the next week the patient comes in for that mock try-in. The way we do it is the first visit we do a whole diagnostics, we take just upper and lower impressions. The patient will then come to the second visit when you do your initial records and your facebow record because then you’ve got casts sitting on your table. And we can then do on those casts as you check you verify them and so that Facebow, we take in we eyes impression compound, [using silicone various pastes], you want minimum accuracy so that when you’ve got us point contacts, and you can verify your cast is accurate, because before you ask the technician to do that very expensive wax up for you, you know that everything’s gonna come back exactly how it should be. So dividers are by cast ?? and jaw relations movement, I do my facebow record, I do my RAP like to prepare record, I verify everything fits on the casts, and then I send it to the technician. Because the last thing is you wanted in this and then technician goes, Your cast they don’t fit together on its facebows, don’thave enough its jaw relation records will direct me to do so that’s just a little tip out there. Separate appointments, it makes life so much more stress free. [Jaz] That’s so true. And it gives you that confidence that Okay, the first phase was correct. Now you can move the next phase and now you can move the next phase being the wax up. And you know that your minimize your errors, your accumulated errors. So dude, I’m so happy that we’ve covered that. Do you by chance? Have you got much experience with a DentoFacial Analyzer? [Salman] Is that the Kois one? [Jaz] Yeah, the Kois one because this might be a whole different episode with someone else. Cuz now that we’ve covered this, because what this what happens, you learn about Facebow, and someone comes along and say you don’t need to Facebow just use a DFA and you’re like, Oh my God, here we go again. Like, there’s so many different ways to skin a rabbit. Now, I don’t own a DFA. I’ve seen it being used in lectures extensively. Like, I’ve been so much occlusion CPD that I’ve seen it being used a lot. And I get the point of it, it’s clever. It’s quicker. I get it. But I don’t use it. So I want to talk about something and perversely in the way that haven’t used it for just wondering have you got an experience on this? [Salman] No, I’ve just haven’t use this. I wouldn’t want to comment on it without proper knowledge on it. Yeah, that thing is, even Facebow records like what case, the main issue that I had in practice was I was trying to pick which case is actually needed for. And some people will say, Oh I use it for all my cases, I used for some cases, I never use at all. So which cases is it that’s kind of like that massive differences? There’s two really interesting papers that I read this year. There’s one in ?? I don’t know if you’ve heard of his papers like dogmas in dentistry, you’d really enjoy it. It’s, he goes through kind of all these. [Jaz] It also talks about the wide centralization isn’t this magical point? Is it the same paper were talking about? [Salman] Yeah. It’s also like why primary and secondary impressions are not required for dentures. What’s the simplest way you can make a denture? What’s the actual clinic, this is actually change your clinical outcome or your final restoration. And there are quite a few papers out there that show that they had kind of randomized control trials, complete dentures, one on facebows and everything. Another one very, very simple approach, No Facebow, was a clinical difference in these patients 20 years later and a lot of them say No, there wasn’t difference. And then the argument is, well, dentures move around, they can adapt, adjustments were made. And so which cases should you be picking these facebows for? And I’ve got just a select few in mind that I always use it for. And the rest, I feel I can get away without it. [Jaz] Oh, we’d love to hear that. So that’s a great point. We can’t be uncovered yet is that when do you, when do we use it in practice? We took over the why. And therefore people can sort of extrapolate the data and figure out Okay, should I apply it to my case, but we like these guidelines. So what are Salman’s guidelines for using Facebow? [Salman] So for me, the first one is like articulating study casts before like, I’m planning a full mouth reconstruction. Because if you’ve got patient come with tooth surface loss, and you send your patient or your technician, just those upper lower casts, just the articulator together, you need to know how they move and dynamic relationships because if you’re planning in raising the OVD, then you’re going to open up the articulator pin you need into some kind of relation between those teeth and those jaw joints at the back. So if I’m planning any increase in OVD, then I’ll be taking a facebow record. So that’s the first one. [Jaz] I mean, essentially, when you are reorganizing, that’s automatically a Facebow, which makes total sense. [Salman] And then the second one is, this is my judgment call on this one. So if, we’re always going for mutually protected occlusion these days, which means you’ve got our posterior stable ICP contacts, and then for stable anterior guidance, so we see that the 3-3 we get good lateral canine guidance. And that means generally if you’re working on a 4, 5, 6, and 7 and the patient has a stable canine guidance, then usually you can get away without using Facebow. If you’re just restoring single two units, four, five, and six will get away with it. Then there’s the whole last tooth in arch syndrome which I’m sure like we get asked a lot. It’s a classic example of like, winning a lawsuit in our channel managers. What’s your opinion on that, Jaz? How do you restore [70 profit], and you just lose all the space. [Jaz] So me and Mahmoud are doing an episode soon all about this different nuances of lawsuits in the arch. So but no, I mean, essentially, it’s important to screen for that case, before you do it, it’s important to communicate to the patient that hey, this could happen. And once you screen for it, and this could happen, you’ve got to have that chat up front with the patient that Okay, we actually might need ortho, we might need a crown lengthening or whatever to be able to do this, before you start or just to know at the beginning that you might just need to prep a little bit more. And can your tooth handle that before you get to it, and then I’ve also done things like [Island prep] before and in various techniques. But yeah, you’re right, and having a Facebow on that can help you to visualize the challenges. What about you? Anything you wanted to add to that? [Salman] Yeah. Well, I was gonna say that a few matches study. So we’ve talked about facebows a lot. It’s also people will ask when do you mind casts in intercuspal position, and when to mind, I mean, that retruded access position. And that brings up a whole another podcast for us to discuss because it’s a huge topic. But essentially, if like you can pan a lot on articulator so you see if you can manage casts in the retruted access position, which is that Hinge Movement of the patient, you need to Facebow to do that. And then you can see the slide from that position is to RCP, and that slides ICP, and you didn’t know if that lower back tooth is going cause your problem before you even start prepping it. So it’s this whole is diagnostics that Facebow gives you, there’s a huge wealth of information that can be viewed just knowing when and how to use it. For me, anterior six, you know, push cases on nearly always use a facebow record a filler, the extra information just helps it up massively, I want to see how the protrusive guidance is going to work. Because I might be heading for the anterior guidance, and I need to recreate it properly. And the last one is the patient has very reflective. So 4, 5, 6, 7 are all ground down and very flats, I can just ask the technician do a handle that situation and making crowns and a four, five and six. But when he moves, everything’s kind of flat at the end, because he’ll just be copying what was there before. If I want to create my cusp to cusp relationship which should give stable intercuspal positions that I need to give the technician a bit more information. In fact, even the facebow record they can put it on an articulator and then they know how the condylar guidance works and the jaw movements work. And they can then create much more stable restrictions for me. So multiple units, increasing occlusal vertical dimension and full mouth reconstructions, and then diagnostics that for me, it’s like my use of Facebow. And static cants, but there’s easier ways. [Jaz] And I’m grateful that you share that with us. And yeah, just on that point about multiple restorations. I used to think multiple restorations equals Facebow and you should do it, it makes sense. But you’re completely right in that scenario, when someone is already canine guided, and they get near immediate disclusion already, that even if you’re doing you know the four, five and six, then you may not need it so much because you already have that disclusion in there. But if you’re conforming, even if you’re conforming, but you’re conforming to group function, and you want the anatomy of the teeth to exist and not just be flat, you’re completely right, because now the technician has to dahl it in and build it up in a way. But you know, the exciting thing going forward is that on the modjaw, you know, people are thinking they probably will enjoy this episode, okay, who needs a facebow when you got a modjaw, but you know, if you’ve got a spare 40 grand laying around, I don’t know how much it costs. But you know, if you’ve got a spare 40 grand laying around, and you want to get their functional chewing patterns, and then build those patterns into the restorations. That’s like the ultimate way to do it. And maybe that’s the future. But for now, as a tool to us dentist, there is a place for facebows we know that and hopefully then from this episode, we know how you can cheat and avoid using one. But really knowing when to use one and giving you that kick up the butt you need to pick it up and stop, you’re afraid to actually start using it and speak to your technician, right? Speak to your technician find out if they’re comfortable in working with it which one they want to work with. For example, My lab works with the artex one and that’s why I’ve got the Artex Facebow. And so it’s so important to speak to a technician. Any closing comments, Salman? [Salman] Jaz, even that this might even bring thinking again, but even that 4, 5, 6 multiple units. When that patient opens and closes, I still want a bit more information on how those cuspal inclines need to be in, so for me, it’s debatable, it might not make any clinical difference whatsoever. It’s that peace of mind so I can sleep at night and I’ll do a good set of provisional and I’ll adjust from there. But Facebow, for me, it’s four, five minutes, it’s no extra harm, don’t be scared of it because like it’s so easy to use. And I just recommend for everyone. Digital is definitely going to be like even I see, it is gonna be the way to go in the future. Because once we can replicate the board like the mandibular movements property, we don’t need to worry about this jaw joint position because we just need to know how to move in relation to each other. And then it kind of goes all out the window and I think that will be how it is in the future. And we’re just sort of waiting for it to happen. You probably know more about the digital side of it and how you find it so far? [Jaz] So far really good. But it is a lot of reliance on the temporary so it’s a lot of data upfront in terms of images, lateral excursions, full face, retracted, using the different DSD tools to communicate that lab, scans at the required vertical dimension. And then speaking to my technician, exchanging emails, they’re sending me digital wax ups, which is slightly transparent of reduced opacity. So I can see through this little wax up and see the existing tooth and stuff, and then just be micromanaging. Okay, make it like this, make it like that, and then transferring that to the mouth. Now, once we transfer it to the mouth, then there is initial hard work to do to make sure that everything is balanced, some testing period to make sure that the excursions are where you want them and where you design them to be. And once that’s been built in, then it becomes much easier. But there is no either way there is a work upfront to be done, whether you’re designing digitally, or the technicians are waxing up by hand to make sure that when you transfer to the mouth is going to be a aesthetically pleasing, which is super important but also, when they bite together, things are hitting at the same time and things are hitting the right times when they move their jaw, whether that’s a functional movement or a parafunctional movement, you got to sort of build both into it [Salman] Even the analog of it, even wants to take that facebow record for this diagnostic study casts. And I opened that pin and I figured out okay, I’m gonna open it this much, I’m going to wax up at this position, or then still go back to the patient and take my record at that OVD upon restore. So it just shows that I don’t trust the Facebow completely in terms of that movement of the articulator, I still need to, I need to make sure the patient can be in that position verified to accept that position and then work from there. So there’s no one trip that you just fixes everything for you. Jaz’ right. It’s just it’s multiple steps to get to that final results. And that Facebow, just one of the small steps along the way that may increase your success rate. [Jaz] And we discussed it in terms of a Michigan Splints as well once before whereby if you you know, yes, there are reasons to use a Facebow, you could do Yeah, you could totally do a Michigan Splints without a Facebow. So what are you sacrificing? You’re sacrificing some information to the lab is now going to be using average values which may or may not correlate to your patient. And then you may or may not then be doing a lot, supposedly, you know, we need these studies to show that okay with an articulator, with a Facebow, without a Facebow, how many more minutes of adjustment are you doing? That’s what you kind of need to decide that, Okay, if you’re only doing extra two minutes, are there any studies showing with respect to Michigans? [Salman] No, There are studies but I noticed that not this time, I couldn’t stop using Facebow. There’s studies that show pros and cons of each but there’s a study by for ??, who did like a study Michigan splints randomized control trial with Facebow, without facebow, no real difference in adjustments. But I would add. I would add with the Michigan splints, you’re creating a flat platform totally. And so do you measure the OVD that you want and the technician creates a flat platform. And is they just take the smallest of ramps are different, they’re going to get anterior disclusion. It’s not the most difficult thing to do, but really in full mouth reconstruction with cuspal incline and forces and everything, then you can’t translate what once they are shown on Michigan splints to automatic reconstruction. So yeah, it does work. It does work. [Jaz] Yeah, totally. And you’re totally right, you know, the Michigan is the you know, an Upper Michigan, the lower buccal cusps are hitting against a flat portion of the upper splint, which is much easier to dahl in compared to the nuances of cusp to fossa relationship. But you’re right, you know, the main key here is if you just give the lab the correct vertical, then you do massively negate the need for that facebow information because as long as it just like you said as long as the anterior, the ramp is steep enough to get some dislusion and here’s the thing, right? If the technician can give you something near enough, close enough, and they make it slightly steeper on the splint itself, you can adjust it intraorally just to make a bit more shallow to dahl it in to the effect that you want. So there are little ways around it and so there we are, food for thought. Salman, thanks so much for coming on and sharing what you’ve been learning in your program and what you’ve been applying. And you know, the main takeaway today is think of cant, think of using that little putty technique perhaps instead of the microbrush technique, stick bite if you’re already using stick bites, but also now if you’re someone who is afraid of that facebow in the corner, just pick it up, use it, just use it, speak to your lab, and it can give you lots more information to your technician. Then the ultimate aim is to reduce how much you got to do. [Salman] Yeah, well that’s it if you are using a Facebow just honestly meant for me like mentoring practice has been what got me to where I am now. Like I’ve stuck out in the same VT practice since qualifying, seeing patients come back and recall the samples for that’s, it teaches you amazing things. Take it on practice. Get a mentor. You learn everything you need to know honestly, you can keep adding on these little tricks that Facebows has and you can use in general day to day practice. It’s possible. I’ve done it. [Jaz] You’re testament to that, mate. Man, thanks so much for coming on giving your time that you’re super busy schedule. I know you’re with family today. So have a lovely time with family. And I hope we meet face to face very soon, where you can just you know geek out over some food and talk more about the nuances of Facebow studies. [Salman] Thanks, Jaz, really enjoyed it. [Jaz] Thank you so much, mate. Cheers. [Jaz] Well, there we have it guys. Thank you so much for listening all the way to the end. I’m hoping that Salman and I were able to have a little discussion, a bit of banter about facebows and how to do things by just photos only, or how to use the putty technique to get your cant correct. And it’s given you some food for thought. And one reflection, one of the favorite things I like to say is that the role of an educator is not to put everything that’s in their mind into your mind, the role of an educator is to open your mind. So I’m hoping that after listening to this educational episode about Facebows that your mind is open. So when you’re thinking about the next time when you’ll be using Facebow think about what you’re trying to achieve, why you’re doing it, and are there any other ways of doing it? Or maybe to pick up that phone to technician and discuss it with them, how do they prefer things? Or what are you trying to achieve with a Facebow that you can’t achieve through some other means? So hope you enjoy that. If you’re listening on Apple, please be sure to rate this podcast. That’s how the podcast grows and gets discovered and keeps me busy and make these episodes for you, which I love to do. Anyway. Thanks so much for listening all the way to the end. And I’ll catch you in the next episode.