Adhesive Full Mouth Rehabs Part 3 – FULL WORKFLOW! – PDP110

Jaz’s Introduction:
Hello, Protruserati. I’m Jaz Gulati and Welcome back to the big one, this is going to be the big one, because we’ve built you up from part one, part two. And now this is part three. So if you remember, in part one, we talked about the mindset of that full mouth clinician, how to treatment plan and communicate to your patient. In part two, we looked at how to get a wax up and how that wax up might be different for an adhesive rehab, compared to a conventional rehab, and then how to actually put that temporary in the patient’s mouth and let them walk away with temporaries in their mouth. And I’m very confident that already just part one and part two, you probably gained more value from some paid courses, again, something that me and Devang are very proud of. But in this part three, we really get into all the nitty gritty details, particularly sequencing. Now you have your patient temporaries they approved it, they want this treatment, you want to do this treatment and the patient suitable and everything’s ready to go. But how do you actually sequence it? Do you do the upper arch first? The lower arch first? When do you do the posteriors? How do you do the posteriors? So all those things will be covered in this episode.

[Jaz]
I truly believe that when a dentist moves away from single tooth dentistry at some point along that journey, sequencing is discussed and I think when a dentist starts to think about sequencing, that is a sign like It’s like in karate kid you know, wax on wax off like and suddenly Mr. Miyagi, thinks that Okay, now this kid has got it, right? I do believe in our journeys, when you start thinking about sequencing is kind of like that, you know, wax on wax off moment, okay, now you get it. You mean, okay, maybe you don’t get it. But you’re thinking in the right direction. So welcome to the world of sequencing, for those who haven’t considered sequencing before. This is a big step in your journey as a step that I’m learning more and more about. And it’s great to have guests on like Devang to sort of share his nuggets and his principles. And of course, different dentists around the world will do it differently in when it comes sequencing. And before that used to piss me off. But now I appreciate the beauty because you might find the patient that is more amenable to Devang’s way of doing it. And then you might find a patient who’s more amenable to another dentist way of thinking. And so if you learn all of these and appreciate the the pros and cons, then you can apply it to your patients.

[Jaz]
To celebrate the fact that Splint Course has relaunched. This is my flagship course, I’m so proud of it, have had over 400 delegates from 16 countries. And it’s not even, it’s almost a year old. So now it’s been tried and tested by hundreds dentists, and they love Splint Course. And I’m so proud of it. And so now we opened the doors again, to allow a new intake of delegates. This time, instead of opening the doors for two weeks, I’m just opening it for one week, I just want a select few bunch who are going to be committed for 12 months of support on Zoom online, and also on the group. And I want you to learn and start implementing how to diagnose and manage bruxism and the correct appliance for the correct patient when to refer and how to manage all the nuances of splint therapy. So if that’s something you’re interested in, head on over to splintcourse.com To enroll and join a community of dentists who want to do better for their patients who are in pain or just want to protect the patients from the harmful forces of bruxism, especially if you do full mouth dentistry so even Devang at the end of this episode, he discusses that, you know, as a part of the protocol of doing full mouth dentistry is that giving an appliance because the same things that the patient did to destroy their own natural God given evolution given dentition they will do to their brand new restorations, it just seems too risky to give these patients the restorations and rely on the idea of occlusion to protect that patient. It just doesn’t make sense. The forces of bruxism are severe.

[Jaz]
The pearl I’m sharing with you, you kind of need to access the Protrusive Dental Community to see this video basically. It’s a video pearl, and it was a live video of my nurses recording of me because I had this patient in who I’ve been seeing for almost two years now, one of the most severe bruxist ever, to the extent that he’s now awaiting to have a full implant reconstruction, upper arch and lower arch. So quite a big job by one of my colleagues. But he has destroyed everything. And he has been a tricky patient managed because he just comes in with these emergencies and to stabilize him we kind of need some go straight to those full arch implant so there’s no middle ground here. But for the first time he came in with a toothache, which wasn’t a toothache and eventually you’ll see the process of how we did it. It was kind of like a diagnosis of occlusion. You do your usual, you know, listen to history. Anything hot and cold. No hot and cold doesn’t give you any pain. You do radiograph, it looks fine. There’s no apical pathology, no teeth are tender to tapping, right? And then you figure out from the history that the pain doesn’t happen when the patient’s chewing. It happens just after the patient has finished a meal. And it intensifies. And when you get the patient to point to that source of pain with one finger, they don’t point to one tooth, they point all over. So he was pointing to his head down to his neck to his ear, right? And these are the clues that a diagnosis was not a simple toothache. It was non odontogenic. It was myofascial pain, with referral. And then the certain criteria we use, research diagnostic criteria and TMD. When we’re diagnosing myofascial pain referral, you have to sort of when you palpate the muscles and trigger points, it elicits a pain. And then you have to ask the patient, okay, is this pain, a familiar pain? And if they say, yes, they said, Okay, familiar to what, and then the main thing is that they say, Oh, it’s the pain for which I am seeking careful, it’s the pain for which I am seeking careful, that is the gold standard way to diagnose someone who’s having the pain from muscles referring to the head and neck structures. So there’s a video of me palpating the muscles coming up with a diagnosis, just giving you a little bit of like an insight into how we diagnose these things on the clinic. So if you want to check that out, go to Protrusive Dental Community. I’ll tag the video for the next couple of weeks as an announcement. So you can see that and I hope you find value from that. So you may be able to think the next time you have a toothache which doesn’t sound like a toothache. You can actually can take a step back and consider that could be myofascial pain. Right guys, no more rambling. Let’s join Devang Patel on part three of adhesive full mouth rehabs

Main Interview:

[Jaz]
Dev, welcome back to part three of adhesive full mouth rehabs. It’s been a real journey in the previous two episodes. And this is really the nitty gritty, the sexy occlusion stuff coming up now. Now we’ve done the mock up and whatnot. We’ve done the mindset stuff. And now we’re going to talk about the how to get that wax up into the mouth, the different techniques, the how do we control the occlusion the left and the right and so we’re coming on to that and I’m gonna do a quick recap. Appointment 0 was a mindset for Full mouth Dentistry. Appointment 1 was the comprehensive evaluation was like a checkup and you sort of screen the patient who’s suitable. Then appointment 1A, you bring the patient back and do a full mouth assessment, some treatment planning, deciding are you going to conform or re-organize. In most cases, you’re reorganizing. Appointment 2 was record taking, we talked about Facebow, CR records, then we talked about your mock up technique and how you’ve guided the technician and you’re doing 4-4, you sent them home with the 4-4 mock up. And then when they’ve come back, you review the mock up, you’re checking how it looks, you’re checking the occlusion. So now we’re on to appointment five, which is you’re building up the upper and lower 3-3. That’s where at the moment so take it away.

[Dev]
Okay, so now I just want to divide two, next steps into two and we’re going to discuss about the adhesive composite build up but you need to understand the indirect steps or the indirect treatment as well. So the steps for the, if you’re doing a composite build up direct or indirect using some sort of, you know, stent or something will be you, for me, at least we’ll be building upper and lower 3-3 and stabilizing the posteriors and then building the posteriors, either one side at a time or one arch at a time will go into detail in a minute. So, it’s pretty simple, for occasion

[Jaz]
Are you going to explained by what you mean by stabilizing the posteriors?

[Dev]
Yes, I will Yes. So, it’s pretty simple or straightforward. But if you’re doing indirect, let’s say you’re doing all the crowns for upper and lower jaw, for complete indirect, full mouth reconstruction, traditional type, then it becomes much more complex. So by this time, if I’m doing in that indirect restorations, patient would have full mouth provisionals, okay? And we discussed about, you know, in when we were actually chatting, the provisional, the way I’d make provisional is I don’t ask a technician to do anything, I would have a wax-up of the area where I’m going to do the provisional. So let’s say I’m doing 4-4 provisionals, then I will prep the teeth, use the wax-up to make chairside provisional, but what I would have done is after prepping, I would have taken impressions just without retraction cord or anything, just impression nice impressions. So that technician can make me a Lab site temporaries as well. So on the day patient goes with my chairside temporaries, a couple of days or a week later the lab’s temporaries come back, and I’ll fit that in. Because I find having a shell temporaries, you know, shell means that it’s just too much faff. I will use them, and at least it doesn’t work in my hand that quickly so I would just I don’t bother with that. I will just make a provisional chairside fit them in.

[Jaz]
And then my experience of shells has also been quite traumatic. But yes,

[Dev]
Some people get it really right. Yeah, so I think that works really well, because patient, technician then has a real prepped teeth to work on. So you can give me a good marginal fit and everything. So I would do that. So patient will, by the time we think about finalizing everything, patient would have had a full mouth provisionals. And that could take number of appointments, I don’t do all provision in one appointment, usually, I would do four teeth at a time maybe. So it didn’t take me a lot time to do that. Once the provision is done, I would then do the anterior 3-3 final. Rest of the whole mouth will be provisional. And tier 3-3 in final crowns. Okay.

[Jaz]
Then again, once, I just want to clarify, we are talking here about the indirect?

[Dev]
This is indirect.

[Jaz]
So remember guys, we’re talking about the indirect protocol.

[Dev]
Yeah, this is indirect. So the direct protocol is very easy. We’re talking about indirect protocol, where everything’s temporary crowns indirect protocol, because you’re going to do crowns or onlays or some sort. So you’ve got temporaries everywhere, then you’re going to do lower anterior, 3-3, finalize them using porcelain, crowns or crowns, basically, or veneers. At this point, you still have full flexibility, because if you want to adjust anything, you can still have all the provisionals in the mouth, you can adjust, I’m not adjusting at this point, my finals. So let’s say on my final comes in, the bite is slide off, I can adjust the upper provisionals to get the occlusion right, okay? So you still have ability at this stage to increase the OVD if you want, okay? But hopefully you would have figured it out in a provisional stage. Once that’s done, my priority, my preference would be to then do the posteriors, lower posterior, so lower right and left both you can do together if you want, or you can do one side at a time doesn’t matter to get this occlusal plane flat, okay? So I will do lower posterior final, then I’ll move on to the upper posterior final and now you locked the occlusion, and then I’ll do the upper anterior, okay? So the, what

[Jaz]
So lower anterior, lower posterior, upper posterior

[Dev]
No, sorry, upper anterior and then upper posterior. So again, lower anterior, lower posterior, upper anterior, upper posterior. Having said that, if you want to swap, if you want to do lower anterior then upper posterior, upper anterior and lower posterior, you can still do that. But that’s it’s a completely different

[Jaz]
One cosmetic question I have for you straight away is when you fit your lower anterior crowns or veneers. And then you maybe have to do a bit of adjustment of your upper provisionals. Are you then taking an impression or a scan to send to the lab so that when they actually make the definitives of the upper, they’re going to now copy your slightly adjusted temporaries?

[Dev]
No, because to be honest, I’m going to I mean, you can do that for me, I’m going to take them out, mount them and redo them anyways, that the lab is only using the shape of the incisal edge, in length and the bulk of the buccal as a copy, which I’m not going to change most of the time. It’s just the palatal which is occlusion. So I don’t really bother taking another impression, because we’re going to remount the models anyway. So patients you know, I’ll get the occlusion right. So, no, I don’t but you can do

[Jaz]
At that point. Have you had to redo the face bow as well?

[Dev]
Every single step. Yeah. So every single time I’m doing indirect, I will do Facebow, new impressions and everything. So it becomes a lot of big stretcher. So that’s I’m saying indirect is completely different ballgame than doing a direct composite or doing any composite, right? Because you have a, you can adjust things a little bit in the mouth and polish really well. And it’s quite a bit more forgiving than doing the indirect restoration porcelain

[Jaz]
You’re spot on with composite, you really do get to use the patient’s mouth as the articulator as we discussed so much in episode one and two of the series, whereas with indirect, you’re relying, you don’t want to do as much adjustment of your ceramic, your glazed ceramic, so therefore, you don’t get the opportunity to use the mouth as articulate as much as you can do with composite. Which is why when you’re starting out with rehabs, just like the reason why we’re recording today, Dev is when you’re starting out the rehabs, adhesive is a great way to learn

[Dev]
100% And I would recommend starting with adhesive full mouth reconstruction because it will take away a little bit the fear of what if something goes wrong because you know, it is more forgiving. It’s not completely forgiving, which means you know, you can’t go back to zero, but it’s much more forgiving. So I would personally start with adhesive reconstruction. Having said that, you know, any full mouth reconstruction, you need to be really good at being single tooth dentistry, and that’s why when I actually started posting more and more on social media, and if you’re not following me then you know, please follow me and you’ll have some more information

[Jaz]
Please do some great content

[Dev]
And I started with posting single tooth dentistry, started posting single edge bonding. And people like, You do full mouth reconstructing, why are you posting? I said, Look, you know what I want people to understand that they need to be really good at doing single tooth dentistry in order to do the full mouth reconstruction. You can have rubbish because you will have, if you do rubbish one tooth you’re going to do rubbish 28 teeth, full mouth reconstruction. So you need to be comfortable doing single tooth dentistry. And again, you know, when I teach, I teach full single tooth dentistry as well as full mouth reconstruction. So when I do courses, or full mouth reconstruction, I would teach good single tooth dentistry because I know that that’s the foundation to do full mouth reconstruction. Okay, so once we’ve done all that, make sure that now we are at the stage where we are building upper and lower 3-3. Okay, so that’s composite build up.

[Jaz]
Now back to direct, we’re making a transition back to adhesive now. Dev, very kindly spoke about the indirect protocol to give you a bit more value from all these series. So look at that, you know, adhesive, but he’s also giving you some structure for indirect. But let’s go back now, put your frame in mind back to adhesive

[Dev]
Yeah, so now all the steps are adhesive, which is composite direct or indirect build up steps. Okay. So now we building front teeth, upper and lower with direct composite, right? So well composite, so when we building upper and lower 3-3, you have two options, well, three options, you can do direct build up using composite, you can do indirect build up, or you can do semi direct build up, okay? So if you’re doing direct build up, you can use freehand technique, which I wouldn’t recommend, you can use putty indices from your wax up and use that to create incisal edges of the lowers. So I always start with the lower first, even if it’s the same appointment, I’m doing both. I’ll start the lower incisors first. So I’ll use Putty indices for lower if I want to, you can use something called memosil, which is bluish material, which you can cure through. But I prefer exaclear, which is a GC product, which is amazing. And so once I started using that I don’t go back because you know, that’s the product I use for, for making my indices. So exaclear, I use for making the indices for the incisal buildups, or if I’m going to do palatal build up, then I can use and if it’s not too thick, then I can use a single sort of buildup. So put the composite etch bond prime, etch prime bond, the palatal aspect, and I use optic bond FL for all my bonding. Because I feel that that gives me the best result and composite on to the stent, I put some composite onto the tooth as well, because if I’m going to have an air gap on one that between the material rather than material and the tooth, so I would put composites on the tooth, and on the indices, and then squeeze the indices to get to stent. If it’s quite big buildup on the palatal shelves, and you can put little bit composite, cure it, put a little bit composite, put a stent on it, take it out, make sure it’s not really going anywhere else cure it. And then you build an increment using the stent by using like a stamp technique to just stamp it and make sure that

[Jaz]
but you’re doing a one tooth at a time here because I can see multiple

[Dev]
I’m doing multiple at a time. So I’m doing alternative teeth. Okay, so the way I would do that is I would putty, I will put PTFE tape on alternative teeth, and I would etch bond cure the alternative teeth, and then start building up alternative teeth. So three teeth at a time. Okay, lower teeth to start with, and then the upper teeth with regards to indirect again, we’re not talking about indirect today but you could use crown veneers, you know, all sorts of gold backing for the indirect or if it’s, if you’re not really comfortable building palatal because that’s where people are a bit more uncomfortable building the palatal sort of shells. Using direct technique, you can ask technician to build the composite indirect shells and you can just bond it like veneers, okay. With the composite heated composite, that’s what I use for if I’m bonding them, okay? The semi direct would be, approach would be composite on the palate and porcelain veneer on the buccal aspect. And if you listen to Francesco valetti who talks about that taking a sandwich technique which I think is a little bit confusing because we also in UK we talked about sandwich technique being posterior when you do just doing molar, you have GIC and then composite on top, we call it as sandwich technique. So is our call it direct indirect. So that’s how I would build the lower and upper three to three. Now there were two questions you were asking, one was, Can I do everything in one appointment you don’t need to. So if you’re doing lower build up, I mean to me, it will take, if it’s a good quantity of upper and lower like a lot of buildup, you’ll take me four and a half hours to do that I’m slow. So I’m doing all direct, I’m not using injection molding or smile fast technique, that’s another technique you could potentially use. To be honest, I don’t have much experience with them. And so I can’t really recommend long term results and people who have got long term data they don’t have 10 years data on them. So I’m not sure but you could use them if you want to

[Jaz]
I can just do input here and say that having used for some significant wear cases using a full mouth adhesive rehabilitation I’ve used both injection molding and smile fast and you know it’s just pick your poison, right? these are just techniques tools. It’s all about the planning that you do beforehand so I don’t get too hung up on which way I’m doing it but having done a few smile fast cases you know that four and a half hour because I’m like you I’m slow for me that four and a half hour appointment can become a three hour appointment so I do share save a little time but then you’re paying a little bit more lab fee as well. So it kind of works out you know, it doesn’t have to be a system specific you should experiment Yeah,

[Dev]
You can do incisal enamel, you can really use different shapes and everything as far as I believe. So you know if I’m not doing buccal veneer I would want upper incisor to to look a little bit better. So by doing a little bit different incisal coloring and stuff. Having said that I’ve restored lots of cases just one shade composite and they look quite good because the complex improved a massively nowadays so and I use G-aenial™ I mean I don’t get any kickbacks from, they support me for my courses, obviously, but they are really good material. G-aenial™ is amazing. So I really love it. And if you’re using single,

[Jaz]
I’m a huge G-aenial™ fan. I just remembered a quote from James Baker, Dev, I just want to share with you shell is Composite is a bit like being married to supermodel. Composite is a bit like being married to supermodel. Sometimes you forget how good looking they can be.

[Dev]
James, Composite is a really good looking guy you know that. He’s amazing guy. So with regards to build up, so these are the techniques you can use. And if I can’t do everything in one appointment of patients, like I can’t sit for that long. And if I’m not sure, then I would book patient next back to back. So if I’m seeing patient on Monday, I will book patient on Tuesday so that I can do the upper reconstruction. That means I don’t need to worry about too much provisionalizing stuff. So I would have pre plan Both appointments. But I want those three to three done pretty quickly. Rather within one or two appointments within two days, basically,

[Jaz]
Hi guys, this is Jaz interfering again with a really important message like have you ever done teeth whitening for someone, and the patient messages you or calls up or come to your clinic upset, because now they have these white patches on their teeth, at least two of you have shown me on Instagram, some messages from patients that really concern you as a dentist, because you weren’t expecting these white patches to appear on teeth. Now this is a, I wouldn’t say common phenomenon. But when this happens, when you start teeth whitening, it can be scary for the patient, and it can be worrying for the dentist. So I have my buddy Payman Langroudi to discuss all about this in this couple minute message, which I think is going to give you so much value if this has ever happened to you before. Or if it’s never happened to you, you probably haven’t done enough teeth whitening and it’s going to happen to you. So why don’t we learn about the techniques to make sure that you are well prepared to A) warn the right patient that this could happen and B) to reassure them because it’s something that’s not permanent. And we’ll go into that in a moment. I just want to take a moment say thank you to enlightened smiles for sponsoring this podcast. This episode, as we know enlighten is the premium brand of whitening and it’s so great to have their support and to be aligned with them. So let’s head on over to Payman Langroudi to talk about these white patches for a couple minutes. Before we rejoin the main podcast.

[Payman]
There are something like 28 causes of white and brown spots. And so you can’t tell by looking at it. Whether it’s mainly a hypo or a hyper calcification has caused that white spot and those two things are very different. So when the peroxide comes across hypo calcification, it does cause chalkiness when it comes up against hyper calcification, it doesn’t cause chalkiness, it’s harder to get through that area. So you can’t, the basic point is you can’t predict which white or brown spot will go chalky, but you need to predict and tell the patient, that there’s a possibility that any of them might. So that starts off with actually noticing that there are white spots, you know, paying attention to that, pointing to that for the patient. And then if the situation you brought up is actually very common in that, often if it’s a Hypo calcification very quickly, those areas go chalky. Often whitening is the first thing you do in a treatment plan. And so you’ve got a patient who’s not really being treated much by you already. And the first thing that happens is something like that. And the key to it is to inform them that that might happen. And that then when it happens, you look like an expert. And it’s often missed, people miss white spots, or maybe they see them, but they don’t tell the patient about them. So I think the key message is just inform your patient that any white or brown spot could go chalky. Now what happens next, the vast majority clear up by themselves in a definitely within the rehydration period, which is a two three week period. So, two, three weeks after the end of, even home whitening will give you dehydrate teeth a little bit, most of them will then clear up. If they don’t for me, I think microabrasion first, before resin infiltration, I’ve had much more success doing it that way around. For me, there are brown spots, that bleaching will turn into white spots, then microabrasion can reduce them, then I can then delete them. But the opposite way around doesn’t really work. If you go icon doesn’t reduce something that microabrasion might be nice. For me, the right order is bleaching first, consent the patient, if you can see white or brown spot, consent them for microabrasion resin infiltration or even composite restorations. And then if you need to so tell the patient look, if you’re after perfection, one or more of those may come into play. I can’t tell you which one or any of them until we’ve done the bleaching first. With bleaching will often delete things by itself.

[Dev]
So once I’ve done that, I will check the occlusion because it’s adhesive, polish everything, nicely make sure the occlusions there canine guidance and protrusive guidance using the the incisors, canine guidance using canine and make sure you have the space you wanted for posterior, right? Because sometime you start grinding the teeth down, that means you are reducing the OVD. So initially, you would have increase the OVD to have the nice posterior onlays done. And now you’re grinding the teeth to get the contacts better. And you decreasing the OVD so just be careful when you’re doing any adjustment that you’re not doing going over the board. I would rather add something to it. So then you’ve got a bit more OVD then reduce it, okay? So you can never have enough OVD. You know, you can never have enough space, especially for technicians if they’re making anything indirect. If you’re doing direct then yes, we’ve got a little bit levy for posterior. Okay, so that’s done, we’re happy with that, you know, polished everything, patients happy. Now we need to make sure that we stabilized the posterior teeth. Okay, you can’t because patients now got the occlusion on three to three. There’s nothing posteriors are in the air

[Jaz]
Patient now has a dahl composite in their mouth.

[Dev]
Yes, exactly. So if you’re going to do dahl, perfect, you leave them as it is, if you’re worried about them breaking things, then you can give a small Essex retainer for just the anterior teeth to wear at nighttime, I don’t tend to, you know, patient tolerated really well. If your occlusions really good, they don’t tend to break it. And obviously your bonding needs to be. So they don’t tend to break them because they are nice chunky composite that you know, good strengthen them. So I never, I don’t usually bother. Even if I’m doing dahl, I don’t bother giving them any sort of appliance, I just let them go. Like that. If I’m not doing dahl, then I would reach them many times I’m I don’t so that I would use two techniques for the posterior stabilization, right? So you want to keep that space, that’s the whole point and keep patient a little bit comfort because if there’s some teeth touching at the back, patient feels a little bit better than just the front teeth touching, okay? So the easiest way to do that is you use your GIC, glass Ionomer cement. Put it’s right in the center of the occlusal surfaces of the upper or lower, I select lower because it’s easier for me to use. Put Vaseline on the upper teeth, ask the patient to close okay, because your front teeth your anterior teeth are nicely done. They will act as a stop and the posterior teeth will close on your GIC. Hopefully it’s touching the GIC and that will then create your GIC would act as a stop for the posterior. Okay and nowadays GIC are really good. They last, you know, they will stay in there. So I would put GIC there and close it if you really want to be modern you can spot etch you can put a little bit bond, you can put some composite on there to get stops to get a bit more rigid stops but GIC works really well, especially if you’re going to remove them, you know as to whether GIC you know, it’s easy to distinguish rather than composite.

[Jaz]
Having previously used the composite for this I now regret not using GIC I think that’s a really great idea actually. So actually, I will now use GIC but any consideration to GIC or it’s a sexier superior cousin, RMGIC

[Dev]
No, I don’t use that RMGIC, I know people use it. The way I taught was that it’s the best of this, worst of both worlds basically, RMGIC so I tend to use normal Fuji 9 GC obviously. It’s really good product and works really well. I mean how I’ve treated patients, you know those patients who come to you with so many caries and you’re just not sure where to start, you put, remove all the caries put GICs in them. I mean I tend to, I mean I was quite sad so I used to call my GIC using a small fine bur and make sure nice and they stayed like that for like eight years because some patients just go right so they don’t have enough money or anything to then have the full mouth done and they come back and you know many of them are, most of them are intact. So GIC is good material. Although I still consider it’s a provisional temporary restoration, it’s a good material they come quite far. So put GIC at the back and..

[Jaz]
And what else you can use GIC? What else can you use?

[Dev]
So this the second thing I use, so I only do two techniques GIC most of the time for adhesive composite ones, most of the time GIC. The second way you could do that is if you have had done full mouth wax up, you can take indices of the wax up of the posterior teeth, and put bis-acryl in there and put those posterior on there, so you need to do upper and lower obviously, and shrink fit like we did on a mock up stage. So you’re going to do mock up for the posterior teeth. For that you need to make sure that you have the full wax up model, okay? So if you have a full wax up model

[Jaz]
In this case, I think you’d be doing some little bit of etch in some areas?

[Dev]
Occlusal surfaces, I will spot etch, at the back, because those provisional will stay there for some time. Because I want to make sure that I’m assessing the occlusion. The problem with them in my experience is that patient doesn’t have freedom sometime to move their jaw and provisionals are not going to be, you know, because the shrink fitted and all that, it takes first of a lot of time to adjust the occlusion if they’re off the occlusion. And also you can cause some time because you haven’t seated the putty properly or whatever posteriorly some sort of a non working side contacts or some interferences so then they’re not completely relaxed, but it’s somehow giving them occlusion just anteriorly when they, when I see them for review in two weeks time they’re nicely relaxed because they’re just nicely gliding on their front teeth. GIC is literally just flat so, you know, there’s not doing anything any much. So again, if any of the tooth is poking into the GIC I would make sure that I would cut the GIC to the only tip of the tooth is touching. I don’t want posterior teeth to interlock into the GIC. I want them to be nice so that patient can glide on top of the GIC

[Jaz]
Occlusal stop

[Dev]
It’s like you and you know you’re doing Michigan splint you want just to point contacts, you don’t want like an intense into the splint exactly the same concept and that’s why I mean if someone wants to do full mouth reconstruction, learn to do the Michigan splint. If you’d learn to do Michigan splint, you will learn so many principles, you will be quite comfortable adjusting things because you know when you do restoration if you need to adjust you need comfortable adjusting things, if you want to, so when I start teaching full mouth reconstruction, I teach Michigan splint first and not because I’m, you know, that’s the best splint or anything but it just gives you occlusal concept, you know, dentist learned occlusal concept, which you then going to transfer into your full mouth reconstruction. So my first two days hands on is splint course, and they’re like Oh we’re here to learn full mouth reconstruction. So you know, by the time we finish, you will know why we started…it’d be not the last step. Last step is to give Michigan splint but we start the first because they need to know that.

[Jaz]
Fantastic.

[Dev]
Does that make sense?

[Jaz]
Brilliant. Absolutely.

[Dev]
Perfect. So we finished with the appointment number five.

[Jaz]
You’ve got the posterior stabilized now. So either on the GIC way or the Bis-acryl way. You’ve got the anterior is beautifully built up because they’re, Dev, upper and lower, you’ve got the posterior stabilized at that second visit. How long have you waiting for before you now convert the posteriors to your composites either direct or indirect?

[Dev]
Four weeks usually, because that takes the occlusion, patient to get used to with everything, making sure patients happy with it. TMJ is fine with it, you know, patients relax. So around four to six weeks, I have done within two weeks, you know, because patients are some, you know, something’s coming up, we need to build it quickly. But my preferred way to wait for four weeks because it’s important that we assess before we go to the posterior, okay? So four weeks is the time and then after

[Jaz]
So now we’re an appointment six, is that right?

[Dev]
The next buildup is before but I will see patient in two weeks time or a week time depending on how quickly I need to do the polishing if I haven’t finished everything. So I’ll see patient in two weeks time to review it to make sure occlusion’s fine. Patients not you know, the CS not change, patient’s bite not change since I’ve done the reconstruction, and then see them again in two weeks. And so I’ll see them two times in that four weeks, four reviews, okay? Within that two times, the second time, if everything’s fine, I would take impressions. And I would mount models, because now inevitably things change a little bit. Okay, so from your first wax up, then I would mount the model and I’ll ask technician, this time mounting model is easy because everything’s in ICP, kind of because everything’s touching you know, you don’t need to use a gigantic Facebow, upper lower impressions done. If you think the GIC is not holding very well then you can put small bite registration but usually you can locate model really well on hand articulator. So Facebow and do a upper lower impression, ask technician to mount the model. And then I would ask technician to do alternative teeth wax up, okay? So I’m building, if I’m, let’s say I’m building a 4, 5, 6, 7, I’ll ask technician to build four and six, duplicate the model and then build, on the same model built five and seven. So the second model will have all the teeth built up but the first model will have only two teeth build up alternatively. Does that make sense? Because this will help in the appointment number seven a lot, okay? So this is I mean, this will save you time I know and you can include the cost of second wax up again in patient mouth, if you doing digital it’s even easier to do that. You just need to click the buttons and print it, print the models. But yeah, so it’s, I’ll do second wax up, which is very important for me, it makes my appointment number seven much much quicker, okay? So now, technician got, we’ve got two sets of model, one model has got alternative teeth. The second model has got all the teeth waxed up. Okay, so you’ve two models.

[Jaz]
Are you doing just one quadrant now? Are you doing a full arch now?

[Dev]
So technician will wax up full arch, upper and lower everything because you can build them up one by one later on. But because your occlusion is locked, almost set now, technician can now go on and do alternative teeth for upper lower, right and left. And then all the teeth for upper lower, right and left posteriorly

[Jaz]
So you got four models in total?

[Dev]
Not still two models. So first model..

[Jaz]
Two for the upper and two for the lower, right? Every other tooth model for the upper and a full mouth.

[Dev]
Yes, we have a total four models. Two for the lower, two for the upper. So four models. Now appointment number seven. In seven, again, there are different ways you can do the posterior teeth, you can do direct, you can do indirect. We’ll be looking at, we’re talking about the direct right now. So in the direct technique, my preferred method is using a stamp technique. So when I’m doing the GIC stops have intentionally not put GIC in between the teeth. So my GIC stops are going to be right in the middle of the occlusal surface. That means when technician has waxed up alternative teeth, my indices will sit really nicely using this in between space of GIC really well. So I’m going to make again exaclear index and one of the struggles I had with exaclear is very runny material. When you put a lot of execlear, it just runs through the model. So what I tend to do is I would put a little bit exaclear just to cover the occlusal surface. Wait for that to set. And then I’ll put more because when you put just to cover the occlusal surface, it will roll over, up to, it just drool a little bit. But if you don’t put too much, you’ve put a little bit, it’ll only drool for up to a couple of millimeter on either side. Once that’s done, I’ll put more, so I’d build in layers, okay? So but I need my exaclear really really thick, okay? I’ll indices needs to be thick. If you can bend them, then they’re no good. Because when you push them, they will just flex and the composite will go everywhere, you will get flat-ish crown, or your if one, flat is composite, and it won’t be as accurate as your mounting, okay? So then I would build again, etch prime bond, PTFE on the teeth which I’m not building. And I would, in this, in posteriot teeth, I will do one tooth at a time. So in the sense that although I’m doing alternate teeth, if I’m building four and six, I’ll build six first and then build four separately, I’ll do one tooth at a time. I don’t want to do two teeth on posterior. One tip when doing that..

[Jaz]
When you’re doing this, are you using rubber dam isolation? Or does the fact because of the memosil, it makes it difficult to, how do you find it?

[Dev]
I have photos actually, I can show you at some point. And but I do use rubber dam. I know. Personally, I know that there is no evidence, at least even in my dentistry, where I’ve used rubber dam that I haven’t they both work superbly well. But it just reduces my stress. When I’m putting rubber dam on, I can go for a tea break, come back. And I know that everything’s

[Jaz]
They go to the toilet break. How many times a patient with a rubber dam on is going to toilet break and come back . Everything’s exactly the same

[Dev]
That’s the reason I prefer rubber dam. Not for scientific reason that it’s gonna, obviously it will hopefully help with bonding and everything. But there’s no kind of scientific evidence per se, to suggest that rubber dam helps with that. So I prefer rubber dam for sake of, and that’s why you can’t use a rubber dam if you’re doing smile fast, because you need, you know, or injection molding, you can’t use rubber dam and you know, if patients got a lot of saliva and everything is very difficult to do that

[Jaz]
The best you could do is split dam in those ways. But usually it just gets in the way. So usually, in anterior an optragate will be fine when you’re using those other techniques

[Dev]
Yeah, obviously just a cheek retractors. And so it just helps you move the cheeks away. So I’d do number four, number six, once I build them up, out, then number five and seven. So that’s whole arch system. Number five and seven, so you will have two indices per arch per side, you’re building, right? So the one indices for those alternative teeth using that model, and the other indices for or for again, the other teeth using the final model. The one tip, when you’re using the stamp technique is that you make sure that your indices are not extending too much beyond your wax up, bucally or lingually. That means that if the wax up stops, like 1/3 of the buccal, you just stop the millimeter after the wax up, beyond the wax up your indices. So that it’s easy to clean the excess of a an excess comes out easily, okay? So just make sure that it’s not going right to the gingival sulcus. But otherwise, you will have a nightmare..

[Jaz]
And then also gives you space to put the rubber dam because if it goes all the way to the gingiva, your exaclear index, then if the rubber dam will push it up, you need to just go slightly beyond the wax up just as you said

[Dev]
Yes. And obviously check the indices fits after you put the rubber dam is one because otherwise, you load everything. And then this is not fitting. So you know making sure

[Jaz]
Here’s a really good idea I just want to share, you probably do this already. But one thing that Harmeet Grewal taught me is that when you’re making your exaclear on the model, or every other tooth or the full arch, you put the rubber dam clamp you think it will be using on the model. So now the rubber dam clamp is there as you’re doing the exaclear so that it’s less likely to interfere, right? Obviously, it’s not gonna be accurate, because the way that it will clamp in the mouth might be different because of soft tissues. But it just gives you another little trick. Tip to turban tip to Harmeet Grewal there.

[Dev]
It’s a good tip actually no thought of that. I just I would just cut it and then use it. But yes, a good tip. Thank you. I’ll try that next time. So yeah, so I’ll build them up. And then I would do, I personally prefer to do and one arch. So I would prefer as I said to the lower arch first if I can build up and then move on to the upper arch later on because then if I’m doing lower arch, then I’m getting occlusal plane correct. And making sure that everything’s fine because for me if the lower occlusal plane is right, then the upper will fall into place. And so I prefer to do lower arch first, but I’ve done one side at a time as well because it’s just easy as well for patient because they’ve got a one side bite. And then the other side is GICs. Does that make sense? So it doesn’t really matter too much, as far as you comfortable, touch your wax up have accurate and you’re going to replicate that in patient’s mouth. So I’ve done direct…

[Jaz]
I just want to the right side at one appointment and the left side another appointment?

[Dev]
Yes, but you can do lower arch in one appointment and upper arch another appointment. Does that make sense? But for patient, it’s easier if you do one side at a time because they got bite, nice bite on both side.

[Jaz]
I like the idea.

[Dev]
So I think that’s where we will be finish with the reconstruction, take everything off, make sure everything’s nice and tidy. Patients happy with it, obviously, you can do direct the build up directly, right. So you can do build up directly, if you really comfortable. And I’ve done that, lots of cases doing that. But it just stamp technique makes my life easy. And I just don’t like difficult life. So I like to make my life easier as much as I possibly can. Because someone was telling me about extractions, like I can extract a tooth using, you know, one force of one thing I said Why? Why make you know, if something makes my life easier, I’ll use that. I don’t want to show the skills, I want to be the dumbest dentist, even with the best tools and get the same result, you know, what’s the point? So do whatever was the end result is good, then that’s fine. So once you

[Jaz]
Now with over the few appointments, you’ve got your complete rehabilitation done now because over two appointments, you know, you’ve done maybe the left side, one appointment, the right side the other appointment, you’ve done your polishing, I find these interproximal sores really useful at these appointments to anywhere where the bond or the composite is joined together to clean away interproximal polishing I love using Eve twist a Polishers, personally my preferred one. What kind of polishes are using?

[Dev]
So I use, Yeah, I’ve used a twist, which they’re really good. So I’ve got different types of it, the car does nice polishing, polishing burs as well composite polishing both they were off quite quickly, but they give really good polishing results, but I tend to use extra brushes, you know, the astro, the golden ones, those polishing brush.

[Jaz]
Yeah, Astro brush, I think I know what you mean, yeah, the gold tinted them

[Dev]
Yes, those are the one then eliminate impregnated bristles, I think. They are good with the white stone and the red. So the gross sort of cleaning is done by using red stripe of bur, then the white stone, and then the polishing within using astro or some sort of a cup or something like that. So that’s all done and patients now you assessed the occlusion, make sure everything’s fine. Now, I review that a couple of appointments, because things can change all the time, really for a couple of appointments. And then maintenance. Maintenance phase would be to fit some sort of protective appliance, which is for me, it’s Michigan splint to start with. However, if I don’t see any, if it’s a patient with the erosive there, there is no need to give the Michigan splint I would give them a soft mouth guard

[Jaz]
Without parafunctional risk.

[Dev]
Yeah, exactly. I will still give them some sort of mark up to make me feel happy. But you know, they don’t have to add anything. And they’re, they’re still fine. So I mean, if you want to really assess the risks, which would be your first case, attririon case or erosion case, I would select erosive patient all night long, you can get really predictable results, very less complications than attrition patients, you know there are things you need to be bit more accurate. But again, technique wise adhesive versus indirect sort of composite versus indirect porcelain, start with composite, then go on porcelain and once you gain some experience and got some cases under your belt

[Jaz]
Amazing, then you have fully blown us away with all these appointments. So we’ll ask you a few more microsteps. Then I want to hear about how we can learn more about full mouth rehabs from you because I know you said he got some courses and we’re learning live stuff online stuff. Before we come on to that. Just want to just find out, how long you tell your patients that this adhesive rehabilitation will last and what is in the contract in terms of like, for example, when I do a bigger cases, I make it clear at the beginning that if you don’t attend for at least one annual checkups and some hygiene, then anything chips you’re paying for it. But in the first year, anything because you know I’m comfident in my sort of diagnosis stuff, any issues I will be there for you. But you also need to do your part. So what are you telling the patient obviously you told him beforehand, but it’s a good point now that you’ve described the process so beautifully. And you’re at the end now to describe the terms and conditions of this marriage

[Dev]
Again, Yeah, so basically, with regards to patient, I would have had this conversation obviously as you said, beforehand, before I’ve done all this, so I always tell patients that the composite, and again, I’m glad that you brought up this point, because when I was young, when I started my career, I did lots of composite veneers, right? So that’s how you start because they’re easy, cheaper, patients say yes to composite quicker, because they’re almost half the price than the porcelain veneers. You can less appointments, more control, because I can control the anatomy, I can control the shade. Whereas if you send it to lab, depending on how good the lab is, so I did lots of composite veneers. But if you ask anyone who has seen their cases 10 years on, which I have, the mentality changes a little bit. I’m very, I do not select composite resin because they’re cheaper modality, I tell patients that look in a long run, they will cost you the same as porcelain, because they need maintenance, things will chip, you know they need polishing, depending on your diet, things will stain because I do everything same for all my patients. And sometimes some patient comes with staining every six months, I’ve got patient, and some patients come after four years and there is no staining everything’s fine. You know, it looks really amazing. And it’s not me, it’s patients so I’ve taken photos, and I would show them to my patients before I start the treatments saying, Look, this is one patient, this is another patient, I’m the one done the treatment for both of them within few months like that. So it’s not that my skills change. And they’re both showing different results. Because this depends on your diet, your hygiene, what you do. So I’m always going, I’m always telling them to take responsibility of what happens in their mouth, rather than blaming towards yourself, okay? So that’s very, very important to ask them to take responsibility, I would, I tell them, I’ve tested different guarantees. And in my experience, it has made no difference to my uptake, okay? So what I tell patients is that I would guarantee for a year, if any chips or breaks or anything, I’ll fix them. And then after that, you need to maintain it, if something happens, you need to pay for it. I don’t expect this to be filled with composites, they look the best on day one when you do it. And then it’s downhill. Now, depending on how good composite you’ve done, the color of that downhill come could be quite flattered. And then you know, gradually going down with a really bad job then after a month, it just started doing really deep downhill. So I would tell patient that five years is the time you need to expect from these things. And you may need some touch up, some refurbishment afterwards. Whereas veneers I would tell them around eight to 10 years. The difference is that again 10 years experience has shown me that, you know, if I have a space, and if I’m not damaging the tooth too much by doing veneers, porcelain veneer, I always prefer porcelain. Because it’s less maintenance, you know from patient and everything is just much easier. Much much much clean. So for me it’s not really cheap, how cheap it is the composite is how much damage I’m going to do to the tooth in order to, because if I’m adding a lot of wax up, then personally we all you need to do is just make a margin and you can stick a veneer in there. It’s not a big deal. So with regards to composite buildups for posteriors, for posterior onlays, I use something called valveless only, which is a very old technique, which is a second generation composite from Kerr and Pascal Magne used to use it before now he’s moved on to composite blocks, and which I’m also moving on to composite blocks, but most of my 10-year-old cases are using those onlays and they work perfectly fine. They’re really rare properties are so good, that they look really good. So for me, so that’s what I tell patients so they need to maintain hygiene. Six monthly hygienists Yes. Checkups, six monthly checkup. And I give them one year guarantee, does that help?

[Jaz]
Thanks so much for that and that helps a lot. And then just to say the problems I’ve seen from colleagues and for myself, when I’ve made a mistake is when in my planning of composite, I did not respect the material thickness that it needs. So I find when I’ve had posterior chipping, one of my colleagues about posterior chipping is because in that area over a cuspal tip, there was only 0.5 millimeters composite in that area. So I think th thicker the composite, the better it can handle stresses, we know that composite is very good and compressive and to minimize the tensile load by building in and dahling in your canine guidance and make sure it’s nice smooth, that will obviously improve the longevity. So respecting the material thickness, and also the ideal occlusal scheme is why you’re getting so much success as well Dev in that so it’s worth mentioning that. Please tell us, where can we learn more from you?

[Dev]
Oh, so I have, you can go to my website, which is drdevangpatel.com, I have various courses there, I have a full mouth reconstruction online course. So I have a pathway to full mouth reconstruction, okay? Because I want all general dental practitioners to be able to offer a full mouth reconstruction treatment to their patients, at least the adhesive full mouth reconstruction. For that, obviously, they need to make sure that their single tooth dentistry is good, which I am going to, I include that as well in my course. So the level that there is an online course, which describes everything that I’ve discussed today plus a lot more, it’s around 20 hours worth of online lecturing, and on practical demonstration of all the procedures, so it’s a practical demonstration of all the procedures. And it covers everything from start to finish, then if and my aim is to make sure that when someone does an online course, they start doing some sort of if a single arch and do something just by doing an online course. So that’s how I made my online course, however, we are hungry people. So you know, if someone wants to really get into the nitty-gritty and do a hands-on course, then level two is the hands-on course. That’s what I do as well. And once the hands-on course is done, you will have, you know, dentists will have a lot of confidence in doing the treatment. And if there are dentists who are like me who, you know, don’t have, they need someone next to sitting next to them for that very first case, then I’m doing one-to-one mentoring as well. So I will go to their practice. And make sure that when they’re doing their full mouth reconstruction anterior and posterior reconstruction, I’m there sitting, nursing for them, so that they get the confidence because once you do the first case, and everything else becomes easy because you’ve gone through that process and feel a bit more comfortable. So some people just need that, you know, just a little bit extra nudge. But the pathway is basically at the end of this pathway, either some people do an online course and they’ll be able to do full mouth reconstruction, some people might need hands-on, and some might need one-to-one. But at the end of the pathway, everyone should be able to do full mouth reconstruction adhesive using composites. So that’s the aim. And that’s the message I want to spread to all the GDPs because by doing that, we’re actually serving our community better. We’re making sure our patients are better treated, because I see a lot of colleagues missing because if you’re not doing the treatment, like you will see in practices where one dentist is doing Invisalign cases like 10, 20, the other they’re just not doing any Invisalign cases, and you’re thinking, the patients are the same. It’s the same practice. It’s because that person doing Invisalign is seeing more. So if you’re doing full mouth reconstruction, you’ll start seeing the patient because before that you probably didn’t look at it properly. It’s like buying a car right? So if you buy a car you start seeing the same car a lot on the road. The same thing. But yeah, so if you follow me on Instagram

[Jaz]
And I just want to say that is amazing.

[Dev]
Yeah, if you follow me on Instagram @dr_devangpatel or Facebook, Dr. Devang Patel, or go to my website, which is www.drdevangpatel.com. And, or reach out to me. And if you have any cases, I’m more than happy to help you guys.

[Jaz]
Dev, this one is really helpful, guys always got time for you. So thanks so much for being so giving to our community. I just wanted to say when I saw you in Edinburgh, the BACD, we were talking about this, and we were talking about how in the implant world, they have such good pathways and good protocols with ITI. And mentorship is such a huge part of learning implants, right? Whereas when we find that when it comes to this type of dentistry unless you do a talk postgraduate master’s degree, you don’t really get that opportunity of someone coming to your practice. And doing that, which is absurd. Because when we’re charging, the amount we’re charging for full mouth rehab compared to you know, one or two implants, they’re fairly comparable. So to have that ability for your level three, in your case for those who need it. I think that’s fantastic. And I think this is the future. I know the future is online as well. And I’m an alumni, a huge fan of online education. But I think it’s great to have that option of having over the shoulder learning, which I think to this day is the most powerful way to learn, my most powerful learning experiences have happened when I’m shadowing someone, or someone’s shadowing me, and I see how much they’re gaining. And I think that’s what you’re providing. So kudos to you, Dev, thank you so much for giving your time over the three episodes. Have been most enjoyable speaking to you. And I’ll put all the websites up and anything that you send me in terms of photos, PDFs, or whatever, I’m gonna stick it all on the blog post. And then hopefully people can log on to the website, see all the different stuff you have, and to follow you on social media so they can check out all these cases and all the tips that you share. I really appreciate you coming on, Dev. Thank you so much.

[Dev]
Thank you for having me, Jaz, thank you very much.

Jaz’s Outro:
And there we have it guys. Thank you for listening all the way to the end. Dev was spitting fire as they say right? It was absolute phenomenal. It’s kind of like one of those episodes where you could not do multitasking right? You could not do multitasking, if you’re chopping onions, probably chop your fingers, right? So it’s one of those episodes, hope you enjoyed it, hope you found value from it, you may have to listen to it again, and maybe a third time just to cement it. Cement the ideas, the bigger picture thinking into your head. So I hope you enjoyed that. Please do join Full mouth reconstruction for GDP. This is Devang’s little baby, little group on Facebook, which is just some loving seeing posts from other dentists and Dev sharing his workflows. Lots, lots of lots of great content on there. So do join Full mouth reconstruction for GDPs. I’ll put a link in the show notes. And of course, if you want to learn more from Devang Patel, there’s so many courses that he does got mini-courses. So if you liked his style of education, you should definitely check out his course, especially when it comes to full-mouth rehab stuff. He’s got courses on that and I’m going to put his website I’ll put it down below for those watching on YouTube. And I’ll readout for those who are driving and then sort of making a mental bookmark for later. Now of course I’ll put it in the show notes so you could click onto it easily, it’s drdevangpatel.com/courses-hub. So essentially if you go to his website, drdevangpatel.com You’ll find the Courses section and you can check out all of the amazing courses got on there. Dev, I know you’re listening to this one. Thank you so much my friend for making this three-part series. It’s been absolutely epic. I’m sure everyone’s gonna agree and what you’ve given to the Protruserati is amazing. So please guys show your support. Join this course, you will learn further. If you want to enhance your full-mouth thinking, check out Dev’s course. Thanks so much, Dev. And thank you for listening all the way to the end