Cracked Teeth and Dentistry’s Tough Questions with Dr Lane Ochi – PDP175

Dr Lane Ochi is such a legend that I wanted to throw ALL of Dentistry’s tough questions at him – and as you guys requested, it’s MOSTLY about CRACKS!

Dr Ochi practiced in Beverley Hills for 43 years and embodies the Protrusive values of a lifelong learner, avid sharer and with so much humility.

Dr Lane Ochi and another of my mentors Dr Michael Melkers will be visiting London on 27th and 28th July in London for a 2 Day course. Click here to book on!

Watch PDP175 on Youtube

The Protrusive Dental Pearl – Intraoral Photographs: encourage your patient to capture intraoral photos on their phone, giving them a copy for reference. This empowers the patient to stay informed, facilitating their understanding and ownership of the situation

Need to Read it? Check out the Full Episode Transcript below!

Highlights of this Episode:

  • 01:24 The Protrusive Dental Pearl
  • 03:40 Dr. Lane Ochi
  • 09:11 Amalgam Restorations
  • 16:16 2 Types of Wearers
  • 19:27 Virgin Teeth 
  • 20:00 Mechanical Failures in Dentistry
  • 27:33 Force Management to Prevent Cracks
  • 34:35 Micro Leakage – When to and When Not to Intervene?
  • 39:32 Should you chase cracks?
  • 45:17 Second Molar Problems
  • 48:41 Posterior Severe Wear without Anterior Tooth Surface Loss
  • 53:42 Management of Symptomatic Cracks
  • 57:42 Direct Composite Overlay Protocol

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​​If you liked this episode, you will also like I Hate Cracked Teeth with Kreena Patel – PDP028

Click below for full episode transcript:

Jaz's Introduction: Should you chase cracks? Should you be concerned when composites come back with staining? Is that actually caries though? Or is it just harmless staining? Is there something we can do to prevent our patients from cracking their teeth? And that age old question of when should we think about intervening on someone who's exhibiting hairline cracks in their teeth?

Jaz’s Introduction:
You see, Protruserati, these are dentistry’s tough questions. There’s no hard and fast rules. There’s lots of opinion because we lack the clinical trials. But you know what? If I was going to ask someone their opinion, I’d want this person to be very experienced. So how is 43 years? Is that good enough for you?

I think that’s pretty good. Okay. What kind of dentist should this person be? Okay. Well, let me tell you the guy who we have on today. This is Dr. Lane Ochi. Not only is one of the most brilliant dentists ever, he’s also the most humble dentist ever. This is a beautiful combination. And he really embodies everything that Protrusive is about, everything our community is about.

This guy practiced for 43 years in Beverly Hills. He treated Miss Americas and celebrities, but when you speak to him, he’s just the loveliest, most humble man. So it’s a great pleasure to host him here today. We actually went live on YouTube and Facebook, but now this is the sort of polished and cut up full PDP episode complete with Protrusive premium notes and CPD. We’ve got one hour of CPD credits in store for you today by answering the quiz at the end.

Protrusive Dental Pearl
The Protrusive Dental Pearl is actually taken from this episode. It was just so brilliant yet so simple. Many of you are probably already doing this, but you know, sometimes it resonates with me that you know what, this simple little tweak, I can use this in my practice and what it was and what the pearl was, is to get the patient’s photos.

What I mean by that is the intraoral photos that you take, for example, of cracks like the big theme of this episode is talk about communication and crack teeth and predicting longevity. All the tough questions, like I said. But a powerful tip is to take a photo of the crack. Now, we’ve said that tip before.

You know that already, but how about now escalating this and getting the patient to take out their phone and use their camera to take a photo of their photo. What I mean by that is now they’ve got a photo of their cracked tooth on their phone. It’s kind of like them finally inching towards owning the problem.

I just really like that because the patients kind of have this and they come up in the next checkup and what Lane says that they come and they show you the image like, hmm, how’s this tooth doing? So it’s kind of like digitally consumed and internalized by the patient, it becomes part of them, which obviously it was already, but they may not have been aware of this crack.

But now that they’re taking a photo of it, it might just pop up in their sort of gallery again as they’re looking through photos of their grandchildren and stuff and be like, oh, yes, I have a cracked tooth. I must speak to my dentist about this. So Protruserati keep taking photos, but let the patient take a little snap as well.

It’s a great little tip. I hope you agree. Just before you join the main episode, just a reminder that our new platform has been launched. So you can go ahead to protrusive. app. I know it’s the usual link, but now it’s going to look completely different. It’s got the completely new interface. It’s got the new platform with the search function, and now it’s free.

Before it was a paywall, but now the community aspect of it is completely free. I’m going to be basically phasing out or archiving the Facebook group, which has been brilliant, but I want to move all the good questions, the good chat, the intellectual debate, the random funny dental memes that we share and the case specific questions that we ask in a safe space on Protrusive Guidance.

So Protrusive Guidance is the name of the platform and the website you need to go to is protrusive. app. I want this to be the home of the nicest and geekiest dentists ever. And this platform needs you so we can continue to celebrate the magic of caring, sharing dentists just like you. I hope to see you on the platform, but otherwise, let’s join the main episode.

Main Episode:
Yes, we are live! Okay, the technology works. It’s a huge stress sometimes, Lane, when I promise to go live and stuff. It adds a lot of added pressure, especially on like multiple platforms and whatnot. So, guys!

Wait, we’re live? Oh no!

I know, I know! Lights, camera, action! Okay, we are live. I am just so, so happy to be here with you today. Just while we wait for the room to fill up, I’ve had a crappy few days. Okay. Because yesterday I slept at home, but the two nights before that I was sleeping in the hospital because unfortunately my son was sick. He had a really nasty stomach bug. He was on IV fluids and it wasn’t looking pretty and it wasn’t looking good, but kids just bounced back.

And so I’m just in a good mood that he’s okay. My son’s okay. He’s back to himself now, which is exactly. So it’s so good. And so I’m in a great mood and to be able to speak with you Lane on these really tough questions, guys. So we’re covering dentistry’s tough questions. And these have all been sent in by the community.

Okay. All of them from the community, which we’re live to now. So Lane, we call the community, the Protruserati, like Illuminati Protruserati. And our favorite thing is chopping onions. So, so far we’re chopping onions because one time someone told me that they like to chop onions when they listen to a podcast. And that’s why they’re now famous for that everyone.

All right. Well, I promise I won’t cry then.

Well, we’ve got comments already. Alex saying thank you for organizing this. Alex, thanks so much for always being part of it. Lovely. I’m just going to give it maybe 20 more seconds to make sure it’s definitely working.

Okay, amazing. It’s definitely working. The technology’s all working. So guys, we have some really great questions to cover today. It’s all about, like, the theme is, really, tough thing that we all hate as dentists, which is cracks, right? There’s questions which don’t really have a black and white. There’s lots of gray.

And I know that’s going to be the way it goes today. But what we’d love to learn from you today, Dr. Lane Ochi, I’m going to call you Lane from now, is your philosophy, your why, your angle that you approach, because every mouth is different. Every patient is different. Every patient has different values and different biomechanics.

I just want to hear how you unpack these sorts of scenarios. Before we talk about those, I just want to introduce you as one of, this is all me from the heart, I’m saying one of the most humble people I’ve met in dentistry. I first came across you, I did lots of CE with Michael Melkers and he used to just like talk about, oh yeah, Lane this and Lane that and Lane this.

I was like, who’s Lane? And then Mahmoud Ibrahim came to my life and he was like, oh my God, Lane this and Lane that. I was like, who is this Lane, Lane guy? And then literally I saw you everywhere. Like you were literally on all these podcasts I was listening to and just your humility and whatnot, like, I read your bio, you’ve treated Miss Americas and all these celebrities and stuff, Beverly Hills, you worked in, how many years were you in Beverly Hills for practicing?

Almost 43 years, so quite a while. Enough to make a few mistakes and learn from them I hope.

Amazing, right? So it’s just absolutely amazing to have you on the show today and like you were a co director of Occlusion, you received all these amazing things. And so this is why I’m particularly excited to unpack everything today. So Lane, you haven’t retired yet fully, have you?

Not really. I’ve actually stepped away from full time practice in Beverly Hills. It was just time. I searched out. It took me two and a half years to find the right person to entrust the practice to. I found that person. I worked alongside for two years, and it was time.

It’s just time for me to go. So now, I’m actually hanging out in the office of a young doctor that I’ve had the honor of mentoring over a number of years. And so, I’ve tried to stay in little relevance still.

Amazing. Very good. And when you making that decision to sort of reduce your clinical. What were the emotions you were going through after 43 years in dentistry in Beverly Hills? What were you thinking? It’s like, okay, it’s time, or I’m going to miss this, or I cannot wait to break the shackles and escape. What was your mindset?

So, it’s funny that you said that. I love clinical dentistry. So I didn’t want to stop. Because you didn’t want to hit that spot where you left your best work on the table, right? Behind you. And that’s a bad place to be. You know what? They all say that a commonality that we see in people who are really, really good at dentistry are the people who really, really love dentistry.

And to love dentistry, you have to have fun. And the problem is, after COVID, in a state like California, it just wasn’t fun to be a business owner anymore. Then something else happened. And the most exciting, important thing in my life happened. I never expected to be a grandparent. My daughter had a grandson. I had a son, so I have a grandson. Now I have a second grandson, so I’m a full time, more like a full-time grandparent, and that was the really deciding factor for me.

I love it. Those are all beautiful reasons. So it’s great that you’re still doing the teaching and the mentoring like you are at the moment because there’s so much that we can learn from you.

I’m actually listening to a book called Positive Productivity by a chap called Ali Abdaal and he talks so much about making sure that work is a fun place that when you are having fun. Then that’s when you’re at your most productive when you’re feeling good. That’s when you’re most productive. And so one of the episodes I’ll be releasing soon, cause I’m listening to that book and I’m trying to draw, like, how can we bring this into dentistry?

How can we bring gamification and fun and good vibes into our daily dentistry in a high stress environment to make sure that we can be practicing for years and years and years. And I probably appreciate when that after COVID and stuff, it doesn’t become fun anymore. And you recognize your time.

Amalgam Restorations
And I think, 43 years, you’ve done your time, sir. So congratulations for your pretty much retirement. So let’s go and tackle these questions because now the room is hot. We’ve got people commenting. Thank you, Sarah, for joining us tonight. YouTube as well. Thank you. Thank you, Raphael from YouTube.

Thanks for writing your name as well, right? Because sometimes it’s difficult to know who’s written a question. So a lot of these questions were inspired by one of the biggest Protruserati his name is Yazan. And Yazan always asks wonderful questions. And guys, by the way, Lane, like he didn’t read these questions, right?

He’s the kind of guy who just wants to just have a lovely chat. And so we can make this very engaging, right? There’s a very rare live podcast that we’re doing. So as he’s answering this, you might think, oh, here’s a secondary question. I will be checking periodically both YouTube and Facebook to see your comments, your reactions, your reflections, and your questions.

So the first question Lane is, is it possible to prevent fractures of posterior teeth with amalgam restorations? Now, before you answer that, I’m trying to unpack that question myself. So we know amalgam restorations stronger than tooth, and we often see like broken custom stuff. So it’s a daily issue. And that’s one of the other questions that are later on, actually.

So fracture teeth are common. They’re more common in teeth with big restorations. It just makes sense. A weaker tooth. What I’d like to know is not only how can we prevent fractures of these teeth that are heavily restored, but just generally, how can we change the trajectory of a patient to be less crack prone? I’d love to know that from the back of this question, actually. So please, what do you think about this question?

I feel like a mosquito in a nudist colony. I don’t know where to start.

How about we start with the fact that you would have seen so many patients with MOD amalgams and you would have seen them for year and year and year without any issues. And then you get people who seem to be breaking them off quite regularly. I think that’s a great place to reflect. Maybe you’re being rhetorical there anyway, and maybe you know exactly where to start.

I do actually. So, you mentioned something really critical, right? You mentioned how, what and why. Okay. And so I’m going to break this out in different conversations because there’s a lot to unpack. So the first part, I don’t think we all understand what our concerns are, right? With large amalgams and teeth, we know the enamel is a wonderful material, right? It makes a compression dome, which holds the tooth together, right?

Unfortunately, if you drill a hole in it, it’s no longer a compression dome and it’s not a torsion box either. It becomes very weak. So, anything you stick in it that is going to weaken the tooth. And unfortunately, as time goes by, fillings need to be replaced and they get bigger holes. And then they need to be replaced because they’re bigger.

We get bigger holes till ultimately we end up in situations like we’re describing with a multitude of people with large MOD amalgams. Now one of the things that what we look at as dentists is like, we don’t want these things to fracture. Right? That’s how we’re training. We’re trying to prevent disease from exacerbating.

But when we look at these teeth, we have to look at a number of data points, right? We not only need to look at how the tooth presents, right? Are there cracks in it? Are there symptoms? We also have to look at the demographics of the person that’s attached to this tooth. Is it an older patient? Is it a younger patient?

Is there occlusal wear? And so, to answer that question, it always depends. Now, we also know the how to treat this problem, right? We have to strengthen the tooth in terms of redesigning a restoration. So that’s where indirect restorations typically follow next. So the most important thing that I think I learned in this, I think which is what you’re asking me, is the why.

Why are we replacing? So how do we predictably replace them? But the question or the problem is, is that the why doesn’t really apply to us. It actually applies to our patients.

Mm hmm. Mm hmm.

They need to know why. Because here’s the biggest problem that we have as dentists, and I see this across the board, is that we tend to always narrate and dialogue with our patients as doctors, which is how we’re trained.

But patients don’t understand dentistry, and if we talk too much like doctors, there’s just all they hear is blah, blah, blah, right? So, the why relates to the patient. If I may go back a little bit on a slight tangent, so this isn’t anything new. I mean, this is a concept of co discovery.

This has been talked about since the 80s when I started coming, when I came into dentistry. One of the biggest advocates, Avrom King, said something really cool, and it doesn’t matter what your level of technical expertise is. It’ll go unused unless, unless you learn how to properly communicate.

And what she meant by that is the ability to profoundly listen to our patients, right? Because if we aren’t hearing them, then we’re not going to be able to do any dentistry. They’re just going to look at us and say bye. In other words, when patients try to learn a why, when they ask us a question, they’re speaking to be understood, where we have to change, and this comes with maturity and time.

We have to get away from listening for how to reply, because that’s what we do. So, when it comes time to educate patients, get them to be co discoverers of potential problems that we see. Fractured teeth, large amalgams, right? So if we can educate them, involve them in the co discovery process, this is how our patients, right, learn to take responsibility for potential problems in their dental health later.

So then when we make recommendations. And Asians don’t go, why, they’ll just go, oh, okay, well, when should we schedule? So I think it’s a whole mindset that we have to take into consideration. So again, as a very broad overview, but Asian centric first, right? Because we just know, are you really going to start messing around with a large filling on somebody that has no parafunctional habits.

They have they haven’t broken anything. They’re mid 30s my answer to you the way I practice is no I’m not going to but I am going to make good note of it I love you know what I love to do. I love to take pictures with patients right put the picture in their file they always have it to look at. It’s surprising how much-

Oh, okay. This is a new one. So, we’ve been banging on for years on this podcast about taking photos and I’m a big fan of the intraoral camera. This is the first time I’ve heard someone say to get those images to a patient’s phone.

Right. So put it on their phone. You know what? They look at it. In fact, I can’t tell you the number of times I’ve come into Hygiene, for Hygiene checks, and they’ve got their picture open. Can we talk about this again? You know, so again-

This is amazing. I’m just thinking about how I’m actually doing this. It’s very simple on the software that we use. Just email them their intraoral photos. Right. This is great. I love this.

Put it on their own phone. They could see, you could take a great picture of a crack with a, you know.

[Jaz] 2 Types of Wearers
You could just use their photo to take a photo of the screen. Yes, of course. Use their camera to take a photo of the screen. Okay, got it. Lovely. That’s my top tip already. I love that. So we’ll, I’m just going to unpack some of the things you said there. Firstly, you mentioned about someone who’s got wear. And one thing I heard, I think Pasquale Venuti said this actually, is that there are two types of people. There are cracker wearers and there are wearer wearers. Do you think this is something that you’ve observed in your 43 years in dentistry as well?

Well, maybe I want, I need to fully understand that narrative. So is he breaking it into there? We have to differentiate between, pure clenchers or bruxers, right, because I’ll take a clencher over a bruxer any day, okay, as bruxers are, their parafunction does way more damage.

So while the clencher, may clench very hard on a solid material like an amalgam. Then our worry is, of course, the amalgam is hard and can act like a wood splitting wedge. Which, oh my gosh, sounds like a very typical talking point dentists use to patients, right? Well, it can act like a wood splitting wedge, you can crack your teeth and their eyes glaze over.

But the real problem is with the grinder, the person who’s parafunctioning side to side, that’s where the tooth wear comes. That’s where the restorative wear comes. And there are very few absolutes in dentistry, but there is one. Okay. Everything, including the tooth. It’s strongest under compression and weakest under shear.

So it’s the para functioning patient that you’re going to see, if you’re going to see cracks associated with these amalgams, right? Where you see them on. You see them with teeth that have O shear wear. You see the occlusal tables a little wider than it should be, and those are starting to be red flags where you start initiating these conversations with patients, right?

And these are where I start to get concerned. And where does that typically happen? Again, demographically, it happens in older patients. We start to really see some of the damage in the 40s if they’re really parafunctioning. And this gets worse through the 50s and 60s. Now, this is an interesting, I’m glad you asked me this question, Jaz, because one of the things that we also forget, right, that the demographics of our patients follow us.

When I was a young doctor, nobody old wanted to trust me. I was too young. Now that I’m an old doctor, all my patients got old with me, but none of the young ones want to come to me because they don’t think I know anything about technology. I’m a dinosaur. So you have to consider that. Where are you in your profession? What is the demographics of your patients?

Very good. And what the whole cracker wear away is just an observation that some people are, I’ve got very steep cusps and they got more, more cracks. And so people got through the parafunctional wear side to side, just as you said, basically they tend to wear away and you get cracks as well, but just an interesting observation there. Now, virgin teeth with cracks. Yes, please.

Yeah. I was just going to do a finger puppet thing, if I could. I understand if you don’t have a crack, you’ve got cuspal inclines, right? And if you’re still occluding on two cuspal inclines, the force, they’re still going to be a horizontal vector as well.

A shearing force.

[Lane] Virgin Teeth  
Exactly. Even under clenching. So these are, something that, again, we have to evaluate. What the patient is doing in terms of habit. And so, sorry to-

No, that’s fine, because it leads very nicely to the next question, actually. This is all a subdivision of the main question about preventing cracks, right? Virgin teeth with cracks, for me, that’s a sign of high forces, right? Virgin teeth has cracks, right? And on the other spectrum you have that sweet old lady who’s had the amalgam for 60 years and you’ve been looking at that buccal cusp with the amalgam shining through the enamel and it’s been there and it’s got no cracks and whatnot.

Mechanical Failures in Dentistry
And that’s a patient on the other end of a spectrum of tooth that should crack, every right to crack, in occlusion with an imposing tooth and doesn’t crack. So there’s a whole spectrum. So my question to you is, how much of the mechanical failures in dentistry you think are attributable to functional forces and function versus parafunction?

Oh, well, okay, that’s kind of easy. So in function, our teeth don’t touch, right? When we’re masticating, there should be food between our teeth. So the better question to ask is what’s more damaging, impact force? Or static load, right? Static load. It is a parafunctional problem, and that’s what puts a lot of stress and strain on teeth.

Even if the teeth do touch when we’re chewing, that’s more of just a quick little impact. There’s a big difference. Then to take, you’re wearing Posselt’s, I mean, how can I not talk a little bit about a occlusion? You’re wearing these teeth.

Of course.

So, one other thing is that we have to look at is, again, look at the little old lady with very narrow masseters, they have a very high mandibular plane angle, they don’t have any wear of their anterior teeth, they’re not chipping.

Parafunctioning patients, when you look at them, and a number of studies have tracked patients over time, that wear on parafunctional patients starts on the lower incisors, so when you start seeing wear on those lower incisors, and what’s the result of lower incisor wear, compensatory eruption, so you’re seeing the gingival levels changing a little bit.

Now go look at the back teeth and see if you have a posterior interference, because as they wear their anterior guidance, they’re going to start putting more stress and strain back there. So, muscle evaluation, I mean, you can tell a lot from a face, even mandibular plane angle. People with lower mandibular plane angles, right, the angle of the muscle pull is going to be more curvilinear. Flat plane, mandibular plane angles, your brachiocephalic patients, the muscle straight vertical, right over what? The molars.

Short face, long face, and then you can see these, when you take portrait photos, you see that they’re weaker muscles versus the latter having the stronger muscles, higher forces.

Exactly. And this is why facial photos, profile and straight on, are a critical part of your data collection. So again, if I may, you’re asking all these beautiful questions. And I think the problem is that, there is no absolute answer. As you said there, it’s great. And the best I can offer you today, and I hope I’m offering you is a whole bunch of data points that you have to look at to help make and guide your decisions.

Yeah, for example, if someone has been having a series of broken cusps, then in that patient, when you look at the other undermined restoration, you think, okay, this is a point where we need to be more proactive, whereas that sweet old lady with the long face and the very rare mechanical failure, we don’t need to be rushing in, even though the tooth looks like it should just crack by looking at it.

Now interesting one, just going on this and we’ll spend probably three, four minutes on this theme before we move on to the next one is I know Jeff Rouse has said this and I saw someone that was lecturing on Friday and an ex Kois mentor used to say this about most failures is what they said that happened during function during eating.

Oh my, I was eating bread, soft bread. It was soft, but it’s always soft bread and my cusp broke away. Whereas people don’t complain of, oh yeah, I woke up with a tooth in my mouth. And so what these guys are trying to say is actually it was during function that it broke. Now, what I say to them is, okay, well maybe that was the straw that broke the camel’s back.

Maybe all the forces from the parafunction weakened it, and it was the soft bread, hence why it was soft. That’s what I think, but I just want some input from you and your many more years of experience.

Oh, I agree a thousand percent. It is the tipping point of that, right? And if I can give you the best question you’re asking, but I don’t have an answer for it, is when does that tipping point occur? And how do you get right in front of it? And the only thing I can really tell you is that’s where long-term clinical experience comes into play, observing your patients very carefully.

And then you start evaluating things in terms of, occlusion, disclusion, as well as muscle activity. You have a patient that, and again, the pendulum is kind of swinging away that sleep apnea does a lot result in a lot of arousal bruxism responses. It’s kind of like, okay, but still, these are all these things that we have to look at.

It’s like peeling away layers of the onion, right? It’s not one thing that makes your eyes cry as you keep doing it for, so, the system’s overwhelmed and it’s the same thing with the teeth. So experience. And this is also where, people, I just have this deep healthy respect for people and educators like you, Jaz, is that you want to share your experiences with the younger doctors.

One of the biggest problems is that in the way we’re brought up, the way we’re educated, right? By the time we fight to get into dental school, we fight to pass dental school. We basically come out of dental school as competitors, which is a terrible thing, right? So, those of us, we’re out for a little while, then we learn to be colleagues, because we have to be colleagues to survive.

But what we all need to do is evolve to where you’re trying to round everybody up in our wonderful profession and be collaborators. And so this is why forums like this is so great, because there is no right or wrong answer, but it’s just nice to hear people reflecting on what they’ve experienced and how they approach things. So thank you for everything you do.

Thank you. That means the world to me. I mean, it’s all about the community of practice and the community of learning. The new app and the platform launching Protrusive Guidance, which I’m sure you love. And it’s tagline, basically, which is the brand new for us, Protruserati. It’s not home of those who chop onions.

It’s home of the geekiest and nicest dentist in the world. That’s what exactly. So these are the two factors I’m looking for. If that qualifies you to be a Protruserati, it’s someone who’s geeky, but you know what? Someone who’s just nice and someone who’s willing to listen and not dogmatic, which is exactly why I’m so excited to have you on today.

Protrusive Guidance:
Hi guys, it’s Erika here, the producer of Team Protrusive. I’m just interjecting here with the announcement that as Lane was talking about community, we’ve now got this amazing community platform. You can access it from your laptop. It’s called Protrusive Guidance. There’s also a native Android and Apple app.

What we really want to do is to harness the power of the Protrusive community and create a platform we can share and grow together. And you know what? It’s way better than Facebook. So if you haven’t already, check it out. Just do bear in mind that we manually approve every single application. So, it might be a little bit slow to approve you, but we only want dental professionals on this network to keep it a safe place and so that we can share failures together. Head over to www.protrusive.app to know more.

Final question on cracks. If you don’t mind, final question, there might be other ones, but that’s a different question. Now here’s an interesting one. There’s been no study that shows that if you give a patient an occlusal appliance, like a population A on occlusal appliance, and population B, you do not give them occlusal appliance.

Force Management to Prevent Cracks
And does population A suffer with more cracks over time? There’s no such clinical trial. It doesn’t exist from what I’ve seen. So in your experience, either a equilibration or an occlusal appliance or canine rises, whatever, something you’ve done to change or divert those forces versus and not doing it.

Do you think it makes a difference? And the reason for asking this question is I speak with some dentists and they say, my patient couldn’t afford the crowns. Therefore, we just settled for an occlusal appliance. Because, at least they’re rationalizing that it will divert those parafunctional forces and hopefully this will reduce the rate of cracking. What do you think about this?

I’m going to go to my default answer, all right? And I learned this from probably the finest prosthodontic educator that ever walked the face of this earth. Yeah, Ralph Youdelis. Ralph Youdelis was the program director for Frank Spear and John Kois. And Ralph said it the best.

We can never stop people from exhibiting or doing these damaging things to their mouth. All we can do in terms of a rehabilitation or rejuvenation is to help patients Brux safer. I think that’s a brilliant answer, commentary. Brux safer. How do we get patients to Brux safer? Certainly a nocturnal appliance helps, right?

The question is what type of nocturnal appliance do you want to use? Is it full tanner or full Michigan? Many people you put something between all their teeth and what do they want to do? I’ll clench harder on it. So for bruxers or clenchers, maybe that’s not the best appliance. You may want to try a different type of appliance to change the force factor.

And so when we talk about I can’t afford, okay, this is what we’re going to start because you can’t afford. You know what’s also amazing? These same patients in the conversation of educating them, so they answer their why questions, right? Come in, and he holds up their nightguard after six months, and it’s got a crack in it.

Did you see the crack? Oh no. Then, they come back and a piece is missing. And they go, look, Dr. Ochi, your nightguard doesn’t work, it broke. You go, well, actually, it worked exactly the way I wanted it to. Wouldn’t you rather have the night guard break than your tooth? This is the evolution of the discussion of managing.

So before they start breaking off those cusps down the line, right? Now they’ve kind of went, wow, this is kind of cool. Then we morph into what you’re talking about. Do we start taking teeth and picking the worst ones that we can project are going to break? Based on location, which is also force management, or do we start thinking, all right, do you believe in equilibration, right?

And understand equilibration, equilibrium is positive, is additive or subtractive, right? So we can do equilibration, selective equilibration, or we can think about how we’re going to put their mouth together. So this will open up into a very big discussion. But manage the forces first, so if you have a nocturnal parafunctioning patient, of course a piece of plastic is wonderful.

As they realize our rationale for giving them one, because they’re breaking it, that takes us to the next evolution of our relationship and what to do next. Because we know, already know the what and the how, right?

Well, the only thing, last thing I have on this appliance therefore, because you mentioned that wonderful thing, is that once they start breaking it, it’s further co diagnosis and then think, what’s next?

Now, let’s say you do a rehab. I’m of the opinion that centric relation is not a vaccine for bruxism, there patients will still exhibit the muscle behavior of bruxism. Therefore, even though, and feel free to, I’d love to know what you do actually is once you’ve finished a bigger restorative case, whereby you’ve tried to implement all the features of force management through the restorations in the most ideal way as possible.

Because of the history of bruxing, despite now having the occlusion set up kind of like an appliance that you’ve got like the bruxism, safer bruxism through the restorations, for example, are you still supplementing it with a appliance to protect those restorations?

Absolutely. Now you just keyed in on the most important thing, and I don’t think you realize this. So you talked about reorganizing the occlusion, right? So we’re no longer building to MIP conformative. We’re building to a new place. And you talked about all the lovely dots on our nocturnal appliance. So we’ve also evolved from an occlusion standpoint, we’ve gotten away from tripods.

We’ve even kind of moved away from reciprocal contacts. So we’re talking about landing pads now. And so a landing pad, if you’re not familiar with the term, is just simply we want a stamp cusp to hit and a flat spot on the opposing tooth, be it in the central fossa, you just kind of make it a little flatter so that there’s a little side to side room or you put it on a flat marginal ridge that doesn’t have any triangular ridges so that there’s a little side to side.

So this kind of freedom to slide around without engaging. A shear on a cusp slope is really critical for our success, as well as, again, supplementing with a piece of plastic. So, you know what, part of my protocol is, for a big case, is it’s always done in phases. And if we can’t complete a phase, we don’t move forward.

Phase one is, I’m a show me kind of guy. I’m going to consider doing this much work on you. I’m going to give you an appliance. You want to call it a deprogrammer, you want to call it an orthotic, call it whatever you want. It’s just a goddamn appliance. So I give it to them is to see if they actually don’t wear the thing.

Right? So they’re coming in and they’ve got a nice shiny appliance with no tartar on it, they’re not compliant. So why would you want to reconstruct them and give them for belt and suspenders, a nocturnal appliance where they’re not going to wear, which also brings us to the second thing, right?

That there are still some occlusal camps out there that think CR is forever. Well, no, CR is not forever. The joint’s constantly remodeling. The occlusion is constantly changing. And that’s why we moved away from this organized tripod occlusion, because it demanded a solid centric and immediate disclusion, but if the centric slipped a little bit, then all of a sudden, those tripods become deflective contacts, and those don’t really solve the problem. In fact, they exacerbate it. So, so the hard conversation is because nobody’s talking about.

I loved your answer. And I just want to highlight one thing that maybe someone missed and maybe someone was multitasking when they’re listening, watching in the future, but the whole get them to brux in a safer way.

I love that. The way I’ve been saying it is get them to brux in a more dentally beautiful way. That that’s how I’ve been saying it basically. So I love that. So I’m definitely happy to make sure that we emphasize on that point. So next set of questions.

Micro Leakage – When to and When Not to Intervene?
Okay. The theme of leakage. I’ve read these amazing, fantastic papers that kind of say that it’s a myth, the myth of micro leakage, i. e. dentists have been accused of being aggressive because they see a yellow line around a composite and they say, well, there’s micro leakage, there’s caries, we’re going to replace it. And so I’ve done it before where I’ve I’ve suspected something’s not quite right with that composite and I started removing it.

And by the time we moved the composite, everything was sound underneath. It was just literally the very outer marginal area, which was collecting some, some plaque and some discoloration basically. And so you kind of have to pick and choose your cases carefully. The question from Yazan is leaking posterior composites, when to intervene? Is it harmless staining around the margin or something more sinister? Which data points are you using now to figure out which of the two is this tooth or is this patient sitting on?

So, restorations go through three phases of failure, right? Staining first, right? Then you get leakage and then ultimately decay follows leakage. So, the problem is when do you move from stains to leakage?

And I don’t think anyone can give you a solid answer. But what we also have to take into consideration is the age of the patient. Again, always, every tooth is connected to a human being. And when you, for example, just because you have a crap margin doesn’t mean you’ve got leakage. So how many amalgams have you looked at with the big oxidized layer, around the cavo surface margin?

You know that sucker’s leaking, you drill it out, and I’m using amalgams because they’ve been around for so long. And then you get to the deepest part and you find a whole bunch of Dycal that is soft. It never hardened. And you find the residual decay that the doctor left because they didn’t want to involve the pulp, right?

So obviously there is no additional decay. It hadn’t moved up the actual walls. It just sat there underneath this amalgam that was leaking. Composites are a little bit different and this is the problem and this is why you’re asking the question. So when I go back and talk about the demographic of the patient in front of you, is this a younger patient, right?

Because what is the current trend in composite, in direct restorations? And that is partial caries excavation, right? You want to get rid of the active caries, but you don’t want to remove all the dentine that may be affected. Want to just have enough solid border to seal it and maintain the bulk of the restoration. So, now, on a younger patient, I’m assuming that may have happened, and probably did happen, so I’m going to be a little bit more proactive on that patient if I see stain beginning.

Because the run from leakage to caries is very short and very quick. An older patient. Again, if I look at that restoration and I could tell a large particle fill restoration from a small particle fill, if it’s an old larger particle fill, I’m probably going to be more watchful of that restoration.

And when I say that it comes with the caveat, and again, this is the co-discovery with the patient. I show them the picture. I said, I don’t know if there’s caries underneath it. We can take x rays every week all you come in because you’re a good patient. You come in every four months. Let’s do this for a year and see if we see any changes.

If we don’t, then okay, I’m going to continue to watch it. It’s just the way you present it. The other thing is too, and surprisingly, this has a very profound, powerful effect on people. Just having this conversation with somebody. What’s wrong with doing a little exploratory? Just pick a margin and open into it. You don’t even have to numb them, right, for this, for God’s sakes.

Mm hmm. Like a test cavity, almost.

Exactly. If it’s not leaking down the side, then fine. Just like, all right, let’s just etch it and seal it up again. Again, I’m not telling anyone how to philosophically practice, nor are you. We always have these concerns. And guess what? I have yet to meet a patient who was disappointed when we did a little exploratory. That we actually said, yes, it is a lot deeper than I thought. I’m going to have to reschedule you to do this properly. And you know what? I always got to thank you for at least trying, rather than again, committing a patient directly.

Because this is what you want to do with practice, right? You want to have patients that trust you and that is the whole point of co discovery.

I think if you’re sitting on the fence and you’re not sure that is a really great practical solution that is a practice builder. So thank you for sharing that. That’s fantastic. I’m very happy. I’m just going to just go on the Facebook and check for any additional questions. No. Good. Thank you, Alex, your comment. I appreciate it. Brilliant. So we’re doing, we’re on track now. Lovely.

Should you chase cracks?
Next question is, back on cracks, but should you chase cracks? So let’s say you remove that amalgam now, you see all sorts of cracks, which cracks do you chase?

Which cracks do you not chase? I know I’ve talked with people, dentists on both sides on the continuum. Some saying that it’s damaging to create, you’ll chase it and you’ll never actually get to the crack. And others say that if you leave a crack, then you’re leaving a problem there. How have you managed it in your decades of dentistry? And has that, I also want to know, has that changed? Have you changed philosophy over time? I’d like to know that as well.

Yeah. So when I first started practicing unfortunately I learned under endodontic philosophy of stressed pulp, right? So if you stress, if you stress the pulp, the data points told you just do it endo, intentional endo on a crack tooth that tested vital, which acts, bothers, I don’t chase cracks today. Okay, I, as long as there’s no caries associated with it, but, and this, again, if I can kind of backtrack a little bit, this is also one of the things we have to be very, very careful of when we make recommendations and to replace a restoration, amalgam restoration with cracks in it.

Completely asymptomatic, you touch the tooth, you overwhelm it, it hits the tipping point, drilling out the caries, following a crack, whatever, prepping it for flow coverage, and the pulp goes south. I mean, you know, 5%, 10 percent of teeth that we prep for indirects will go south. And so now you have mud on your face.

This patient is not going to trust you or we need to do this too often. So always go into it with, again, the education with the patient. This is where also you’re taking a photograph and then making sure they have a copy of the photograph of the restoration and caries remover that shows the crack and you tell them look, we don’t know if this is going to be a problem, but I want to share it with you now because I’m conservative.

I don’t want to go into the nerve because once we take out that nerve, yes, you won’t have any pain. But we also take away the blood supply of the tooth. And what happens when we take away the blood supply of anything in our bodies? It gets very brittle. Do we want a brittle tooth to make, that’s got a crack in it to be more brittle?

And we surprised at the number of people who said, no, let’s try Doc, I understand. And they, if it does go south, they rarely get mad. So, I don’t chase cracks. Okay, I try to do, I’m still a total etch person. So, I’ve been fourth generation dentine bonding, everything under rubber dam.

Opti bond FL?

No, I still use the All-Bond, so I-

Okay. Mm-Hmm.

John Kanca developed All-Bond, so that’s-


Surpasses a wonderful product. Also, I just mentally it’s a little too, looks too thick to me, so it bothers me to use it, but it’s a great product. But again, technical execution I think also goes a long way to success and getting away with things that we may not necessarily get away with. Now, if you’re going to ask me, well, should we [inaudible], blah, blah, blah, I don’t know because there’s no good data. There’s no good science on that. So anyways.

So the conclusion there was at the moment you don’t chase cracks, but every case on his, if it’s like a carry, if it’s caries within the crack, then you’ve got to deal with that.

And then sometimes it’s a tough call, but if you’re just generally chasing all cracks, then you’re going to run into more trouble. You’re going to run into more pulpal issues. And I think I follow that as well. So I’m very happy to hear that.

One thing. That like is like a crack at different parts of the tooth. If I see a mesial distal crack that goes across my pulpal floor or the prep, not pulpal floor, the bottom of the tooth, then I’m going to probably say, you know what, let’s just stabilize this. Let’s build it up. Let’s temporize it and wait. I may capture the impression at that point, but just wait and get an endodontic consult as well. So.

I like that you said that because I’m a temporary crown and weight kind of guy as well in those dubious situations. My internal struggle is how long to wait for. Now, for example, if I’m using something like a Duralon or zinc polycarboxylate cement, I’m happy to admit on the show that I’ve had some patients have my temporary on for nine months to a year.

And then we said, okay, let’s change it over. But I’ve heard some colleagues criticize me in a nice way and say which has, that’s a bit too long. I worry about caries. I worry about all these sorts of things, which hasn’t been an issue in my experience. Have I waited too long? Because I just felt when the patient’s ready and I’m ready, then let’s both go for it. I was confident that my restoration was well sealed with a temporary provisional restoration. Any guidelines in terms of how long you waited?

No, you know what? As long as humanly possible, half a year, just not atypical at all. And nine months, I’d actually prefer. Many times, if I see these things at the cleanout stage, I’ll just go ahead and I’ll do my buildup and I may decide not to prep the tooth and provisionalize it, but actually take it slightly out of occlusion and tell the patient just to be cognizant of that.

But you know what, even using bisacryls, which are a little bit brittle and not as durable as GMMA, I find cementing Duralon they’re fine for up to a year, no problem at all. But you should be recalling from the checks of every single month. Absolutely.

No, no, totally agree. Totally agree. Just some hellos now. So Mahmoud on YouTube saying, so good to see you guys, one of your mentees obviously. So that’s great. Getting loads of comments on Facebook [live listeners] says cracking show, which is great.

Love it.

Someone’s asked question, which I’ll come back to later. Sunny saying Maha is really happy about the, the fact that you mentioned fourth gen. Alex is asking, is that all Bond plus from Bisco? Is it a Bisco product?

Yes. Bisco.

[Jaz] Second Molar Problems
Okay. Cool. There we are, Alex. It’s a Bisco product. The next question we have was sent into me by a Swedish dentist. So Protruserati from Sweden, who I believe is a mother of three kids. And an observation that she made in her practice is pregnant women coming in with second molar problems.

Now, this is not something that I’ve noticed, but she actually made a point in her email to me about this episode said, I’ve noticed that these pregnant women are coming in and they’re having these second molars severely cracked and shortened clinical height and lots of restorative challenges in restoring the second molar.

So I guess my question to you, Lane, is this an observation that you’ve noted? Second molar cracks and pregnancy, that aside, the question she asks is why second molars are so prone to cracks as well as restorative challenges.

Okay. To the first one, observationally, I can’t, I mean, I am trying to process, my gray matter is not as good as it used to be, but I don’t remember much correlation. Okay. And that may be just lack of observation. I can’t even remember my wife’s birthday. So, it’s like, but yes. So if you look at where studies going back to her question, when you follow people for really long periods of time, nice occlusions, no issues reported TM issues no crown and bridge, either their natural dentition or very, very minimal direct dentistry that you see very specific wear patterns.

And we mentioned this before, wear always occurs here first, then wear occurs on the lower second molar. And that’s where you run out of clinical room, right? Because you’ve got the ramus going up, so these are the hardest teeth to restore.

Small clinical crowns are often a huge restorative challenge to actually get the enough retention resistance form on second molars.

Correct. And then the question is, well, why lower second molars and not upper second molars, right? We all see this. I don’t have an answer. I have a theory and the theory is an occlusion-based theory is that most of the damage in para functioning, right, is this side to side, sand, wax, sand.

So if we think about how the whole jaw fossa apparatus works, right, we know that but the non-working condyle, the medial pole of the condyle will be against the medial wall of the mandibular fossa, but not so on the working side. There’s no lateral wall. So as you’re drawing this side, this condyle is actually moving out and up.

And as it’s moving out and up, think about the curve of Wilson that the upper buccal cusps are higher than the lingual cusps. So now if that lower tooth is moving that way, it’s going to get a lot of wear and tear, right? So that’s why I think the lower second molar takes most of the abuse. And so not only, again, should you be looking at the second molars on patients that you have seen show a lot of wear.

Look at their anterior teeth as well. And if you see that wear, guess what you do? You put them in plastic before they start losing their anterior guidance and damaging their lower back second molars. That would be my side.

[Jaz] Posterior Severe Wear without Anterior Tooth Surface Loss
I’m satisfied with that. So I’m so sorry, Swedish dentists. I forgot your name. I had it written down somewhere. I lost it, but I will be emailing you with a smile and say, check out what Lane had to say. So thank you. Next question is from Jean Marco de Andrea. We went skiing together across in February. It was great to catch up with you, Jean Marco then. Jean Marco would like to know his thought process on management of posterior teeth with severe wear without anterior tooth surface loss. He says he finds these cases super tricky due to the reduced height of the molars. So severe posterior wear without anterior tooth surface loss.

Okay. That’s a pretty atypical situation. I typically only see those in what I would say are class three tendency types of patients.

And maybe anterior open bite patients, maybe over time wearing their posteriors away as well, maybe.

Yeah. Same thing. Yeah. AOB patients, look at them skeletally again, look at the mandibular plane angle on those patients. And when we have these low mandibular plane angle patients, again, the force vectors just put tremendous amount of pressure on those back teeth, the brachiocephalic patient.

The other thing, that this is where we kind of, get into trouble, that none of us are any good at complete dentures anymore because it’s just not taught. And there’s a very classic say, in dentistry, if you want to get really good at occlusion and really good at aesthetics, you got to get really good at complete dentures.

What’s one of the first things we learn in complete denture assessment, the, at evaluating the vertical dimension of occlusion, is phonetic speaking space, right? So when you see these wear patients like that, typically, you just see wear. You don’t see any passive eruption of the back teeth. They’re just wearing, wearing, wearing.

And if you check these people with the vertical speaking space, you can use S, you can use M, whatever you like to use. You’ll find that they have very, very little space, like half a millimeter. So these are the ding, ding, ding, red flags, danger, Will Robinson, danger. How do you open these cases if they have no space to build it, right Jaz?

So before you pick up that hand piece, that’s the assessment you have to make. It’s like, do they have vertical space to build back what they wore away? These are the patients that crown lengthening becomes mandatory. They have a set vertical. They kind of ground themselves to it. So, again, educate yourself, spend more time looking at your data points, that’ll help you make the decision.

Excellent. I mean, we can talk about days about that kind of scenario, which is why you’re coming with Michael, July. I’m just going to get the dates up and just talk about this because I really want you and Michael to have the Protruserati, which you’re going to love these guys. So it’s on 27th and 28th of July in London. I think you’re doing at the BDA. Am I correct there?

Yes, that is correct. Two days, two days of Michael and me. Now, the cool thing, the really cool thing, and that that we make it, we’re probably the most unique speaking combination team out there that, that talks about occlusion, communication, soft skills, as well as hard skills because, again, if you can’t get the patient to accept the why, understand what their problem is, what, how to own that problem, you’ll never be able to get to do these cool things that we’re trained to do that we want to do.

And so that’s what makes it kind of fun because you get both. You get the clinical aspect, all the little tricks, if I may say, all my F ups, and how to try to avoid them, as well as how to help your patient understand how they got to now and what the future holds for them. If I may use this narrative, I hope Michael’s not listening. We’re kind of like an old married couple. We’re kind of fun to watch squabble.

The way he was talking about you when I went to his course in Sweden, I thought, yeah, like it was like someone who keeps it messaging or referencing their girlfriend kind of thing. Like it was like, oh, Lane this and Lane that.

Like I said so I can see the chemistry in terms of the bromance between you and the sort of chemistry and the amazing sort of workshops they’ve done in the past. I’ve seen great stuff about, so this one’s called communication, case planning, occlusion. So I would say if you haven’t seen Miguel and Lane speak before, or even if you have just come again, 27, 28 July, and that’s going to be at the BDA, the link for it, I’ll put in the show notes.

Once the live stream finishes, I’ll put it on YouTube and on Facebook for those that are on there. But I think this is going to be a real special one. I don’t think you’ve ever done a workshop in London together, right?

No, it’s like, well, yeah, this would probably be it, for coming across the pond. You know, we all have issues. My issue is airplanes. I hate flying. So it took a lot to convince me to do this that so, well we are-

Let’s make it worth your while and make sure we show you a good time. And so yeah, we will see you in the summer. But we have, let see, before I take any questions from the audience, we have one more question from Satnam that I have, and then I’ll open up to Facebook and YouTube.

Management of Symptomatic Cracks
So this last question is, it would be great to learn what is Dr. Ochi’s management of symptomatic cracks in those dental emergency. Once again, cracks, those densities, tough questions, right? So symptomatic crack emergency and how you communicate the options and next steps to the patient. So essentially patient comes in.

Classic crack tooth syndrome. You’ve tested with the tooth, whatever. What is the emergency management that you found to be most successful? And then how do you have that conversation with the patient? Because the difficult thing about that conversation is the ifs and the buts. Well, the tooth could die and you might need a root canal, or maybe the crack will be too deep and it can’t be savable, or maybe it’s going to be okay and just needs a crown only. So any communication tips once you’ve kind of put the fire out?

No. Well, I think you kind of summed it up. Putting the fire out is the most important thing, right? Patients are so grateful to be able to be seen on an emergency. We hate them because they mess up our scoreboards royally.

And so this is one of the very few times where you’re, if you have scripted responses, and we all do, to really fine tune them because all they’re interested in is getting out of pain. So whatever your typical script is. Well, the symptoms that you’re giving me and what I’m seeing are a cracked tooth, which means there’s a crack that’s communicating to the sensitive part of the tooth, the nerve.

So we don’t know if the nerve now is overwhelmed or not, but the first step is to do an exploratory. Let’s clean out this filling. Let’s look for a crack and then let’s just, or a new foundation and make this tooth as strong as possible. And then we’re going to sit back and wait and see how it does.

Just the nitty gritty details here for the younger colleagues. At this point, you’ve taken out that MOD amalgam, let’s say you’re going to clean out any caries or take a photo of the crack, of course, send it to the patient’s phone, obviously, right? And then you’re going to reduce those cusps and then put a well-sealed composite as an interim. Is that generally the management of emergency cracking syndrome in your practice? Yep.

That is pretty much it. And then and I think it’s important when we talk about our buildup materials, right? So not only do we want the best bonding possible, again, we don’t, once we cut a hole, we don’t have a torsion box. So we need bond the walls circumferentially as well as possible.

So we have to follow our best bonding protocol and we have to pick for our buildup materials. The higher the fill, the better, and you probably also want to use a self cure buildup material to make sure that there is a cure a hundred percent. Dual cures, or light cures, again, may not fully polymerize, so these are little material things that you may want to think about.

So I happen to like Core Paste by DenMat and even though it’s bright white, patients don’t seem to be too upset, they’re just out of pain, that’s all they care about. But basically, I think you and I follow the same kind of protocol the same language, everybody, you’ll develop your own talking points, and that’s fine, but again, one time you can take advantage of somebody really listening to you and saying, go ahead and do it, please, please, please, because I’m in pain. Pain is a wonderful motivator.

Yeah. I like what you said that in terms of communicating with the sensitive part of your tooth giving issue, let’s just get out of pain. And then once you deal with the fire, once they’re in a calmer mind, just to say, look, there’s many different ways it can go. Let’s just see you again and see where it lands and go from there.


[Jaz] Direct Composite Overlay Protocol
Perfect. I’m going to go ahead now and check the comments. Okay. Thank you so much. Facebook. Okay, Mustafa. I’m going to ask your question now and there’s nothing on there. Lovely. Okay. So Mustafa, I haven’t read his question yet, but Mustafa asked, do you like direct overlays? And if so, do you prefer doing them using stress reduced protocol with fibers or with injection overmolding such as the bio clear method? So direct composite overlays, was that a part of your protocol or restorative skill set, would you say?

Okay. I kind of need some clarification here because I want to make sure we’re saying the same things. When we’re talking overlays, are you talking like occlusal? On lays on top, or are you talking composite veneering? I’m not.

Sure. So this is kind of like the emergency scenario we just talked about, the crack tooth, you’re going to cap the cusps and fill the entire MODBL. So you’re kind of doing like a direct core foundation, basically covering over the cusp as well, basically. So that restoration, because it’s a good question in the sense that our traditional data points that we use to say that, okay, this tooth is now veering towards an indirect rather than direct in the last 20 years.

We’re doing more and more huge composites, right? We’re doing them more. We’re putting a lot more faith, a lot of trust, a lot more gambling happening on these large composites, which really a lot of colleagues would be saying, okay, this needs ceramic. This needs something indirect, but we’re really putting our composites to the test.

Now, going back to things that you already said in the show today, which is every patient is different. You’ve got to look at their facial features, how much force and that kind of stuff. But was this a restorative modality for you in terms of the work involved to get good contacts, mesial and distal and the kind of morphology and get it right in the occlusion, but to say to a patient, okay, this is it.

We’re done. We’ll revisit it in 10, 15 year’s time. Maybe we’ll need a crown then. Or was that always for you a transitional to an indirect restoration? Does that make sense?

Yeah. So, I got it. So, if you’re asking me, I’ve got taking everything out, everything’s cleaned up, and there is just a shell of tooth left, it’s not structurally sound.

We want to put it back together, but we don’t want it to split, so you would reduce it, cover it, the biting surface as well to put composite under compression, and also get, try to eliminate the lateral shear forces of the tooth. I rarely did that because, quite honestly, I suck at building up that much direct composite because you really, if you’re going to not have it break, you’re going to need at least a couple millimeters of reduction anyways.

I mentioned the torsion box concept a little earlier. So, what I would typically do if I had that situation where the tooth just looked structurally weak after the internal’s been all gutted out, I would create a torsion box, so I would use e fibers or Ribbond, and I would bond a circumferential as well as two U shapes.

And rather than reduce it and put a composite on top of it, because it’s just too hard to manage for. But again, I’m looking at the physics and if you’re not going to do and create what enamel dome does with supplemental fibers of some sort, then yes, that’s your really only option, but that’s a skill set I just never really worked on, so I just did not use it in my toolbox.

Great. I mean, so Mustafa just clarified. He did just mean cuspal coverage with composite and posterior teeth. But yeah, as you mentioned, there was a place for it, but it’s a difficult thing because we’re doing a lot more of these big composites and it’s a blurred line about, okay, should we go to ceramic?

The one thing I think is, are you going to achieve decent contacts? I mean, when you’re doing something that’s really ambitious for direct restorative, the one thing I say, which no one ever talks about is the reason why a composite compule has the amount of composite that it does in that Compule. It’s because someone very intelligent said, okay, this is probably about the amount of restoration needed before someone’s going to be considering indirect restoration.

And if you’re reaching for two compules, then you’re really thinking, okay, are you really doing the best in terms of strength? The best in terms of the contact areas that you’re going to make the best in terms of the final occlusal anatomy. And at one point you’ve got to think, okay, let’s accept this as a foundation restoration. And then communicate that so that it can be upgraded, if that’s a fair enough word to use, to an indirect.

Yeah, I like that. In fact, I’m going to steal that two compules. I love that. That is a brilliant observation because again, how much tooth is missing if you did more than two compules? That’s a lot.

Absolutely. Lane, you’ve answered all questions. One last glimpse on YouTube and Facebook to make sure the Protruserati are satisfied. Even I struggle. It’s getting late guys, like 10pm, right? Amazing. Lane, thank you so much. I can’t wait for you to come to the UK and bear that flight. And so guys, I’ll be putting it in the show notes so you can book on.

To visit Lane and Michael, their lecture, I’ll put the image, their banner as well in the show notes. It’d be great for us to show the true Protrusive love to our good friend, Michael Melkers, who’s been on the show before. And of course, Lane now, who’s been finally on Protrusive.

Yeah. Oh, I will point out on the signup, if there is a five-person signup discount, so she’s got like four friends and you want a little bit of a discount and take sign up for that every little bit helps. Right. By the way, I commented about your shirt, the Posselt’s did you notice mine? Did you notice the little mustaches?

Ah, lovely. Very nice. Excellent. Very good.

Or mine’s not yours though, so.

You rock it well. It suits you. it looks great. But guys, you heard what Lane said there, right? So if you’re on the Facebook right now, and you are and you can come see us maybe tomorrow and you’re interested in going to Lane and Michael on the 27th and 28th of July. I’m going to bring a poster up again. Yeah, great. Then maybe if you all sort of comment in the group saying, yeah, you know what?

I think I’m going. And then if you all just full club together, you get a little discount there as well, which would be great. the reason I’m supporting this is because I generally think these are fantastic educators and to not miss an opportunity to see them together would be, I really want to show them our support.

So, thank you so much, Lane, for making time for it to come on Protrusive. It’s been great to chat with you, and it would be nice to keep in touch and maybe a round two. I know you do talk about all sorts of things, like there’s so many directions we could have gone in. So I’m going to be, as you’re less and less clinical now, I’m going to be trying to really squeeze that brain of yours for everything inside.

Beautiful. I’d love to Jaz, I consider you my brother from another mother, same passion, same joys, you are actually, I consider you a mentor from afar. So thank you again for the invitation and hosting me today. Appreciate it.

Amazing. And Esa has actually said on YouTube saying, could you please talk a little bit about occlusion philosophy? I think next episode we can talk about the different camps over time and what your how maybe you’ve changed your occlusal views and practice and maybe a, a nice history. I think that’d be a really cool thing actually. So watch out everyone for part two and undisclosed date. Maybe it’ll be in September. So September is occlusion month on the podcast, basically. So we’re going to get you back for that.

Love occlusion month. I’m going to find an occlusion t shirt though. I can’t rock yours.

Jaz’s Outro:
I’m going to give you a hoodie when you come in July. Okay, sounds perfect. Alright guys, thank you so much.

Well, there we have it guys. Who better to answer those tough questions than Dr. Lane Ochi, and you bet I’ll bring him back for Occlusion Month in September 2024. If you’re in England or in Europe, actually, and you want to come to listen to Dr. Lane Ochi and Dr. Michael Melkers, two brilliant dentists who I consider real close friends and mentors, please support their two-day lecture.

It’s on the 27th and 28th of July. I’ll put the link in the show notes. I think it’s going to be probably the last time they ever do something in London like this, so it’s a great opportunity to catch them. And of course for CPD, can you answer the following question? The question is, what did Dr. Lane Ochi reveal was his preferred material for a foundation restoration?

Kind of like a core. Was it paracore? Was it denmat core paste? Was it EQUIAForte? Or was it Gaenial injectable? If you remember which one it was, then that’s one of the questions answered and you’re on your way to getting a verified CPD or CE for this episode. Some questions test your knowledge that you gained from the episode, and some test your retention to make sure you listen the whole way through.

The way to answer it is if you scroll down on Protrusive Guidance app under the premium section, you’ll be able to answer the questions. And if you’re not yet on Protrusive Guidance, then please come and join us. Head to protrusive.app. And if you check out the Protrusive premium plan, you can actually get CPD for all the episodes.

I want to thank you again for listening all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Hosted by
Jaz Gulati

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