Occlusal Equilibration Ain’t Dead! With Dr Koray Feran – PDP094

Jaz’s Introduction: Equilibration is just one of those really controversial topics within occlusion and within dentistry in general, right? It can really split a room. Like the other day on Facebook and on the telegram group when I asked you guys which episode Do you want next? And I suggested we could have one about a Equilibration. My buddy Saranga said, Hey, we still do a Equilibration? I thought we didn’t do equilibration anymore? And I remember attending a BDA event. I think I was maybe one year qualified. And Professor, actually I was a dental student, and Professor Robert Ibbotson, who was there, you know, very experience towards the end of his career, restorative consult at that time, he said he hadn’t done an equilibration since 1984. And he thought it was pointless. Whereas I know other great clinicians who I really respect who carry out equilibration, a fair amount because they’re doing bigger cases, and they see it as a really vital tool, a really vital step as part of their reconstruction. So which is the right answer? Hopefully in today’s episode, you’ll get a bit more information about equilibration, which is actually really difficult to find if you open your textbooks or if you search online, it’s not much out there about equilibration, which is why I’m so excited to bring on an absolute superstar guest today. His name is Dr. Koray Feran, an absolute legend. I saw him lecture when I was just two months qualified, and I am pretty sure he is the guy that put me on the path towards really loving my dentistry and really wanting to improve bit by bit. He taught me that the two pillars of restorative dentistry are illumination and magnification, and I will never forget that lecture that inspired me and amazingly, eight years later, here we are, I’m now interviewing my hero, Koray Feran. I remember shadowing him actually, so I went to that lecture, then I shadowed him in his clinic, I think, it’s near Harley Street. It’s Wimpole Street. It was the first time I’d been somewhere where there were two nurses working for one dentist, so I’d heard of 4-handed dentistry, but I had just seen for the first time 6-handed dentistry and this beautiful screen in front of me where he was showing me the sinus lifts as he was doing it. It was just a crazy experience for a recent grad. The Protrusive Dental Pearl I have for you is a bit tongue in cheek in a way because I know we’re talking about equilibration, which is essentially the removal or the balancing of teeth via removal of tooth structure right? That’s equilibration. But the Protrusive Dental Pearl I’m giving you is a communication one. And it is this, it’s something that Ed McClaren taught me at the Tubules Congress as he was lecturing, when you have a patient who has a crowding, and you want to convince them to have some orthodontics because you think that by prepping for veneers, you will be too aggressive and you’re in root canal territory, which you never want to be you know, you never want to be in dentine for your veneers. So to get the point across a really good communication tip that Ed McClaren shared was you tell the patient, you don’t say Oh, I have to remove this part of the tooth. You say I don’t want to have to remove your healthy body parts to be able to achieve this goal. I don’t want to remove these healthy body parts. What’s a great way to communicate that? So I just wanted to pass it on to you and it’s really tongue in cheek in this episode, because you’re thinking okay, Jaz, you’re being really cheeky here because we’re talking about equilibration. But actually the other way to think about equilibration so it just ties in nicely is that there are some dentists who think that ‘Oh, I’m not going to do equilibration because I don’t believe in equilibration but I will prepare the 28 crowns, what’s going to be less invasive? An equilibration to get some balance or to get the “correct bite”, or 28 crown preps? So just think about where an equilibration come in. And sometimes equilibration is like partial equilibration. So you’re doing partly additive on one side, maybe and you’re equilibrating just a little bit so the overall you’re having to place less restrictions, but you know, this is everything that we’re gonna talk about with Koray Feran in terms of the workflow, the protocols, the whys, the why nots so hope you enjoy this episode. And yes, we have Zak Kara again. So you know, it’s gonna be a fun one. I’ll catch you in the outro.

Main Interview: [Jaz]
Koray Feran and Zak Kara, welcome back to the Protrusive Dental podcast. I hope you both well. Today we’re talking about equilibration and I just want to do a little bit of introduction for you Koray before you take it away. I’ve said this before on this podcast maybe two or three times now, but when I was in DF1 it was 2013 November, I think. And you did a lecture, I still remember the title of it is called excellence in restorative dentistry. And that two hour lecture you did was such a huge inspiring moment in my career that I just didn’t know you could practice like that at all like coming from like a dental school and then early on DF1, that was a huge needle mover for me. So it’s an absolute honor to have you on today. For those very few people because you are global, my friend, you are global, you’re well versed with the BARD and also European societies. And I know I think you’ve done some work in with Megan as well as that they’re pretty International. So please tell us a bit about yourself for those listening all around the world.

[Koray]
Okay, so I’m a general dental practitioner, I haven’t got a specialty. I did Perio Msc, but I’ve been restorative and implants and everything related. For me, generalism is a specialty. Because I think the kind of patients that I have seen over the years, don’t come in neat packages, they come with a whole host of problems. And unless you know how to put all them together and diagnose them and put them on, you know, the treatment together, you come across. And the thing I’ve learned is, as I’ve been a GDP or you know, all this time, I might be known for implants, but I’m actually probably getting more better known for treatment planning, we’re doing something big with Tubules, as well, with regards to treatment planning and consent and communication. But for me, today’s topic is an integral part of dentistry. And I think it’s not very well taught. And it’s really not something I was into or understood in the first decade of my practicing career either. So I’m now principal of a four surgery practice in the West End, I’ve been on the West End for close to 20 years. And you kind of gradually make mistakes, everyone makes mistakes, everyone misses stuff. And my practicing protocol is basically the case of the rule of incremental improvement is every time we do something wrong, you learn from it, and you make sure you’re incorporated into your next bit of protocol, which makes me really anal. And it makes me really [Zak] Surely not [Koray] It’s just a bit OCD, but it means the people who come to it fresh, sometimes find it overwhelming, you know, sure as Khan has joined me a year and a bit ago, and when he sort of first arrived he sort of said, ‘I get this. I get this. I guess but this isn’t you’ and he’s gradually sort of come to me says like, ‘Okay, what do I do here then?’ It’s like, ‘Well, you know, you’ve done all the right things, then all you got to do is this.’ I was like, ‘Okay, I get it.’ Okay, so as you learn gradually as you make the mistakes, which are often expensive, not just financially but reputationally, and relationship wise on patients, you learn to work in a certain way where you don’t leave any holes in the safety net. And that’s kind of probably what I’m known for more than anything I don’t cut corners.

[Jaz]
I can definitely vouch for that after having shadowed you and seeing you do a sinus lift at that time, I was very newly qualified dentists. So I mean, if I had a been an implant based dentist, done some sinus lifts, what you were doing was gold I’m sure but for me just being in your presence and the way you communicated and just your, the way you work 6-handed Dentistry that was something cool to see. I never seen that before. That was amazing. Zak, Welcome back to the podcast, my friend always welcome guests. Tell us, Zak, before we actually pick Koray’s brain, have you had much experience with this dark art of equilirations?

[Zak]
So some of my backstory, my historic stuff in dentistry comes from the Pankey Institute in Miami in Florida. And actually, you know, along those lines, I’ve got a real interesting question for you, Koray. And both of you actually, because both of you are proper occlusion. That’s right. Kois’ really, really interesting. And I’ve shattered Kois as well. By the way, this isn’t some sort of plug for just keep knocking on Kois. I’m sure he doesn’t just want to be watched everyday. 300 emails about to land in your inbox. However, just to say, you hit the nail on the head with something a second ago you said that generalist, being a generalist is a specialty of its own. I think that’s beautiful. Why is it then that both of you have drawn yourselves to occlusion? Why does that seem to be some sort of key to becoming a generalist who really gets it? A comprehensive thinking, generalist. Why does that matter so much?

[Koray]
Well, for me, it’s a little bit like if you’re going to build a block of flats, you just got to make sure the ground is level, right? So equilibration and occlusion isn’t a dark art. It’s a set of very simple basic diagnostic steps. That if you get right will mean that your dentistry is much simpler and much more predictable, and if you get wrong, can be a nightmare. So all it is, is it’s just checking that, you know, a lot of dentist think about teeth. But really what you need to think about is the dynamics of how those teeth relate to each other statically and in function. And that, to me is occlusion. But it’s a combination not only of tooth positions and tooth contacts, but it’s also about where your temporomandibular joint is, where your discs are, how stable it is, how the muscles are acting on them, how the patient is adapting to those relationships. So it’s actually just a chain of you’re looking for the right things. And once you’ve seen them, and once you understand what those signs and symptoms mean, you start your restorative dentistry in a much safer position. So essentially, it’s just leveling the playing field before you start building. That’s all it is. It’s nothing. It’s not a dark art. It’s just good anatomy good physiology, good dentistry.

[Jaz]
But the reason I call it a dark art at beginning, equilibration is twofold, okay? One is a lecture attended by Professor Richard Ibbetson. I believe his name is at the BDA and he literally poo pooed it, he said I haven’t done any equilibrations in 1984 and he was like this is a mumbo jumbo stuff and it’s really teeth fiddler need to stop, that was his sort of thing. And then in my hospital years in restorative both at Guys and at Sheffield and I’m happy to be challenging this but I’m pretty sure very few of those many consultants like 20 plus consultants have ever even done an equilibration, so why there’s something about the UK and UK-trained dentistry and certainly the restorative consults who are friends of mine, dear friends of mine, they don’t practice equilibration, have never done it so they’re obviously somehow work their way around it or whatever but maybe they are approaching it just in a complete different way. So let’s go back to the very beginnings what, how would you define as an equilibration? And then let’s just go from there and then we’ll get Zak’s input what Pankey perhaps for him

[Koray]
Okay, so my first thing is that the tooth Fiddler reference, you shouldn’t be tooth fiddling. Okay? Equilibration is should be something done quite precisely. Okay, my first Golden Rule, equilibration should not be done in somebody that has an unstable temporomandibular joint relationship. If you have TMJ disease, you diagnose what that disease is, you diagnosed clinically, if necessary, mean you if necessary, if you take an MRI, if there is a disc issue, if there’s a disc displacement, if there is protracted muscular problems, you have to resolve that first and that’s the other dark art of deprogramming of using splints and stents. And when do you use what design of stent and splint you know, I only use anterior deprogram as well, okay, you probably not doing your serve patients the best service then. ‘I only use this, I only use that.’ No, if you make a diagnosis is where your TMJs are, what your discs are doing, if you’re not sure, then MRI them, I think we’re under utilizing MRI, we had a very interesting chap called Kevin Lotzof lecturing with us on our recent TMJ course, he’s probably the preeminent guy who understands not only how to take a proper open and closed TMJ MRI, but how to decipher what’s going on. And he’s actually saying, guys, you’re under utilizing icy stuff every day that you guys are missing, and you are building your dentistry on unstable foundations. So the first thing is are the TMJs functioning correctly? Are your discs in a reproducible or stable position? And is the new musculature that controls your joint movements and your jaw movements? Healthy. If it is, okay, then you diagnose where your occlusal problems are. And then you decide whether you need to equilibrate, whether the patient is already adapting it is, it’s an occlusal premature contact, does it have to be equilibrated? Or has the patient adapted? If you don’t diagnose it, then you don’t know what you’re treating. And you find that out when you start the treatment dentally and you suddenly find that your jaw relationships change, or the patient can’t tolerate what you’ve put in, or things start breaking for no apparent reason. And when you’ve lived it, you understand. So then you have to trace your way back and say, ‘Well, why is this happening?’ So for me, equilibration is a tool to level your ground before you start, but the TMJ diagnosis must come first. You don’t equilibrate until you’ve made a TMJ diagnosis and a functional diagnosis.

[Zak]
Can you elaborate a little further on the assessment side of things, but specifically you said neuromusculature, this is something that’s sounds very specific, but actually in reality, you hear about different methods of diagnosis, including all sorts of things including, you need to get a stethoscope out, you need to get all sorts of stuff that’s going to help you in different ways, and I think would that becomes, that becomes one of the barriers to entry to this seemingly dark art which is not that dark and art actually, because you’re absolutely, Would you agree with that, Koray? You made a face there as if you’re not sure.

[Koray]
I think the stethoscope might be overkill though I can understand why people might say I can use a stethoscope, you know the best telescope we’ve got really is just the pads of our fingers. And if you actually just get a patient to open and close and jiggle their jaw, you can see exactly what that joint head is doing or not doing. Sometimes it moves cleanly and it moves back, there’s no noise. Sometimes one side moves, the other side doesn’t. Sometimes it rotates, but it doesn’t move. Sometimes it locks, sometimes it opens but it can’t close. All of those are diagnostic. And there are five stages generally of TMJ disease from healthy, mild problem, more advanced problem, more advanced problem and joint totally buggered. And the question is [Zak] Did you read that on your notes? [Koray] Yes, dude. I mean, as a pointing fact, I’ve just got a patient at the moment and literally, I’ve just had an MRI before we came back. With diagnose, she’s got a vascular necrosis of the entire condyle, there’s no blood supply to it, it’s just black, you look on an MRI, it’s gone, it’s not there. And you know, and yet, if you don’t take an MRI, you won’t see this her disc is, you know, relatively normal position. So the, what I’m trying to say is that that is in its in a start diagnosing where the disc is, and what the likely cause of that is now it could be an injury, it could be occlusally related. It could be accompanied by muscular dysfunction, so the mandible can’t open very wide, it can’t go to one side, very wide, patient gets pain, there’s a whole routine, I mean, we run a whole two day occlusion course. And there’s a whole list of things that you look for, you know, they’re not multi, you know, they’re not hundreds of things, but there’s, you know, 5 to 10 things that you really need to have a look at. And then when you put all those together, and if you know if this is positive, this is positive, this is negative, this is negative, then you come to a diagnosis. And then from that diagnosis, you say, well, is the cause occlusal? you know, is the patient has the patient got muscular symptoms, and difficulty opening on pain because they’ve got a premature contact somewhere? Well, How’d you find that out, you put in a deprogrammer, you get rid of the contact, if the pain goes, and then when you take the deprogrammer out, the pain comes back, it’s a pretty good chance that it’s going to be occlusal. But you then still have to make sure that the TMJ is healthy, and the muscular spasm is gone. And the jaw could be put into a centric relation and the discs in the right place before you decide what to equilibrate. And if an equilibration is required, and it’s all step by step, there’s no magic to it, it’s just have I got the information. And this is like anything, if you if every single one of us had exactly the same information from a patient. In other words, you know, if adequate time is spent looking, recording and diagnosing and thinking, we should all come up with the same diagnosis, we may all have different treatment plans, but the diagnosis should be the same. Okay? 10 dentists don’t come up with the same diagnosis, then either there is inadequate information, or there is inadequate knowledge. Okay, so for me, if like if I know what’s going on with TMJs, and it looks like there’s a tooth involved, that’s a problem, or a patient comes in with me and says, Look, my front tooth keeps falling out, can you make a stronger post, and the dentist goes Yeah, I can, I can drill a bigger hole, I can put a bigger post in and what happens is that falls out too or the tooth starts drifting, or the root fractures, it’s nothing to do with the post, it’s got to do with how the occlusion is. So unless you diagnose all of these and see all of these, you’re gonna end up doing, not doing the patient the best service. Equilibration is one bit of the pie it’s a tool. It’s not a magical process. It’s to resolve a situation that you’ve diagnosed. It’s a resolver problem.

[Zak]
I can imagine so many people driving their car right now or chopping the onions or doing their gardening or whatever they’re doing listening to this thinking Ah, that’ll be why the front tooth, Do you know there comes a point in everyone’s career doesn’t it, you know that tipping point between I didn’t know what I didn’t know and oh my goodness, that must be why. Because a lot of times in dentistry, particularly as an undergraduate taught restoratively and you’re taught procedures on you. And you’re taught that if you miss that particularly important step in the bonding of this very technique sensitive system. If you get that wrong, then you must have done something wrong. But actually, we don’t think about the bigger picture enough for you until you become more comprehensively minded and usually through failure of your own. You stop looking at a single tooth and you start looking multi tooth in a segment or in an arch or in a quadrant but then you start looking whole mouth and go Crap I got to look around the mouth now. I’ve got to look at the jaw joints and their ligaments and I go. Look at my human in front of me, how about the shape of their face?

[Koray]
Just give him a bit of chewing gum and chew, sit in front of them and see what their jaw does. You know, people said ‘Oh, how should I restore this upper premolar when the palatal cusp was fractured off?, Oh it should be done in gold, Oh no, it should be done an amalgam, Oh no it should be done in composite. No. What should we done as you look at the contralateral canine first to see if the guidance has worn away and that’s why that tooth is, has got you know, it’s got an interference in the occlusion that’s why I fractured. You know, if the guidance isn’t correct, then whatever material you put in there is going to break or wear

[Zak]
Yep. And then you go Okay, so why would you restore the canine at that particular angle? Well, you need to look at the contralateral [Koray] condylar angle Right. [Zak] The thing is, Isn’t this thing brilliant when you think about the whole picture?

[Koray]
When you put it all together, it’s really not that difficult. It’s, I mean, it’s like you don’t you take a bite wing and you see caries, and you put a probe on it, and it’s soft, and it’s brown. And there you go, it’s caries. You know, you stick a probe into a pocket and it’s nine millimeters and pus comes out, that’s perio disease. It’s the same thing with occlusion, if you don’t look for the signs, you’re not going to diagnose the disease. And occlusal diagnosis is just as important as caries and periodontal disease.

[Jaz]
With you mentioning that the equilibration is a tool. What are the, what is the end goal? So let’s talk about what are a few example scenarios where you think, okay, here’s my diagnosis. Therefore, as part of their management, one step of their process will be equilibration. Now, what is it that you’re trying to achieve with that equilibration? And what alternatives could there be? Or adjunctive therapies that you could have as part of the equilibration?

[Koray]
Perfect, good. All right, great question. So the first question is, what are we actually trying to achieve? What we’re trying to achieve is comfort and health and stability. All right, you can have patience with all sorts of malocclusions. Okay, I have a clicky jaw. But I’ve had a clicky jaw for 30 years. And my dentition isn’t deteriorating, I’m not fracturing bits of. I’m not in pain, and I can function, Do I need to be equilibrated? I have premature contacts and a slide on my premolars. I don’t. Because they’re not in the way of my function. Alright? So I have occlusal disease, but it’s not destructive occlusal disease, I have to diagnose it, I have to show the patient and I have to then say to them, it probably doesn’t need treating, as long as you know about it. But if somebody comes into me says, look, you know, I had a root filled tooth up here that broke and then I’ve got another root filled down here that’s broken as well and now my front tooth here is broken and ever since that broke my left joints been really painful. I’ve got you know, I have a patient who has occlusal disease just the same way as a patient who has periodontal disease with caries, that person has not got a stable occlusion. So the ultimate aim of any occlusal diagnosis and procedure or source of work is to ensure that the temporomandibular joints sit in a stable position where they’re not doing damage to the discs with a disc sign in a stable position on the condyles, you want the condyle to be on the disc, not on one edge of it, not off it, you want it on the disc, you want it to move with the disc, and you want the muscles around the joint to all move harmoniously without giving pain and allowing full functional movement. That’s the end result. Now, if what is preventing that is a dental contact, then equilibration is to eliminate that dental contact in a controlled fashion. So you do it on models first with the patient articulated in centric relation. And you look at what happens if you adjust that contact. If you adjust that contact, then another contact is going to need adjusting and then another and then another and then another. And equilibration is seeing which contacts, which tooth contacts need to be adjusted to allow the condyles to fully seat, for the occlusion to be then fully stable without interferences in any dynamic position. Now, to be able to do that, you have to get the patient into centric relation reproducibly. If you can’t do that, you have to use a deprogrammer first. The deprogrammer will have two effects, it will relax the musculature and allowed mandibular repositioning. But it also diagnosed whether the problem is occlusal. It could be traumatic, somebody might have fallen off their bite. Somebody might have got into a fight. Some people you know might have just had their jaw held open too long when they’re having their wisdom teeth out. If it’s traumatic, it has a different diagnosis, it’s a traumatic temporomandibular joint disorder. But if it’s occlusal, the equilibration is to eliminate the problem that is causing the dysfunction. That’s all it is.

[Zak]
One of Jaz’s favorite catchphrases at the moment, by the way is can we make this a little more tangible? Can we make this tangible, Koray? I just want to slow this down for some people who might be listening to this and I love how fluidly by the way that you talk about this. This is obviously in your heart and soul is like part of using it and I love listening to a lot yeah, you can just tell right away and you can tell the passion that Koray has about his subjects, which is brilliant. The thing that I’ve found in my first two or three years out of university, is that I didn’t because I hadn’t had enough experience in seeing enough hundreds and thousands of mouths yet. I hadn’t been there and done that and seeing the negative end results of if you don’t catch these things early enough. So can we make it a little more tangible? What happens if let’s say, we’ve got a premature contact on a tip to lower pre molar, which is not axially loaded. And you can see other signs of tooth surface loss elsewhere. And you can see that this person potentially has a heavy set mandible, let’s say big, strong masseter muscles and all the rest of it. What are you thinking?

[Koray]
Okay, first of all, before we do, I mean, when a patient comes in for a consultation with me, you know, they fill out a whole load of paperwork, which, you know, is very onerous. And they, you know, they fill out the medical history

[Zak]
Very onerous, by the way you choose. But isn’t that also just a subtle thing? By the way? Isn’t that also on purpose? Because you’re trying to select an audience for a reason?

[Koray]
I want somebody to realize that we’re asking questions for a reason. So they come in, and we sit for the first 10 or 15 minutes, just get to know them. What can we do for you? Why are you here? How did you get here? You know, what do you hope for us to achieve today? The first thing I do clinically, I obviously sit, I sit them up, and I look at them whole symmetrically, the first thing I do is I stand behind them. And palpate everything. I put my fingers on their TMJ. And I say can you open as wide as you can for me, and I look to see what the mandible and the condyles do, and you can shut your eyes and do it because you can feel the way the condyles move, or don’t move. You can see which way the mandible deviates, you can see if one side moves better or worse than the other. Now the next thing I do before the patient gets tired, I lie them fully back. So I tell them, I’m gonna lie you almost tilt your head down. I lie them fully back, I extend, I adjust the headrest, so that I can extend their neck right back, making sure they don’t have any ankylosing spondylitis or neck problems that prevent this, obviously, medical history. But as long as I just tell them, are you okay, lie back, are you okay lying flat? And tell them I’m going to extend your head as much as possible, I didn’t get them to almost just kind of look, you know, try to almost arch their neck, I ask them to get open a little, just a little, I then get them to roll the tip of their tongue to the back of the roof of their mouth. And I get them to slowly close and I say, Where do you first hit Left or right? And they say, right or left they point. So then get a piece of articulating paper in millers forceps, dry the teeth, and getting to repeat it, just tap, tap, tap it. And the first photograph of the patient we take is that single point of contact where they hit that is their centric relation contact position, or whatever you want to call it, since

[Jaz]
That’s my preferred term as well as CRCP

[Koray]
Centric Relation. So is the first contact point in the centric relation. In other words, their, mandible origin. Now, here’s where the first point of diagnosis is, can they actually get into centric relation? If you ask them to tip their head back, roll their tongue back, and their mandible is out here. And they can’t get back. I already know I have a muscular problem. That person, the first thing I’m thinking is this person is going to need some deprogramming, okay? Now, but if they can get into centric relation, and I have the same dot on two separate attempts, that’s my CRCP. I record it photographically on every patient. At the same time, what I record is in that point of contact, I record the incisal relationship. And then I ask them to clench together until they’re fully in intercuspation. So centric occlusion, or maximum intercuspation, or ICP or position, or whatever you call it. And I then see what the mandible does, and where it slips to. So I have two photographs, one with them slightly open and one with them close. And that’s the difference between your CRCP and your CO.

[Zak]
Can I just say if you’re listening to this, rewind, rewind, rewind or listen to the last five minutes, 20 times, go and listen to it 20 times that is gold.

[Koray]
That slide is going to, if you don’t diagnose it, it’s going to be the bane of your life. If you’re doing something extensive on that patient.

[Jaz]
I just want to put the context for those listening correct is they have to understand that you are treating patients who are often being referred to you or self referred, and they’re not coming in for that denplan check with you, right, they’re coming for a thorough assessment. It can be done quickly, but this I want people to understand that what you’re doing is I know you’re not specialist but you do is very specialist in nature. And you’re treating full mouth, very comprehensively. And that is the cornerstone, the very foundation of it. So a young dentist who’s a few years out being 10 minute checkups. Yes, it might not be part of your protocol, but you need to know when it should be protocol if you’re doing anything more ambitious, full mouth, and that’s the kind of time you definitely want be checking because just like you’ve said,

[Zak]
Jaz, I’m gonna counterbalance that. And always like always, yeah.

[Jaz]
I’m not saying always. I’m saying if you’re doing big full mouth dentistry, then I think that’s where you begin? [overlapping conversation] [Koray]
I think this is something I would actually slightly disagree with. I think you need to do it on every patient.

[Jaz]
You should. But that dentist 10 minutes examination, they’ve got their BPE, the jackets got be taken off by Mrs. Smith. By time she walks in sit downs. I’m just trying to make it real world for the majority of clinicians.

[Koray]
Then you come to the other bit of the philosophy. Why is your consultation 10 minutes?

[Jaz]
Oh, 100%. No, I’m with you there. I’m with you there hallway. Everyone deserves a comprehensive exam. I’m totally with you in there.

[Koray]
Here’s the issue. If I take a photograph of a patient who’s got an MOD restoration on an upper four, and that first point of contact is on the palatal cusp, and I don’t see it, I don’t record it. And I don’t tell them. And three weeks later, they come in with that cusp fractured, whose fault is it? [Jaz] Absolutely.

[Zak]
Well, you can wiggle your way out of it in several ways. It was probably, it was probably the Rolling Stone everyone [Jaz] It was a soft bread. It was a soft bread [Zak] Soft bread cheese sandwich.

[Koray]
No, he came up with the soft bread that he broke while you were grinding on it [Zak ] You’re absolutely right. [Koray] So you don’t diagnose that. To me, that’s as big a miss as missing caries into the pulp. It’s a diagnosis of occlusal disease and instead of seeing as occlusion as a peripheral thing, we have to see occlusion as a fundamental part of the examination. Now, if you spot it, and you tell the patient is they look really what we need to do is get some occlusal Records. See what would happen if we equilibrated you and then once you’ve equilibrated you take the load off that cusp, you may prevent a fracture just by doing and invariably what happens is patients who aren’t even aware that they’ve got an occlusal interference, once you go through the procedure which is completely non invasive, by the way you you take records, you take centric relation records, you put them on an articulator, you do it on the articulator first, you show them what the adjustment requires, they then consent or not. Okay? It consent to it and you adjust them. They will almost 99.9% of the time say, Blimey that feels so much more comfortable. They didn’t know they were uncomfortable, right? Now I’m not saying every patient needs a equilibration but if you see a premature contact causing damage, crack lines, history of a fractured cusp, TMJ, muscular problems, displacement of the joint when they’re occluding. You have to tell them. If you don’t spot it, it’s a missed or a maldiagnosis or misdiagnosis

[Jaz]
I like that example. I like the example you gave cuz I think that makes it very tangible with premolars, that was a fantastic example I think. Zak, you’re challenging me, Zak, I said so that busy guy with 10 minute checkup that he can’t be, he or she can’t be doing in the real world, the bigger problem is why are they doing 10 minute checkup? Now I’m completely appreciate that.

[Zak]
No. We’ve covered this previously, right? We it’s all about designing your own life. If you’re in a scenario where you’re listening to a podcast of this type of nature, well actually you’re clearly interested in something along the lines of advancing your career or learning more about what’s out there in your working world. You’re not just sitting listening to the same nonsense at lunchtime with you around some, around the normal people you do.

[Koray]
Let’s rewind a little bit. You say your 10 minute checkup. This shouldn’t be spotted at a checkup. This should be spotted at an initial consultation.

[Jaz]
Comprehensive Exam. No, this is so true.

[Zak]
And so what you plant in this as the seeds of thoughts in the minds of our patient base becomes your working world becomes your own destiny. What you’ve then done is you’ve designed yourself a future where you’re gonna have a diary filled with emergencies. Now, Koray, can I just put something to you? I’m sure during complicated rehabilitations and work that you do, full mouth comprehensive dentistry, once in a while something will happen, something will debond or something as a temporary that was intended to come off at some point will come off and it needs to be receipted but how often is it that you have somebody who has let’s say completed their all encompassing course of treatment whose mounds fail?

[Koray]
Luckily it’s rare. I couldn’t afford it to fail regularly but we do get them, we do get enamel chip, you know we do get chips, we get porcelain chips just like everybody else’s. You reconstruct somebody top and bottom in ceramic, you’d get it i’m not saying we don’t.

[Zak]
Do you have a diary space every day allocated for one, two, three people’s teeth bust? [Koray ] Absolutely not. [Zak] You don’t need it right? And so if you’re listening to this thinking, Oh no, that’s normal to me. I always have something squeezed in that something happened where something happened. Well ask yourself why you don’t like [Jaz] Get the GIC out [Zak] It’s plastic, isn’t it? But it’s self perpetuating the problem, Jaz isn’t it? Because as soon as you start slapping Fuji 9 on everything, then everything becomes a Fuji 9 and then you do single tooth dentistry. No wonder

[Jaz]
The nurses got it ready with every emergency that the trays have been set up for it, right? And I’ve joined a practice now where the dentist for, bless his heart he’s just retired, amazing dentist, great at diagnosing caries, great diagnosing perio but not having those discussion about wear, mobility, fremitus, crack lines, so missing the whole occlusal disease element and now I’m coming in, I’m having those you know, this practice went from doing zero deprogrammers to like several factors of them and having those bigger mouth discussions and now converting these cases to go more comprehensive dentistry. But that is exactly we have these emergency spaces in everyday and most common emergency we get is a broken tooth, a cusp fracture. And it goes back to what Koray says you need to examine that at the initial consult, not a terminal examination. But Zak, when I did suggest that, Hey, if you are that dentist who’s has to pick and choose who you can and can’t, unfortunately, give a comprehensive exam to and you’re going to be now treating someone like a young dentist, typically their foray into or their entrance into treating bigger cases would be a dahl technique, okay? Whether you love it or hate it, I truly believe that the young dentist in the UK, when they’re starting to think bigger, they’re taught the dahl technique. That’s the thing that they’re all undergrads are taught. And that’s what they might do. Now, even in that case, you still need to check your centric relation contact point. But Zak, you were saying perhaps that’s not necessary, right?

[Zak]
Well, no, no, I was, you were making the point that your CRCP isn’t always possible within a 10 minute checkup. So when we said that CRCP can be identified for everybody. I completely agree that that is actually a cornerstone of identifying the things that can go wrong. And it’s usually for me, a start point in a conversation about how things can progress inside people’s mouths. So one of the problems with every single unique individual, individual that you look after, is they don’t have the benefit of the all encompassing nature of the general public’s mouths that we’ve seen. They haven’t seen the way that mouths progress over the course of people’s lives. They haven’t seen the 20 year 30 year 40 year saga that I’m in unfolds before us. Now you don’t have to be and by the way, it’s encouraged definitely that, that you stick around in one practice for several years, because seeing your failures and seeing the way things go wrong is ultimately the best learning method, right? But you can see people in your patient base even within a year period, let’s say who were in their 20s, their 30s, their 40s, their 50s. Put your Sherlock Holmes hat on and ask yourself, let’s be a detective today. Why did that person in their 60s, end up that way? Now let’s find somebody in their 20s who might be going that way. And let’s see if we can identify that pattern spotting and dentistry for me is quite a lot of pattern spotting. You spot these things all day, every day that you there aren’t that many variables in the head and neck and mouth. There’s quite a few but there’s not as many in the whole body as in the whole body. We’ve got to be doing as looking and using your eyes and one of the best things that you taught me, Koray, is that you need screens. So I have so many screens in my office now I was

[Jaz]
Overboard.

[Zak]
I mean, for me, I now have a 34 inch ultra wide and I have a 27 on top of it and I’m like that’s about as far as it goes as far as my missus will take let me take it but the fact for me is if you see stuff because you’ve taken the time to take that photo to step back to look at the big picture and discover exactly what’s happening. You focus proper attention on people and I tell you it comes back to pay you dividends that’s fine.

[Koray]
That was going to be my next point I said the person that you can’t afford the time to spot this is the person that you’re going to spend hours on sorting out later. Spend 15 minutes diagnosing it and save yourself 10 hours, seriously. You know the caries, I’ve just busted the lingual cusp off my lower 7, Oh we’ll just do it online for that Mrs. Jones. Come in, do the prep, turn back, no space. Come back to suddenly you have no occlusal height left. Oh, and now there’s an anterior open bite. What? What happened? What happened was you didn’t diagnose the CRCP was on that seven. And as a result of that instead of equilibrating everything first and then coming to restore the tooth. You then have already launched into restoring the tooth and then have to equilibrate everything in retrospect as an excuse

[Jaz]
Or Koray having that discussion with them that actually orthodontics might be needed here before you then do it and then suggest the orthodontic space and then yeah 100% when I learned that and I started to use a leaf gauge to screen for these things and whatnot or whatever tool you want to use and your way, Koray, I haven’t heard of that way before, that’s amazing about their posture and you described it really well and how quick and easy you made it. That is so that’s how you can do it in maybe 10 minutes but my argument, Zak, was busy clinicians who are based on single tooth dentistry. They will not see the value of it yet until this

[Koray]
It takes 60 seconds. Doesn’t take 10 minutes, take 60 and also, I find that I’m not a big fan of manipulation [inaudible] Well, people just push it out. If you can, if you’ve got relaxed TMJs, you can get back yourself. So to me, letting the patient do themselves just by posture and tongue rolling, for me is still the best way of seeing whether they can achieve CRCP. We try to

[Zak]
For everybody else you basically saying every other time that, that’s not possible or not reproducible, then there’s a muscular issue and you’re going to be deprogramming.

[Koray]
Basically, that’s the flowchart. Correct.

[Zak]
Jaz, the designing your own life thing really comes into this comprehensive minded dentistry, doesn’t it? We’ve talked about it previously and equilibrating. And maybe you know, there may be aspects of some people listening to this thinking, equilibration is just drilling bits off teeth, isn’t it? Well, you hit another nail on head a second ago, which is that orthodontics can be a huge part of what we do. And so it’s very possible to really just step back from the average single tooth dentistry mindset for a minute and listen, because this stuff is, there’s more to it. Then I’m just gonna tickle and fiddle about with a few teeth. And I’ve heard that that’s a dark art on that what will go on.

[Koray]
How many orthodontists use articulators?

[Jaz]
The face group, two in the UK.

[Zak]
There are many orthodontists who think they do but then when you ask them, ‘Do you know how what happens if you can’t reproduce that position? Or what happens if you’ve got a particular let’s say a brachyfacial type of patients, somebody with very strong masseters and somebody who’s obviously going to resist manipulation’ ‘I will just use a leaf gauge.’ ‘Well, what happens if you push back onto retrodiscal tissue?’ ‘Well, no, that will be fine.’ And so people think they’re doing things, exactly. What happens next? So this is the thing until you become an all encompassing comprehensive minded dentist, no matter if you’re in one specialism or another, you’re not really doing all of your patient base the best service in my opinion.

[Koray]
I mean orthodontics has been called full mouth rehab with teeth [Jaz] in enamel. [Koray] So basically, if you moving teeth around, you got to make sure they mesh together your teeth to settle in, if you like, but you need to have healthy TMJs for that to happen. And you need to have a decent relationship between your final arch and yes, you will get micro movements and things settling in and over erupting a little bit and tilting a little bit yeah. You know, you need a really good orthodontics for me is 80-20. It’s it takes 20% of the time to gauge the result. But the real tweaking occurs at the end. And that’s very, very difficult and most orthodontists and most patients lose the patients at the end to carry on and get the tweaks right. For me, if ever I refer somebody to an orthodontist I work with Moira Wong and Asif Chattoo. The patients know that at the end of their orthodontics, they’re going to come back and have a full occlusal analysis and equilibration, that’s part of it. The orthodontics doesn’t end when the braces come off. So for me, that’s part and parcel. Now, they may need a equilibration? They may not need equilibration, the level of a equilibration may be such that it’s actually better to do additive. So this is where the diagnosis comes in. If you find that your equilibration, you know, chops everything off every tooth to get the mandible in the right position, then the correct solution is to raise the vertical dimension and add not take away. So it’s not chopping bits of teeth. It is repositioning teeth and it has to be made very clear to the patient equilibration does involve the irreversible destruction of some enamel [Jaz] And you say that you use the word destruction [Koray] I use destruction. I’m gonna remove parts of the enamel of your teeth [inaudible] back but it’s being done with a diagnose, the diagnosis and a therapeutic goal and is to prevent bigger problems in the future. And basically instead of you spending years wearing the thing away and causing yourself TMJ problems, I’m going to do it for you in a way that allows you to settle and this is how much I need to do. And one of the things I do when I equilibrate is I have the equilibrated models and I photograph every step of my equilibration. So it’s literally this is where the contact is. This is what adjust, photograph [Zak] Of course he does.

[Jaz]
Do you still write in your notebook? You just tell me you used to write like this.

[Koray]
No. I just have a sequence of photographs. And I know where the dots are and I know wherever equilibrated and every single dot in the mouth during a equilibration must have a corresponding contact on the models if they diverged at any stage. I know the mandible has moved back and my initial record was not correct.

[Jaz]
Wow. So what you’re suggesting is that when you’re doing equilibration it actually, it is the beauty of it. What’s happened on the articulator is more or less happening in the mouth which is just the point of articulators, right? Which is amazing.

[Koray]
If your centric relation is correct. If your centric relation is out, you’ll find out very quickly because what’s in the mouth will not be what’s on the articulator and you will know at that stage that your equilibration was incorrect. Now even if the first point of contact was correct, it may be that there’s a slight rotation. And then the next point, the contact isn’t the same in the mouth. If that’s the case, then you deprogram them further, you then retake the lower impression against the upper, the record against the upper, rearticulate the lower cast, repeat the process. You have to be honest with yourself. If you’re good at what you do, if you get used to taking records and you see the reproducibility, it’s really rare, I need to do that. It’s maybe happens once a year. But I see between 50 and 70 new patients a year roughly, of those I would recommend, I would probably recommend between a third and a half, go through a full occlusal analysis, and at least a partial equilibration process. It doesn’t need to be much. It might be one tooth, it might be a couple of teeth. But invariably, when you do it, virtually all of them will immediately report that they’re more comfortable. They didn’t realize they were uncomfortable until they have it.

[Zak]
Koray, I just briefly add to that, is it also worth adding? What do you tell people? The main benefit of this is or what’s the risk of not doing this? Is it that you’re straight to the point and you explain that root fractures and mobile teeth and those types of things may be possible. Very good question. Future outcomes.

[Koray]
So basically, what I say to them is this dot is the stone in your shoe, okay? It’s the thing that stops your lower jaw from relating to your upper jaw, the way your muscles wanted to relate. Basically, it’s something that’s stopping your door closing properly. Now you can push the door, and it’ll be fine. You’ve got no TMJ symptoms, you’ve got no crack lines in the teeth. You know, you’ve got no drift in, no history of breakages. And you’ve been like this for 20 years, you probably don’t need to treat it. But if you do find that things start to deteriorate, I’m going to recommend a full occlusal analysis. Would you like to go through a full occlusal analysis to see and see what would happen if we adjusted this? You know, the risk is you can get a spontaneous tooth fracture, things can drift, things can crack. But you know, I will say actually, you’re probably pretty low risk or I’ll say, you know, what, can you see that crack line? And can you see that, that tooth has now started to wear and the one that was behind it was the one that you broke two years ago and had a crown? And now that crown is out of occlusion and this tube is taken abruptly. And then it’s important, I’ve got one lady at the moment who’s lost a tooth, keeps losing the crown on a lower six, can I just make a bigger crown for her? No, her centric relation when she closes her anterior open bite is five and a half mil. So it’s like she has a major, a major discrepancy in every axis, anteroposterior, transverse and vertical. She’s basically pivoting around her sevens. And, you know, you speak with a maxillofacial surgeons, well actually, this needs to be a forward rotation, not the full error, mandibular osteotomy. And yet, the patient is ‘I’m not having surgery on my jaw just for this, I just want to have this crown replaced.’ No, this is the diagnosis. And if I can replace your crown, and you will break it, or you will break the tooth, and then the next tooth and then the next tooth. But when they see it, they understand. It doesn’t always mean that they will go ahead with what you’re recommending. But they will understand why things are deteriorating, and then they’ll start working with you. As opposed to you having to give them an excuse as to why something’s failed.

[Zak]
That’s key. That’s absolutely key. I would love that door on hinge analogy in the stone in order something in the way the snack in the way and

[Koray]
Not be able to tolerate it. But it might be giving you back ache.

[Zak]
I specifically like the door on hinge analogy, because as soon as you start saying, Well, I can push the door closed, and I can really force it. But what might be I would probably at this point, if I was to sort of think through this, in my mind, I would probably expect somebody to push back. Or I’d ask somebody, what would you expect to happen next? And they go Well, you know, they’d be probably the hinge wouldn’t there, right? Okay, there is the hinge but where’s the hinge in the mouth? There. And that’s probably one of the most fragile and potentially damaging outcomes of this type of condition

[Jaz]
Of the most used joint in the body. And patients can relate to that very much and when you make it relatable to their daily issues, that chewing and their function, that’s how to get the patient on board. So these analogies were brilliant guys, I really appreciate. Now just want to pick on the nitty gritty details. Now we can’t explore every single indication in the scenario. And I would you know people ask me all the time, can you recommend an occlusion course. At the end, please do tell us where you teach Koray because you know I’m a big fan of your work and the amount of equilibrations you have done. I don’t know anyone in the UK who has done as many as that basically. So there’s that’s why I’m so excited to have you on today and learn these little details that you share. In that case with that premolar as we said that premolar of the first contact which may be at higher risk at fracturing. If you take that patient, you’ve taken their scan or your models, you’ve taken a Facebow record and I correct me if I’m wrong here, [Koray] Absolutely [Jaz] you mounted it on [Koray] you must [Jaz] of semi adjustable articulator

[Koray]
Just a semi adjustable articulator, you don’t need I mean we do run a two day occlusion course which you can find a LCI, the academy but the thing is you don’t need hugely advanced you know, you don’t need to look at lateral shifts and things like this, it just needs to be a status centric relation position is a skeletal position and it should be reproducible, it is reproducible if you get it correctly. And the key to this is to look at the anatomy not of the lateral pole of the joint or not the outside bits of the joint, but the inside, the medial aspects, because that’s actually where the anatomy doesn’t allow the condyle to move anywhere else. We look from the side you think Well, we know this condyle can be anywhere inside this socket. But actually when you look at the fact that it’s a football and it’s the medial aspect of your jaw joints, of the actual socket that guides where your mandible is, you can see what centric relation really means. And if you can reproduce centric relation, your equilibration should be a doddle way and once you’ve done it, that becomes your backstop that the mandible is stable there. You can then go forward laterally, you can decide what your guidance is going to be, you can decide where the interferences are if you need to add the teeth or adjust teeth. So the the equilibration is really just to get them into centric occlusion in a reproducible way. From there, you’re then going to look at their protrusion, you they’re going to look at their lateral excursions and you’re gonna look at their outside in and inside out function. So that’s another thing you know, we get people to bite on stuff and slide sideways. That’s not how people chew. Remembering if you slide sideways you’re using basically using medial pterygoid which is a slightly weaker muscle. When you’re closing and you’re grinding from the outside in using all of your major closing muscles, your temporalis and your masseter so the outside in force you apply to an occlusal guidance contact is higher than the one you use when you ask the patient to slide sideways. So always also test them from the outside and getting to chew on articulating paper and see the marks

[Jaz]
When you’re actually assessing those marks on the models and then you’re

[Koray]
I don’t do those on the models. I actually do the guidance in the mouth

[Jaz]
Yes but when you’re actually doing the trial equilibration on the models [Koray] Yes [Jaz] When you doing the trial and then you’re going to take that to the mouth. Now what are the fundamental rules of equilibration in the sense of where to adjust. So for example, what you don’t want to be doing is just hacking off cusps making everything flat, so how can you do it in a safe way anatomically driven way?

[Koray]
Slopes not tips. Slopes not tips. And which aspect of a slope you adjust will decide which direction of tip travels, okay? So if you’re in a cusp to cusp relationship and you don’t want to know which way to go, what basically what you do is you adjust one aspect of one cusp and the other aspect to the other and you get the tips to move in relation to each other without losing hunt. So slopes not tips is the primary one and the second one is go for the bigger cusp rather than the thinner cusp okay? So don’t overthin a narrow cusp take a little bit more of a thicker cusp. It’s the usual way it goes. But when you look in the mouth, you kind of gradually get a feel for where which aspect of the cusp is best to adjust. Depends where you want to move the tip, you would ideally want your cusp to meet in fossi and not on marginal ridges and not edge to edge and not tip to tip. So as he say well actually you know I’ve got this kind of relationship you know where do I adjust? I don’t want to adjust the tip I want to kind of adjust this aspect to this one that aspect of the other and then to mesh together. So it’s a little bit of thought but the general rule is adjust slopes not tips. That’s the main rule

[Jaz]
I did an equilibration this morning so it’s fresh in my head. What do you do and this is me in so at the very beginning stages and I’ll tell you the rationale of why I did an equilibration on my patient, I’ve down the moment but the thing I remember the most the biggest challenge I had was being confused or not confused but being a bit like whoa all these red marks and then having to rub away and then go again. So any hack you can give us? And obviously that if you’ve never done the equilibration before, go on a course and I don’t know many courses that teach equilibration so I would recommend Koray’s. At the time at the Dawson, I got taught by Dawson but I don’t know if that none of the other occlusion courses I’ve been on actually teach a equilibration so definitely check out Koray’s but how can you help us to be more clinically efficient with the marks because otherwise all you see is a sea of black and red.

[Koray]
Correct. So what I do is I actually get the laboratory to paint a very thin dye relief all over my occlusal surfaces and my incisal edges. So it’s, the models come back with a red surface, I then use a dark blue articulating paper, and I held it in my hand, I don’t actually hold it in millers forceps. And what I do is I just make sure the pin is up so that the pin isn’t stopping the teeth from coming down. So the pin has to be up. And then what you do is you just close and just give a little tug. Close, just give a little tug. It’ll either pull through or it won’t. Where it doesn’t pull through should be a bullseye, not a streak, not a mark. But a bull’s eye. The bull’s eye indicates that the cusp tip has gone through the paper and contacted. The bull’s eye is what you adjust, okay? And the bull’s eye on the model, the first one should correspond with your CRCP that you took your first consultation, or after deprogramming if you’ve had to deprogram first before you equilibrate. So the corresponding mark on the model should be exactly the same, then you will notice that when you pull, if it pulls through, ignore the marks. If it doesn’t pull through, and it’s bull’s eye, that’s your first one. And you should get to the point where eventually as you equilibrate the number of bull’s eyes, it gets more and more and more, until every contact has a bull’s eye, then you fully equilibrate. Now in the mouth, it’s interesting, you end up actually doing more on the casts normally. But in the mouth, you get there a little bit quicker, you don’t need to do all the fine control, because there’s a level of vertical movement, obviously within ligament of the tooth. So on the casts, you’ve got to account for the fact that they are totally immobile. And sometimes there’s a couple of false positives, but it’s actually a safe thing because you know, you end up actually doing less in the mouth than you do on the, on guard. Also, once a equilibrated, I think invariably you get a little bit of shift of mandible, it’s a little bit more relaxation that you maybe didn’t have with the deprogrammer, and I get them back in a couple of weeks later, and I just fine tune them and make sure they’re back.

[Jaz]
I was just gonna ask about that. What’s the protocol for afterwards?

[Koray]
Provided all the dots correspond to what you’ve got on the models. And then you just fine tune it and make sure and invariably and you must repolish things, don’t leave them rough. I do it with the red diamond, then I just go with some brownies or some greenies and just just polish the enamel.

[Zak]
Can we add a little bit more context for somebody who’s maybe never seen, maybe even never have definitely never done one of these equilibrations, but never even seen one of them happen. How do you guys make sure that, that person is in CRCP every time that they close together?

[Koray]
They have to be in CR, okay? So the same way where you do the equilibration with them lying back in the same position as you took the centric relation record, okay? And you got to make sure that when they touched teeth together, that you can feel that their mandible is doing this consistently not swinging around, okay? If they still not doing, if it’s still not in the right position, then [Zak] It’s still not deprogramed [Koray] You’re premature. You have to keep deprogram. Now with the deprogrammer, what you’ll find is if you make let’s say, a Michigan appliance, which is the most common one that I’d prefer to use, you’ll find that when you first fit the deprogrammer, as soon as you fit it, their muscle do a bit of relaxation during that appointment. And the first thing that happens is that, you fit the deprogrammer, and you immediately find that your heavier contacts are towards the back of the deprogrammer, and you do a little bit of adjustment there. And then when you get them in for a review, you find that it’s still heavy on the back and you do a little bit more adjustment. And then gradually what happens is the deprogrammer, you do more adjustment at the back than you do at the front and then everything stops moving, nothing else moves, it becomes stable, or the anteriors and the posteriors all hit at the same time. You fully deprogram, the have muscles of relaxed, the condyles have moved back. And they are now stable in their centric relation positions. There is no further movement backwards. And that then when you start getting even contacts on your deprogrammer with no more of the anteriors being lifted off slightly while the posterior is then you know that you’re fully seated. You know, from there, you can equilibrate. [Jaz] Have you seen an equilibration gone wrong, Koray? [Koray] By assuming the equilibration are wrong? No. I’ll tell you why. Because there are two things that can happen. The first thing that can happen is that your lower cast is not articulated properly, you’re unlikely to get your facebow record majorly wrong. You know, there are only two ears, you know, but you can sometimes find that when you’re taking the centric relation record, the patient posture slightly and you don’t quite get. So what you then find is that what you do on the models is completely unrepresentative of what you see in the mouth and you think this is wrong. So all I do there is I retake the records. Again, rearticulate the lower cast. Alright, it’s that simple. And then I come back. So that’s the first thing. So the first one is an error of recording before you do anything. Yes, it costs time and money to do it again. But that’s just the way it is. Once you do the equilibration on the models, you then look and see how much equilibration is required, okay? Now if you need an inordinate amount, don’t start. The correct procedure for that is probably additive. And to probably reconstruct an occlusion rather than adjusted away [Jaz] Plus or minus ortho [Koray] plus or minus ortho, plus or minus orthognathic surgery, sometimes. A big transverse relationship especially, but once you have seen on what you got it, you know, if you’ve got a reasonable amount of adjustment that you’ve done on the casts, and it’s totally reproducible at the mouth right down to the last dot, then invariably, the equilibration is successful, the patient is more comfortable, the occlusion is more stable. You would, but that’s the first starting point, that is where you get the maxillomandibular relationship stable. On there, you still have to check your protrusive and laterals and make sure that you’re not got any non working side or working side interferences. Then you have to play with your canine guidance, new insight or guidance and if you have got those and you still got interferences, then you may need to orthodontically move teeth or you may need to adjust posterior cuspal slopes as well. That’s slightly more advanced as you get on but the main thing is to get that maxillomandibular relationship stable so that if you adjust any tooth, if you do a crown prep on a tooth, it’s completely stable. What you start off with is what you end up with. So you don’t have any mandibular movement in relation. If you don’t diagnose it, and you start adjusting the tooth that is the first point of contact. It’s like starting an equilibration and not knowing where it’s gonna go.

[Jaz]
Zak, this is your cue for Am I naughty if? Zak’s ‘am I naughty if?’ So am I naughty if? And sometimes not just him. It’s just like he might be speaking the mind of a young dentist. Am I naughty if I do this?

[Zak]
I’m Baron on Am I naughty ifs for equilibration? Because Do you know what I think the thing that most people will have with this is a complete blank. They think, Jaz, that actually most people in dentistry in the UK will have kind of no real concept of this. Why does this not radar of most dentists, Koray?

[Koray]
I think it’s just not given sufficient. It’s just not given sufficient coverage, maybe in dental school.

[Jaz]
I think was not mentioned. Not the word of equilibration and all occlusion

[Koray]
When you get back to Richie Davidson and said, Oh, you know, I’ve never equilibrated anybody. Okay, I’m gonna I’m going to qualify that. It may be that he’s treating full mouth rehab cases where he’s doing all of his equilibration through restorative work. [Jaz] Yes. [Koray] Now, he’s getting his centric relation and then it’s what is it easily gold surfaces everywhere and gold palatals. And he’s done his equilibration by rehabilitation, [Zak] and you’ve equilibrated in temporaries at that point [Koray] but I bet my bottom dollar that he gets his central relation record right. Okay? But he can’t say to me if somebody’s got temporomandibular joint dysfunction, and their muscles aren’t working and they’ve got an immobile joint, and they’ve got pain on the other side, and they can’t open more than 25 millimeters, that you can restore that patient and they’re going to be comfortable. There was no way that’s going to happen. And anybody who says that that person doesn’t need occlusal analysis, and deprogramming and getting their neuromusculature and the TMJ is healthy before they go into a restoration. For me it’s irresponsible. I don’t believe them. I don’t believe them. I don’t think you can do it. If you want the lucky ones, but he won’t happen consistently.

[Jaz]
Yeah, absolutely. Well, I’m gonna ask this am I naughty if because I just want because I know the answer gonna get and I think a really important message to say safe is, am I naughty if I’ve got someone with occlusal trauma and some fremitus and I started just making some marks and I start drilling away to reduce the loads on these teeth with occlusal trauma.

[Koray]
Very naughty, very naughty.

[Jaz]
What is the correct protocol?

[Koray]
Because to two reasons, first of all, you have no idea where it’s going to end, okay? And you may find this somebody becomes much more uncomfortable. If you remove them from there, if you remove that reference point that they used to, and suddenly they can’t relate and suddenly, yes, their muscles might relax, but then they have no occlusion, because you know, I used to meet here. Now if you just adjust that and then suddenly you’re through the enamel, Ouch, that hurts. Equilibration should never be never go through the enamel, never. Okay? If the equilibration has to go through that enamel you finally have to chop a large amount of a tooth. You should consider orthodontics. Or you should consider additive reconstruction to the whole occlusion. You shouldn’t need to adjust three, four millimeters of a tooth. It’s ridiculous. Sometimes you might need to be heavy, you know you’ve got an over erupted upper seven that’s hitting the distal of a lower seven. And you might need to adjust quite a bit off the anterior plane of that tooth. Because intruding orthodontic is very difficult, you know, you can’t easily intrude a single posterior molar, you can put, you know, TADS, palatally and buccally and try to put elastics and things but actually, it’s not practical. So sometimes you do need to adjust quite a lot, you just have to say to the base, you know what, I actually need to remove four millimeters off this tooth and devitalize it about a two millimeter crown on it to get your occlusion correct. But if that’s the diagnosis you come to, it’s inescapable, you know, what, extract the tooth and put implant or you know, if you want to eliminate the contact, and that’s the only choice you have. That’s the diagnosis.

[Zak]
And actually, if they’ve decided on balance, that the negative potential consequence of not doing that outweighs the treatment itself, then that’s consensual, that’s an absolutely valid treatment.

[Koray]
They can say, I don’t want to have equilibration, I don’t want to have this, I don’t want you to do that. And then you say, okay, it’s fine. But I think that like the hinge principle, if you’ve got something in the way of the door, and you keep trying to slam it, you’re going to break something, it’s like, then I would recommend that you perpetually wear a night guard, then you make them a proper Michigan appliance that allows them into centric relation, but it’s been adjusted properly and so and then get a couple of duplicates made I mean with CAD CAM now you can just, you know, just get three of them made all identical [Jaz] milled [Koray] milled, or you know, and then just say, I really would recommend you wear this II don’t wear this, the chances are that you’re going to do something like this. Now 90% of the patients may never fracture their upper four. But the ones that do and they come back with a fractured, you say I did say and then you can play you know, smuggling like let’s do what I recommended the first time shall?

[Zak]
At that point, it becomes their responsibility at that point rather than [Koray] They’re fully entitled [Zak] That’s the really big deal. It’s not your excuse. At that point. It’s their responsibility

[Koray]
Exactly that. It is entirely down to their level of concern. If they don’t consent to you doing it, you can’t do it. What you can’t do is not diagnose it and then try to gloss it over when they come back and say you know, why did my tooth break? You know, why did mention? Breaking teeth is quite difficult. You need a lot of force.

[Jaz]
Well, you’ve answered all my questions, Koray. Zak, do you have any questions about equilibration?

[Zak]
I want to add one thing. I wanted to hasn’t if we were obviously enjoying ourselves, like Uber nerds on a Saturday night. I, you said something, right in the beginning of this podcast, which I think is golden, very, very important. By the way, there were segments of this that I’m not gonna listen back to myself and go tonight that you summarize that incredibly well there. Sometimes you just pick up those nuggets and gems where you go, I’m gonna Nick that I say this a lot, don’t I that we add these things to a patchwork quilt. And you’ve no doubt Koray become a product of some of your mentors and some of the things you’ve learned over the years and some of your colleagues, no doubt. You said something, incremental improvement. Incremental improvement to me is a progressive movement in the right direction. Let’s hope always for the progression of our careers, but your it also made me echo. I know a good friend of yours and a mentor of mine too, Basil Mizrahi. It made me think of Basil’s way of thinking about incremental improvements and incremental steps in the right direction of our patients treatments, psyche and treatment acceptance and treatment outcomes. So Basil’s approach no doubt and same with yours is that you always make small changes in the right direction. And in order to achieve the end outcome, you cannot go from zero to hero, you have to take one step up the ladder, one step up the ladder, and so on. So what your equilibration might become part of it. Is there anything? Would you echo that And is there anything to add to that?

[Koray]
I do. I mean, one of the things I lecture about is what I call stepping stone dentistry. So you know, you got to get from one bank to the other without falling in the water. And you know, every single one of these things we do is a stepping stone that makes the next step more predictable. Now the interesting thing is that even after you’ve done all of this and you rehabilitate somebody new, you know, you put implants in in your bone graft and you do that perio and you do their endo and you know get their jaw relations correct, you provisionalise them, you provisionalise them again you just the provisionally everything for them. And then three years later, they come back, their jaw relationships have changed again, things change. So then at your checkup, you must again look to see whether anything new has developed. How do I go to new premature contact? Have the teeth worn and my implant crown remained unworn? So that my implant crown is now my crcp. Why did my screw fracture? Why did my implant crown break? Why did it loosen? The chances are that your tooth contacts may have been fine five years ago, the patient hasn’t been back for five years because they’ve been fine. And then suddenly, the implant crowns come loose, or the abutments fractured. And you look to see and the photographs show that actually, the teeth in front and behind have worn. These patients have [Zak] Materials haven’t worn at equal rates. [Koray] The materials haven’t worn on equal rates and suddenly the implant crown has become proud. There’s no periodontal ligament, suddenly the entire occlusion is pivoting on this implant crown. So as after you’ve done all of this and you’ve restored the patient, it doesn’t end there. Every single checkup must also incorporate is the occlusion still stable as the temporomandibular joint still in the right place? Can you still get centric relation? Have you still got even contacts around the arch? Have you still got guidance that allows posterior, instant posterior disclusion? Have you still got the balance and function that you built in? You know when you did the rehab. For this reason we don’t get we only guarantee our work if the patient is coming back at least once a year. Usually, we said we will depending on their level, we set it when I write the letter and it’s usually twice a year for checkups and four times a year by hygiene. But it can go up and down based on that patient’s level of stability or instability in the past. If they don’t conform with that, and they come back to me three years later and say, Well, this crowd is now broken and I’ve got a five year guarantee on it. Well actually, you don’t have a five year guarantee on it if you haven’t come back for checkups [Jaz] 100% [Koray] because things change. Patients change. Patients’ functions change. Somebody was very calm person may have started a new job where they’re highly stressed. And there’s suddenly started bruxing and clenching. And yet, you didn’t have that two, three years ago. So you’ve got to keep the observation that they got new carie,s they’ve got new periodontal disease. Have they got new occlusal disease? Have they got stability?

[Zak]
What you’re talking about is the thing, that’s key with this is like we always say, Jaz, it’s relationships, isn’t it? It’s about keeping consistent relationships, because you can’t step into doing dentistry, by the way, something I’m going to steal off of you, I’m going to quote that to my patients, because I think that’s very, very important that you instill it in their minds that they cannot go from zero to hero, they have to take every single step at this appropriate. But you’re also doing something very key along this the same time, which is that you’re building a relationship and mutual trust and respect with that person, so that you get to know what they’re about. And you’re never going beyond your competence level. And you’re never taking them into something which you don’t in your heart of hearts think is right for them. So you can kind of as long as it’s a safe stepping stone to stop on, you don’t offer the rehab. Do you see what I mean? Is that fair to say? [Koray] I agree.

[Jaz]
Koray, I’m gonna get bombarded by the end this episode where people want to know about your occlusion course. Is it just in London or multiple locations and can you just give us some details about that?

[Koray]
At the moment it is just in London, obviously, because we’ve come out of lockdown, we’ve not really had anything concrete laid down. And the only times we’ve managed to is at the practice, and somewhere close to the practice where we do the lectures. But we need hands on for the scene, it needs to be out of practice. So I run it with Shiraz Khan. We run it together because there’s obviously a lot of elements involved in especially patients who are sort of doing general practitioner orthodontics and aesthetics and lengthening anterior teeth and this sort of thing really needs to have a good foundation and occlusion. But the bottom line to end all of this off is diagnose it, see how you treat it is another matter but if you don’t diagnose it, you’re doing yourself and the patient a disservice and when you’ve diagnosed it or you feel much better in yourself, you sleep better at night, but also the process of going through this is also an it’s a lucrative treatment option. It’s like you know, Oh I make more and more implant you know, people say Oh, I do implants because I make more money. No, it’s not like that. This is a valid treatment diagnostic and treatment process that also will fill your book and allow you a stability of your patient base. That means your book isn’t filled with emergency with Mrs. Smith from crown has come up again and Mr. Smith fractures as lower six again after the third time. This actually gives you control over your entire patient population. I mean I do full mouth rehabs but I do a lot of General Dentistry that’s why I get patients coming in for composites and an endo and one crown, you know, that’s fine, but they still go through the same you know, they still go through the same occlusal analysis process.

[Jaz]
But for me, Koray, dentistry becomes fun when you’re moving away from single tooth dentistry. And having the comprehensive exam and the knowledge of working knowledge of occlusion is the basis for you to have more fun because it allows you to move away from single tooth dentistry. And that’s why I got into learning about occlusion. So please do send me the date and the website, I’m gonna love to stick in the show notes. Because I’m sure people love learn from you.

[Koray]
The website is, is www.lciadacademy.co.uk. [Jaz]Perfect. [Koray] We also we also run photography, so I think photography is an integral part of this, we run a separate course with Shiraz, and also a an occlusion course with Shiraz. And I think the two of them, those two courses, actually will, I want, I gave a lecture to the Scandinavian Academy on this over a one day period. And I actually stood up in front of that, say what I’m going to say today is going to change your life, right? And I did it with tongue in cheek. But it really did, because people said I’m now going to look at my patients in a different way. I’m going to see stuff I didn’t see before. I’m not going to fall into holes I fell in before. And I’m going to have far more control over the work I do than I did before. And the genuine, the genuine, you know, I got bought a lot of beers at the end of the night. Because some of them said, No one’s ever, I’ve been in practice 10 years, no one’s ever told me this before. And I see all the stuff you showed, I know which patient. You showed me that, you know, Mrs. So and so has that you showed me this. I know why Mr. So and so’s crowns failed. You showed me that I know why that implant, you know, crown broke. And suddenly they get it and when they get it, this little light comes on and suddenly run back to the practices and they start seeing these they didn’t see before. And that to me is the epitome of teaching. It’s about showing people something that was never seen before.

[Jaz]
Amazing. Brilliant. Koray, thank you so much for giving up your time today. I know how busy you are and on holiday as well. It’s so great to have you on and you’re a fountain of knowledge and it’s great to share your passion. Just like you inspired me in 2013 I’m sure you inspired hundreds others now listening, Protruserati about this very

[Koray]
[overlapping converation] and you’ve been fantastic. Both of you.

[Jaz]
Zak you as well, my friend. Thanks so much, buddy.

[Zak]
Likewise, buddy. Well play. Thank you, Koray.

[Koray]
Thanks, guys.

Jaz’s Outro: So there we have it, guys, thank you so much for listening all the way to the end, you now know about that dark evil side of a equilibration. I mean, I can count on one hand how many equilibratio I’ve done, because in my previous working experience, I’ve been influenced by hospital based dentistry. And a lot of the TMD literature which is made in hospitals is very much like controversial, like, Hey, don’t do equilibration because this is not effective according to the studies, but the studies themselves are not very high quality. So I do think there is a role like in everything we have to you know, keep our mind open. Everything has this place. Okay? Although it’s not mainstream, I do think a equilibration has a role. In fact, I’m investing at T scan I’ve just bought a T scan. And I can see equilibration becoming more and more into my practice, especially as I take on bigger cases. And as much of a controversial area it is, you have to keep an open mind to it. So that’s my philosophy anyway, you know, I like to listen to everyone and make up my own mind and my own practice. And I think it would be great to contribute to practice or to research one day, I was actually emailing Riaz Yar, Then I said Listen, I want to contribute to research. How can I test my splint theories? How can I produce some TMD data? How can I produce some outcomes based on Hey, can equilibration help? Or can this serve this type of splint be proven for this diagnosis eg myofacial pain. so I’m always thinking about it. So if anyone out there actually I’m just this is my plea to you. If anyone out there is involved in research and practice, I would love to do some of that. So please get in touch with me. Anyway, I hope you enjoyed that. The next episode will be on planning your CPD and not burning out. So you know it’s going to be a cracker. I’ll catch you then.