Next Level Occlusion (Basics Part 2) – PDP091

Jaz’s Introduction: Hello, I’m Jaz Gulati. And in this episode, we go one step further carrying on from basics of occlusion part one, right,? Thank you so much for the awesome feedback you guys gave for part one, and I’m so happy to have my brother from another mother cut from the same occlusal cloth, Mahmoud Ibrahim, who is a fantastic dentist, you see his work on Instagram. He is amazing. But just learning about a story from this episode is so, so great, because it’s the first time we had a proper chat. I’ve been following him for a few years now. And I didn’t realize that he hated dentistry when he qualified right? And I look at his work now. And I think whoa what happened so as well as so many clues or gems. So I’m going to give you a little preview of in a moment that we share with you. I love just him sharing his story with you of what happened, what was the spark that changed him from hating dentistry and actually trying to follow a career of making websites to then falling in love with Dentistry again in a big way. And they’re really killing it at the whim as he is. Now, I hope you got your coffee ready because there’s a lot of stuff that we’re gonna cover in this very intense but very jam packed episode. Hope you like the analogies and stories and in cases that we discuss, we’re trying to make it as friendly as possible for all my beloved listeners. The watchers is great to have you if you’re on YouTube, hit subscribe. But for those who listen, you are the originals, I will always make sure that the content is easy for you to consume on your commutes. Right? So the kind of things that we cover is what is the difference between the so called tripodized contacts, and is it really better than cusp to fossa and how can we maximize stability with a cusp to fossa occlusion? Okay, we go very much back to basics there. We also talk about what happens when you store someone not in centric relation? Like we talked about a couple of scenarios where you might do that in the previous episode, but what actually happens, what are the risks that you accept, okay? and we also cover what is this concept of freedom in centric or freedom from centric and where do we apply it? where do we believe in it and if so, how do we apply it, right? So if you’re still hungry from that part one occlusion, just listen all the way to the end. This is absolutely jam packed Mahmoud you were absolutely awesome. The Protrusive Dental pearl from this episode is something that we actually discuss in the episode and I’m not sure you just highlight it here I think it’s so good that it deserves its own place which is basically when you’re checking the occlusion, okay? On that topic again when you’re checking the bite, imagine you’ve done a restoration at the common thing to do is to stick your articulating paper on the side where you’ve done the restoration and just look at the marks, right? But what I like to do is after I’ve finished restoration, take my rubber dam off, let the patient have a bit of a rinse or swallow whatever I just put them back instead of checking the same side where I’ve done the restorations I actually checked the other side. Now I know my articulating paper is 19 microns, okay? So I check on the other side. Now, if the patient is holding on that side, I either the articulating paper is not passing through. I know that my occlusion on the right side where I was working is accurate to within 19 microns, okay? Now if that articulating paper passes through, okay? Then I know that I’m out by at least 19 microns so then what you do as Mahmoud says in the episode as well is you double up the articulating paper now we’re on 38 microns, right? So you, patient bites together, you’re checking the other side okay? And now the patient is biting, okay? They weren’t at 19 now they are at 38 microns ie thicker paper. So now you know that you need to do between 19 and 38 microns of adjustment. Okay, now you’re saying ‘Jaz, I don’t know how to do exactly between 19 and 38 microns of occlusal adjustment.’ It’s more just give you an idea, right? Ideally, you want to be checking the occlusion like with an indirect restoration before you cement, right? So if you can do this, before you cement you know exactly how much you need to adjust. Like I’ve been there before, adjusting crowns in the past, where I’m just doing tiny little adjustments and checking it, tiny adjustments and checking it, okay? Had I checked this and I know that way, I’m way out on the other side, I would be more efficient in my adjustments. So hopefully that makes sense to you. Join the main episode with Mahmoud and at the end, I’ll reveal one of the future episodes that are planned regarding helping you with your occlusal goals.

Main Interview: Welcome, Mahmoud to the Protrusive Dental podcast. And I just wanna say like it’s been great to know you last couple of years, mostly on like, you know, WhatsApp, Telegram, social media. I love seeing your adhesive cases that you do and I love how much you love occlusion like me. We’re all geeks and your contribution to our telegram group you know, with over 300 something dentist now, your contributions, always really welcome. You know so much wisdom that you share. So thank you for coming on my friend.

[Mahmoud]
Thank you very much for inviting me. I mean, it’s very, very flattering, actually that you’d asked me to come on here have a chat with you. You’ve had some serious sort of occlusal heavyweights on here.

[Jaz]
I regard you in that same line and honestly, some of the content you post and the stuff that you put on telegram I, you know, you know what we’re talking about. And I want to be able to share that and put you on a pedestal and really champion people like you who have been, you know, like I said in the last episode basis of occlusion, but we’re on a journey, right? at different points. And I feel as though we mean, you have had a similar journey. But I like how you are constantly running, you’re running in this journey. And you’re like, yeah, let’s keep going. Let’s keep going. I’m learning. I’m loving it. So just give us a flavor actually a about where you work Mahmoud. Where are you qualified? And what has your, particularly with occlusion, What has your journey look like? And maybe I’ll say a little bit about my occlusal journey in terms of the courses that I’ve done the past as well.

[Mahmoud]
Sure. Yeah, I mean, you might find that there’s a the crossover is more than you think. Because obviously I listened to you on your podcast. I know a lot about your part of this, so I qualified in Manchester 2005. And, believe it or not, this is probably where our journeys do differ a little bit. I absolutely hated density when I qualified. I did not want to be a dentist. The first five years were me trying to find a way of earning a living not doing dentistry or earning a similar living not doing dentistry.

[Jaz]
Wow. So you diversified into different fields. Give us a flavor like what does that look like? What were you doing? Did you open some sort of a franchise or something or like you know what were you doing?

[Mahmoud]
No, no, I didn’t get quite that far. So I taught myself how to sort of build websites, WordPress and things like that were fairly in their infancy at the time so it was a bit it was a bit more challenging probably than it is now. But yeah, built a couple of websites. I had an idea for doing a bit of a dental bind group sort of thing. I think that exists now. But yeah, I tried my hardest to not have to be a dentist for the rest of my life. And then looking back at it I’m like, that part of me is like Oh, that was such a waste but you know, our paths were a little different and I probably wouldn’t be where I am now if I hadn’t taken that time to figure out what it is that makes me enjoy dentistry, No.

[Jaz]
So what sparked you? What changes give us that moment where everything changed for you? What year was it? What happened? Was it a cause? Was it a mental?Was it a patient? Was it an experience that you had that you thought you know what actually I do like dentistry after all because I the reason why this was a shock to me and for those who already follow you, know you, like you produce such beautiful dentistry and you’re so, you’re oozing passion when it comes to enthusiasm for dentistry. So to know that hey, at one stage you’re like building websites and you are trying to stay away from denture as much as possible not only is that going to be inspirational to some people who may be going through what you’re going through at the moment, right? And say you know what, you can get to the other side because I think if you are practicing dentistry there’s a danger of not loving it, there is a real danger if you let the day just if you’re clock-watching all day long, you know in any job, in any profession especially dentistry, I don’t want to be in that so I want to know, so share with everyone what changed? What was the spark?

[Mahmoud]
It was a disappointment. It was, so I was doing a class four composite actually on a patient and I was doing it the way they taught you at dental school, you know, no rubberdam up to date, No, you know, mylar strip, you’re not building a palata wall, you’re not doing any of that, you’re getting the strip in place somehow, you’re squeezing all composite in, you’re pulling it and you cure it and you kind of end up with what you end up and I looked at it and I was like, this is absolute garbage, it’s rubbish. So I was like well okay, every other thing I’ve tried so far to get me out dentistry hasn’t worked, so I’m going to do it, let me at least do it well, and believe it or not the first place I went was YouTube. Things would probably so this was in about five years in so it’s 2010 maybe and qualify 2005 until 2010-ish Yeah, I just started looking up YouTube videos. How’d you do decent looking class four and as I started to get into it and realize all the tools you had at your disposal and I started getting better and my crown fits went from being ‘oh my god I hope it fits. Oh my god, I hope the occlusion’s okay. What is occlusion?’ You know that sort of thing. When it became ‘I know this is gonna work. I really enjoyed it.’ The occlusion part of things actually again I probably will find this very similar to you. It was, what is called? The

[Jaz]
Yes, DT. The original DT

[Mahmoud]
Yeah. You know Lane Ochi, Michael Melkers, john off the these people. So I was starting to get into my Dentistry and I was like, Okay, I want to do slightly more intricate work, slightly more complex work. And I was seeing these guys producing this work. And the great thing about that the website at time was you know, they’d be step by step and especially the people we call mentors. Now You know, Michael Melkers and ? , they didn’t just before and after, and there you go, it’s more of a, here’s the before, this is what the patient presented with, what would you do? And it wasn’t I do 17 veneers it was, how do you find out how to? How are they gonna last you know how you’re gonna make them last? How are you gonna make him look good. And it was all about

[Jaz]
Making a method out of it so that you can actually get to a good endpoint. And what I respect about both those clinicians is that they’re really also great educators in the realms of communication as well at how do you communicate a big case, rather than, Hey, you need, you know, 17 crowns wherever, like, Hey, you know what, here’s a problem. Are you gonna own your problem? Or not in a way?

[Mahmoud]
Absolutely. And, yeah, that’s kind of where it started, really, because I learned, luckily, without making too many of my own mistakes, what to look for, in terms of red flags and things. And that’s kind of where it started, it became a, like a growing up when I was at school and stuff, like my favorite topic sounds such as so geeky, but it was physics, right? Physics I really enjoyed. Because you could be given a certain set of facts, you know about how the world works. And you can then take that and apply it to a new situation, and figure out and possibly predict what’s going to happen. Whereas biology or something, some of it is a lot more learn, you know, learn by memorizing or that sort of thing a little bit. I kind of always equate occlusion to physics in a way. Because it’s all about force distribution. It’s all about resistance. It’s all about figuring out how to make things last in a hostile environment. And it’s kind of like the CSI part of dentistry if you like. And that’s what drew me to it, it was very, each patient is different, and you just go put the pieces together and try and come up with a formula that would work for them.

[Jaz]
That’s a really cool way to put it in. I always, as you’ve heard me say many times a podcast like you know, as Steve Jobs said, you can only join the dots when you look back, and then we look back at your physics interest. And then it only make a sense that, okay, you’re applying it through occlusion. And you’re right, there’s so many similarities there. Like, you know, in a hostile environment, like aerospace engineers, they’re designed these aeroplanes to work in hostile environment. And they’re thinking, Okay, what about the fo-, you use that word force distribution. And I mentioned about the force management that Ed McClaren said in the last episode, and I definitely see occlusion like that. Now there is a danger and I know you know this already as more, I’m just showing this for everyone else. There is a danger in making it like overwritten it, making it too much about engineering and then dissociating that from the patient as well because there’s so much resilience that everyone’s has, you can get away with a lot as well. But it’s knowing with which patient you can get away with it, and which one you can’t. And then being able to apply the the force management because you want your work to last longest, but also realizing that there’s a whole bio psychosocial element to it as well. So let’s just, why don’t we just dive right in to the main question, you know, I got around about four or five questions I want to just to quiz you on but then also add my input, and then also have a little debate and I said to you already, man, if we disagree with something, which I don’t think will happen, but if it does happen, amazing, because I want to be able to just sound out a couple of ideas, right? So when planning for contacts, what I mean by that is, when you do your restoration, and you stick your articulating paper in and you get the patient to bite together, what should those dots look like now there is something called Tripodized Contacts, and for a little bit of history is like more an arthrology and this is essentially it’s like cusp to fossa, so the lower, let’s say the lower molar, lower first molar, the buccal cusp in the central fossa of the upper molar, except there’s now that cusp is making three little dots in that fossa, right? It’s making three little tripodized dots. Okay? And before I really go into it, just explain what your understanding? Is any more that you want to add on to that?

[Mahmoud]
Yeah, that’s exactly right. And I think another important point to make is that it’s important that the cusp tip in Tripodized Contacts does not make contact with the opposing tooth that’s a part of the definition I believe. So the tip itself, the very tip of the cusp doesn’t actually, it’s the three point to contact where into which the cusps sits prevent the tip from hitting the bottom of the fossa if you like

[Jaz]
Yeah and then that’s good because with the Tripodized Contacts is the main claim benefit and it makes sense in terms of engineering is that the net result of the force from this tripod is through the long axis of the tooth which makes sense engineering wise and but there is a problem with that. And this is why many of us include myself and I know you have as well have moved to cusp to fossa so so just talk about what are the challenges? Maybe when you first learned, did you just try in doing Tripodized Contacts or did you learn from your mentors that actually, this may be overkill, what are the challenges when you’re trying to implement this Tripodized Dentistry?

[Mahmoud]
Yeah. So I mean the way I learned specifically, I’m a very visual person. So the way I looked at it when I was looking at Tripodized Contacts versus cusp to fossa, was okay, so if I’m going to try and replicate this, whether it be in a direct restoration, or an indirect restoration, first of all, it’s very, very difficult to achieve.

[Jaz]
Can you see that Mahmoud, by the way? Can you see this? So I just put the image up, can you see this?

[Mahmoud]
I’ve got it.

[Jaz]
Alright, sweet. So this is a you know, obviously, you mean, you I want to make sure that we respect the listeners of the podcast while you’re commuting, chopping onions, or gardening, that kind of stuff. But if you’re watching on YouTube, then you can see a visual, but we’ve described it. So this is just a visual aid for those who are watching.

[Mahmoud]
So as you can see, I mean, the three point contact, sort of in the middle of that lower molar, for example, being able to build your cusps. in that fashion, getting each one exactly right, to get even contact on each side with the opposing tooth, is difficult. Now, let’s say you’re just gonna grind it down into that, if somehow you grind one of them slightly more than the other two, you’ve been introduced inclined contacts, which are very, you know, inherently unstable, as we know. But even so you get it right on that first time. Now, what’s stopping the patient from wearing one of those contacts more than the other two? And again, introducing an incline contact. The last one, again, is more of them brain exercises, depending on how close those contacts are, you know, the tripod, how small that tripod is, if it’s a bit bigger, how hard are you getting your patient to clench when you’re checking that contact? Because that is then going to affect how much shearing force you’re going to put on the sides of those cusps? So if you’re not doing it hard enough, what if they are a nighttime clencher, or daytime clencher or whatever? And you’ve done this in your beautiful ceramic, and you find that it starts to crack. So it’s just and then the last thing I guess is, is it necessary? I know that the concept was introduced to give the tooth positional stability, but I think we’ve seen through Pankey, Dawson, Spear, I mean all teach cusp to fossa, as you show on the picture there.

[Jaz]
So I’ve just put a photo of the cusp to fossa on which we’ll describe and go into and maybe their advantages over the tripods. But as you’re saying, you’re saying exactly how I agree with you, yeah.

[Mahmoud]
Yeah, you know, that we can’t forget, for example, that the main thing we learned at dental school, for example, about positional stability fatigue is neutral zone. Now, your neutral zone is still there. So if you can get one or two, maybe even three, cusp to fossa contacts on the tooth, it’s sitting within a socket, within a periodontal ligament, you’ve got the tongue, the cheek on either side, you’ve possibly got mesial and distal teeth on the mesial and distal. Chances are it’s going to be stable, it’s probably an unnecessary addition. Unnecessary complexity to add the Tripodization?

[Jaz]
Well, the only thing we haven’t mentioned is that okay, we mentioned the case of a direct case and you’re trying to get those contacts and the challenges that we have there and then also about what if the patient is a clencher, and then how well you’ve engineered that tripod. But also if you’re doing any, if you’re doing a big case, a full mouth rehab case and you’ve prescribed to your technician, a tripodized scheme, like your technician will be spending forever in a day to try and get that and then you know, what is the chance that as you fit those crowns, it’s going to be exactly how it was on the articulator, okay? We know that doesn’t happen, and therefore then you’re grinding and doing it and then essentially, you’re getting these cuspal incline contacts. So it’s much easier and better and by the way strong pay respect to Mr. EM Langenwalter, DD, it’s DMD for these images. That’s why I’ve kept this EML on there because this is his work. That’s why I base, it’s one of the clearest diagrams I could find online of tripodized versus cusp to fossa. So yes, lab work is going to be challenging with that, so it’s not best to do and then one thing to just summarize what you just said there is that Okay, if you’re going for tripodized contacts, what is the alternative? We know cusp to fossa, but then some people might say that Oh, with cusp to fossa, then you because you only have one contact. It’s not stable enough. But just as you said, we know the tooth is not going to go mesial and distal, because if you’ve got a tooth, either side, you’ve got the contacts. We know it’s not going to go buccal or lingual because it’s in the neutral zone, right? And therefore, this serves the purpose and it fulfills the purpose of maintaining that vertical position of the tooth. And together this is why many dentists are cusp to fossa. But one thing I know that you’re very good at because we spoken about this before is that actually the definition doesn’t just finish at cuso to fossa. It’s a cusp to a flat area, flat landing pad or flat area rather than finishing on incline. Now I know you are very good at implementing this you know show me photos of you implementing this, it’s something that you’ve been speaking about on our telegram group as well. So if you don’t mind just explaining a little bit about How to Maximize cusp to fossa for our benefit in terms of the flat areas. And what’s the benefit of that?

[Mahmoud]
So it’s all about simplifying the process in order to get the end result correct to the patient. Basically, landing pad occlusion is something I learned off of Michael Melkers and Lane Ochi initially. And the concept is that you take the, where the opposing tooth is going to contact your restoration. And instead of it being at the bottom of a fossa, you raise the bottom of that fossa up into like a little flat receiving area where the stamp cusps or the functional cusps directly contact thus directing the force down the long axis of the tooth, number one. Number two, it gives you an area that’s very easy to adjust if the occlusion is high, and we can maybe talk about the trick of you know, figuring out how high by doubling up your articulating paper, etc. But it’s very easy to grow in that flat area down keeping it flat. Whereas if you’re trying to deepen a fossa, it becomes very tricky. And the other thing it does is because that area is flat, and it’s usually sort of hard, you know, maybe a millimeter diameter, or at least that’s what I tell my technicians to do. It’s got sort of inbuilt into it, something we will discuss later, which is that freedom in centric concept. So that’s why I really, really like it. And it’s made my indirect restoration adjustment fit so much easier.

[Jaz]
Absolutely right. And it just makes sense physically, rather having your three dots and now going to cusp to fossa but not just cusp to fossa in the depth of the fossa, you actually have a strategic area, which is going to be perpendicular to the functional cusp or the stamp cusp. And just it’s not only it’s beneficial to us as dentists, for the technician, because it’s easier for them to make. And it gives us that freedom in centric or freedom from centric, and we’ll talk about that. So the conclusion of this question is okay, we used to do tripodized contacts, because an arthrologist believes this was the optimum way. Now the change has happened to us to cusp to fossa but it’s a cusp to flat receiving area or landing pad different terminologies. And that makes sense. Now, before we get on to like how to check how high the occlusion is a little bit, I just want to ask a really important question, which is some dentist might be thinking, listening to us and saying, Wait a minute, wait a minute, does that mean I now have to start fiddling around with everyone’s natural forces to create these flat landing pads? What do you say to that, like, you know, how can we implement this on Monday morning? When should we be implementing this and when should we be accepting the status quo?

[Mahmoud]
I mean, if the patients, I mean, you know, this, I think there was a, I can’t remember who said it, but it was either Pete Dawson or one of those said that I did hundreds of equilibrations on hundreds of patients and some of them may have even needed it. It’s a kind of a similar concept where, if someone’s got no functional problems, they don’t have tooth wear, they don’t have tooth mobility, they don’t have sensitivity, they don’t have TMJ issues, muscles headaches, if everything’s working for them, there’s absolutely no need to change it. The only time I apply these concepts is I’m restoring the tooth anyway. And all I’m trying to do is give the patient something that’s going to work so they can chew on it, it’s not gonna be sensitive, it’s not going to break hopefully it won’t break. So you know, you only apply these things when there’s a need because you are already doing some dentistry or sometimes it’s you know, the patient has an aesthetic concern that is there that’s the main reason they’re here but you are also responsible for making sure that your dentistry last so if you’re going to then be changing the guidance or opening the vertical because you want to you know give them more freedom whatever is, then again I would apply these principles because just because their natural dentition had something for a while. If I’m then going to be putting my own stuff in there I’m going to give it the highest chance of success without compromising things like aesthetics or function you know, I’m not going to give patients teeth they can’t chew with just because then they won’t be able to break them. But you’re also want to use as many of these tips and tricks as you can to make your life easier to make your work more predictable.

[Jaz]
I just want to highlight that, Mahmoud and I clearly agreed, the reason it’s important to highlight that is because I don’t want young dentists listen to this and then next Monday morning, they checked the patient’s mouth and the patient’s got like some craziest skeletal class three occlusions that Oh my God, I’ve got to get my handpiece out and start drilling to create these flat landing pads. No, no, it’s not the case at all. So the way I like to explain it as just like you know, to add on to the beautiful way that you said it is a one definition by Jeff Okeson. So Jeff Okeson is a very big name in the world of TMD occlusion. He defined the dynamic individual occlusion, okay? Which is the occlusion is considered acceptable if the patient is functioning efficiently without pathosis, okay? So that’s one thing and then when I did the Dowson Academy, Ian Buckle following on from Pete Dawson introduced the concept of ‘okay you have your general patients and you’re complete patients and your general patients are the ones who you know even though they have an AOB, okay, there’s no, they don’t have any fractures, they don’t have much wear, they’re doing fine, they don’t have any pathology at all, no TMD they’re doing fine, stop, don’t fiddle around with them for the sake of fiddling around with them and changing anything because they are, that occlusion is working for them. Then you got your other patients whose occlusion is not working for them. And then they may or may not also want an aesthetic improvement or they may not have like several caries lesions and then you need lots of crowns and restorations.’ Now if you’re going to be now doing committing yourself from dentistry anyway, then just like you said, why not take that opportunity to maximize success and put this engineering concepts in to get better longevity. So that’s why it’s important to say that hey, don’t go around thinking that Okay, everyone needs to have this if what they have is already working for them then great. But if you’re intervening, whether it’s single tooth, and you’re just going to make your crown and you’re gonna tell your technician just like you do to have this and we’ll talk about the level of training that you individually need to you know, speak to a technician have that communication because you can’t just write in your technicians lab slip, please give a cusp to flat landing pad occlusion and they’ll just do what you want. You have to spend that time sit down with

[Mahmoud]
No. What I did was got them to come on your course. I got both of them to come on the 2020 occlusion

[Jaz]
Amazing and that was so good to see and you know, massive hats off to you for for getting them on there. And massive kudos to them for wanting to learn and say okay, how can I make better work for Mahmoud, you know, so that is a amazing. So that we can maximize the time we’d, you didn’t mention, that’s not the official question. But we as we’re talking, let’s talk about a scenario where, you know, patient bites together after restoration. And now it’s high or is proud. I’ve got a little video that upon just recently about nine little techniques, little tips to make sure that you don’t have high restoration. But let’s say well, we are proud. And what is that little trick that say about doubling up you’re articulating foil?

[Mahmoud]
So we’re assuming we’ve already cemented it in

[Jaz]
Yeah, let’s go for it you cemented in and the patient bites together. And we think we’re high.

[Mahmoud]
Yeah, I mean, assuming you know that, you need to know the thickness of your articulating paper, but I would put it in on the contralateral side. You know, let’s say it’s 20 microns, and it pulls through, I would double it up, put it in on the contralateral side, if it pulls through, you know that you’re going to need to reduce by at least 40 microns, maybe more and double up again. And you keep going basically until it holds that will give you an indication of how high your restoration is. Now obviously, ideally probably want to do this before you’ve cemented on. Because if it turns out that you’ve got to reduce a millimeter and you know you’ve only done a millimeter and a half reduction, which again might come on to something we speak about later. You probably want to re prep.

[Jaz]
Absolutely and so that’s beautiful pearl, it’s a great way to test it. And in the opposite scenario, you know, you check and the patient is biting. So sometimes you don’t checking the occlusion, I will do this technique straight away. I won’t even check the occlusion on the side I’m working on, you probably do the same. I check on the contralateral side. Okay, they’re holding my 20 microns. So I know that I’m at least within 20 microns, I’ll then pull out my shim stock foil and check the contralateral side. Okay, they’re holding on the shim there, amazing. I’m within eight microns now. And then I’ll check the tooth in front and behind the one I’ve worked on, and they’re holding it on there, right? I don’t need to check anything, really. So that’s a good way of doing it. So I’m glad we’ve covered that as well. So look at how much value to build in this episode. Shall we move on to now, What do we check in a basic occlusal examination?

[Mahmoud]
Okay, so when I did my MSC at Manchester with Stephen Davies. And he absolutely and he uses a form on his TMD clinic in Manchester called a three minute articulatory system exam. And I found this fantastic because it gives you a very easy to follow checklist of everything you need to check. And it’s something

[Jaz]
We can. I asked him by email, Can I share? This was like four years ago, I asked him Hey, can I share this with dentists? He emailed me back saying yeah, that’s totally fine. So you remind me, what we’ll do is if you go to the blog post for this website, and on the telegram and on the Facebook group, I’ll stick it on. So it’s three minute occlusal examination, what you need to record and it’s really quick and easy. It’s really valuable information by Stephen Davies. You know, all his work, amazing, we’ll stick that on to benefits of all.

[Mahmoud]
I have added a few little bits to it. In terms of additional thing or or maybe you know, what do you do when it’s an you know the result or you’re finding is negative or you find a problem? Because if everything’s a no no, no and everything’s clear, it’s fine, you’re done. But what do you start to look at if it’s a positive and that isn’t or so it just as a memory jogger.

[Jaz]
Can we put their Mahmud modified version? If that’s okay with you?

[Mahmoud]
No. I’m not gonna claim with some yeah. All got it in for that. And but yeah, so it covers things like, you know checking the TMJ palpation, for pain, you’re checking for noises. So clicking, popping, crepitus. I don’t have a Doppler, but I do like to use a stethoscope. And then you’re looking for range of motion protrusive, lateral, maximum opening, and you’re looking for any deviation. And then we do the muscle palpation origin, insertion. And I like you also don’t believe that lateral pterygoid can be palpated. So I do a resistance test. And then the rest of that form goes into skeletal class, incisor class. And then see, again, something we’ll look at later, which is does CR occur in MIP. So that’s actually something we’ll need to clarify on the forum because it says CR does equal CO.

[Jaz]
Which is using the older definition. Exactly, which is why everything in you know, it just goes back to this the definitions, right? So Exactly.

[Mahmoud]
So we’ll clarify that but and then it goes into checking things like working side interferences, non working side interferences, I put them in air quotes. And then whether the patient has canine guidance, group function, etc. And then at the bottom, it’s got a sort of compression test. Now, I used to wonder whether that’s the same as a load test or not, I think the objective is slightly different because you’re only compressing the joint on one side. So basically put like a tongs bachelor or cotton roll. Yeah, on one side I’d get the patient squeeze hard. And if you, again, this is where I go back to sort of visualizing again, if you’ve got something in between the teeth on this one side and you squeeze, you can imagine your condyle is going to move a little bit higher up on this side and compress the joint space. If that if you get pain on this side, it could be that there’s an intracapsular problem. But it also helps tell you if there is discomfort on this side that it might be muscular. And again it’s not you know, you’re not dissecting the patient, you’re not doing an MRI, not you know, it’s a three minute exam. So it’s just to give you a base to start

[Jaz]
The compression test I learned it as it is load testing at one side. It is load testing at one side at a time. So it’s very similar and I think it can be and a lot of people tell me ‘Hey, Jaz what I do, I don’t have a leaf gauge. And I that’s the advice I give them Okay, get a spatula on the other side. And then the only difference to add on to that is I will actually what I do is I use a hand upon my hand and I put it on the angle of the mandible, the opposite side where the spatula is and actually push a little bit so I’m really maximizing how far the condyle is going up against the glenoid fossa. Yeah, so that is just given the extra and then you find it Okay, is there a load test negative or positive. So I got a little diagram here for those watching, again we’ll describe it like the side that you put the spatula, it almost gaps the joint there, the physiotherapist called gapping the joint, right? So you’re moving the entire mandible, like you know, in a side to side kind of way. So now there’s a gap, supposedly, where you got a spatula, because the spatula is in the way between the teeth, there’s a gap. But on the other side, there’s compression. So as you get the patient to bite together and put your hand on the angle on mandible will push upwards, that is a way of load testing. And it’s great that Stephen Davies had this on the form, because not everyone has access to a leaf gauge. So this is the quick and easy way to do that. So that’s awesome.

[Mahmoud]
Brilliant. I mean, if you don’t mind I wanted to go sort of a little bit into how I because it’s great to do this on every patient because then you have a baseline I do also maybe think about things a little bit differently when I know what I’m doing for the patient. So Spear teachers, I think four positions of occlusion, right? But the one of them has two lumped into it, so I tend to think of five. So you got if you think from as far back as you could go no more. Okay, let’s consider it Yeah, as far back as you can go physiologically and comfortably, all the way forward. It’s easy to think about, so you got centric relation. Then a little bit further forward, you got MIP that’s two. Further forward is your pathways, your guidance pathways you know there’s protrusive, lateral intrusive, wherever it’s the guidance pattern, and then you end up on some form of edge to edge position. And then past that you got crossover. So generally what I think about it is with what I’m doing with whatever treatment I’m doing, what am I going to be changing? You know, what is my restoration going to be in the way of? So, you know, a few of the cases I’ve posted on my Instagram recently are sort of composite veneers and things like that it’s, you know, everybody’s doing that these days. So, purely facial composite veneer, you’re not gonna be changing, you’re not gonna be affecting CR. Obviously, we said you do the baseline examination, because you want to know that there isn’t any pathology, there isn’t any reason to interfere with those positions. But assuming that the examination is clear, your composite veneer is not going to affect CR, chances are, it’s not going to affect MIP, it might affect the guidance pattern, depending on how much length you’re adding. So then I’m thinking, alright, I’m just going to make sure that whatever length I add, isn’t going to make the guidance any steeper. So by making sure that the composite that I add if the you know, if the angle of the palatal surface is sort of that way, you know, whatever the angle of the palatal surface is at the moment, I’m either going to try and maintain that, or make it shallower. And then you’ve got your edge to edge position, which is probably the most important when you’re doing something like composite venners, you want to make sure that on that terminal, you know, only when the patient sat on the edges, again, you get forced distribution. And everything is smooth. When by smooth, I mean, the when the patient gets onto the edge, or if they want to slide on the edge, there isn’t any clunkiness to it, there isn’t any point the patient can grab, hold of and add resistance, because that resistance means they can put more force on because while the mandible isn’t moving, so they’re just gonna push harder. And then the same sort of thing with crossover. You know, you don’t if the patient naturally goes past the canine position. So crossovers, basically, once the patient has guided, let’s say left, and they’re coming onto the tip of their canine and they’re sitting on that tip, that’s their canine guidance. Once they go past that tip. They’re into that crossover. That if they go past that tip, and it’s a big drop, you know, or for their central incisors.

[Jaz]
Or they crash together

[Mahmoud]
Yeah, exactly the lower incisors crushing for the

[Jaz]
Jerky movements. It’s about identifying and eliminating those jerky movements from the transitions.

[Mahmoud]
Exactly. Keep everything nice and smooth, the patient has nothing to grab hold of and push against. That’s probably hopefully going to make sure your restorations last a lot longer.

[Jaz]
I think in the last 60 seconds, what you’ve covered here is if you can program your restorations, to always have a degree or a high degree of smoothness, and I don’t mean like a highly polished surface. I mean, as the mandible is moving, everything should be smooth. And then also everything to be shallow. If you can do that, like you will dramatically reduce your rate of failures with the anterior restoration just those two gems that you gave there will make a massive difference to everyone’s listening or watching or doing their restoration. Just remember, if you don’t remember anything else in this Episode, remember smooth and shallow. Okay? You will be absolutely fine. So I’m glad you’ve added that in. Now in the interest of time, let’s go to because it you know, following on from smooth and shallow, let’s talk a little bit about freedom from centric or freedom in centric. I’ve got a diagram to show later as well. In fact, let me just load it up. And then we can talk about it while I’ve got the diagram up.

[Mahmoud]
This is probably, this might well be the one place where not necessarily we disagree, but we might have differing conclusions but yeah, just

[Jaz]
Okay. So tell me about whether you believe in or you incorporate freedom in centric or freedom from centric, whatever you call it. But you know, from the way, What is that you understand about this concept?

[Mahmoud]
Freedom in centric, freedom from centric, long centric, I see them as all the same thing. And I think it was introduced by Schuyler?, and it was basically supported by the theory that CR, centric relation is not a pinpoint position. Now, I don’t know whether you agree with that or not. But to me, that tends to make sense mainly because if you take a system such as the articulatory system, you’ve got two very big shock absorbers in the system, you’ve got the disc and you’ve got the periodontal ligament. Now, any system that has shock absorbers in it, there’s gonna be some play. Again, just that’s the way it makes sense in my head. So to assume that Centric Relation is an exact pinpoint, didn’t sit well with me. So this makes sense. And it’s all about taking something that you’re designing on an articulator putting it in the mouth, they’re not the same. The articulator is there to basically the only function of the articulator is to make sure that you’re adjusting for less time in the mouth. Basically. So you can’t, I don’t want to call it a fudge factor but freedom does give you a little bit of room for error of one function. Okay? So that’s what we talk about when we’re talking about landing pad occlusion because the other thing is when I first got introduced to freedom in centric, it was really an anterior, you know something to the anterior teeth, little bit of room behind the upper incisors for the patient to wiggle

[Jaz]
So I believe that is the long centric concept, right? So, yeah, it’s a very similar context. So in one, in long centric, you’re looking antero-posteriorly and freedom in centric. You’re looking left and right. Is that the, what you follow as well?

[Mahmoud]
The thing is, I think it’s probably one of those things that in practical terms, it doesn’t matter. Like it needs to be in all those directions because the patient, you can’t tell them, okay, you can have freedom forwards and backwards, but I’m going to lock you in left and right. So you deal with it. So I just think, again, it gives you the thing that I didn’t understand before it was like, okay, you’re giving them this freedom at front, but if you are giving them Tripodized occlusion at the back, what’s the point? They can’t move anyway. So this is why landing pad oclusion give them that room to wiggle around, couple it with the anterior long centric. Give them that freedom to move slightly where the teeth are still actually loaded. So that’s the important thing, is it? Cause if you just give them that room, but they are moving and hitting the inclines at the back. Yeah. There was a problem. So they’re still actually loaded on the teeth, but as soon as they’ve gone past that area of freedom, you’re engaging the anterior guidance. Now the other advantage is as, because they’ve moved a little bit, hopefully you’re thinking that condyle has started to move and hopefully if you can get the condylar movement in harmony with your anterior guidance, you’re going to separate the back teeth, everything’s going to be again, that magic word, just nice and smooth and shallow as needed. Well, a shallow is, can be while still discluding your back teeth. Yeah, that’s kinda my thought with freedom in centric, basically.

[Jaz]
I agree. And just to add on to that I think the tubs, is it freedom in centric or freedom from centric? It doesn’t really matter because the term centric here is used as the MIP, centric occlusion. Okay. So just whatever that bite is. And I usually, when we’re doing, you know, rehab dentistry, it is in, within the arc of centric relation. So ie centric relation and MIP are one and the same when there sort of designing either these splints or this many restorations or rehabilitation, so let’s just take it from that. And then as you move within that space or away from centric relation, there is a bit of freedom and I’ll just call this like a wiggle room. Okay? And sometimes to understand what something is, we must understand what it isn’t. Okay? So I learnt freedom in central freedom from centric the best way I learned it is to, to rationalize it like this. Okay? First learn what it isn’t. It isn’t this. Okay? It isn’t that as soon as you bite together. Okay? You A) you’re locked in. And B) when you grind left and right immediate, I mean, absolute immediate disclusion that you’re pretty much on an incline and you’re just discluding straight away. That’s what it isn’t. What it is, is that when you bite together, you can just a little bit, tiny bit tiny wiggle room left and right. Little bit forward. Okay? Before that inclined starts, okay? Now it is debatable and we will never know whether this has any success or importance or bearing, but just like he does to you, it makes sense to me as well in a system which has got squashy parts to attack, to give, make your life easier, to have a little range rather than a pinpoint area. But also I just do find that this also reduces resistance, right? Cause I had that initial flat bit, they’re not on an inclined straight away, and that is contributory to reducing resistance. So I, something I would incorporate in a bigger case, but here’s what I do. I’m going to stopped sharing my slide now. Here’s what, how I incorporate it into orthodontics. So there’s what Andy Toy taught me. So I started to apply this to orthodontics and the way that when I finished an Invisalign case. Okay? And for those who do orthodontics, any form of orthodontics, just when you finished, okay? Get the patient to bite together and get them to clench hard and get them to grind left and right, I had a case the other day, it was a class three case I had, and I just got rid of the anterior crossbite. But now when I got her to grind left and right. Upper lateral was in fremitus, okay? We don’t want that. Okay. Because that was a tooth that was in crossbite. Now I got it back into position. The reason it was in fremitus is because all those years of being in crossbite, it never had any pathway wear so had this like massive kind of like mamelons, but this huge concavity of the palatal of the incisal edge. Right? Whereas if you look at the other teeth, they were nice and flat. So I got my bur and I smoothed it to sort of accelerate it. Now people often think like some orthodontists say, no, no, no, I’m not gonna do any tooth adjustment. I’m going to do lots of put the patient in nine months or finishing to get everything as it is. That doesn’t make sense to me, because the best analogy I have for this is I imagine the maxilla is a lock and the mandible is a key, right? Now through orthodontics, you are tampering with that lock and you’re tampering with that key. You can’t expect the lock and the key to now fit together. Yes, they are the same lock, same key, but just slightly different. Right? So you need to now get your tools out to just reshape that key and reshape that lock so now things fit together better. So the way I can make it tangible in terms of that orthodontic case is I do a bit of adjustment on that palatal, the lateral incisor in enamel. Okay? Now I’ll check again still a bit of fremitus, okay? But not so much, again, I get a soft Lexis, just smooth it out. Get rid of that sharp corner of the leading edge of the lower incisor. Okay? Again, that contributes to making it smoother as well. Okay. And patients love that. Okay. And now that tooth is no longer in fremitus, but now here’s the magic thing. Okay? So as per Andy Toy taught me this, and I’ve been using it and getting lots of success is you get the patient to clench together grind. Okay? And then as they grind left and right, you ask a patient, ‘can you tell me if you can feel that there is a back tooth in the way, is there a tooth that’s in the way’ and straight away, she said, ‘yeah, over here.’ So she pointed to her upper left premolar, and I put my finger on it and I got to grind left and right. And that was in heavy contact. Now the beauty is when you finish an Invisalign case, all the teeth are mobile, right? They’re a little bit mobile because everything’s moving, right? So you can actually feel it more on your finger. And when you just adjust that a little bit, now you don’t need much adjustment, you’re just, you’re almost creating a flat landing pad with your lovely littel bur, but just literally a tiny bzz, that’s it, that’s all you need. And then get the patient bite together and grind left and right again, everything feels smooth and even, and that for me is how you finish an orthodontic case as inspired by Andy Toy. And I’ve been getting a lot of success with that, so that there’s no more fremitus, everything’s balanced, everything feels smooth and everything feels comfortable with the patient. And the patient is not aware of any tooth as she is clenching and grinding. And that’s all point, I want to test it during the clench. I want to test it when it’s going to be a maximum loaded. I want to test it through a potential parafunctional activity. And we test everything to parafunction, where we hope that it’ll surpass it in function. So that’s another way of how I incorporate this little bit of freedom within the patient’s post orthodontic occlusion.

[Mahmoud]
That’s fantastic. And the analogy is,

[Jaz]
Thank you. I thought of this morning before speaking to you, I thought, okay, let me think of, I was thinking of how can I explain this the best unless you don’t have this morning, but I’m gonna continue to use it. Thank you so much. I’m glad you liked it. So okay. We talk about freedom from centric and how we both like it. And again, once again, it doesn’t mean that we go to all our case and start incorporating this in, when everything’s working for that individual is when we are doing dentistry is where we’re doing a full mouth rehabilitation in an enamel aka orthodontics. It’s when we’re doing crowns and anterior restorations, you want a little bit of wiggle room, right? So I hope that helps people in terms of learned the definition. I’m glad that we, yeah, I don’t think there was any disagreement between us, buddy. I think we both agree there. We talk about a basic occlusal examination as well. The only thing I might do differently is a lot of a new patient examination. Like there’s so much to check for sometimes. So I will check for the degree of hypertrophy of the muscles, but I won’t in every case check the origin, the body and the insertion of a masseter, for example, I’m saving that for, okay, are we now going further? Are we gonna be doing some dentistry or is this a patient who’s complaining of headaches or they do actually have significant hypertrophy. So I, sometimes I reserve that for my so the, my basic is like a, BPE, Like a BPE of occlusion. I’m doing certain things, okay? This is a high functional risk I’m going to do more. And one thing that you do, which I don’t actually do it, you mention the full range of motion. I think that’s great practice by the way. So I think you should do it, but for me, the first time I see someone, can you stick your three fingers in your mouth? They can. Okay, fine. I’m going to move on now. Okay. That’s my BPE. That was a code two or code one, or code zero BP. If they can stick their three fingers in that’s a code four BPE equivalent, right? So like, okay, now I’m going to get the ruler out. So it’s about, it’s about maximizing your time and efficiency, but I think if you could, everyone could do it the way you do it, it’s the best. It’s the gold standard way. I’m just giving those people who might have only 20 minutes new patient examinations, something to work with here you see. Right, let’s cover now, buddy, the relevance of the centric relation contact point. I’m just looking at the time. I think we’ve got another 10 minutes of this episode. We have to cover in the next 10 minutes. Okay? The relevance of the centric relation contact point, and then which ties nicely with this. What if you rehab someone not in CR what could happen? So, Mahmoud, let’s go for it. What do you think is the relevance of the centric relation contact point in terms of you as a restorative dentist?

[Mahmoud]
Okay. So I mean, it becomes relevant in a few cases. Number one, I think, and the most probably important one is when you’re trying to restore the terminal tooth in the arch. So if you have a lower seven that’s fractured and you’ve discussed it with the patient and you’re going to crown it, there is a hot, you know, there’s a good chance that tooth is the centric relation contact point.

[Jaz]
This last tooth in the arch syndrome. Okay. As requested by Oh gosh, I forgot his name. I’m so sorry. He messaged me yesterday. Might have been Jordan. I’m not sure. He says, can we have an episode on this? And I was like, yes, this needs its own episode. So yes, in lawsuits in the arch syndrome is one. But I think we can, we’ll literally that half an hour talking about how to recognize it, how to prevent it, how to communicate to the patient with it. So, yes, let’s just take that as a point. That yet that is one very important point, but I’m probably gonna get you back, buddy. And we’ll just discuss all about that, this concept. Okay? Because that can take a whole, a lot of time. So yes. Can tell me some more? Because I want that to be its own episode.

[Mahmoud]
Okay. So next I use it, personally I use it to verify my centric relation mountings so you know, you check what it is in the mouth when you’re doing your so most of the times he ends up for, to use a leaf gauge. So I’ll find the centric relation contact point. I’ll take a picture of it. Now you verified it with shim stock. You know, it’s not a false contact. Once you’ve taken your two or three CR bites, then you’re getting the mounted. I will then check that contact on the mounting, if it’s exactly the same as in the mouth. And the two bites are the same, you’re pretty comfortable that your mounting is correct. So if I’m going to do an appliance, whether it’s full coverage or anterior only I will check where their centric relation contact point is, and that will also give you, it will show you how much space you’re going to have at the front, if they can only hit on that point. Now, if they have a huge gap, you know, that should they, deprogram enough and you get mandibular repositioning and they do end up with an anterior open bite. You can show them how much of an open bite they’re going to get. And that gives you really good informed consent because they’ve seen it. And we know all the other social risk factors around zero.

[Jaz]
I’m just going to remind everyone. So the A), if they have a large slide and then when you put them in centric relation with the leaf guage, for example, and then suddenly their mandible opens up. Okay? Especially if it’s vertical and now they look very different than mandibles moved a lot. And if they, just like you, Mahmoud said, if they deprogram, then they could have an AOB, not because the anterior intruded or the posterior distruded it’s because the manual shifted. But the other two risk factors here is if they’ve got a lack of a cusp to fossa relationship with the back, if they’ve got all flat teeth and then the mandible almost will find it difficult to remember, ‘oh, this is how I used to bite, because it can’t find is bite again. And the other one is if they start off with a minimal overbite in the first place, then even a tiny shift of the jaw will reveal the underlying AOB. So those are two other factors. So yeah, another great point there, so also to identify those who might be high risk of AOB, and like you said, I love the fact that you said it’s not only anterior only appliances. It’s also Michigans, Tanners, any appliance, okay? Can cause this. And some people naturally over time through nothing at all will develop an AOB because over time the teeth flaten and they almost deprogram themselves. And then now that all my teeth used to fit together, now they don’t anymore.

[Mahmoud]
They’ve equilibrated their own centric relation point around the point basic. Yeah the other time we use it, again, if you are, if you have a anterior tooth wear patient, occasionally you can, if you find that centric relation contact point again, you check and see that can give you enough space anteriorly to do your restorations. And the reason that is handy is because again, if you think about it, if you restore them in that position, they’re actually still at the same OVD posteriorly. So the risk of them having a problem with that thing or, you know, as studies have shown, you know, whatever OVD they had after you’ve restored them, they’re going to resort back to that OVD somehow. You don’t have that problem because you’ve actually maintained the same OVD

[Jaz]
I believe it’s also to do with the muscle length, the muscle length at that CCRP is the same as it was in MIP sometimes. You know, sometimes if you have a vertical component, technically there is a vertical change, but at least that the muscle length would still be happy at that first point of contact. Cause it’s already used to going there, you see as it’s developed with it.

[Mahmoud]
Exactly. You’ve explained it so much better than me. I tell you that you’ve been this living a lot longer. Yeah, I think

[Jaz]
Those are all ones that, yeah, I mean, I just wanted to bounce off to you to cover those. I mean, the main thing is we know, as we discussed from the last episode and hopefully you agree with me, Mahmoud that it is a position of a high restorative convenience reproducibility, which is very advantages to us as restorative dentist. And I like the fact that you covered the last one, the big one is that we’ve got tooth wear you feel like, oh my God, I have no space to build up these front teeth. But actually when you check the, you suddenly have some space in their centric relation contact point, and that will be useful. The only other one I’d say is if you do screen your patients routinely for where is their central relation contact point, and when you check it’s on a tooth on, let’s say a premolar or a first molar or a second molar but that tooth has got a large restoration. It’s got a nasty crack point there. Then that is something that you, you know, if you take a photo and show the patient that look, this is your position where it hits first, and it might be no coincidence that this is a tooth that’s the most battered or most destroyed, most damaged because when we grind, we like to go in that position. And so therefore for this tooth is high risk. Maybe we should be more proactive with it rather than reactive kind of thing. So sometimes just to identify, is it on a tooth that’s already quite compromised? And perhaps when it comes to restoring that tooth, you may be then opting something indirect, gold, perhaps rather than direct because, oh, now I now know one more piece of information about this tooth that this is actually the centric relation contact point so this may change. You might actually be a little bit more destructive and sometimes, very rarely, but to make sure that actually your future proof the restoration, right? And then this leads nicely to the two scenarios I spoke about last episode. Mahmoud, you’ve been absolutely brilliant spiring on me here. It’s been so good to just bounce ideas off. I want to say that last episode I struggled so much. It was like, ah, it was like just the monologue. I just loved having your head. And you know, you’re such a knowledgeable guy, you said all the right things. It’s amazing. So that, that scenario that you have that I discussed in the last episode, whereby you have someone who’s very class two div one, right. They’re very goofy. And then you find that if you take them into centric relation, they become googier or you have airway concerns. And then maybe in that position, you’re going to just restore them in arbitrary position. Okay. What are the disadvantages of doing MIP, complex dentistry versus not doing or versus doing central relation contact point complex dentistry?

[Mahmoud]
I mean the disadvantages yeah. You lose, you probably lose the repeatability of the position. So, I mean, I’ve had a few people so ask in terms of my workflow when I do these things and it’s like, okay, you, you know, you’ve got your CR and you’re going to get a wax up and I’ll always do my best to try that wax up on, you know before I touch anything. So you always try for an additive wax-up and then, so you do the additive wax up, you flush it on and the bites all over the place and you think what’s going on? Well, it’s probably because you spent 10, 15, 20 minutes deprogramming the patient when you took the CR by records. So what makes you think that now you can just stick, you know, they’ve not been wearing an appliance, they haven’t been wearing a anterior deprogrammer and you’ve tried this flash on in, and they’re not biting on it the way it is on the articulator, because their position is different. You haven’t deprogrammed them again. So it’s kind of, it might be the same thing, you know, you’re going to assume you’re going to restore them in this position that isn’t CR, so you, it’s not repeatable you do your wax up. And basically you’re going to have to rely on putting it in and adjusting it and using the mouth as the articulator and hoping you can adjust in enough and it might be fine. It might be absolutely fine. Or you might end up adjusting the daylights out of these frustrations. You end up with teeth that looked like chewing gum or fracturing easily because they’re thin, or I guess worst case scenario is if that patient does go into CR when they parafunction, you’re probably going to be, you’re going to have them, they’re probably only going to be occluding on sevens. Now, chances are, even if your beautiful zirconia or whatever it is you put on there, you probably still won’t be enough. It might well fracture. And that is not even taking into consideration all the other, you know, there’s three parts to the system. You got the teeth, you’ve got the TMJs, you got the muscles and, you know, the failure might happen with any one of them. You can have symptoms of the TMJ, you can have symptoms of the muscles. You’re gonna have problems with teeth. So it’s one of those where I would draw their beans CR because I know that it’s a repeatable position. So when I take my wax up, put it in the mouth, when I take my provisionals, put them in the mouth, I know that I’ve got repeatability. So again, like we said earlier, it really is a position of convenience and there’s nothing magical about it. It just happens to be somewhere you can guide the patient into, or their muscles can guide them into, which is my preferred method. And unless the bone has remodeled, then you’re going to get them there, thereabouts every single time.

[Jaz]
Well you, you said all the main points that I had in terms of what are the compromises that you make, but the main one I’m going to highlight is the last one you said basically, where if you just build everything into MIP and sometimes you have to, because of those two scenarios that I said, right, but just accept the fact that when their the masseters and temporalis everything contracts and the mandible distalizes and they hit their centric relation contact point then they, just like you said, maybe occluding only in the sevens and just like maybe the, before the crown that you did or before the restorations that you did, they already had a battered and destroyed tooth. Well, they’re going to do the same to a restoration. So factor that in. So maybe this patient will need some sort of appliance or, you know, whether it’s built in to CR or not to give them that extra protection on that tooth, because you know that, okay, you haven’t been able to mitigate that one scenario because the fact that you’re taking compromise. So basically imagine that they’re grinding backwards into their centric relation. And as they’re grinding backward stairs, there’s no smooth transition. They’re hitting against, these are Rocky bumpy inclines of the crowns basically. And that’s where potentially chipping and problems can happen as well. Wow. That was an intense one, Mahmoud. We covered all those and that was really intense, but I really loved it, man. I honestly really enjoyed talking to you. I enjoy sparring with you there, and I think me and you are cut from the same occlusal cloth and yeah, I’d love to have you on again, on a last tooth in the arch syndrome. Cause I think that’d be really useful. It’s really bugging me that the, my colleague who messaged me saying, ‘Hey, Jaz, can we have the episode in this?’ I’m going to find it, I’m going to record it in the outro. So thank you for the person who recommended that. Mahmoud, you are having, number three, your wife is having number three soon, right?

[Mahmoud]
Correct. Yes, definitely not me.

[Jaz]
Yes, of course, she has some role which is why you’re off today because it might have been happening. So yeah, I wish you all the best. And you know, it’s great to have you on and thanks for being part of our telegram group, It’s been really great to have your input and I hope that we may meet someday very soon. Where’d, you live again?

[Mahmoud]
Sutton Coldfield so.

[Jaz]
Amazing. Well, I hope we meet one day soon. I’m sure we will, mate.

[Mahmoud]
Yeah, I’m sure. Thanks so much for having me. It was good fun, actually.

Jaz’s Outro: Well, there we have it guys. Mahmoud Ibrahim. How awesome was he. You need to follow him on Instagram, it’s drmoidental, moi as in Francais, right? moidental. So dr-m-o-i-dental, his work is amazing, message him. He’s such a great guy. And if you’re enjoying our telegram app, where me, Mahmoud, lots of others are on, they’re always helping out, Pav’s on there. It’s protrusive.co.uk/telegram and that’ll take you to the telegram group. Join us. We’re always a helpful community there. And I just want to say a shout out to Dr. Chiggz, Gohil Chiggz. Thank you. It was you who recommended that we cover the last tooth in the arch syndrome ie you place a crown or you do a crown prep on the last molar and you get the patient to bite it together and you’ve lost all the space. How can we manage that scenario? So we’ll cover that at some point soon as well. And also before I forget on the website, protrisive.co.uk under this episode, I will put the three minute occlusal examination initially by Stephen Davies and contribute to or modified by Mahmoud. So I’ll stick that on again, as a handout, I’ll even email it to you if you’re on the newsletter group. Okay? Thanks so much for listening all the way to the end and I’ll catch you on the next episode.