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Occlusion Questions from Students – AJ005

See blue dot. Erase blue dot. That was my clinical application of Occlusion at Dental school!

This episode was ‘Occlusion for Dental Students and New Grads’ – as featured on The Very Dental Student podcast.

Oklahoma based Dental student Mohamed Abo-Basha asked Jaz questions to make Occlusion tangible – exploring topics like using a face bow, understanding the importance of centric relation in everyday dentistry (and why in our DAILY bread and butter Dentistry, it’s not very important for 99% of our patients), and strategies for improving our ability to adapt to our patients’ occlusions.

Watch AJ005 on Youtube

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

Highlights of the episode:

  • 0:00 Intro
  • 02:37 Mohamed Abo-Basha and The Very Dental Student Podcast
  • 05:33 Always check Occlusion Pre-Op
  • 11:29 Articulating Paper
  • 16:43 Centric Relation
  • 26:39 Facebows – what and why?
  • 39:02 3D Scanner – can it replace traditional impressions and Facebow transfer?
  • 43:57 Occlusal Diagnosis – does it benefit single tooth dentistry?
  • 58:19 Outro

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax-deductible Nando’s per month?

Learn Occlusion Online

If you liked this episode, you will also like Your Occlusion Questions Answered by Dr Michael Melkers – PDP015

Click below for full episode transcript:

Jaz's Introduction: In this Ask Jaz episode, we had a dental student called Mohamed from Oklahoma in the USA, asking me some really great questions around occlusion. We covered things like when and why should you use a face bow? What is the relevance of centric relation to our daily dentistry? And how can we become better conformers to our patient's occlusions?

[Jaz]
The episode itself will be featuring on the Very Dental Student podcast, so it’s great to be on there, but I thought why not take this opportunity to share it with you guys, to Protruserati, and especially some of the younger dentists and the students coming through, who also have these same burning questions, so that we can all benefit.

Now, as you’ll see from this episode, we could have gone and on, and on, and on, answering all these questions, and we kind of ran out of time, so there may be a part two, but if you have any burning questions for an Ask Jaz episode, or occlusion in general, then do type it in the comments, and we’ll make sure that if we film a part two, that we cover those questions.

Now, before we join the main episode, I’ve had some really great news actually, on Instagram, Course Karma, our good friends at Course Karma, they’ve just messaged me saying, congratulations, your podcast has been voted a top podcast of 2023. So for anyone who voted, even though I didn’t ask you, even though I never emailed you to ask you, I really, really appreciate the fact that you went on, you saw the podcast and you clicked on it, and you voted for Protrusive Dental Podcast as your favorite dental podcaster.

Honestly, it means so much to me and it keeps me going. So thank you everyone for your support. Thank you for the subscribers who keep coming back and I’m only just getting started. I’ve got great, great plans for next year to be more inclusive for all dentists and dentistry students all around the world and to continue to make dentistry tangible.

Oh, and one more thing, those who watch the podcast and not listen to it, you know that we have premium notes on the screen. Now, usually about halfway on YouTube, especially so it’s a free platform. We cover those notes with ads because we reserve the premium notes for our paying members on protrusive. app.

Now, because this episode is for students, primarily, we’re going to give all our premium notes away for free. So the premium notes are there on the screen. And also you’ll get the PDF summary, the premium notes and the transcription. And I usually have this in a hidden place for paying members, but I’ll put this on the main website, which is protrusive. co. uk, and I’ll link it in the show notes below.

And I am working on something for students, like a student scholarship. So all students, all dental students around the world can get a bit more access to the paying stuff that General Dentists pay for access. And that’s how they support the podcast. I’m ever so grateful, but I kind of want to do something for students.

So keep your eyes peeled for that. There could be something coming in a couple of months, which I’m not going to reveal so much, but something just to help access for students. So watch this space. Thank you so much once again, and let’s join the main episode.

[Mohamed]
Hello, everybody. Welcome to another episode of the Very Dental Student Podcast. I’m your host, Mohamed Abo-Basha. I am very excited to announce my co host today. I have Dr. Jaz Gulati joining me from the Protrusive Dental Podcast, and we’re doing a bit of a simulcast today. For those of you who don’t know me, listening from Protrusive Dental Podcast. I am a Protruserati and I am also the host of the Very Dental Student segment of the Very Dental Student podcast.

So it’s a new segment. We’re doing mostly topics that would be interesting for dental students, but also topics that would be interesting for young dentists as well. So, yeah. And Jaz, if you would like to introduce yourself to my listeners who maybe don’t know who you are.

[Jaz]
Oh, no, thank you so much for introducing me. Thanks so much for having me on. It’s great to speak to students. We’re perpetual students of life in every way. So it’s nice to be here. I’m a general dentist based in Reading, UK, and I’m a bit of a geek, right? I did so much like extra CE in my first five years out of dent school, when I just, the learning never stops.

And then I started to share a little bit and the podcast was born. And now I get to have conversations with people just like you and dentists all over the world to help elevate everyone’s game. So that’s kind of areas that I’ve grown an interest in, in my own clinical field is things like occlusion and TMD and that kind of stuff, which is a complex topic.

It’s a complex topic. It’s a scary topic initially. And I guess it kind of attracted me. It’s like dark art. It attracted me towards it. So that’s me in a nutshell and the host of Protrusive Dental podcast. Thanks for mentioning it. But yeah, great to be on the Very Dental Student podcast.

[Mohamed]
Absolutely. So, one thing that I will just plug the Protrusive Dental podcast is it does a really good job of making really complex clinical topics more tangible for the novice listener. And that’s something that I’ve really appreciated. There’s very few podcasts that I really have been able to extract as much clinical wisdom from as the Protrusive Dental Podcast. So, as he kind of alluded to, he’s a bit of an occlusion guru, specifically, which I thought it would be appropriate for us.

[Jaz]
I wouldn’t call you a guru, honestly. Let’s not go there. It’s just a geek, right? I’m just an occlusion geek, right? And, and even then, like one thing we’ll get onto is I couldn’t care less about the Bennett shift, right? I couldn’t care less about various other factors that you read in textbook.

I’m more about the real-world occlusion, which why I love the kind of questions that we discussed beforehand. I love the themes that you’re going in because that is the real world, right? The textbook stuff sometimes gets a little bit too heavy, and that’s why some people get a little bit put off. They take a step away from occlusions that this is a bunch of mumbo jumbo. So I like the real world stuff, which is why I like some of the topics that you chose actually.

[Mohamed]
I’m really glad you mentioned that because that’s actually how I was going to start was mentioning that sometimes in school when we discuss occlusion and we discuss all other like operative and fixed and stuff, it’s almost like they just discuss them separately because even the faculty don’t really know how to really tie them in together.

So hopefully we’ll be able to get into some nitty gritty. And I’ll go ahead and start with our first question is just like, what is one of the most basic things we should avoid when doing single tooth to quadrant dentistry, which is what most new grads or student dentists will be doing?

[Jaz]
Absolutely not. I would say that even once you qualify, it takes years to get up to, if you want to, should you choose to, to try and do more full mouth stuff. Some people are completely happy to do conformative dentistry. That’s the key word there. Because when you’re doing single tooth dentistry, when you’re doing quadrant dentistry, you are conforming.

So let’s just take a step back. What is conforming, right? Conforming is the patient’s bite is pretty much working for them. They’re biting together and they got maybe enough teeth so that they hit together at the same place every time and it’s fairly reproducible for this patient. And you want to go in and you want to do your work and you want to make sure the patient leaves fairly similar, if not identical, to how they were before.

If that’s appropriate for the patient, because you’ve treated the disease, let’s say you’ve treated the caries and you put them back together, how you found them. I liken it to when you’re a kid and you want to have a cookie from the cookie jar, but you don’t want your parents to know. So you’re going to slowly creep up, you’re going to grab that cookie.

And then you’re going to it’s like you’re hiding your tracks. You’re making sure there’s no crumbs left behind you. You’re closing that lid exactly how it was in the exact position. And we should be treating our patients the same way, because the best kind of dentistry is when the patient has to do the least amount of adaptation possible.

So, what we do, or what I did, certainly, I know lots of colleagues do, is when we’re at dental school and beyond, you do your restoration, you check the occlusion, you see the dots. You start grinding away the dots, you check again, you see the dots, you start grinding away the dots, you check again, oh, there’s no more dots.

And okay, that’s done. How does it feel? And the patient says, oh yeah, feels great. Feels like you’ve hardly done anything at all. And then you move on. And so, is that a mistake in a way? Well, yes, it’s an easy thing to do, right? The whole plant it low and let it grow. Have you heard of that one, Mohamed?

[Mohamed]
Yeah, I have heard that.

[Jaz]
And then if you’re also guilty of this as I was for many years and and sometimes accidentally you become guilty of it but something that we kind of just did and so the big mistake there is have you actually truly conformed if before the tooth was functioning and was in the occlusion and now you’ve done a restoration now it’s no longer really in the occlusion. You haven’t really conformed.

And I think all of that begins, firstly, going back to your main question, the biggest mistakes is do we actually check the occlusion before we actually pick up the handpiece? It took me years before I actually would actually make a note of it. So before none of the stuff would be out my bracket table, there would be no articulating paper.

There’d be no shim stock foil. We’ll talk about that. And so you just go on in, you’d numb the patient up and you start drilling. Okay. And then only at the end, when you’re checking with the Arctic paper, you’re thinking, oh, hang on a minute. What was the occlusion like before? Is this how it’s supposed to be?

And so it all begins with, are you actually checking the occlusion to begin with? And so if I was to say the basic things we need to do is if we’re treating an upper first molar, for example. Is the tooth behind, assuming they have one, holding shim? So, shimstock, do you use shimstock, Mohamed? Do you have that?

[Mohamed]
I’ve never used shimstock. I don’t even know what it is, to be honest. I know articulating paper, that’s all.

[Jaz]
So, okay, let’s talk about that. How much do you know? And not to put you on the spot, but, it’s totally cool if you don’t know, because I was the same as you, right? Like, when I was at your age, two years in dental school, I had no idea about there’s different types of papers beyond color, kind of thing, you know? So, all of that was like a brand new thing. So, do you know how thick the paper is?

[Mohamed]
No idea.

[Jaz]
Exactly. And so I was the same, right? And so we’re using it. So someone might be using 200 micron paper, right? And then someone might be using 20 microns. I use like 22 micron, 21 micron, right? And so why is that relevant?

Well, if you use a 200 micron, it makes a big splodge on the tooth, makes a big mark. And if you use a smaller paper, thinner paper, it’s going to make a smaller mark. And so what you get with a thicker paper is false positives. You think the tooth is an inclusion in that area, but actually it’s not. So it goes down to the basic things out.

And the reason I mentioned shim is shim is this foil. It’s articulating foil. It’s not paper, it’s foil. It doesn’t leave a mark on the tooth, but what it is, is eight microns, right? Which is like super thin. And so sometimes teeth look like they’re in occlusion, but when you put the shim through, it’s not holding shim.

We call it a shim hold. And therefore we know that actually this tooth isn’t truly in occlusion. So this is relevant because if we’re treating that upper first molar basic occlusal restoration, right? Simple thing, right? But if you check the tooth behind, which is the second molar, bite together, it’s holding shim, you know?

You’re trying to pull the shim out, it’s not pulling out because now the tooth, we know the tooth is in occlusion. We check the tooth in front. Is the premolar holding shim? It is. Okay, great. And so what you want at the end is, once you’ve done your restoration, you’re checking occlusion, the first thing to check is, okay, are the tooth behind and in front, are they still holding shim?

Because if they’re no longer holding shim, you know by definition your restoration is proud. Right. And so you work with that and at the end you want to basically make sure you’re holding shim as it was before and then on the tooth that you’re working on itself, you look at the dots and you want to see, okay, is the dot in an appropriate place?

Is it on a cusp or incline or was it there already? And so there’s so many different things that we need to do, but it all begins with actually checking the occlusion before you started. And the best way that I found Mohamed in practice is an intraoral camera. I checked with the shim, I checked with the color paper, bite together.

I see where the dots are. I’ll take a quick photo with my intra oral camera. And then when I’ve done my restoration, I check the dots again. Look at the before photo and look at the after photo. And I think, okay, is there a dot? Firstly, it’d be nice if there is a dot. There was a dot before. I’d like there to be a dot again.

And is it roughly in the same position where we don’t want is like the dot to now be on the interface where that composite touches the enamel, right? Because that’s where all the load is going through. It’s like harmful forces going down that interface, which is the weakest area. So little things like that, that we need to assess before and then check again after.

[Mohamed]
That makes a ton of sense. One thing that I kind of wanted to follow up with in terms of the dots when you’re checking the arch with the articulation paper, one faculty has kind of told me like you want it on functional cusp tips and you want it on like fossa and otherwise you don’t want. it to be hitting anywhere. Is that, is it, can it really be that simple? Or is it kind of more nuanced than that?

[Jaz]
So this is very similar to another question, which is do you use rubber dam?

[Mohamed]
I mean, so I haven’t started treating patients clinically yet, but in the same clinic we do.

[Jaz]
Yeah. Okay, fine. So when you get to it in the future as well, the joke is you take away the rubber dam, you check the occlusion. You grind it away, and now all that beautiful anatomy that you labored over is now gone. It looks like a very flat restoration. And so people say, should my composite sculpting, should it resemble the textbook? For a first molar, it should have three buccal cusps and two lingual, that kind of stuff.

Should it look like that? Well, kind of, we use that as an inspiration, but really, it depends on A, what the tooth looked like before you started, and B, what’s opposing it. Because if what’s opposing it is completely flat, then good luck trying to give this bulbous, extravagant anatomy. It’s just not going to match.

It’s not going to match the patient’s existing dentition. So the reason that’s similar to the question you ask is, well, if in an ideal world, yes, we want a functional cusp, for example, an upper premolar, the palatal tip, right? Up against the central fossa of the lower, for example, the marginal ridge of the lower, but it really depends on where the teeth actually in the correct place, because a lot of people don’t have that beautiful cusp to fossa relationship to begin with.

You get the cards that you’re dealt with and you work. You can try and conform to that existing occlusion. So if they started with the incline contact, meaning like, for example, that buccal incline, right? There’s a dot on there. It’s not on the tip. It’s on the incline. It’s not in the faucet. It’s like halfway between.

And then you do your restoration and then You can’t now suddenly change the orientation of the opposing tooth to now meet it in the fossa. You could try and maybe manipulate it a little bit to make meet a little bit closer to the fossa, but you get the tooth positions that you have in front of you and you do the best you can with what’s in front of you.

Where your faculty is completely correct is when you are reorganizing. When you’ve decided that the patient’s seclusion is not working for them and we need to make a wide scale change, for example, opening the vertical dimension, doing lots of restorations. At that point, we can then, along with the technician, decide that, okay, the previous occlusion wasn’t working so great.

What can we do now to minimise failure? How can we optimise the occlusal environment to make sure that everything works well? And to have that sort of cusp to fossa relationship is a nice thing so that it avoids that incline contact, which an incline contact gives a sideways force to a tooth.

It causes flexure. So it’s totally good to have that, but the rules of occlusion do not apply to dentate patients who’ve got M. O. D. amalgams and composite and you’re conforming. You throw the textbook out. The textbook says that we got to work with what’s in front of you. But when we are starting with a blank slate, then yes, that is very true. So we got to make a distinction of what we’re, what’s in front of us.

[Mohamed]
Okay. Yeah, that makes a lot of sense. So in a lot of cases with single tooth dentistry, we really won’t be able to produce ideal occlusal outcomes. Is that basically a good summary of that?

[Jaz]
It is. And it’s a sad summary, isn’t it? We learned all that occlusion and like in the first patient you see, and then you can’t actually give the cusp to fossa, but we try and optimize, we do what we can, like we conform.

But conformative doesn’t always have to mean that the broken down shape of the tooth that we’re going to copy that exactly, we try and change and improve the shape while still making sure that when the patient bites together, it’s comfortable, right? So there are some things that we can do. So, for example, if before there was a really harmful, steep incline contact that we try and sort of shallow it out.

So that it’s not a steep, for example, it’s very difficult to explain without giving a very concrete example of a photograph of it. But the main thing is that, yes, you can only follow those principles when you’ve got like a beautiful wax up and try and do it. But when you have a patient in front of you, you can’t always achieve all those things.

Like the textbook says that everyone should be in there, I don’t want to introduce this term too early, but in centric relation and that kind of stuff. But only 3 percent of patients are in. Just walking about their own centric relation. Everyone has a slide and stuff.

So the rule book, it doesn’t really apply to these dentate individuals. You have to work with what you got. You can optimize what you have, but you’re not going to be able to achieve like a checklist of occlusion on your dentate patients who otherwise are doing conformative dentistry. You have to assess the occlusion before you start.

Make a judgment call of where you’re going to copy it exactly or copy it mostly, but maybe manicure the opposing tooth to remove that sharp cusp tip. So it’s nice and smooth. So that also moves the dots in a certain direction. So those are little things that you can do those little wins that you can get.

[Mohamed]
Yeah. And I guess knowing the textbook principles will let us allow us to kind of decide where we’re going to make those compromises and where we’re going to make those judgment calls as well. So one thing that I’m glad you brought up was centric relation.

So in our occlusion curriculum, we had to memorize like the seven bullet point definition of centric relation and we had to practice taking facebow transfers as well and honestly, I can tell you now that I have no idea what any of it meant, nor how to find out whether patients in centric or honestly, what do you like how to even know?

What the facebow transfer is doing for me. I know it gives us some slightly better anatomical perception of where exactly the patient’s occlusal plane is with relation with their TMJ. But other than that, I don’t really know what is the reason why we take a facebow transfer? When does that really come into play?

Do I need to take one if I’m doing any crown and bridge work or is it usually yeah, just go ahead and run off with that, if you will.

[Jaz]
I mean, yeah, I mean, great, great questions. And I remember being in the same exact position as you. We were doing these central relation bite records on each other. Right? And it was like I was in third year of five in the UK and I had no idea what we’re doing once we did it, I didn’t know why we were doing it because you’re so deep in conformative dentistry when you’re starting out that this whole thing about shifting the jaw and finding this centric relation position is so far from what you’re actually doing on your patients.

So it’s a great opportunity to now let’s see if we can break this down. Let’s make it tangible. So there’s two ways we can go about this. We can talk about the facebow first, but I think maybe beforehand, let’s talk about Centric Relation.

[Mohamed]
Okay.

[Jaz]
Centric Relation does not apply to your daily dentistry. If you ask a general dentist, a general, not a prosthodontist, if you ask a general dentist, what percentage of their patients, are they actually recording Centric Relation? Working in centric relation, which is basically centric relation, if for those who don’t know, is nothing to do with the teeth.

Centric Relation is not to do with the teeth. It’s to do with the condyle being in a snug position. I’m going to use my terms basically. It’s a snug position in the glenoid fossa, right? It’s anterior superior, but it’s a nice snug position. It’s a bit like a ball in a cup. The ball fits very nicely in this cup.

Basically, there’s no other way it could be. And so the condyle fits nice and snugly in this matching sort of reciprocal fossa. And there’s a disc in between it. Whereas, the way the teeth meet together, right, precisely, it’s not necessarily where the condyle is snugly in the glenoid fossa, it might be that the condyle is slightly further forward.

And therefore, where the teeth meet together is called maximum intercuspal position. And the condyle had to come slightly forward maybe, so that the teeth could meet together nicely. Because that’s just the way the teeth erupted. Now, if we move the condyle into that snug position again, the teeth are no longer in maximum intercuspal position.

And so when the condyle is moved, and we’ll talk about how that can happen, is moved into that snug position, you will now be hitting on the centric relation contact point, or it’s known as the recruited contact position, RCP. So really the question to ask is what relevance does that position have to our daily bread and butter dentistry?

It’s very minimal. Right? Very minimal, because when you have a patient and you need to do two fillings on two premolars, okay, position has nothing to do with what we’re actually doing. How are we going to serve our patient and improve the dentistry if we’re just trying to make sure that we can get rid of the decay, get a nice seal, make sure we get a nice tight contact, and when the patient bites together, it feels comfortable and everything, everywhere else is hitting at the same time.

So, the whole centric relation thing, it gets more into play when we are, again, doing more comprehensive dentistry, we are reorganizing, we decide, we make a decision that the patient’s occlusion is not working for them. And therefore, we need to start with a blank slate. And when we’re starting with that blank slate, again, we go back to designing the cusp to fossa relationship and making everything perfect we can.

And so the reason that central relation in many occlusal camps is a favored position to start from is because it’s reproducible. One more great way Lincoln Harris explained it is basically, if I have my arm is out straight completely, right? That is a definite position, right?

If you tell me Jaz, put your arm out straight every time I can go pretty much in the same position, right? But if I was to describe to you this angle that I’m making right now, just put my elbow in, right? Like if I do it 50 times, it might be slightly out every single time, but this position all the way extended.

And this position, all they contracted are the two definites. So, by having the condyle in beautifully in the fossa is a reproducible position. And we like reproducible because imagine now, you have to fit 24 crowns at once. And you fit 24 crowns at once. And then now, you get the patient to bite together.

And Random places are hitting. It’s not quite where you want it. So what can you do? You can manipulate the patient, put that condyle in the fossa in centric relation and start from there. This is where I want it. This is my end goal. And so the reproducibility aspect of centrifugation is restoratively convenient.

And that’s the main reason, right? A lot of people take it too seriously. Oh, it’s when the muscles are in a beautiful position. It’s when patients will stop bruxing. I don’t believe that it’s where they will be able to have a better sleep, whatever, blah, blah, blah. It’s It’s not as powerful as a reproducibility element. So before we talk about face bow stuff, does that make sense regarding centric relation and why actually we don’t use it that much in general dentistry?

[Mohamed]
Yeah, it does make sense. So essentially, you’re saying that it’s when we’ve already decided to rework the occlusion. That’s whenever we need to understand centric relation as kind of like this is the position, the reproducible position where we’re going to build everything out in.

Because you can’t just pick a non producible position because then when you go to the crown seats, whatever type of reconstruction you’re doing, and then you’re not getting the initial positions that you had already taken because you took it in an unproducible manner. Is that kind of what?

[Jaz]
That’s a good way to describe it. And also, have you started to learn the theory of complete dentures? Is that something that you’re on to yet? So, which position have you been taught to use for complete dentures in terms of which jaw position?

[Mohamed]
So, I believe it’s centric. We’ve been talking about VDR minus three as being a good VDO, like a good VDO position.

[Jaz]
That’s the vertical, right? That’s the vertical. But how far forward do you want your patient to bring their jaw? Do you want them like protruded? Or do you want ’em to, you know? What about in the anterior posterior plane? So this is where centric relation comes into it because let’s say you come to the wax try and you’ve got the teeth in in the wax and the patient bites together and they’re breaking off teeth everywhere.

Well, actually, if you now just relax their jaw and there’s ways to do it and you get that condyle back in the fossa again, in that snug reproducible position you have somewhere to work with. Oh yeah, this tooth just needs to, I just need to melt this wax and get this heat up bite together.

Ah, yes. Now we’re together. There was one tooth that was in the way. Hence why I was breaking. So it gives you a reference point to work with basically. So we use it in complete dentures because again, that’s the very first full mouth rehab, right? We use it when we’re doing multiple restorations and completely redesign everything.

We use it in our stabilization splints. So it’s very other times we use it, but most of that dentistry for young dentists and dental students, the work we’re doing mostly is conformative. Whatever the patient had in front of us, wherever the dots were, we’re roughly conforming to that. We’re not having to find out this slide, and the slide is basically when the condyle is in that snug position, the fossa, certain teeth may touch, maybe one tooth will be touching basically.

And then when they bite hard, and they clench together, and then all the teeth suddenly touch, that condyle had to come forward. One or both had to come a little bit forward basically, make that little adjustment. And that adjustment is the slide basically. But this slide only is relevant when we’re doing more comprehensive dentistry. Does that help?

[Mohamed]
Yeah, it does. So do we always have to like, deprogram the patient in order to find out where their centric relation point is?

[Jaz]
Really great question. And so there are two types of patients. Okay, Loosey Goosey and Tighty Whitey. Okay, Loosey Goosey patients are the kind where there’s this way of doing a central relation whereby use a chin point lift.

So you grab the chin, and you just get it nice and loose. And just one thumb and one index finger on the chin. And then you start doing people and some people suddenly that you feel like a release. Like you’ve got full control of their mandible like, hinge it and these patients are Loosey Goosey.

And so that patient, they don’t need much deprogramming. You can very easily get their condyle in that snug position. Other people, and a lot of people actually, are Tighty Whitey in a way that the position of the condyles is controlled by the lateral pterygoid muscles. Lateral pterygoid muscles are actually connecting onto the condyle and onto the disc as well.

So, if all of us, you and me, when we bite together, our teeth, they bite together in MIP consistently every time, right? It’s not like we are knocking in to our centric relation contact point or RCP and then sliding to our MIP every single time we bite together. And we can thank our muscle engrams, the muscle memory in between to the fact that we can bite into MIP every time.

That is what helps us. Now, what we need to do to find the central relation point or central relation in general is how do we switch off those muscle engrams? How do we get those muscles to forget? How do we get that lateral pterygoid to let go? So only when that lateral pterygoid lets go is the condyle allowed to get snugly in the fossa.

So then for those patients, we need to do deprogramming. Now you can do it with an occlusal appliance, you can do it with something called a leaf gauge, you can do it with something like a Lucia jig, and there’s loads of instruments you can do it.

But essentially, a lot of patients will need it just a couple of minutes. Some patients may need to go home with an appliance for several weeks before we can get those muscles to forget how the teeth bite together. Because the muscles are very powerful, but remember, once you get them to forget, then it’s much easier to get that condyle and the fossa.

[Mohamed]
Yeah. That makes a ton of sense. Yeah, that’s definitely cleared that up. But I do want you to also-

[Jaz]
And the Facebow then?

[Mohamed]
Yeah, yeah. To touch on the Facebow as well.

[Jaz]
Yeah. Okay. So facebow again was this weird thing that we did at dental school and it looked really funny and then one tutor at dental school even joked that if you do it for your patients, the patients think, wow, this is really fancy.

It justifies the fees that I’m paying for the work basically. And actually if we look at the evidence base behind facebows, there’s the use of a facebow improve or decrease how much adjusting you’re doing when it comes to stabilization splints? No, it doesn’t. Does it improve the occlusal accuracy and how much adjustments that you’re doing or the overall quality of complete dentures?

No, it doesn’t. So there’s a lot to be said about when and why should we using it? So if we start off the very, very basics, what is that, what does it actually do, right? So if you read the text textbook, it gets your maxilla and it relates it to the terminal hinge axis. Now, what does that actually mean, right?

In real terms, when you actually put a facebow in, let’s do it like a Denar one, for example, it’s got a little fork. That fork attaches to the maxilla, not to the mandible. Right? That only is the maxilla. Therefore, what the lab get is the imprint of the upper teeth, the maxillary teeth. So we know that, okay, the facebow has something to do with the maxillary teeth.

The other part of the facebow is usually going inside the ear. So it’s now we’re relating someone’s maxilla to the ear. So why is that got to do anything? Well, your ear and maxilla might be a slightly different position and orientation to mine. And when we send that to a technician, what will they do?

Because the clue is here. Now, what was that? How are we using that information? And the technician will be using that facebow transfer jig to mount the upper maxillary cast, the mandibular cast is not even in the equation yet. Okay. That upper maxillary cast in the correct plane in the articulator, because the articulator has got this receiving area where the jig goes in.

So that now the hope, and this is the main crux of it, the hope is where the maxilla is in the patient’s mouth in relation to the TMJ is kind of similar to where that mixed maxillary cast is to the pretend TMJ on the articulator. All with the hope that when we do the movements on the articulator, it will mimic or recreate our patient.

Now, fast forward. It doesn’t. Okay. But it’s the best thing that we have at the moment. Well, it’s not the best thing. There’s other things out there, digital things, which are absolutely amazing. But the articulator for many years was the best thing that we had. And it’s all to do with how can we reduce adjusting time?

How can we make sure that when we send for a wax up and the wax up comes back and you try it in the patient’s mouth, that it will be somewhat similar to what we attended on the articulator. How can we recreate the patient’s head and jaw movements onto articulator? And so what the face bow does, it just gives you a little bit more precision and degree of confidence that the way that the articulator moves is a bit more similar than using a average value articulator without the facebow.

So that’s what the facebow does. And then of course, once the maxillary cast is in, in the correct plane on the articulator, which is similar to the patient’s mouth, let’s say, then the mandibular cast is related to the maxillary cast using a bite record that you took. And suddenly now you have the patient in an articulator. So that’s what the facebow does. Does that make sense?

[Mohamed]
It does make sense. And yeah, we’ve definitely worked through those exercises in school. So we’ve practiced mounting them on a semi adjustable articulator and everything. One thing that I take issue with though, is that we go through all this trouble to get the record, the maxillary record.

But then what we’re taught to do is to just hand articulate the mandible, which to me, it’s like, if it doesn’t make sense to me that I would go through all this trouble to articulate the maxillary and then I would just kind of like articulate it where it kind of looks right for the mandible, but-

[Jaz]
There is a good reason for that, right? So, the best, okay, for most patients, not all patients, the best, for most patients, the best bite record actually is no bite record. Because when I have your models, for example, right, and I squirt some silicon BPS, bite registration material on your teeth, and I get you to bite together.

That silicon bite record has some thickness. It has some shrinkage. It has some flex when you take it out. When you take it out, sometimes it deforms a little bit, right? And then when you use that to put your models on, there is adding a little bit more, one more layer of error in the equation. Whereas you get some study models together and sometimes you fit them together and they fit together beautifully.

You know that, okay, this is the patient’s bite. And so the beauty of that is you don’t need the bite record for that individual patient because their teeth are so well located. That actually the no bite record is the best bite record because there’s a one less thing that shrunk. There’s one less thing that had an error.

Where this doesn’t work is when patients don’t have a beautiful cusp to fossa relationship. When they’ve got loads of flat amalgams and they’ve got an AOB because this, the moment you start hand articulating that the models almost don’t fit together, you’re kind of thinking, wait, how does this even fit together?

So if that patient, you are merciless, you are at the mercy of the bite record. You need a bite record in that scenario. But for most, well dented people, young people, you don’t need a bite record and there is actually more precision in that than using a bite record.

[Mohamed]
Okay. So the true value, as you mentioned in the facebow transfer was kind of minimizing adjustments on the day of delivery for indirect restorations.

So beyond that like, so if I’m doing a single crown, is that the only benefit I’m actually getting from this? Like, or is it something to, I know it’s something to do with like the excursive movements are more accurate definitely when we have a facebow transfer, but just, could you just touch on that just a little bit?

[Jaz]
Yeah, so for a single crown It’s not worth the time. So the time that you do it, for example, four or five minutes you’re going to spend to get the facebow, the expense of the silicon or the bite registration material, the technician, making sure that nothing came loose in that transit.

The technician then carefully spending their time that their hard work and time to actually put it on a semi adjustable articulator all for a single crown. And all that time that the dentist and the technician cumulatively spent. Actually, had you not used that facebow and it was a minute adjustment or no adjustment to do with that single crown, then you didn’t really save time.

You just added one more layer of complexity to the scenario. So for a single crown, you don’t need to use a facebow because for a single crown, as long as they have the bite record and if they have a nice bite record or no record of how the crown sits in the patient’s mouth, then the tap, tap, tap.

They can check on the model with a shim stock on the model to make sure that actually the crown is happy in the bite. And the information that they use for the correct angulations of the actual anatomy of the teeth is the adjacent teeth. Right? The tooth behind, the tooth in front, and the opposing tooth.

They all tell you what the anatomy of the tooth should look like. And so with that information, you don’t need to give this extra information of how the maxilla relates to the condyle. Because if we’re just checking the tap, tap, tap, and it’s a non guiding tooth. Let’s say a patient is canine guided.

And so when they move left and right, they’re not even guiding on that first molar crown that you’re doing. So as long as you get the tap, tap, tap happy, and then generally the inclines of teeth are similar to the tooth in front and the tooth behind, then it was a big waste of time doing that face bow.

Where a face bow becomes more critical is when you’re doing more than two units. So three units, for example, okay, doing quadrant. And now you don’t have those references anymore of how I should make those inclines, for example. And so to have the movements on the articulator be a bit more similar to what the patient may have in their mouth, it might then therefore save you adjusting time and give you more predictability in the correct shape and the angulations.

[Mohamed]
Okay, I have kind of two follow up questions for that one. When we’re going with more units in a quadrant, like you said, three or four units, would taking a pre impression and pouring up that model. Help them also kind of guess the angulations and so on that they could build those crowns in if we had a model poured up before we started doing any preparation?

[Jaz]
Yeah, I’ve just reminded something that the other benefit just to mention the facebow is actually is really good for the occlusal cant. Occlusal cant is when the front teeth are just off to one side like that, go down to the right, go down to left as that maxillary cant. It’s really good at giving that information because the patient might have a cant.

But when you send the impression without a facebow to the technician and they will just make it straight because, oh yeah, the patient should be straight. So they’ll make it straight. And now the entire patient on the articulate was really different by several degrees to what the patient has in the mouth because the technician just deleted that can and made it straight on the model.

They made it parallel to the worktop. So that’s the other benefit of the facebow, by the way, when you’re doing aesthetic work, it’s nice to give that there’s other ways, stick by it and stuff around it, but when you’re starting out, I think it’s good practice to use it, to go see what the technician does with the facebow.

And listen, it’s a skill that a lot of people have to relearn by going on expensive occlusion course in the future. So you might as well nail it now. Get some practice. Okay. And it’s a good thing to do. Now, great question. And the answer is yes and no, because quite often you are doing three crowns in a row because there’s like a broken cusp and there’s like a huge MOD amalgamation, there’s a crack in the tooth.

And so when you’re doing that many teeth, you have an opportunity to work with the technician to try and change a few things about, to try and get more ideal occlusion. You apply the textbook a little bit more here because you got a bit more wiggle room to do it a bit more. So therefore the pre impression, it’s not going to be something that you’re going to be aspiring to as much.

However, does it still give you a useful information to the lab? Yes, it does. The way I do it digitally in practice, I do a pre-prep scan. I scan the teeth, how they are before I prep them. So yes, the technician can see what the teeth look like. So maybe if they’re changing certain parameters, they can kind of get inspiration from what the teeth looked like before.

So that is a good way to do it. The other way is that if you’ve got like a broken a tooth with broken cusps. And what you can do is put some expired composite on that tooth. No etch, no bond, put some expired composite on the tooth. And then get the patient to chew, bite together, tap, tap, tap, grind, grind, grind, tap, tap, tap, grind, grind, grind.

Cure it. And now if you take an impression of that or scan it, now not only do you have an impression of the opposing tooth, and where that lands on it, but also with that, by them grinding around, you now know the limits, you can’t really make the new crown bigger than this because otherwise the opposing tooth is going to hit it.

So it’s a good, it’s called a functionally generated path technique, and it’s a really good way of when you have a tricky case and you don’t have any anatomical landmarks in that tooth to use function, use the patient’s opposing tooth and plus function to give some information to lab by the way of a pre impression poured up.

Or a scan they can send to the lab. So the answer is yes. Sometimes it can be helpful, but sometimes you’re doing it as a reference, but the technician will be using the textbook to try and get more idealized occlusion to what was there before.

[Mohamed]
Yeah. So using expired composite to kind of build up. The tooth would almost be like having like an immediate wax up that then you could take a portion of.

[Jaz]
Correct. Immediate, functional wax up, guided by the patient’s own anatomy, because the best articulator is the TMJ. Which is why, one of my buddies, Mahmood Ibrahim, he loves face bows, articulators.

I don’t use them as much because what I tend to do is I’m doing a bigger case. I’m going to get the temps on, but I’m going to now check all my adjustments as though my patient is the articulator. I’ll get them to grind left to right. I will adjust, I will adjust, I will adjust. I will get that occlusion happy on the temporaries or the composites in the mouth and have that trial period rather than laborsome getting it on the wax up and then there is an error when you get it on from the wax up to the patient’s mouth.

But both ways are valid. And I do think The beauty of using a facebow articulator and waxing up, it gives you great skill and practice of what teeth should look like, how teeth come together, what the excursion is like, I think it’s a great thing to do if you’re a student and you have the opportunity to do this kind of stuff, I still think it’s really good to do because you understand a lot more about how the jaw moves, which can apply to adjustments on teeth in the future.

[Mohamed]
Yeah, that’s really great. Another thing you kind of might’ve alluded to a little bit was I wanted to talk about how using a 3d scanner, like what aspects of traditional impressions and facebow transfer can a 3d scanner replace, or what is it not so good at? Cause I remember listening to one of your episodes and you mentioned that sometimes there’s an AI that kind of reads the wear facets on adjacent teeth. And that can help it kind of analyze where the excursions would be. So can you talk about what it can do what it’s good at and what it’s still not so good at with regards to replacing the facebow transfer.

[Jaz]
You’re a very good listener Mohamed. I’d say very good. I’m very impressed. So what it’s good at is static like, you’ve done a two crown or two crowns and you scan the opposing arch, the working arch, and then get the patient to bite together. And because the patient has got lots of teeth and they’ve got a reproducible, MIP, we’re not anywhere near the centric relation.

We’re not worrying about that ’cause we’re doing conformative dentistry. You get the patient to bite together, you make sure you’ve got enough occlusal clearance, enough space for that material that you’re gonna use emax or zirconia, whatever it might be, and then you scan it. And that static scan gets sent to the lab and they print the models.

And so it’s good at doing that. Some scanners do, but some scanners don’t. So the iTero, I don’t think it does. At least if it does, I’ve been missed this function basically. I know the TRIOS I used to use did, it doesn’t send over the motion data to the lab. So it’s okay if static, but it doesn’t give me the left and right excursions.

Whereas a TRIOS, that certain TRIOS versions do. The best thing out there is something called a MODJAW. A MODJAW is this, it’s a French company that make it. Essentially, it motion tracks the mandibles. They’ve got these little like sensors on, there’s like a camera, and the patient’s like chewing gum for example, and looking at these little sensors, it actually gives you the pure function.

That data can be sent to the lab, and so when they’re actually designing the crowns digitally, the digital wax ups, right? It’s with the programming data of exactly how the patient functions and power functions. Whereas when we’re using these AI algorithms, so essentially I send my scan to the lab of the tap bite together only.

And then the computer has to do some work. It looks the way that the opposing teeth that we haven’t prepped, how they look. And it guesstimates, okay, I think this is how the jaw moves. And now I’m going to put this anatomy on the crowns that we’re doing, which roughly matches the orientation and angulations.

And so it’s really cool that we can do that. Now, sometimes you’re doing a bigger case and you’re mixing the two together. You’re getting the digital models, but then you’re also supplementing it with an analog facebow. The other way to do that digitally would be to take really good photos. If you get really good photos of the patient stating standing nice and straight.

You got retractors inside and they’re moving their lips out the way. So now you see the plane of the teeth and behind you is like a nice for example, blinds, like something that’s really horizontal, a reference point and then you get someone from the side as well. Then the technician on the digital software can just tweak and tinker and kind of create facebow effect within a digital articulator.

So I think if you’re kind of doing full mouth dentistry all day, every day, you’re a prosthodontist and something like a module is amazing. But for what us humble general dentists are doing is we’re doing the best we can with what we have. So a scan will get that static for most people.

And then we’re relying a lot on the other information from the teeth, the wear facets on the teeth and anatomy and the inclines of the teeth, or the AI algorithms, if you’re using a digital technician to work out the occlusion.

[Mohamed]
That makes a ton of sense. Do you think that maybe the AI algorithms as they get better will maybe be able to make the whole process much more simple so you can just take two full arch scans and a bite record and that’s all we’d need?

[Jaz]
I think so. I think one day it will. But I think without that motion data of exactly how the teeth come together, cause there’s a whole thing about there’s rats and cows, right? Some people chew very vertical. They go up and down. Some people move, swing their mandible wide, and so that will affect what your cuspal inclines will be like.

And also to know how the patient parafunctions. So what I mean by that is, when you are checking the occlusion on your composite or your crown, you get the patient to bite together, and you get the patient to grind left and right on your articulating paper, that is not checking function. We don’t chew.

When we’re chewing food, we don’t bite together all the way and then grind left and right, right? That’s not how we chew our food. We’re kind of swinging our jaw in, into the own position and that’s function. So what we’re checking for when we’re doing that grind left, grind right is parafunction.

We’re checking, okay, if the patient grinds their teeth at night, for example, which way is the mandible moving and which teeth are touching? And then we get the wear facets to match up. Then we know, okay, this is how the patient parafunctions. And it’s really important that our restorations are in harmony of that. Otherwise you get more D bonds, you get more chipping, you get more flexure and you’re going to get more failure.

[Mohamed]
One thing that I kind of wanted to ask as well. So we mentioned about checking the occlusion beforehand and kind of keeping a mental image of that. But when would you say that it’s actually necessary to get an occlusal diagnosis for a patient?

I’ve heard that term be thrown around before. I don’t really know exactly what it means or what it means to somebody when it comes to daily dentistry. Like what would occlusal diagnosis really do for me if I’m doing single tooth or quadrant dentists dentistry?

[Jaz]
I think this will hurt a lot of people. Do you include the real occlusion gurus out there? I think it’ll hurt a lot of people, but I agree with you. Like, I think there’s a lot of stuff that we get told to record, which is actually not adding any value to what you’re going to be doing. And I think if we boil it down to the bare basics, if you have primary disease, then really we want to get in there, prevention, change their habits, change the diet.

Restore, get the seals that we need. Okay. On these, let’s say direct restorations or temporary crowns and just get the patient good enough that they can still eat their sandwiches and eat their food and stuff because we’re not really there to change the bite just yet. We’re not doing complex stuff because we’re still in that stabilization phase.

And so it’s often in the stabilization phase where you’re just putting out fires. Now, sometimes you enter the realm of occlusal disease, which is not a great term, and we’ll come on to why that’s not a great term at the end, but if you have someone who the whole reason why their dentition is destroyed is down to the occlusion and severe wear and that kind of stuff and nothing to do with the caries.

Well, then, yes, it becomes more of a big deal to make sure that we get all our occlusal diagnoses before we embark on this case, because this case will probably need opening the vertical dimension. And therefore, it’s become a lot more complex. But if you are serving your patient by just doing a few restorations in otherwise bite that seems to be working for the patient.

You don’t need to go overboard in the things that record it wouldn’t mean would it be helpful if I just read through some of the things I have my basic occlusal examination form that I do for my patients?

[Mohamed]
Yeah, I think that would be extremely helpful, yeah.

[Jaz]
Okay, so history wise, I would want to know about any history of joint noises clicking and popping. Because, what you’ll find is that, especially when you do rubber dam dentistry is, you start doing your dentistry and then they’re there for like an hour and a half, couple hours. And then at the end, you find that they’re not able to close their mouth together as they were before. Or they’re getting severe pain and aches because their muscles are on fire.

And you want to know all these things before you start. The other classic one we see is, I didn’t have a click before you did the filling. But actually they always had the click, but they just weren’t aware of it. And because they had a little acute episode of pain, they started to focus on their click.

And so having just a bit, it takes a few seconds just to put your fingers by the condyle and get them to open, close, open, close and figure out if there’s a click or not. So these are, I think, I don’t think it’s too much to ask for just to get a basic joint diagnosis in terms of, is there a displacement, are you click or not?

Is there any history of locking, popping joint noises that we just create as a baseline? And it may not, it’s not going to change which composite you use. It’s not going to change exactly the dots or what you’re doing with your restorations, but it’s patient management as a whole to make sure it avoids trouble.

And you identify those patients that perhaps, even though it’s simple dentistry, you may want to refer this patient because actually every time they have a restoration, they have this terrible jaw ache. They have clicking popping, their bite never settles. And so why should we treat that patient?

And really a prosthodontist may be better serving that patient by seeing them, for example. I also want to know about any history of locking, because the difference between just a click as a sound versus locking is huge. Locking is when they can’t open anymore, right? Like there’s a catch. The disc is out of position.

They can’t open anymore. And so that is a very unstable situation, especially if it’s like they lock and then they unlock and then they lock and they unlock. And that’s linked to lots of degenerative changes of the condyle. So I want to know what I’m up against because I do not want to do any comprehensive dentistry.

I don’t want to do more than a single unit. I don’t want to do more than stage one extirpations, extractions, and fighting the caries on someone who’s got a joint like that. I’d rather get that joint healthy first. So it really depends on where you are on that ladder with that patient.

If it’s like fighting fires, then yeah, whatever joint say is to have, you accept it and you do the best for the patient. But once you’ve got them stable and you want to serve them better, you need to make sure you don’t jump in without knowing all these things. Sure, I wonder about their pain from the jaw.

Headaches, migraines, because again, it’s one of those things that if someone is a headache-y person, migraine-y person, it’s linked to them not having a great adaptive capacity. How well can they adapt, basically? And so, even within the TMD realms, one of the 12-13 diagnoses you can make within TMD is a TMD headache.

So it’s relevant and people are thinking, well, again, it’s not gonna affect the crown that you’re doing in the lower first molar. It’s not, but it literally takes 10 seconds to ask and if usually answers no, you just move on only if it’s like, yes, the headachy and they get pain for the jaw and they used to have locking that paints a different picture of a patient says sometimes it’s not the information in isolation.

It’s information altogether that you must consider. So this very quick and easy thing just to find out a change in bite. Like I totally want to know if the patient has reported a change in their bite because I don’t want to be that dentist who’s placed that crown or done the filling. And they come back and they say, oh, yeah, I can’t find my bite anymore.

My bite keeps changing. Thankfully, these patients are not very common. Most patients, they got a nice stable MIP, maximum intercuspal position, and we don’t need to worry about it. But in the one in three in a hundred that have this issue. You want to know about it. It’s so easy just to ask it.

Have you ever noticed a change in your bite? Most people are just like, no. And it’s so easy to ask. A lot of these things that might seem like, whoa, it’s too much detail, but it’s, it’s very, very quick. Awareness of Bruxism. And it’s the question to ask is, you don’t ask, do you grind your teeth? Because they’re always going to say no, right?

No one’s aware of it. So it’s like, are you aware if you grind your teeth? So either they say, yes, I’m aware or no, but all they’ve said at that point is I’m not aware of it. It’s for you at that point to make a judgment call by doing your grind scene investigation in the mouth to see, okay, are there wear facets present?

Do they match up? And therefore you, they are a probable bruxist basically, different diagnosis levels. So just finding out, hey, are you aware if you grind your teeth or clench your teeth? And then just write what they say very very simple basically and have teeth shortened or discolored over time. So I want to know that are we dealing with someone who’s aware that their teeth are wearing away. So that’s like the history extra orally.

All I want to know is the size of the masseters, right? This is something I didn’t do for many years until after I qualified, before I got taught an extra oral exam I checked the lymph nodes. I checked the masseters but I wasn’t really sure what I was feeling. But if you get the patient to actually bite together and clench, you will feel a huge difference in your patients.

Some patients have got like a nice normal muscle contractions and other patients, when they bite down, there’s like these two huge golf balls coming out of their jaw. Those patients are going to generate a lot more force. And that may influence the type of material I may use. That might influence how much occlusal reduction I do for that tooth.

That might influence whether or not I think they may need an occlusal appliance afterwards. And if they’ve done a fair bit of expensive work, and I know that they’re going to be chewed up by the patient, that is worthwhile considering. So their occlusal risk, their occlusal force is informed by the size of their masseter.

Same with the TMJ, I’m just feeling for, is there any tenderness, just palpate, is there any tenderness, clicking we already discussed, but in the history, but now you just get to check for yourself, open close, most patients, nice and smooth, there’s no major sort of deviations, deflections, the jaw’s not moving in funny ways, because in that five out of a hundred patient that has these funny jaw movements. Do you really want to treat that patient?

And one of the things I really stand for is feed the specialists, feed them, right? Let them, don’t let them go hungry. Okay. Because to cherry pick as a gen, our job as a general dental practitioner is so tricky, Mohamed.

I don’t know if you were a speciality in your mind that you want to do in the future, but being a GDP is so difficult because you have to literally be a jack of all trades. Right? So it’s one of the best bits of advice I can give to any dental student is, it’s completely okay to cherry pick. It’s completely okay to refer, refer the ones that you don’t like, or you don’t want, you’re not interested in and live a happy life.

Go to Disneyland with your kids, not have to worry about all these kinds of patients, right? Whereas if you keep saying yes to everyone and you don’t have like an inclusion criteria and exclusion criteria, you’re going to really struggle because you get all these curveball sense. So back on task, if a patient opens and they have to move their jaw and all these funny positions when they open, then maybe you don’t want to be doing a crown on that patient.

Because there’s other 99 patients waiting for your crown that don’t have a funny jaw, that you might not exacerbate, that you might not mess up unless you’re really confident in that area of dentistry. Does that make sense?

[Mohamed]
It does make sense. All of these kinds of diagnostic questions are also in a way you’re using them as a screener to decide whether this patient is really somebody you want to be treating in your practice essentially and if and if there is enough red flags, then it’s it’s most likely somebody that you would have to boot off to a specialist.

[Jaz]
That’s it. So, simple dentistry on a complex patient is still complex, right? So simple dentistry in a complex patient is still complex. So knowing all these things, and again, did it take a long time in your basic checkup to just check get them to open up and close? It didn’t take very long to do that.

And so all I want to know at that point is mouth opening. Can they get three of their fingers in vertically into their mouth? If they get three fingers in, I’m happy to do a molar root canal. I’m happy to do a molar crown. If they can’t get their three fingers in. That molar root canal they need, that’s going to the endodontist, right?

Because they are so much more skilled than I am and they’ll do a much better, faster job. And the whole reason why they can’t even open three fingers means that, okay, maybe they’ve got a TMJ kind of history, muscular history, that you don’t want to be the one who exacerbates that by having them open their mouth for so long.

So, basic thing there, do they pass it, do they fail it? And then intra orally, do they have cheek ridging, do they have tongue scalloping, lingual tori? These things are, are, are weakly associated with the bruxism. We’re looking for wear facets, right? These shiny areas of teeth, flat areas. Remember, if it looks like a dentist has gone in with a burr and gone, bzzz then it’s probably the patient chewing up their own teeth.

And you want to be aware what you’re up against, right? You want to know about these wear facets. So the more wear facets they have, the more it feeds into the fact that, okay, they may be a bruxist and therefore that changes the occlusal risk that you have for the patient, you want to make sure that the crown that you put respects the pathway of the way the jaw wants to move because bruxism is a behavior.

It’s a muscle movement. You don’t want to make sure that you put your restoration in the firing line before it was flat. And now you’ve given it this extra length. The patient is just going to exhibit that behavior again and break it. So you want to make sure that you conform. So it’s much easier to treat a patient who doesn’t have much attrition.

Than to treat a patient with significant attrition because you’re just at way less risk treating someone with less attrition So just noting these things that are very important and lastly just knowing are they class one? Are they class two? Are they class three? What is their overbite percentage and you can just get this from a photo, right?

These are basic records that you do because at the end if something changes in the bite which happens very rarely, 1 percent 2 percent or less even you have something to fall back on. Is it really asking for too much? If you record in the notes of their class one, class two, what their overbite is?

I think this is just basic checkup, right? And then just checking their occluding scheme. Are they group function? Are they canine guided? Simple thing to note, get the patient to bite together. And a top tip here for students is don’t just get them to grind left and right, get them to grind card and go left and right.

What you thought was a canine guidance might actually be a group function. Right? Because if they’re doing it in their sleep, they might be doing it really, really hard. And so check it when they’re clenching as well. And the reason why that’s relevant, Mohamed, is if you’re going to be doing a premolar restoration, and it’s going on to the buccal incline a bit, and you know the patient’s group function, then you know that you’re dealing with a guiding tooth.

And so now you want to conform to the dot, but maybe you also want to think about conforming to the line. Or making a judicious decision that actually I’m going to this tooth is a very weakened tooth. I’m going to choose to keep this line out of the occlusion, i. e. I’m happy for the other teeth to take that excursive movement, but I don’t want this tooth that’s just had a root canal and it’s got a crack to have that excursion. But you wouldn’t have known that had you checked beforehand.

[Mohamed]
I think all of those questions make a ton of sense as screeners to kind of give us a starting base of knowledge of the patient’s occlusion that’ll help us make informed treatment decisions as we’re doing our dentistry. Jaz, I’ve really enjoyed having you on.

I did have more questions, but it seems like maybe we’ll have to do another episode sometime. Yeah, to talk about a little bit more complex things, but it was really a pleasure having you on. This was my first really nitty gritty clinical episode on the Very Dental Student podcast, and hopefully there will be more coming. So yeah, it’s been a pleasure. I’ve learned a lot for sure and I hope the listeners have as well. Is there anything you’d like to close with any remarks?

[Jaz]
I think you guys are in a wonderful position. Remember that dentistry is this career that there’s so much doom and gloom out there. But remember that we are in a fantastic profession that’s always changing.

And that’s a good thing. There’s so many technological advancements happening and to embrace it and to not get overwhelmed by all the stuff that we see on Instagram, on social media, and this feeling that you’re inadequate, that you need to catch up and stuff. If you go at your own pace and you serve your patients well, and you look after them and you go for that CE or you go for the extra knowledge.

Cause dental school is like a license, right? It’s like a driving license. You only really learn how to drive after you get the license. So don’t beat yourself up over this fact, but enjoy the dental school experience while you have it. But remember that that’s the one chapter closed and then a new chapter of continual learning and improving and refining all those things that you perhaps didn’t understand the first time around at dental school, and there’s no shame in admitting that.

[Mohamed]
Brilliant. Thank you so much, Jaz, for all of the information you’ve been willing to share. And to the listeners, we’ll see you on the next episode. Thank you.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end of this Ask Jaz. If you found this helpful, please do send it to a colleague who may have an occlusal itch that needs scratching.

We also have a whole bank of questions that you guys send in, so please keep it up. Write it in the comments or send to us on Instagram on @protrusivedental. It’s always nice to read your questions but also your reflections on the episodes and generally just to chit chat on Instagram. I’ve actually caught up with questions from guys that we’ve collected but if you have any more questions please do comment below if you’re watching on YouTube.

If you’re listening maybe on Spotify, Apple. Thanks so much for being a loyal audio listener. Feel free to reach out on Instagram once again. It would be really great to connect and have your questions via a direct message so we can tackle those nitty gritty details that you want covering.

The producer for this episode was Erika Allen Benitez. The CPD lead, so even though it’s a student’s episode, there is no CPD for students, but those premium members, they can still answer the quizzes and get 55 minutes CPD for this episode via the usual route on protrusive.app and so Mari, thanks for sorting out the certification. And the premium notes were done by Emma Hutchinson, who’s part of Team Protrusive.

Thanks so much. And I’ll catch you same time, same place next week.

Hosted by
Jaz Gulati

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