How to Place Posterior Composites without Destroying Your Anatomy – PDP200

Teaser:
Some patients are like princess and the pea, whereas other patients are like everything feels amazing. And the very last thing you check is how does that feel? That’s like the last. Why are we getting patients to feel their bite?

They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say, how does it feel? How does it feel? They’re feeling their bite. Something that really should be not really present for them, if you like.

Once you get quicker and slicker, I would urge you to start checking front teeth as well. Because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock. And I think you’ll be surprised.

Jaz’s Introduction:
So you go on a posterior composite course, you brush up on your anatomy and you’re excited to place posterior composites that actually look like teeth instead of just white amalgams. And so what happens is that you have like the best fun ever, trying to create all the fissures and the inclines and anatomy. And with rubber dam on, you take that photo and you just stare at it for five seconds and you think, yeah, this is a work of art. I’m going to post this one on Instagram. And then you already know where I’m going with this.

You already know what I’m going to mention next, which is you take off the rubber dam and you get the patient to bite together. And literally like the bite is so open, right? You have to get the big bur, right? You have to get a big bur throughout and just grind away all the anatomy. Now you have a white amalgam left.

Obviously, it’s composite, but it’s now flat. It may as well just been a white amalgam. All that fun you had was wasted and you’re getting evils from your dental assistant because you just wasted up to anything up to 20 minutes. Earlier in my career, it could take that long to get the bite right.

And you think, wow, what a waste. What a waste of time to doing anatomy. What a waste of clinical time. What a waste of my DA’s lunch hour. And this is not profitable. This is not fun. It’s depressing. So this is why this episode will give you such a good framework to eliminate or at least significantly reduce how much adjustment you have to do for your composites.

So they can still look good. Like I’ll be honest with you. Sometimes you just can’t do a beautiful composite in that scenario, because guess what? All the other teeth in that arch are quite worn and you can’t give a 70 year old a 12 year old’s tooth. But in our daily scenarios, we give you some really tangible pearls and tips and technique advice to reduce the amount of adjustment, be more purposeful in your composite placement, but still take some degree of pride in the anatomy that you’re placing.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re a regular watcher or listener, please do hit that subscribe button. You’ve been listening to us for so many years, you might as well give us some love. And if you’re new to the podcast, definitely hit subscribe because you don’t want to miss another episode and you want the algorithms to show you all the other episodes we’ve done over the last six years.

This is an important episode because this is episode 200 of PDP as a podcast we have almost 300 episodes including all the other branches of the podcast we do. But in terms of the original PDP it’s such an exciting number and I’m especially grateful to about five to eight hundred of you who’s literally stuck by me from episode one.

So when I used to make my first 10 episodes, so there’s about five to 800 people that would listen to watch full stop back then we were audio only. And now I look at the numbers and it’s amazing. We are a top 1 percent podcast in the world, in any genre. And it’s thanks to you guys sticking with Protrusive, the feedback and the guidance you give me, to allow us to make great content. I’m not going to take up too much time. I just want to say thank you again for being a Protruserati.

Dental Pearl
Now every PDP episode I give you a Protrusive Dental Pearl. This one’s regarding our basic posterior composites. So it’s very much in line with the theme of today, getting the occlusion right in your posterior composites, but actually this is due with cavity configuration.

We want these proximate exit angles, which are smooth and flowing. And so recently I posted a pre molar I did, and I was quite happy with the anatomy I achieved, and yes, it was perfect in the occlusion. And I posted my cavity prep on Protrusive Guidance, and I said, guys, please do critique me. Is there anything I could do better?

And despite me using an old science scaler to remove the Friable enamel. I’m using like a needle diamond bur just to smooth out those exit angles. One of the Protruserati Sai still said that, you know what, we can get this a bit smoother. Have you considered using a soflex disc? And I’m like, whoa, I use soflex discs all the time.

So at the end of every composite, I will always use a soflex disc. And for my anterior dentistry, I’ll reinforce my bevels with a soflex disc. I find discs great to get rid of the friable enamel, the unsupported enamel. But I did remember now that I’m out of habit of using these discs posteriorly at the time of cavity configuration.

I usually pick them up after I’ve completed the composite restoration. And so really it’s reinforcing what I re learned and reminding you guys that a flexible coarse disc used in the backhand stroke can really help you to get nice, smooth, flowing enamel, those lovely exit angles that we desire for our composite bonding.

So thank you Sai and thank you everyone who commented on that post on Protrusive Guidance. If you’re not already on there, it’s the home of the nicest and geekiest dentists in the world. There’s no such thing as a silly question. I’m really enjoying seeing the chat thriving and people posting more. Now we’ve already got six years worth of podcast data on there.

Plus all the feed posts for the last six months. And so the search function is so valuable. If you’re looking to learn something, just search it on Protrusive Guidance. More than likely, we’ve already covered some element of that before. Anyway, let’s join a familiar face, Dr. Mahmoud Ibrahim, to make sure you don’t have to remove the beautiful anatomy of your composites anymore.

Main Episode:
Dr. Mahmoud Ibrahim, welcome back again to the umpteenth time to the Protrusive Dental Podcast, my occlusion brother from another mother, as I say. How are you today?

[Mahmoud]
I’m good, man. I’m good. I’m feeling like a bit of part of the furniture now in Protrusive. So that’s a good thing.

[Jaz]
It’s a good thing. You’re an integral part of the Protrusive community. It’s great to see your minimally invasive Mahmoud Ibrahim, the Mimi cases on PG. You need to get back on those and your contributions. Like anytime someone asked, like Nabila was asking the other day on the community, can someone just explain to me like what different composites are out there and like which one should I use and stuff.

And I gave a little, I chimed in a little bit, but I was like, okay I’m going to tag Mahmoud and he’s going to take it away. And you wrote this beautiful like essay and when I say essay like not in a boring way like every sentence had so much value. So thank you for all that you bring in terms of from occlusion perspective and composite perspective. And so we’re marrying exactly those two themes together on today so we can help dentists to stop doing this mistake that we all have made, we all continually make on a daily basis, which is you place your composite.

This could be anterior, gosh I’ve been there, and this could be more commonly posterior, rubber dam or not, whatever, rubber dam police, pipe down for a second. You place your posterior composite, and it looks beautiful, like you’ve been studying the books, you’ve been going to some courses on anatomy, and you think you’ve absolutely nailed the three buccal cusps, the slopes, everything, the secondary and tertiary, the marginal ridges, everything and the patient bites together and you’re like, holy crud.

You now have to adjust everything away. And then by the end of it, it just looks like a squashed banana or something, right? And so it’s no good. But before we discuss these pain points and then more importantly the solutions, this is not like a clickbaity episode. We’re going to give you brilliant solutions that you can apply straight away and this is going to absolutely solve this problem.

So this hopefully will be the most career changing daily tangible podcast you may have ever listened to because we make so much of our income from just bread and butter direct restoration. So I’m hoping this will have a huge effect over those who haven’t. For some reason there’s the, like they saw the title, this is the first ever episode they’ve clicked on Mahmoud. Can you just tell us about yourself?

[Mahmoud]
Well, yeah, so my name is Mahmoud. I’m a general dentist. I’m nearly 20 years qualified now, like I said last time. And yeah, when you combine occlusion and composite for me, that’s where my passion lies, you mentioned the little essay I wrote. And honestly, sometimes I need to reel it in, right?

Like I’m sitting there, I’m trying to answer this question as comprehensively as I can, but I’m also conscious of like my wife shouting at me and kids are climbing up on my head, but yeah, those two things really, really get me sort of get the creative juices flowing and want me to give as much value as I can. And yeah, if you ever want to check out sort of what I do, I post a lot of it on Instagram, so it’s a DR M O I Dental is my handle, and you’ll see the kind of stuff I love doing. So day in and day out.

[Jaz]
I would put that in the show notes link because it’s actually a work of art, your resin stuff. I’m not anywhere near that. I mean, I like to get my primary anatomy, like my line angles and I’ve had a good day and my patients, my specialty is taking patients from a 3 out of 10 to an 8 out of 10 if on a good day. Whereas you’re like taking people from like 7 to a 10, which is a whole another skill. Okay, so kudos to you, my friend.

Guys, if you haven’t listened to any of Mahmoud’s stuff before, just go back, like if you’re on Protrusive Guidance, our app, just search, use the search function. We’ve paid a lot of money to developers to have that search function in there, I promise you. Okay. Hit that search button. Just type in Mahmoud and just binge on his posts.

But importantly, some of the previous episodes we did on like basics of occlusion stuff, he talks about his journey that you almost gave up dentistry, right? And what a loss to the profession and what a loss to my partner in crime that would have been had, had we lost you to the web development world or whatever it was at the time. But Mahmoud, let’s talk about this problem. Okay.

[Mahmoud]
Sucked at that too much. I couldn’t do it.

[Jaz]
I’m glad you managed to reel back into dentistry, my friend. So composite, where do we even begin to discuss this mammoth topic? Let’s just describe, paint the picture, okay? Let’s start posterior, because I think there’s different strategies and tools we can use, posterior and anterior.

So let’s start posterior. Occlusal restoration, okay? What do you think is the first thing we should do, okay, because I’m already hinting at the fact that, okay, it all starts at the beginning rather than after you place your composite. How can you do preempt this and actually solve this issue before you’ve even done anything to the tooth?

[Mahmoud]
Well, we always talk about the fact that 90 percent of our work is conformative dentistry, meaning I’m not going to change the patient’s bite, right? I want to keep things the way they are. You give a lovely, lovely analogy of a kid trying to get a cookie out of a cookie jar, right? The idea is you don’t want to leave any trails.

You don’t want anyone to know you’ve been there, but in order to conform to something and not change it, you need to know what was there before. So the first step is always going to be examine the patient’s occlusion before you pick up a handpiece before you numb them up, okay? And generally speaking, actually it’s something I do when I’ve decided this tooth might need a restoration, right?

You’ve diagnosed the caries, you’ve done your bitings or whatever it is, right? And it’s at that point that I’ll also have a look, just get the patient to bite together. I’ll just have a look, you know? Early on in my career, this has happened a couple of times where I’ve done the restoration and then I get the patient to bite together and then I realize they don’t have an opposing tooth. And then you’re like-

[Jaz]
Been there, been there.

[Mahmoud]
I feel like an idiot.

[Jaz]
I think we’re all smiling because we’ve all been there.

[Mahmoud]
Yeah, yeah, 100% happens and you’re like, hey, easy day. So, but yeah, just check what it was beforehand and we’ll go through sort of the steps, but that’s where it needs to start.

[Jaz]
Now on this point, cause it’s so, so important, this aspect, and it sounds like simple. It’s like, oh, I’ve heard this before, but so many of our friends, our dear friends, our colleagues are just not getting into the habit. All it is, is a habit. Once you do it for 21 days in a row, form a habit, whatever it is, it just becomes second nature.

And it doesn’t even have to be, when we say check the occlusion, what we don’t mean is, get a stethoscope, listen to the joint, measure the mouth opening. We don’t mean anything like that. We literally mean a pair of Miller forceps, okay. Articulating paper. I like AccuFilm, which is 24 microns, double sided. What do you use at the moment?

[Mahmoud]
I use TrollFoil.

[Jaz]
I love TrollFoil too. So I use that for my anterior stuff as well. And sometimes, yeah, for ease, TrollFoil, if no one’s used it, it’s very clever. It’s like, supposedly it’s like eight, but the data says maybe it’s more 12 micron range, which is still thin. It’s great. Okay, and then you literally like peel it away. So it becomes its own Miller’s forceps. So it’s like a handle that you can hold that’s not going to ink on your gloves.

[Mahmoud]
I’ll confess. I still use it with Miller’s forceps.

[Jaz]
Yes, I know you do.

[Mahmoud]
You still, you can’t move the cheek out of the way without the actual Miller’s.

[Jaz]
That’s true. I get a little lazy. I just round my fingers in and just get the cheek out of the way like that. But your way is more effective, okay? So TrollFoil is great. So it’s nice to sometimes just talk about what papers we’re using. And note that we’re using thinner papers, because again, we’re going back to basics when I, like I was lecturing or doing a webinar for Generation D in Malaysia the other week.

And I just asked the room on Zoom. I said, does anyone actually know what size your articulating paper is? And I think there was like 40 people on that zoom meeting. And I think only one of them knew. Okay. That’s it. So 39 did not even know. And so the problem with that is if you’re using that horrible thick stuff, which has its use, by the way, when you’re checking function and anterior envelopes, that kind of stuff, when we’re using that 200 thick cardboard paper, right, and you imprint the patient’s occlusion, you get them to bite together, you are getting too much data.

The whole tooth goes blue, and you’re thinking, okay, what do I actually adjust? And you end up just mowing the whole thing away. That is not being precise. When you get smaller markings which are more truly representing the true contact, even then you get some false positives, i.e there’s ink on the tooth, which does not actually represent a true contact. It’s just a smear a smudge on a tooth. So if you want to be more precise, please first thing find out what size articulating paper you have and make sure you are using something thinner. It doesn’t break the bank and it’s good practice.

So first thing to make it actually help the people move the needle forward. So if you’re not already doing this number one check which articulating paper you’re using. Make sure you’re using something thinner and tell your nurse about it as well. Educate them and okay, this is why we’re using this and this is the one I like the most from now on. And then number two, if the Miller’s forceps and the articulating paper is not on your bracket table before you start the procedure, i.e. it’s somewhere behind you, it’s not going to happen.

[Mahmoud]
Exactly right. I think that probably is the biggest thing. Now we’re in all of dentistry, whether you want to take more photos, whether you want to check the occlusion. Just be prepared. Have it out already. So my nurse knows to have red and blue arctic paper out. Does she always get the red out? No, sometimes I still have to remind her about that for some reason.

[Jaz]
So Mahmoud, this is red Troll Foil and blue Troll Foil is what you’re using, yeah?

[Mahmoud]
Yeah, I know it’s expensive. And then some shim stock, okay? And we’ll talk about shim stock in a second.

[Jaz]
We’ll talk about why shim stock, otherwise not move forward, okay? So we’ve decided that, okay, you’re going to have your correct arctic paper, and we’ll talk about foil as well. And it’s going to be there, and you’ve had that chat, that all important chat about, why you’re doing something because what nurses hate the most is that you go on a course, you come back, you start doing some random shit you’ve never done before, and they’re like, what the hell is going on?

Because what nurses crave is routine and predictability. So anytime you’re introducing something new to the scenario, we must do our due diligence. and just have that chat. Oh, Zoe, before we just bring the next patient in and she’ll roll her eyes like, what now? What have you bought now? What have you done? I was like, no, no, no, this is really important. This is what I’m going to do from now on, because-

[Mahmoud]
This one will really stick, right? As opposed to all the 17 other things you’ve tried you don’t do anymore.

[Jaz]
It’s like when you explain to someone what you’re doing, fine, but when you tell them why you’re doing it, then they’re more likely to agree, right? It’s one of those psychological experiments, right? So when I tell Zoe I’m doing something new, and Zoe’s great, she actually wants to know why, which I really respect Zoe for that reason. So I tell her, This is what I’m doing. This is why I’m doing it. And this is why I’m not using the old protocol anymore.

So if we are still using the same protocols for eight years ago, yes. That’s a comfortable thing, but I don’t see that as evolution. I’m constantly changing my protocols because I hear something better. I like the sound of something. There’s new techniques coming out. So it’s really important to educate our colleagues that work with us day in, day out as well, because they’re the ones who actually selecting the stuff.

They’re the ones who are going to make a bigger order of Miller’s forceps, or maybe you don’t have any Miller’s forceps in practice. And maybe that’s a good place to start to order some Miller’s forceps. Right? So now we’ve got our Miller’s, we’ve got our arctic paper and you mentioned the foil. Tell us more about why mean you love shim stock foil.

[Mahmoud]
So shim stock foil for me probably again is like that makes a huge jump in your accuracy for not much work. And shim stock is essentially, depending on the brand is like eight to 11 microns, non marking foil super thin and it has no ink on it. And the way you use it is you want to get it between the patient’s teeth, ask them to close into their habitual bite into MIP and you’re trying to pull the shim stock out from between the teeth, right?

If the patient’s closed and you’re trying to pull it and it doesn’t come out, That is called a shim stock hold. Now, you know that there’s true contact between those two teeth. If the patient is closing and you can pull the shim stock straight out and just come straight out, you know, that actually there isn’t any contact between those two teeth, despite what you might see using the marking paper.

There is something in between where you will feel it sort of drag a little bit. And I do think that’s, again, it just takes you up a level where you can notice the drag. That just means that the teeth are close to touching a tiny bit, but not hard in contact.

[Jaz]
And the reason why this improves our precision is that like this is like the opposite end of that 200 micron paper, right? Which again has its uses but for daily MIP IER tap tap tap bite. It’s a bit overkill. It’s too thick Okay, so at the one end you got less precision. Okay, which is a 200 micron paper and on the other end is this foil which is eight microns. And it tells us is there a true contact in the patient’s bite because if all we rely on is our eye. And we think, oh, this premolar cusp sits nicely into this premolar fossa, this tooth is in contact.

But actually, so many times you put the shim stock foil in and you can pull it out and you’re like, ah, actually this tooth is not in bite. Now, why is this important is because once you’ve done your restoration, just like Mahmoud said, guys, if you don’t know what the occlusion was like before, How can you really check it at the end?

So maybe your composite isn’t proud. Maybe your composite’s just fine, because yes, the shim is pulling on the premolar, but guess what? It was never in contact in the first place. So when you know where your shim stock holds are, you can truly conform to the correct bite at the end that’s comfortable for the patient, and this is a great way to do it.

So we’ve talked about the importance of thin arctic papers. Everyone go out and do a purchase of shim stock. We are not sponsored by Hanel or Coltene. We wish we were, kind of thing but we’re not. We’ve influenced so many dentists to buy Hanel. They’re like, their stock prices are ever rising, right? But anyway, we don’t get any part of that.

We just truly believe in some thin foils, other foil products may exist. Okay. Whatever. So we have to say that like the BBC, right? I wouldn’t know which ones, right? So anyway, we’ve now decided that we’re going to be checking the occlusion. Now, here’s my question to you, man. When in terms of maybe our protocols differ here, right?

But in the interest of efficiency, what I’ve been doing for the last few years, okay, is, I’ve been doing my usual pleasantries, showing the patient a radiograph, warning them about the root canal, having a nice little chat, basically, and then tipping them back, numbing gel, and as the numbing gel’s working, well, sometimes, even while the LA is working, then I’m doing my checks. Now, is there a concern you have here? Like, you know, does the fact that the patient’s numb on one side, does that change their bite so that your recordings are altered.

[Mahmoud]
Again, it depends, right, is the best answer to most things. If they’re completely numb, yeah, and I’m doing more than one unit, and they have teeth that don’t interdigitate super well, then, yeah, I would probably do it before.

[Jaz]
Give us an example of that. Make that point tangible. What do you mean? What’s something that interdigitates well and something that doesn’t interdigitate. I’ve said it very carefully well?

[Mahmoud]
So people that have like really cuspy teeth. So deep grooves, long cusps, and things fit together really well as opposed to someone who’s ground all their teeth really really flat. And they can sort of you know bite here.

They can bite a little bit to the left. They can bite a little bit to right and when you ask them to bite together, they’re like, oh which ones you want? That sort of thing.

[Jaz]
The analogy I use here is to study models analogy. When you’ve got someone’s models, right and you bring them together, you know you don’t need a bite record. They just fit together like this Mandible belongs in the maxilla exactly here, right?

This is like perfect, okay? Well, when you have exactly lock and key, when you have models and you’re like figuring out bloody hell, how do these fit together? That’s someone who doesn’t have great interdigitation because anatomy doesn’t guide you.

[Mahmoud]
Yeah, so in those patients and like I said, if I’m doing maybe a couple of units on the lower, like I’m doing a lower left first and second molar, I’m going to give them an ID block. Yeah, I’d probably rather take my occlusal sort of analysis, do that before they’re numb, but if it’s, I’m just doing a class II. And they’ve got really good interdigitation. They can find their home base really easily. Then for the sake of efficiency, I’m going to start the numbing process as in do the topical, give them the injection, and then I’ll do my paper and my shim stock as they’re going.

[Jaz]
And it doesn’t take that long. So just talk us through, let’s talk about a scenario classically, lower first molar. Back in the day, it’s your first restoration you’re ever doing. It’s the lower molar occlusal. Okay, you’re doing an occlusal and you’re going to be really good. You’re going to spend half an hour getting rubber dam on because you saw on Instagram it’s important to do and you’re going to struggle and you haven’t done my quick and slick rubber dam webinar yet on the app, so you’re going to go and get that.

But then now you’re going to be slick and you get it in two minutes. Anyway, you got rubber dam on, okay. But actually before you get rubber dam on, when you’re doing these checks, okay, can you just describe what this looks like for a lower right first molar in this pretend patient?

[Mahmoud]
Okay, so really easy because I would have checked. I can see that they’ve got a repeatable MIP. Yeah, they go the same place. So once I’ve numbed them up, I’m just going to dry the teeth. You can use a tissue or you can use your 3 in 1. Dry the teeth. I’m going to put the blue paper in. We’ll just talk about MIP for now. So I’ll put the blue paper in, I’ll just get the patient to tap, tap, tap. I literally say to them, tap your teeth together and then go like this. Yeah, because I want them to do that.

[Jaz]
Now what if some patients protrude their jaw and they come edge to edge? Because that’s what some people, when you say bite together, some people do that.

[Mahmoud]
Yeah, just accept it. Okay, just accept that this step, there’s just no- We get asked this maybe every single webinar, every single occlusion camp. What do you say to patients to get them to do what you want? Sometimes it just takes a little bit of coaching, right? Just a little bit of patience.

[Jaz]
I found telling him to bite hard. Bite hard sometimes helps a lot actually because they’re not able to bite on their front teeth. Instinctively they’re just, that helps.

[Mahmoud]
I’d just be careful doing that after you put your restoration in because if it’s high and they bite hard you don’t want to end up having to repair it. But yeah, for me, again, you develop your own words that you use and how you do it. For me, bite on your back teeth and tap tap tap seems to get me there, 95 percent of the time. A few people, yeah, they’ll bite on their front teeth and I’ll say, bite on your back teeth please.

[Jaz]
And once they get there, just show the mirror. Yes, this is the bite I wanted. This is good. So when I say bite on your back teeth, you’ve now coached them. This is what you do. And they were like, ah, I thought you meant bite on my front teeth when I said back teeth kind of thing.

Because I thought my bites, so many patients walk around thinking our bite is supposed to be edge to edge. Like patients think we’re not supposed to have over jet. Like that’s what patients, they look at cartoons and look at like growing up and they think that everyone who’s got even a slight over jet think, oh man, my teeth are crooked. I need to, have you ever encountered those patients?

[Mahmoud]
Yeah, yeah. And they’re the ones who always want your composite as well your anterior composites to everything like just be straight, but okay. So going back you’ve known the patient I’ve dried the teeth. I’ve got the blue paper in there I’ve got them to tap tap tap on their back teeth and I’ve got some mark. I need a way to remember or document those marks and there’s several ways to do it my preferred and the easiest way is you take an intraoral photo. I think that’s what you do as well?

[Jaz]
Yes.

[Mahmoud]
Photo with an intraoral camera, okay, and that stays on your computer and that you can reference that at the end of the appointment. The other way you can do it is you can just make a note, right? So sometimes I used to, before I had a camera, I used to do something called an occlusal sketch.

I learned this from Stephen Davies, Dr. Stephen Davies in Manchester. He had this like little arch of teeth drawn and you can print it out and then you can just mark on it where the occlusal marks are and in fact, I’ve adapted this into the occlusal prescription worksheet that we’ll be using on our courses and stuff. And essentially you just want a way of knowing where the marks were beforehand. So take a photo, write it down, make a sketch. Okay. Or if you’re really clever, you can memorize it.

[Jaz]
When you’re doing this for a while, some younger colleagues may be thinking, whoa, how am I supposed to memorize all that? But actually most straightforward occlusions daily bread and butter dentistry. Once you see it in a class one occlusion, generally the contacts are usually where you expect them, right in the middle of the groove in the lower molar, for example, on the cusp tip of the upper palatal, mesio-palatal cusp on the marginal ridges and the premolars. And it becomes quite easy to detect a bit after a while.

[Mahmoud]
Yeah. And bear in mind, like I’m not asking you to remember like 17, 000 dots on all the teeth in the mouth, right? You were just doing. We’re treating a lower first molar. I’m probably only caring about maybe the second molar behind it, and maybe two teeth in front.

[Jaz]
That’s really important, because people get freaked out, and I think you’ve made a great point there, like, don’t worry about the dots everywhere, just in your local area that you’re working, that we need to nail that.

[Mahmoud]
Next up for me is shim stock, okay? And if someone is thinking, I really like, this is just too much. Honestly, the shim stock makes the biggest difference. And again, on OBAB, I show a case where I was just doing an indirect restoration at the time, but when I put the provisional on, you could see very clearly in the photos where the paper marks were correct. They matched the pre op, but the shim stock was off, right? And the patient could tell. So the shim stock just takes you that little bit.

[Jaz]
Some patients are like princess and the pea, whereas other patients are like, everything feels amazing. Whatever, you just put a rock in their mouth, and you send them off, and you tape it, and exactly.

So, yeah, just bear in mind that patients don’t go. We’ll summarize this at the end, but there’s all the different checks you make at the end to make sure we have conformed well. And the very last thing you check is, how does that feel? That’s like the last. And sometimes, some protocols that some educators taught me don’t even ever ask them that, because the bite is your domain.

You’ve done your checks, okay? You’re happy, then you’re all good now, sir. Or ma’am, right? You know, you don’t need to ask him how it feels because then what Barry Glassman says that why are we getting patients to feel their bite? They shouldn’t like become obsessed about their bite. We’re kind of edging them closer every time we say how does it feel? How does it feel? They’re feeling their bite something that you really should be not really present for them If you like.

[Mahmoud]
It is a little risky nudging them in that direction. However, you do need to build up the confidence So now that I’ve got this protocol and I know that if at the end of the appointment I am convinced myself that the byte’s right, because I’ve done all my checks and stuff. Honestly, even if the patient says, it feels a bit weird, I will say, you’re just a bit numb, leave it until tomorrow and it’ll feel fine. And because I’m so confident in how I say it, they’re like, oh, cool. And then they’re fine, right? Because once you’ve built up that confidence, then you can look them straight in the eye and tell them, don’t freak out, you’ll be fine.

[Jaz]
Because you’ve done your checks and you’re happy that your objective data, your shim holds are as they were before, your dots are as they were before. And therefore, you’re happy, basically. The other check, well again, we’ll talk about this at the end when we do a summary. There’s muscular checks you can make as well. But right now, I just want to start at the beginning, where you’ve talked about shimstock as the next thing after the Arctic paper. Please carry on.

So with the shimstock, I will check the tooth. Obviously, I’m going to be working on it. I want to see if it’s holding shim or not. I’ll now usually do the tooth behind, the tooth in front, and one tooth on the other side. And that, again, I will just get my nurse to document. Let’s say we’re doing the lower first molar restoration.

So I’m checking the lower first molar and say, I’ll Get the patient to close on the shim stock and I’ll tug. If I can’t pull it out, I’ll just tell my nurse, lower right first molar or lower right six or whatever you want to call it, hold. Okay, and she’ll just document, write that and she’ll put an H. And if it doesn’t, she’ll put no hold.

And if it’s a drag, she’ll put a D, right? And it’s just four teeth. It takes literally 10 seconds. However, like this freaking everyone out, just please do it, right? When you’ll realize actually the tooth that you’re working on is holding shim. So in our case, the lower molar. The lower second molar is also holding shim.

Okay, the tooth in front is also holding shim, and on the left side it’s also holding shim, which about maybe 70 80 percent time is the case in case someone’s got a nice occlusion. Then this is, you know, it’s not complicated at all. You just verify. Exactly. It takes literally seconds. Sometimes, like when I’m doing indirect, and I’m going to be feeding this to the lab, and unusually you’re doing posterior teeth, right?

I’ll check all the back teeth, some molars and premolars. Most of the time they all hold and my note on the prescription will just be molars and premolars hold on both sides. And as we discussed guys in the couple of episodes ago, if you haven’t listened, we had gray and my technician on and we talked about how to get the occlusal prescription, right?

How to make sure our inlet restorations are in the bite correctly. And so we gave some great tips on there about how important it is to give your shim holds to the lab Because the bite record that we sent the lab more often than not There are some errors in it and therefore if you’re relying especially on the digital world, then we’re going to get a lot of errors occlusal errors.

So only once we give the shim holds and then the technician calibrates your models, whether digitally or on the actual physical models, then we get the correct occlusion. Again, I’m sorry we’re taking so many detours. Kind of is a big topic to cover, but just to summarize there, it’s not rocket science guys. Just get that shim stock, do it. It takes seconds and now you’ve got objective data. Is there anything else you’re checking?

[Mahmoud]
So just carry on with the shim stock thing is once you get quicker and slicker, I would urge you to start checking front teeth as well because it’s actually going to inform you as to how often front teeth do and don’t hold shim stock and I think you’ll be surprised and if you are working in the analog world with models, remember, probably one of the biggest problems with models is they will rock backwards and forth. So you can very easily make front teeth touch when they don’t on a model. So again, very valuable information to give to your lab technician.

[Jaz]
Great. So also as you delve further involved the anterior teeth as well as a reference, which is great. Are you checking excursions?

[Mahmoud]
Remember when we said I’m checking if the patient A has a tooth opposite the tooth I’m working on, or if it’s going to be a really easy day in the office. Yeah, so I’ve checked. Now while I’m doing that, I’m also then at that point checking my excursion, right? And I’m seeing whether this tooth A is, does it contact in excursions or not? And if it does, is that area, number one, is it likely to be involved in my restoration? So can I see a massive caries bomb that’s going to undermine that cusp? And if it is, what am I going to do about it? And then the other thing is considering, okay, well, if, and if it isn’t contacting it, I just need to make sure once I restore the tooth, it isn’t contacting either.

[Jaz]
So again, going back to conforming in tap, tap, tap, but also conforming in excursions where it’s appropriate.

[Mahmoud]
Yep, indeed. Okay. And you can apply a lot of the stuff we talked about in the previous episode about guiding teeth and stuff like that. But essentially when I’m checking, repeatability, I’m also getting the patient to grind, I’m checking if the tooth is involved or not, and then I’m making a decision as to whether it will remain involved or not.

[Jaz]
And in the case of our example tooth, the lower right first molar, if it’s an occlusal, then you might find that the distal buccal of that lower right first molar is involved in a group function kind of guidance maybe, but that occlusal area probably is not involved very much. You might find little line from the palatal cusp, so just make a note of it, but more often not it’s going to be okay. When you’re doing different surfaces, maybe a distal involving a bit of the buccal might become more of an issue, but it’s important that you’ve made this check. And the way to check it is, again, you use a different color troll foil. Now you’ve got the patient to move, make that movement basically.

And it’s also nice to check the other side as well. And you just compare where is that dot and where is that line? Now one thing that we do by line, we mean that excursion. So one thing that I think we both do is it’s often good to check the excursions first, so now you’ve got the lines on there, and then go back to the blue and get them to bite together.

So what you have now is the dot has overlaid the line, so now you know exactly where the starting point is and where the movement goes. So just rewind if that didn’t make sense. If you want to add anything to make that more tangible, Mahmoud, please do.

[Mahmoud]
No, so yeah, sometimes the order in which you explain things isn’t always the order in which you do things. But yes, essentially what I do is I will check the excursions first with the red paper, So dry the teeth, check the excursions with red paper. So red paper in, patient chews, left, right, grind, you know, hard. Check the other side and then I’ll take that red paper out. I won’t let the patient close, I’ll say just open and stay open.

Now put the blue paper in and then we’ll do our bite on your back teeth and tap, tap, tap. The reason is blue will overwrite red, so I’ll see my blue dot on top of the red streak. And you’re avoiding, because if you do your excursions after you do the tap tap, it just smudges your MIP sort of mark.

[Jaz]
So all you then get, if you do it the quote unquote wrong way, there’s no wrong way, but if you do it the other way, whereby you do the tap tap first, then the excursions, when you look at that tooth now, you only really have the excursions data.

But if you do the excursion first, then the tap tap, you have both data at once basically. So it’s just more efficient to do it, which is good. So that’s a nice little point there. So in our case, our example tooth isn’t heavily involved in excursions, but it is in occlusion, okay? And so we’ve established that, okay, we want our restoration to hold shim at the end and we need to make sure that we’re conforming.

And it would be a disservice, like we talked about this before in a couple of episodes ago, where we are doing a disservice to a patient. If we are putting this composite shallow because we want to make our life easy. We don’t want to spend time doing adjustments and being so precise. We want to do a quick job that we just make a very shallow composite.

It’s completely out of the bite and now you don’t have to worry about it. And we are doing a disservice because now you’ve removed a tooth potentially or a part of a tooth from the occlusion. So that’s not what we want to aim for. We want to aim for precision dentistry. So we want to conform. What else are you going to do? Is there anything else in the pre op that you do before we even have touched a bur to the tooth?

[Mahmoud]
We’re scaring the bejesus out of people now. As we are sticking to back teeth at the moment, that’s probably all I will do. Okay. So I will check my MIP contact, my excursions and my shim hold.

[Jaz]
So I think you do all this, but you haven’t verbalized it yet. So just chime in here and say that, okay, you’ve done all the objective data. Just have a look, you know? So usually you have like an old leaking amalgam and it’s like flat. It hasn’t really got much morphology and you’re thinking, ah, okay. I can convert this into work of art here. I can really make this tooth look sexy again, get your fissure stain, which I’ve never used before, which you talked about in the Protrusive Guidance app recently. So newsflash, the community, we did a hot and cold poll on fissure staining, and where are you on that spectrum?

[Mahmoud]
I used to be hot. I used to stain fissures all the time, and now I don’t.

[Jaz]
Okay. So you’re in the middle or you’re cold?

[Mahmoud]
A bit towards cold. I do use it when I want to see. So if I’ve carved my anatomy in and it’s really deep and I’m thinking they might be like getting food stuck or anything like that in there, then I might seal it with some tin.

[Jaz]
You know, with those deeper ones that you do, basically, like someone once taught me, why are you actually putting in fissures and composite? They’re just going to come back and they look terrible. They look ugly. They’ll stain. And there we are. The natural stain just comes in and figures it out. Find this natural place. You don’t actually need to put stain in, guys. It just self staining right? That should be like a feature in composites, like in the box, self adhesive, this, that, self staining, all that kind of, no one will ever buy it.

[Mahmoud]
You don’t have A5 composite? Just put in A3 and don’t polish it. About a week later, it’ll look like A5. It’s all good. They can just prescribe them espresso coffee for a week.

[Jaz]
But if it brings you joy, like, there’s another post I saw about millennials and Gen Z and that kind of stuff. And your avocado toast. And I was like, you know what? Can you just let us enjoy our avocado toast and like that one shrivel of joy we have in our life?

Let’s just have it right see all the doom and gloom and dentistry if it makes you happy. If it makes your day to stain those fishes by god get the choco stain out go for it, knock yourself out. Okay, and have some fun and take some photos and share with your friends and everyone just enjoy Okay. So anyway.

[Mahmoud]
I use a lot of tints. I just use them on the front teeth. That’s that’s where my joy lies.

[Jaz]
That’s your passion. Okay, so you’re looking for joy at the actual occlusal morphology of the old restoration. Okay. And if you see a very flat amalgam and then you’re dreaming about how you’re going to stain it and how it’s going to look and stuff, right?

You still need to appreciate the angles of the old restoration, especially if you now see a dot on the old restoration, especially if there’s a dot there, because there’s two facts there. One, it’s in occlusion, but two, you know that because there’s such a flat amalgam, it’s not representative of what used to be there.

And so what’s happened over time, there’s been occlusal changes. And if you now put a beautiful composite that’s going, rolling back the ears and making it look like what you used to, it’s no longer going to fit against the opposing tooth. This is the number one place we go wrong. We put some lobes in where there is no space for the lobes anymore because the opposing tooth has eaten the space for that. This, I think, is the number one mistake. What do you think?

[Mahmoud]
Yeah, and once you start looking at teeth, you’ll notice this a lot, right? I have a theory as to how this starts. Usually it starts by that dentist that was maybe having a rough day. day and thought, okay, I’m just going to make my life really easy when I’m putting this amalgam in.

I’m going to take this giant burnisher, right? I’m just going to burnish the bejesus out of the bottom of this occlusal amalgam. And it’s just like a massive well, right? And there’s no occlusal contact and it’s nice and easy. You’re done. The patient goes away. And what happens to that upper tooth is actually that palatal cusp build.

That’s opposing it, might tilt and it might come down a little bit and now instead of getting a point contact when the patient’s chewing because that upper tooth has over erupted slightly or the lower tooth has over erupted, it’s now like gouging out more and more of the internal surface of this lower tooth.

It’s what we call a plunger or plunging cusp, right? And now you need to replace that lower amalgam, but that upper cusp is sitting so deep and snug into this well in the lower tooth. There’s no way you can then create your ridges and all that sort of stuff. And maybe if that dentist had followed what we’re saying right now, 10, 15 years ago, this wouldn’t be an issue.

But I see that a lot. So if you do see this sort of well shape on your lower restoration, look at the tooth above. Chances are you’ll find that it’s hanging down. You need to be aware of that because if you just build this up to how you think it should look, there’s no way it’s going to fit in the bite again. You see this on lower second molars. All the time.

Interjection:
Hey guys, it’s Jaz again, just interfering. If you are wanting to learn occlusion and it’s just a confusing topic for you, then me and Mahmoud are doing our live course. The next one, we have one in mid October and one at the end of November for 2024 and it’s called The Basics of Occlusion.

We’ve got nine different workshops and one of our favorite things is to engage with our delegates and to help to break down the seemingly complex topic into daily protocols. Just like kind of what we’re discussing today. Allowing it to finally sink in and improve the predictability of your dentistry head to protrusive.co.uk/boo. That’s B-O-O, Basics of Occlusion. To secure your place or join the wait list for 2025. Back to the main episode.

[Jaz]
The reason we’re having to go back and make our beautiful composites that we’ve put on Instagram with the rubber dam on we don’t put the photo after the rubber dam because it now looks like not so nice. Not so pleasant. It looks very flat like it looks dead right, is because we’ve missed this point. And so how do we resolve it because there’s only two ways I see it here is A, you accept it, right?

You swallow that pill, you accept it, and then therefore, you’re going to be purposeful when placing this composite. So you’re switching this amalgam to a composite, but you’re going to respect the anatomy and actually where you want to, or you attempted, every morsel in your body wants you to put a lobe there, but instead you’re going to put like a flat area to kind of match the amalgam, and that’s where you have to kind of do, basically, in a way.

Or, you have to now think about adjusting the upper tooth. In most cases, you have enough space for the minimum thickness of composite, two plus millimeters, and that tooth is not involved in excursions, and there’s no guidance and stuff. Therefore, why do you need to remove the opposing tooth enamel, right?

We kind of reserve that technique. We talk about this technique a lot when we’re encountering challenging situations where we need space, and therefore, it’s a good compromise. It’s a good way to get space. But in that scenario, what do you think? Is it right that we should be amputating? Not, amputating is a bad word, but doing some equilibration, let’s say, adjusting that cusp to give us more space for a beautiful composite.

[Mahmoud]
Would I do it for beauty? No. Would I do it for other reasons? Yeah, sometimes. Now, if you imagine that upper cusp, usually it’s like really big and it’s got a lot of enamel on it, whereas the lower has been completely shallowed out, and if it’s a lower second molar, it tends to be a little bit short, but also you’ll have like the buccal and lingual enamel walls tend to be thin.

Now, chances are, the reason this is being gouged out, it’s not necessarily involved in guidance as such, but during function there’s like a cyclical movement, right? So it’s not like the upper cusp moves up and down. So you’re going to have to maintain the thinness of the cusps on either side if you then want to like keep the chewing space essentially.

So sometimes what I will do is not just shorten the upper cusp but I’ll slenderize it a little bit just to give a little bit more sort of freedom for that cusp to move within the confines of my new restoration in order to try and protect those sidewalls from fracturing. I wouldn’t do it just to make my composite more pretty, but I might do it to increase the longevity.

And sometimes I’ll say to the patient, you’ve got a really sharp, ragged cusp at the top, and it may well be the reason why the lower tooth has now cracked, right? Because usually the amalgam’s cracked or something’s broken. So I don’t want that to happen to our new filling. Would you mind if I just polish it and round off a little bit? That’s like the language.

[Jaz]
See, you ask permission and I see why you do that, right? And so just communication here. And the way I picture my patients, like, okay, this is not going to work unless we smooth this upper tooth. It’s miles away from the nerve. You’re not going to feel it, but it’s going to make a world of difference in terms of how long this filling’s going to last. And they kind of nod and we do it. Basically. So-

[Mahmoud]
I use a carrot. You use stick. It’s all good.

[Jaz]
Yeah, exactly. Carrot and stick, right? So anyway, so this is an important point guys, to assess the general shape of what you’re starting with. Because this is the number one thing where you can go wrong. So you made a decision that, okay, I’m not going to be able to get as many likes on Instagram today because it’s flat.

Or maybe you’ve got space, maybe you’ve had a look and actually. This existing tooth, this restoration isn’t that much an occlusion at all. The upper tooth didn’t manage to over up so much because there was other teeth and larger ridges topping it. There’s the cheek and the neutral zone stopping from tilting that worked in our favor and therefore now we get to think about having some fun and we can actually put some lobes in and it’s all in the planning.

Now you know what space you have to deal with, like with everything, you can actually plan for that. The other thing to look for is generally the cuspal inclines, I’ll get my probe and I’ll just put it against the cuspal inclines. And I just get an idea of how shallow or how acute am I going, basically, because it’s going to guide me when I’m actually shaping my composite. I’m using my probe along. It will just give me like a quick guide that just takes like three or four seconds to do. Anything else?

[Mahmoud]
One trick I did learn. So, well, two things I’ll mention A, in our example, we’re talking about an occlusal. Restoration, right? So you could attempt the stamp technique. Have you ever tried it?

[Jaz]
A few times, to be honest with you. I just feel though, by the time I get, oh, Zoe, can you get the X to clear out kind of thing? Like, again, it’s one of those things that it’s the same as someone not having the middle forceps. It’s just not there. It’s just to leave the room to get it. And therefore I’m just more than comfortable just eyeballing it and getting it pretty much right in the eye way. But yeah, are you a big fan of the occlusal stamp technique?

[Mahmoud]
Look, there’s a lot of things that we learn off Instagram or we see on social media. And we think, oh, I give it a go. You give it a go and you, maybe you prove to yourself that you’re capable and then you never do it again. And that was one of those things where I did it. I didn’t use ExaClear. So I just used Liquid Damp. So Liquid Damp onto the existing tooth with a micro brush, pick it up and then final layer of composite before you set it. Put some PTFE on it and you squish your little stamp on top.

[Jaz]
I find when I did that it just felt very fragile probably because I didn’t give enough bulk but that’s the issue right? I mean to give it enough bulk and there’s an art in make sure you get it exactly right and stuff. But yeah it’s a valid technique and I think everyone should do it at least once and then decide how much they love doing that and that’s fine. I think it totally has a place.

[Mahmoud]
Yeah so there’s that and the only other thing I’ve picked up over the years is sometimes you can measure the depth of a restoration if it’s an occlusal that you are replacing.

There’s an amalgam in there already. You drill half the amalgam out and you can actually measure the height of the amalgam from the base of the cavity to the top. Then it gives you again just an idea when you’re done how high that restoration needs to be. I found it again of not a lot of value because a lot of time you’re removing decay and then the measurement is going to change etc.

And I think you know with enough practice all these things can be useful but with enough practice for me the cuspal inclines and using visual references that I take before I prep the tooth. So I’ll look at where the marginal ridge is compared to the base of the cavity. Where’s the bottom of the fissure pattern on the adjacent tooth, for example. Use those visual references and then the angle of the cusp. So the angle of the cusp is probably, for me at least, one of the most important ones.

[Jaz]
And I think if we were to talk about the scenario where, by now that we’re talking more operative, we’ve taken the birds of the tooth and like you said, you drill half the amalgam away. And if you don’t have to drill anything further at the base, then yeah, that can work well for you. If you rebuild half the composite and then measure it and just do any adjustments, I’d add a bit more or brush some away so that you get the right height that can get you pretty much near or near enough, which is good.

And then if we’re doing a M O D O we’re doing involving the wall, the proximal wall, then we can actually measure. the actual height as well before we restore it. So for example, we’ve now cleaned our cavity, we can measure the space that we have, the height that we have, and then when we place our composite we can actually build, like we usually do for class two, we build the wall first, the proximal wall first, and then we can just use a perioprobe again to measure. Is that something that you do?

[Mahmoud]
Yeah, and that’s very, very handy. In fact, I had someone ask on OBAB. I think probably the most valuable thing I could tell them is once you’ve assessed the occlusion beforehand and you’ve seen that dot, you’ve seen where the dot goes on the tooth before you’ve done it, don’t put an incline there.

Do not build an incline in that vicinity because as you’ll see towards once we get to the towards the end, we want our MIP contact on a flat receiving area, right? It’s going to be very difficult to carve that out, out of an incline. So people have crossbites, people have all sorts of weird occlusal contacts and stuff.

So don’t just assume that because, I went to dental school and I know that the buccal cusp on a lower molar is a functional cusp and they have always have a contact in the fossa and one on the marginal ridge. That’s where the opposing cusp is going to be. And that might not be the case.

So find where the occlusal contact is and just make sure when you’re building that composite up, you have a flat-ish area, small, flattish area there that you can then adjust down to create your new MIP contact. Don’t put a big sort of inclined lobe, whatever you want to call it.

[Jaz]
That’s a huge tip. So if everyone was multitasking, please reel back in and just remember the place where the opposing cusp will sit. Don’t put any acute angles. And we talk about mountains and valleys. Don’t put any valleys there. Instead, have a nice lake there, where the opposing cusp can come into, right? Yeah, nice quiet lake. It would be good, basically. So just remember that point. Now, also, marginal ridges. A good guide is the adjacent tooth.

So look at the height of the marginal ridge of the adjacent tooth, if we’re doing a DO, for example, and just use that as a guide. That’s a very quick and easy win. And sometimes, if you’ve got a matrix band, that’s like kind of like way too high, going too far high. It’s like sticking out of the contact area.

Then if you just drill that down to approximately the height you want your composite to be, it just makes it a no brainer. It just helps you quickly put your enough height of composite there in the first place. So that’s another tip that we can give and share to help reduce adjustments because a common area to have to do adjustments is the marginal ridge area. For that reason, people overbuild, they make the wall too high.

[Mahmoud]
And LM-Arte have like a really cool version, like a Posterior Misura, I think they call it, where you can place it and it can measure the adjacent marginal ridge and transfer that onto the marginal ridge you’re building.

[Jaz]
Oh my god, I just had an epiphany. So if fissura means fissure, mesura means measure. Oh my god.

[Mahmoud]
Oh my god, are you serious? You’ve just figured that out now? I don’t know if that affects my estimation. Come on, dude.

[Jaz]
What does misura mean in Italian? I just want to see if there’s, yes, it means measure. Okay.

[Mahmoud]
For measure, yeah, obviously.

[Jaz]
I need to brush up my Italian.

[Mahmoud]
I’m going to pretend this conversation never happened. He is human, everybody. He doesn’t know everything.

[Jaz]
Definitely not. You guys, hopefully that’s evident from the kind of stuff I post. Good opportunity to plug the event. So if you’re seeing my mistakes, because my main lecture kicking off the event on 16th of November, where Dr. Michael Frazis and Lincoln Harris will be joining, is I’m kicking off the event. I’m kind of like the warmup act, right before the main, like the big guns come out around, the little warm up act. And I’ve got these videos of me just actually making these huge mistakes. Okay. So I’m actually going to just show you, but I’m also show you what I did to kind of recover the scenario and then if it was irrecoverable, what’s the best way to do in terms of communication and the clinical management.

So that’s on 16th of November. It’s a hybrid event. So it’s either a live stream plus a 30 day replay, or you bums on seats. You come and eat with us. You join us. You get some blessings from Lincoln Harris by touching his feet. You know, you’ll know if you’re on my email list what that means. So head over to protrusive.co.uk/rx to join. What I think is about one of a kind event when it comes to. Treatment Planning and failures because also we have a live patient. Okay, we have a live patient that Lincoln Harris, he knows nothing. We’ll just bring up the radiographs and the images on screen. And so he just has a conversation because we’re kind of seeing, okay, how does Linc communicate?

But then also now that we’ve put all this information, like a dental school exam, an unseen case, he has to then treat and plan and then, convey that treatment plan to a patient live on stage and then dissect it all with us and give us some tips based on that. So I think that’d be quite unique.

[Mahmoud]
Make it clear. The patient’s there. The patient’s actually going to be on stage. That’s amazing.

[Jaz]
Yeah, that’s pretty cool. So I found my main patient and this is not like a all on four and zygomatic, I don’t know, block graph, that kind of stuff. This is someone who needs a few crowns, needs a few fillings, maybe some whitening.

Maybe it has some aesthetic concerns. Like, this is like a daily, I was really keen on finding a real world patient, and I found her. So, I need to find a backup patient now. Anyway, mesura, okay? Italian for measure, guys. There’s an instrument that you can get there. We are not sponsored by LM-Arte, but good instrument.

I bought one. I have it somewhere. Again, I don’t have it out routinely. So, I just love, I spend the most time on that part of the restoration, right? Where you’re building the proximal wall, right? Usually, the nurses, they’re eager to get the light cure, but when Zoe sees that I’m working on the marginal ridge, you know, she might as well go outside and have a fag, right? Not that she smokes, but I’m just giving an example, right? She might as well just do that because I’m going to save my sweet time here to get that bit right.

[Mahmoud]
Yeah, there’s so much to do, right? Like, get the seal right, get the height right, get the thickness right.

[Jaz]
A hundred percent. A composite tip that Andrew Chandrapal taught me and he suggested do the wall, and I’m guilty of this. I’m kind of naughty. I can’t do it in one a lot of times, unless it’s really big. But like he do, he says do half at a time. So do like the buccal side first, then the lingual side. There’s even less like shrinkage stress. Is that something you do?

[Mahmoud]
No, again, makes perfect sense and it’s a great tip and it’s all about decoupling with time, right? You’re giving the dentine bond more time to mature because you’re just messing around in the box.

[Jaz]
I like it. It’s a good tip. I don’t always use it. So the whole point is guys, there’s no perfect way to do it. Well, there probably is a perfect way, but then you need to have a patient for like five hours on the chair for a simple composite, but you’ve got to just pick up your wins and this is to help you be quicker and not have to do any adjustments.

We’re not even going to get to anteriors. We’ll have to save that for a live in Protrusive Guidance, but let’s just finish off this series. Okay. We’ve done the marginal ridge. If we’re doing a DO, if you’re doing an inclusion, obviously not involved, and you’re going to remember everything at the beginning, do you have space for the lobe or not?

And so the begs the question. should we be following posterior anatomy, like the textbook, like you’ve done, is it János or János Makó like billion day course on occlusal morphology and stuff, right? So based on that, right, how can we now implement that? The real tricky thing here is we know, for example, in the real world, the amalgam is flat.

There’s no space for beautiful anatomy. And now your composite has kind of conformed to that, but then now you’re not getting the Instagram likes. So what are you going to do? How are you going to make a composite look good, Mahmoud?

[Mahmoud]
Photo editing. No, I’m joking. The thing is, you can still make it look reasonable by having in some fissure patterns, but it’s important not to just think, okay, I’m just going to take what I saw in the book and stamp it onto these teeth.

I love how you describe, when you have like a 75-year-old patient in the chair and you’re replacing this class tooth. This tooth’s been in function for decades, right? They’ve eaten pork scratchings and I don’t know what else on there. And then you want to create this tooth that looks like it’s just erupted in a seven-year old’s mouth.

So you say, why are we putting a seven year old tooth in a 70 year old man? It doesn’t make sense. So you do have to respect the space that you have, but you can still get a little bit creative and make sure you have a really sharp probe. And this will go back to our tinting.

You can add a little bit of depth by having, running a little bit of poo colored tint into your really deep fissures that you carve. So you can still get that satisfaction, get the likes. But for me, ultimately, I want to make sure this restoration is done efficiently, that the patient is happy and comfortable, and they don’t come back in my chair with this problem again.

[Jaz]
So number one, you don’t want to be drilling everything away. You want to be there or thereabouts. Okay. So that all comes down to a pre op checks, a visual check of the cuspal inclines, roughly where the opposing tooth is. So you can make that Lake there instead of like a valley. And then, you’re going to make sure that you don’t underdo it either.

You’re not going to go so shallow. So if you’re like in two minds, should I add a bit more or not? It’s better to maybe add a little bit more. So you actually have a contact at the end. So you’ve done your composite, you’ve cured, you’ve taken the dam off, and then you’re going to do the checks. And then let’s talk about the protocol for actual adjusting in the way that you’re not going to mutilate your composite. So what’s the first thing you do once the rubber dam’s off and the patient’s like settled down from the trauma of rubber dam isolation?

[Mahmoud]
Give them the rinse and stuff, because all the blood and crap, and then you want to dry the teeth, right? So you’re going to dry the teeth, you’re going to check – funnily enough, most of the time when I’m doing a posterior restoration, if I’ve decided that the tooth isn’t in guidance or I don’t want it to remain in guidance, a lot of the time I’ll actually go and check the MIP contact first.

I’m just being real. You should get into habits. Should you check the excursions first? Probably. I would probably say dry the teeth, put the red paper in, get the patient to grind left and right and then open, stay open, put the blue paper in and get them to tap, tap, tap. This goes back to why I said, Oh, my nurse doesn’t always put the red paper on. And then check the tap, tap, tap. And at that point you’re seeing marks. Now, unless there is one mark, if there’s only marks on my tooth and nowhere else, then I know I’m going to need to adjust.

[Jaz]
So by tooth you mean there’s only marks on your composite and nowhere else?

[Mahmoud]
On my comp, yeah, on my restoration. And nowhere else. I know I’m going to need to adjust. Now, sometimes you get marks on your tooth, your restoration. and the teeth next door. That doesn’t mean I’m done. At that point, I will reference my images that I took at the beginning to see, A, are the marks the same, and I will do my shim stock check.

[Jaz]
I’m just going to make that point tangible because, yes, you have some marks on your composite, marks on the tooth, and the value of that pre op photo that you took is, before, there was a marking on, let’s say, the fossa of that lower molar, and there was no marginal ridge dot, but now, you have a marginal ridge dot, which there wasn’t there before.

So perhaps, now we’re obviously extending it more to a DO scenario, marginal ridge being too high. And now you know that, okay, I might be there, but I might be just a little bit proud in this area. And that’s what the power of the pre op visual gives you.

[Mahmoud]
And then the power of shim stock is then there will be no doubt in your mind. That’s what I love about it is it makes me so confident. If I check my shim stocks, my shim stock after that.

[Jaz]
So what does that look like? What are you actually checking?

[Mahmoud]
So I will then check the tooth behind. Okay, and actually often you will find the tooth behind will hold, okay, and it’s to do with sort of the hinge motion of the jaw. You’ll find that the back tooth might still hold, but the tooth in front of the tooth you restored won’t hold, if the restoration is a little bit high. So that’s why I always check both and then check one on the other side. Now let’s say that happens, let’s say my shim stock hold that used to be on the tooth in front is now gone.

Now I know that my restoration is a little bit high. I’m not asking the patient how it feels. I’m not asking anything. I’m getting my yellow rugby ball. And the reason it’s a yellow rugby ball is because I have a mark on the tooth in front. That tells me, and I know my paper, right? This goes back to us talking about how thick our paper is.

I know that troll foil, doesn’t matter what their marketing machine says, etc. It’s below 20 microns, even if it’s 25. Because there’s a mark on there, I know that those two teeth are so close to touching that I don’t need my red band. I don’t need my coarse bur, I just need to tickle the contacts that I’ve got on my restoration. Because the occlusion is so close to being perfect. I only need to make a minor adjustment.

[Jaz]
So what you’ve done is you’ve checked, so the right side is the one where you’ve done the restoration, and then that’s the side you’ve used the paper, and that’s how you’ve deciphered that information. Usually what I do is I go on the other side.

The contralateral side. So let’s talk about it that way. Let’s say I’m using my 24, 25 micron Parkell paper. I know I’m close, but the shims aren’t quite there. So I know I’m a little bit proud, like maybe 20, 30 microns, I don’t know exactly how much yet. So if I take my 25 micron paper on the left side, the other side, get the patient to bite together, if it’s holding, I know that I’m proud, but I’m proud less than 25 microns.

Okay, if I’m using let’s say 15 micron paper okay, and now that’s pulling and for some people really to visualize and imagine and slow down here, right 15 microns pulling It’s not holding. Okay. I know that I’m high between 15 and 25 microns. Not that we do a 15 micron paper. That’s a bit too precise here, but you just know you’re proud by a little bit It’s just like you said the way this is useful is let’s understand the opposite scenario, right?

You use a 40 micron paper and it’s pulling on the left side. You’ve done the restoration on the right side, the 40 micron is pulling. So you know you’re proud on the right side. Your restoration is proud by at least 40 microns. You fold your 40 in half. You have now 80. Get the patient to bite together.

It’s still pulling. You then fold it again, 160 microns. Now it’s biting. You better pick up your green, or at least your blueber, and you’re going to have to press a little bit harder, and you’ve got to really figure out, look at your pre op images, Ah, I think I’ve got, my marginal ridge is way too high, or I’ve got a valley, I’ve got a slope here, where really I needed a lake, so you’re going to mow away in that scenario.

Go for lakes not valleys. I love this. Okay, cool. So that just gives you now an idea of how much pressure you’re going to put with the bur which grit diamond you’re going to use and how long it’s going to take you and how aggressive you’ll be. So this is why this information is important. And hopefully if you’ve done everything correctly with the pre op visualization, you’re going to pick up the yellow Rubby ball, round, if you’re just winding the lake a bit, remove that bit, which probably shouldn’t be there.

And actually, Mahmoud, top tip, before I even do this, I’ll get like a mic, because I love Eve Twist polishes, right? Or an Enhance, get a polisher and just rub it all over the tooth, because what we find is that there’s like smears of resin or bond on the teeth. Sometimes that’s what’s making the the tooth proud.

Not our composite. So once you get rid of all that stuff and then just wash and dry, you might find that you actually nailed it. You don’t need to do any adjustment at all. So the cleaning polishing protocol, figuring out how much, how many microns you need to adjust, go ahead and do it. And then be proud that you’ve conformed.

[Mahmoud]
The tip about the enhanced point is huge. Do it on the other teeth as well. Because a lot of the time when you’re doing your, you put your bond on and you’re thinning it and it just goes everywhere.

[Jaz]
And air abrasion particles.

[Mahmoud]
Yeah, so just get your enhanced point and yeah, I clean everything up. Great point, great point.

[Jaz]
And so hopefully now we are looking like the dots are in the places where we wanted them in this example scenario we gave, and we don’t have to now spend ages adjusting our composite away, and we still have something that looks good. Yes, it may not look as good as if you completely ignored the pre op anatomy, right, but sometimes when we have space then we can go back to the textbook and see, oh, so this is how a seven year old’s first molar looks like, and we can give that 50 year old patient a 7 year old’s tooth if you want to, okay? And get the likes and the applause on Instagram.

Okay, great. So the final thing to wrap up on is, we didn’t get time to do anteriors, so we’ll do that on protrusive guidance live one day. And what we’ll talk about now is a final, just to wrap it up, use your senses. So I think Riyaz Yar was the first person to talk about it in this way, and I loved it. I was already doing this stuff, but then the way he said using your senses, I love that. So a hat tip to one of our mentors, Riyaz Yar, absolutely a brilliant guy, teaches occlusion as well, really great guy to learn from, so shout out to him.

So use your senses, you’re using your eyes. You looked beforehand at what the shape of the composites were. You’re using your fingers, okay? And we didn’t talk about this, but for anterior teeth may be more relevant. You’re putting your fingers. We talk about fremitus. We’ve got a whole episode on fremitus that you guys should check out.

Like how much of a thud, how much pressure is going through that PDL, the periodontal ligament through your fingers, okay? So using your fingers, using your eyes, you’re using sound, okay? This is what a feeling sounds like when it’s proud. This is what it sounds like when it’s good. Was that feeding through into your headphones?

[Mahmoud]
Yeah.

[Jaz]
Everyone just like save that like a little voice nugget. Okay. And like, hmm, let me just compare this, calibrate this to what Jaz did on the microphone one time during a podcast. When you’re in doubt, when you’re not sure, just like oh yeah, that sounds like a lot of teeth touching at once, and the patients usually laugh.

[Mahmoud]
Oh, get the patient to do it, not you do it to them.

[Jaz]
Part of the whole visual is you’re obviously using the ink paper as well, basically, and part of the feel, again, using the shim stock. So all those things means that you now will never have to adjust composites again. Obviously, with tongue in cheek, you will obviously do a little bit, but you know what, hopefully, this is giving you a new perspective, or reinforced some existing perspectives, or maybe giving you one, that one nugget that’s going to shave off one minute from all the composites they can do for the rest of your life. And therefore has saved you two weeks in your career. Who knows, who knows Mahmoud?

[Mahmoud]
Two weeks, extra holiday.

[Jaz]
Two weeks of life that you couldn’t bone about some, I don’t know.

[Mahmoud]
You’re welcome.

[Jaz]
I don’t know. where I’m going with this, but anyway, I’m tired now, guys. This is a great point to end the podcast. And we just talked about one. A beautiful issue for this long. We didn’t get to anteriors. We’re such sad bastards. Guys, thanks so much for listening. Mahmoud, thank you for the time. If you’d like to learn more from us, we have occlusion. online, occlusion course.

We also have the live course running October 11th, 12th, and also November, end of November, and the website for that is protrusive.co.uk/boo not because it’s scary because it’s Basics of Occlusion B-O-O. So come and join us that if you’d like to learn more. Otherwise, we’ve got plenty of other episodes for you to get your sink your teeth into excuse the pun. And we’ll catch you same time same place next week. Thank you. Mahmoud.

[Mahmoud]
Take care everybody. Thank you.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. This episode is eligible for an hour of CE credits. We are of course a PACE approved provider. We also satisfy the GDC criteria of enhanced CPD. So answer the quiz below and you’re thinking, where is this quiz?

Well, you need to get on the protrusive app. It is a stunning app. We’ve invested a lot of time and money into it. So please do check it out. There’s a cool little quiz on there. You get 80 percent to prove to us that you’ve learned something and there’s an area where you can reflect and you get your certificate emailed to you like clockwork. Every Wednesday and every quarter, we send you your entire folder of all the certificates you’ve gathered, because we know what happens. They get lost everywhere. So don’t worry. We always keep your copies. It’s a great way to rack up your CE credits throughout the year.

The website is protrusive. app. Make an account if you haven’t already. I look forward to reading the comments from this one. I want to hear from you. What’s the most important thing that you learned or the thing that’s going to make the biggest difference in your practice you think?

I do enjoy reading all the comments on YouTube and now I’ve got more systems in place to make sure I don’t miss any comments. And I can reply to them all. Thank you so much for making it to the end once again. I’ll catch you same time, same place next week. Bye for now.