Q&A with a Dental Technician – Shade Matching to Contact Points – PDP137

Jaz’s Introduction:
It was about nine years ago now. I remember exactly where I was, who I was with. What I was wearing is just like, really emphatic advice to me at the time. It’s just stuck with me throughout my career, and it’s not too different to the advice that Finlay Sutton gave. A few episodes ago. If you scroll down and listen to that episode about Scandinavian Design of Partial Dentures, and he said to find a technician who’s a similar age as you, who’s got a similar appetite for dentistry as you do and grow together.

Hello Protruserati. I’m Jaz Gulati, and welcome back to another episode of Protrusive Dental Podcast. This time, it was actually a rare face-to-face episode that I recorded. I drove over a hundred miles to see Graham, my technician, and the theme was to answer your questions that you’d sent on the Facebook group, everything you wanted to know from a technician.

But NEVER ASKED. We covered things like digital versus analogue. Is digital there yet? Should we be opening contacts for veneers? Heck do technicians like it when we open the contacts for veneers? Their answer might surprise you. It certainly surprise me how to match the shade for a single central incisor and a huge mammoth topic of how to get the occlusion right.

Now, we covered that in good depth in this episode, but me and Mahmoud go into in loads of depth in our upcoming occlusion course, we’re almost done. It’s being Beta tested. It’s something we’re super stoked about, but it’s covering all these scenario-based themes to make sure that it’s extremely practical and tangible occlusion tips.

I also took the opportunity while at Graham’s lab to film some content for OBAB. OBAB is Occlusion Basics and Beyond. And if you wanna join the waiting list for this course, head over to occlusion.wtf. That’s occlusion.wtf. Actually, it’s a real website on a browser you can sign up to updates for when our occlusion course is ready.

Hopefully coming in March, April time. So this is huge. It’s like in the final, final phases. This episode with Graham is eligible for CPD, so you get one hour of CPD. If you’re part of Protrusive Premium, just download the app. If you haven’t downloaded the app, what are you waiting for? If you are true Protruserati and you enjoy these episodes, that’s well worth joining the app.

And you’ll be able to download the Premium Notes. So if you’re already used to watching on YouTube, you see the notes coming up on the side. Well, those notes are neatly presented in a PDF that every premium user can download via the app, and it’s just a nice summary and it solidifies your learning.

Protrusive Dental Pearl
The Protrusive Dental Pearl for this episode is very much relevant to this theme of working with your technician. It is time, my friend, that you find your IDEAL DENTAL TECHNIQUE. Just like I said at the beginning of this episode, the average dentist working with a good technician will go very far. And it’s been critical for me. Funny story, actually, I posted a case recently that me and Graham did together. It was like a single onlay.

It was a beautiful onlay. And so I posted the step by step, what I did, what my prep looks like, and one of the photos was actually bonding the ceramic with Panavia and taking the occlusal photo. And I wrote on there, Graham did an awesome job. And remember Ahmed from Australia? Hope your hand’s feeling okay.

I know you post on social media that your hand was injured. I hope you get better, my friend. You are a true Protruserati, sending my love your way. And anyway, I made comment to saying, wow, I’m just amazed that you know your technician’s name. Now I agree with him. I think it’s pretty cool that I know my technician’s name and I get to be on a WhatsApp basis, and leave voice notes.

And that’s why I love communicating with Graham so much and any of the technicians I work with. But most of my colleagues that I speak with, they use a big lab. And it doesn’t matter if you use a big lab or a small lab, but the person on the other end who’s making that crown, making that onlay, making that veneer, making that denture, they don’t know that person’s name.

So if you don’t know their name, how are you gonna build that relationship? How are you gonna grow together? With that technician, Protruserati, how are you gonna find your Graham? This unicorn, this good technician I was referring to. Well, the guess what today is Graham Entwistle. He’s a brilliant technician I’ve been working with for coming up to just two years, so not mega long time, but I’ve been really impressed with our communication, the voice nodes, the loom videos that I sent to him and how he responds back and how receptive he is to my advice and how open I am to receiving his.

I tell him, Graham, if I send you some junk, you tell me I’ve sent you junk. And likewise, if there are any protocols, we’ve adjusted. We worked a lot on vertical preparations and getting the vertical crowns with the correct emergence. And he was really good to take my advice on board and change a few parameters.

And together we’ve got some great results with vertical. But the funny thing is that I found Graham by accident. He DMed me on Instagram. We started talking and he started listening to podcasts and I knew some really great dentists like Rustom Moopen, Elaine Mo, Kiran Bhogal. I know, I knew these guys were using Graham.

So then he had just about enough capacity to take me on as a client. And boy am I glad he did. And I think every restorative minded dentist should have a good technician that they know by first name basis that can just pick up the phone and give a call or leave a cheeky voice note. I think it’s absolutely imperative.

So Protruserati, don’t do what I did. DON’T WAIT AROUND for your dream technician to DM you on Instagram. It’s not gonna happen. That’s like a unicorn scenario. Now, Graham’s not the only technician I know. Graham, sorry, I am cheating on you with another technician, also called Graham and the Dan as well at Precision Dental Studio.

So, I use a couple of labs. Graham’s one of my main guys I use. But even though I use the second lab, which is my local lab, I still visit them now and again, they know me by my face. I know them by their face. I know what their voice sounds like. I leave voice notes. They leave voice notes back. We have REALLY GOOD COMMUNICATION.

The tip I can give to any dentist who’s working with a bigger lab, maybe a chain of labs or just a lab with lots of technicians, and you don’t know who’s making your crown, it’s just go in one day, meet them, try and get the same, try and ask for the same person to send back your crowns and then grow together.

Be open to getting feedback and criticism from that technician. That is scary, but it will really, really elevate you. In fact, I urge you to make it your mission to visit your lab. Perhaps you’ve never visited your lab before. Show your face, shake some hands and agree to who is gonna be your dedicated technician and just watch the magic happen.

The best time to find the ideal technician was once you qualified. The second best time is right now. And one last thing with your technician, because they do all the hard work and sometimes we get the glory. Once you’ve delivered a case, it’s nice to sometimes take a photo and email it to your technician, say, ‘Hey, we nailed this together and your craftsmanship was amazing.’ And it’s great for these technicians to see their work fitted. I don’t think enough of them get to see that. And I can tell you they really appreciate it. And so with that, let’s join the main episode with Graham Entwistle.

Main Episode:
Graham Entwistle. Welcome back again to the Protrusive Dental Podcast. How are you my friend?

[Graham]
I’m actually quite good.

[Jaz]
It’s nice to see you. Nice to meet you in the flesh. So, just to set the scene guys. I’m at Graham’s lab. Where are we? Romney Marsh. Where the hell is this place?

[Graham]
It is literally the middle of nowhere, but it’s Romney Marsh, Kent, East Sussex border. Pretty much.

[Jaz]
Well, I was like trying to find my way here. I was like, where on earth is this? So I’m glad to have discovered a new place. It has been amazing to work with you in the last couple of years. I’ve learned a lot from you. Communication, like is exactly what I wanted. Like I think as a restorative dentist, one of the tips I wanna give to everyone is find a tech who you get along with, who you like preferably, who you can just exchange on a daily basis. I pick up the phone, I can call you. I feel at ease about picking up the phone calling you. Although our favorite mode of communication is WhatsApp voice message, which is much more real. Well because you know, you might be busy doing something and just get back to it. There’s no pressure.

So we do lots of, you see our WhatsApp trail images. I do lots of loom videos, which I’ll ask your opinion how you find those, cuz it might be hit and miss. You might hate those and you know, might be tolerating them. I’ll ask you that in a moment. If you guys haven’t listened to episode 74 already, that was Graham with five things your technician wished you knew.

So that was helping us dentist. Today I’ve been asking on the Protrusive Dental community Facebook group about what is it that you guys want to know when it comes to anything you wanna know from a technician working better with our technician. So, Graham, just for those who perhaps didn’t listen to episode 74 yet, a little bit about yourself in terms of what drives you, why you became tech, how is it that you’re able to run this lovely facility with five kids, work-life balance.

[Graham]
Blindly. I dunno where to start. So what was the first question?

[Jaz]
First question my friend Is a little bit about your background. Like what got you into being a lab tech basically?

[Graham]
So first of all, never really been the type of person to get an office job sitting there in front of a computer, day in, day out, doing the same thing.

It’s monotonous, I’m autistic and yeah, it just doesn’t suit me. So found a job, King’s Collage Hospital and went for the interview. They got me to carve a whistle out of chalk and do a few other bits and got the job and I loved and hated the job throughout the time. And I went into cosmetic dentistry after I left.

And I was only doing that for about a year. Then I run bars and nightclubs for about four, four years.

[Jaz]
You left for being a cosmetic lab tech?

[Graham]
Yeah.

[Jaz]
Right, for bars and nightclubs. So tell us a little, tell us about that. What happened there?

[Graham]

So I was working in Basildon in at the time for a well-known technician and I’m reliable. I didn’t drive, I was relying on ferries, I was cycling and it just got a bit much. So we kind of parted ways amicably, and I just found a bar job to make ends meet while I was looking. Within four or five months I had a bar manager’s job. Four months after that I was an area manager and four years later I was like, let’s get out of this. Go back to what I’m good at. So, yeah.

[Jaz]
So do you not miss being a lab tech or perhaps you were still early in your career at that stage, and perhaps you didn’t quite know exactly what kind of a tech you wanted to be. I mean, tell us a bit about that.

[Graham]
I didn’t really know what I wanted to do, so I had to go out and taste the world for myself.

And I think being in the bar industry enabled me to do that and learn a little bit about myself, but it came with its own problems.

[Jaz]
Mm-hmm.

[Graham]
So, yeah, I got back out of the industry and I struggled to get back into dental technology actually, because nowhere wanted to pay any decent money for a technician is, we still find that these days that, you know, we kind of price ourselves down in the market because everyone wants cheap.

[Jaz]
You wanna compete in dentist world.

[Graham]
As a result of that trying to attract technicians if you’re not charging a decent price is very difficult. So the price is then driven up again. So yeah. You either find unskilled workers doing your work for cheap, or you to find skilled workers is now very difficult. Cause we haven’t trained our own for a long time.

[Jaz]
But what I, what I found is on the main dentist Facebook groups, I found that a lot of the comments and threads are like, where is the best price or where is the cheapest to get X, Y, and Z for lab work? That’s the kind of conversation that’s happening.

[Graham]
Yeah.

[Jaz]
I also see where is the best. So I see two different polar opposites. I see where is the best price is not an issue, price, tell me where’s the best. And the other half is like, I need the cheapest, but still good. I want cheap but good.

[Graham]
It all depends on your business model. At the end of the day, I think, you know, it’s not down to what it is you want from this, that, or the other. It’s your business model that counts the most, I think, when you’re selecting anything and then you adapt to that and you try and find the best you can for that budget. So yeah.

[Jaz]
When you were working in a bar and in the nights industry and you were working with people, you were seeing people all the time, people in your face, and now I look at your lovely little laugh.

It’s as little are you watch a chocolate in the corner there and just you and your phone do WhatsApp, voice messages and waxing up and stuff.

[Graham]
Yeah.

[Jaz]
Is that like a big shift in change in terms of your working life?

[Graham]
It is a big change, but I’ve gone through a lot of big changes. Like since having my first child, I had struggled with addiction for a while at points in time, a little bit about myself.

[Jaz]
Mm-hmm.

[Graham]
And I’ve managed to overcome that and this has been part of my journey and I now enjoy my own company. So yeah, without the bar industry, I wouldn’t be who I am today. I learned how to run business. I learned a lot about people, I learned a lot about communication, how to be a host, and kind of got a bigger picture of who people are.

I try not to take away the humanity from the business side of things as well. So yeah, it’s kind of a difficult balance.

[Jaz]
What I love about you, Graham, is I said it already, the communication side. I think, I just think I would really urge all dentists who care about their restorative dentistry, who are really aspiring to be the best they can be.

You won’t get nowhere unless you’ve got good lab tech on your side. I genuinely believe that, that some advice that was given to me when I was one year qualified by Raj Rattan is an average dentist with a good lab tech will really do well.

[Graham]
Oh yeah, for sure.

[Jaz]
And it makes a huge difference. So I think I’m grateful to have you in my sphere and grateful to be able to work with you as well as some of the other labs I’ll work with.

Like shout out to Precision Dental Studio and Alan and the team there. I use you guys for different things. I know where me and you get along well, like your vertical preparations. We’ve talked a lot about that on calls and WhatsApp stuff, so you’re my go-to guy for that. A lot of my splint work that I do will go to another Graham, so if you are a technician wants to work with me, your name has to be Graham. Fun fact.

[Graham]
Alan.

[Jaz]
Yeah, Graham, that’s true. That’s true. So, look, we’re gonna, firstly thank you for sharing some admissions there. You know, I really appreciate the human side of that and that’s really good of you to do that. I think it really makes, humanizes us and I think we need that in life and work and stuff.

So I think that’s really great. Another feature about you, I’m gonna go and just find those questions that were on the group that the Protruserati already had for you. Some of these are like my own little questions and some of these are from everyone. So, let’s start with some of the things that I was talking to you about as we were coming up the steps, which was, you took me to the plaster room and you said that’s hardly being used nowadays because a lot of your work is now gone digital.

So I said to you, well, you know, I’m very digital, but when I get like a bigger case, multiple units, I still pick up the polyether. I still like to do that. And you are like, well, you know, it depends. So where do you lie on this? The benefits or the advances of analog or do you really think that actually the advantages aren’t really there of analog anymore. So it’s that you read can do everything digitally. Where are you on that scale?

[Graham]
It just entirely depends on what your technique is with both. So analog impressions, I dunno if you’ve noticed, but if you’ve ever had an analog models for myself, I do not split models.

So it’s always a solid model single dies. So single dies come out the first pour cuz that’s the most accurate pour. And then the solid model, master model goes into that. And what I find with that is you’re not stripping away the gingiva off of your model so you know where the gingiva actually sits and you’re not, you’ve got more an idea of emergence profiles.

So we’ve got that and then we are not spliting the model. So we’ve got no expansion contractions, sort of like differentials there because you’ve actually just kept it as a one piece. So you can wax everything, wax up little copings on your single dies, transfer them over to the master model, finish your wax in, transfer them back, seal the margins, reseal the margins, then take it off, invest, press, get them back, and hopefully crossover. Everything’s great.

[Jaz]
Did you like find it?

[Graham]
I find the same with digital. Okay. So if I’ve got a large case, sometimes I might design the models twice. So I’ll design the first one as a solid model and then I’ll design the second lot, get removable dies and I’ll print them separately.

[Jaz]
Or let’s just explain what this is, because there might be some like young dentists who just, this is all in a different language that for you, you know, being lab tech.

[Graham]
Yes.

[Jaz]
A lot of people probably don’t know what a solid die means. So let’s just break it down. Okay. What do you mean by a solid die? And then what do you mean by split? Just, just really dumb it down for us.

[Graham]
So a die is basically the prep. So you’ve got prep that you can remove from the model that is a die. So all of those removable parts of dies. When you’ve got a solid model, it’s an unsplit. No saw cuts, no saw lines or anything that’s moving within the market.

[Jaz]
So you like to work with that unsplit model where the full model without the splits without the dies, right, with individual dies, yeah. And do you think that if someone’s working with the technicians are using, sending back everything on a die, so everything’s split, is there a disadvantage though?

[Graham]
Well, yeah, cuz when you put a saw cap through your models, you then got expansion, contraction.

And as much as people say, oh, I put retention slots and this, that and the other, when you take a model out and put it back in, dust on the undersides of things and little bits of wax gets stuck and it doesn’t always go back where it should exactly. Because obviously things have expanded contracted, so you get little discrepancies between your contacts and sometimes even occlusion. Whereas if you’ve done it on something that doesn’t move, then it hasn’t moved.

[Jaz]
It’s just more moveable bits and I can completely get that now. That leads us very nicely to it. Another question, which was on the group, one of the questions that we had was veneers, like we mentioned while we were walking up the stairs about, we actually mentioned, squeeze a lot of conversation, geeky conversation and just in that one small stairs, but veneers, a lot of people have a bias towards impressing towards analog because they believe that to get the highest quality of veneer work back from the lab tech, it has to be analog. What do you think about that?

[Graham]
It depends on what type of veneers you’re looking for really. So feldspathic, obviously you can need to produce an analog impression because you need refractory dies. I don’t offer that service here, unfortunately.

[Jaz]
What is a refractory die?

[Graham]
A refractory die is a die that you can stick in your furnace basically. So it’s a heat resistant material that you can layer your ceramic on, putting the furnace with it.

[Jaz]
And so you don’t do that because you don’t work with that anymore?

[Graham]
I just don’t work with that type of process. My prices don’t reflect that type of work. So, I like to consider myself quality laboratory, but I’m not really a top end laboratory. And I don’t cater services towards that. That type of restoration.

[Jaz]
But you do veneers, but you do mostly like, lithium disilicate. Pressed?

[Graham]
And pressed and layered

[Jaz]
Okay, now we’ll do a little deviation from that. So, we established that, okay, if you want to do a feldspathic, then you need to really go analog, right?

[Graham]
Yes.

[Jaz]
But if you are doing a big case, lots of crown preps, traditional chamfer, shoulders, vertical margins, et cetera, do you feel there’s a difference in terms of the quality that you can produce or the quality, the end result, the end product between analog and digital? What I’m really trying to say to, you know, is digital there yet?

[Graham]
Digital is there. I do believe printers these days have made massive advances, but it also depends on what printer the lab’s using, what settings you using, you know, and if you are outsourcing your models, are you really getting back what it is that you want? You know, are the dies you know, retentive enough as they go in? But the more times the dies come in and out of the models. The more loose they become, the more give they’ve got, the more inaccurate they become.

[Jaz]
But you just said, and I know the answer, but I’m just saying everyone else. But you said that you don’t like to work with individual dies because you like the whole model to be together.

Therefore, it’s a Geller type setup, right? Is that the right term for it? Is that the right term? When you can actually take the prep out, but the model itself is still the same? Is that what you’re referring to?

[Graham]
It’s just a scale model.

[Jaz]
Yeah.

[Graham]
Yeah. You’ve still got removable parts.

[Jaz]
Yes. So, in case someone got confused about you take something in and out. When Graham sends my work back to me, if there’s multiple units, for example, or even single unit, the model is a whole, there’s no splits, but you can take the preps out.

[Graham]
Yes.

[Jaz]
And that’s unique to digital, right. In that way.

[Graham]
No.

[Jaz]
It’s easier?

[Graham]
You can set that with analog as well.

[Jaz]
Is it a lot more harder to do that?

[Graham]
It takes a bit of tweaking to get your parameters right and every single sort of type of tooth. So my settings for getting a molar in and out of a model will be different to an anterior tooth coming in and out of the model because of just like the surface area that comes in and out of the model and the friction that’s caused there.

So yeah, there’s a lot to think about. It’s a minefield and obviously if you do choose to use that type of model system, then the more you take the die in and out, the less friction that’s there. The more give that’s in the model and the less accurate it becomes. So like I said, sometimes I print two dies to go into one model. One can come in and out, one just sits in there.

[Jaz]
And that’s like the master where you check everything. .

[Graham]
Yeah. Master.

[Jaz]
Yeah. Okay. Very good. So the whole debate to summarize, you do feel that digital is there for like feldspathic kind of veneer work? Maybe? Yeah. We still need analog, but for most other work, for even for my rehab kind of stuff, you’ve got clients sending you all digital scans?

[Graham]
Yes. So I’m getting all digital scans and had good success so far.

[Jaz]
Because, I haven’t made that leap to full digital. I’ve got like more than maybe eight units. Okay. Not that I’m doing, I’m not prosthodontist, I’m a general dentist, but when the more units I have, the more reason I’m gonna go for analog.

But that might be changing and I think, you make a good point that nowadays digital is really great. So yeah, it was actually, Cheng was your question. What percentage and one of the things that you mentioned, what percentage of analog impressions are excellent?

What percentage are acceptable and what percentage are unusable? Now obviously you’re more digital now, but based back on your time at Kings and your previous sort of reincarnation, what kind of quality of impressions are we getting?

[Graham]
Okay, so let’s take it back to when I came back into dentistry.

I worked at a predominantly NHS kind of driven laboratory out in Canterbury. The boss was a really nice guy, but the work that we were getting from dentist was kind of slap dash, you know, that you couldn’t really see margins. No one was using cords. And sometimes you’d go back to the clinicians say, look, this isn’t really good enough.

They’re like, do your best. You know, and it’s just like, okay, well, okay, I’ll do my best. You know? So, and then even when you do your best, sometimes it’s not good enough, it comes back. It’s like, well, I did say. So I’d say the percentage of success with impressions and digital is again, based on a business model.

So if your business model is high end, sort of like top quality restorative work and you’ve spent a lot of time as a clinician on your work, refining what you are doing and taking nice impressions or nice scans

[Jaz]
And long appointments using they’re not short appointments

[Graham]
Using cords, then your success rate is much higher. Whereas if you are cutting corners doing knife edge margins that are not readable and you know, just doing a quick scan without checking and there’s a lot of people who still don’t check their scans even with top, top end work, you know, find that people aren’t quite checking their scans thoroughly enough and you know, there’s a bit of moisture somewhere and it’s caused a bit of a defect in the scan data and I can’t then extract the die with the margin intact in areas.

[Jaz]
And you’ve sent me a WhatsApp image when I’ve done that before.

[Graham]
Yeah.

[Jaz]
When in one distal corner. And it is good. It’s great to be able to work with the technician who will send you your little minor clock ups. Right. It’s great to have that and I think, I really appreciate that. I think more technicians should not be afraid to message that dentist like, oh look. And, the screenshots you send, the photos you send, I think that is wonderful to help improve us.

[Graham]
So look, a word of advice is always check your impressions. Always check your scan it, you know, an extra 20 seconds could actually save you an appointment.

[Jaz]
So the advice I would also give to dentist is if you’re new to digital, a lot of people who’ve been in the digital game for long enough, you guys know this already, but if you’re new to digital, remember that for digital actually you need a slightly more aggressive retraction compared to analog. Cause with analog impressions can seep into the nooks and crannies, right?

The wash impression can seep in. Whereas if the light can’t get somewhere, it can’t record that. So I’ve found that I need more aggressive retraction when it comes to digital to get an acceptable model.

[Graham]
Yeah.

[Jaz]
I dunno what you found with that. Do you feel as though when you see some digital models come back and you feel as though, okay, this really needed more retraction. Do you often say that to yourself?

[Graham]
Sometimes, yeah, sometimes I don’t. And sometimes you’ve already told the person three or four times and by the fifth time, you know they’re not really gonna change. So, you know, you start letting things slide as a technician, because you touch your time, do your best, you do your best.

You know, there’s only so much advice you can give somebody before it then becomes just an everyday practice that’s how it’s kind of gonna be. And then you put up with it for a little while and then you’re sort of like, after a few months you might just drop that little nugget again, just hopefully plant a little seed in their brain.

 Like, do you remember talking about this? And it’s like, oh yeah, yeah, yeah. I think you’ve gone away from doing that. You know?

[Jaz]
But it’s good that you do that. Technicians are your colleagues might be afraid to say that-

[Graham]
Badgering people is bad. But if you can kind of just drop little seeds every now and then, hopefully people will start to realize, actually, I could be doing this better.

[Jaz]
I think one thing that dentist can do right now, not even tomorrow, right now, pause this episode and do this. If you don’t have your technician on WhatsApp, get your technician on WhatsApp, firstly. Secondly, WhatsApp from the following VO voice note saying, ‘Graham, if you find that I am slipping in my standards, or if there’s something I can improve, please tell me. I’d love to know. I welcome any feedback. I take criticism very well. I really appreciate to grow as a clinician with you as a technician.’ If you say that to a technician, wouldn’t they feel like much more at ease to give you more feedback? Right?

[Graham]
Yeah. Yeah, for sure. And I ask the same with my clients. If they find that my work is slipping or it’s not right in some sort of way, and it’s like more than one occasion, please tell me and I can do something about that.

Or we can take a look at what we are doing as a whole. Because sometimes it might be the fact that you’ve changed a material that you are using or you’ve changed the way that you are temping or it could be anything. Just get down some nitty gritty, get to the bottom of it straight away, nip it in the bad, and then hopefully we’ve got no problems.

[Jaz]
Awesome. So firstly, Zane, Risby, sends his love. Okay.

[Graham]
Hi, Zane.

[Jaz]
Bikram nice to CMS from you, buddy. Bik’s, fantastic dentist. I’ve seen a lot of his works. Brilliant. To break contacts or not to, for veneers, like to me, that’s more of a clinical decision making, I think. But in terms of, for you, like if every veneer prep came back with a broken contact, perhaps it’d be an easier thing for you. I don’t know. Where do you stand on this?

[Graham]
As far as I’m concerned, getting contacts, right with veneers is a nightmare. They are fiddly, they moved, they pop off the models every time you’re trying to adjust the contact. So for me, breaking contacts is a bit of a pain, so I prefer it if you didn’t as a technician.

[Jaz]
Really? Okay.

[Graham]
For ease of doing a restoration. But I would say it depends clinically on where the contacts are actually are in your patient’s mouth. If we’re looking to realign things and how it’s gonna be realigned, obviously also, are we gonna have enough room for the restorative work that’s needed or the quality of restorative work that’s needed?

Because if you are doing a lithium disilicate, for instance, if you’ve got a full contour, then you know you’ve got a certain amount of emax that’s minimal. But then if you’ve got a dark core, you need more space. And then if you’re gonna layer it, then of course you need even more space. So it just completely depends on the case by case.

[Jaz]
That surprised me a little bit because I thought, in my mind, I thought you might have said, I prefer broken contact cuz then give us the freedom to recreate everything. But actually you made raise a good point that actually it’s so fiddly to actually recreate the contacts that if the contacts of that-

[Graham]
For ease of use. It would be great if I’ve never had to touch a contact.

[Jaz]
Yeah.

[Graham]
My job is to do that. But if you’re not gonna break contacts, then the shape of the veneer prep is obviously, and the margin is kind of paramount. So you kind of need to come round the contact and go underneath into the cervical and kind of break that area down.

And that allows the technician to gain that nice emergence profile. Especially if you wanna try and close any black triangles whilst having that contact stay. If you can understand what I mean.

[Jaz]
Just rephrase it in a different way. Cause I’m trying to envisage what you’re saying as well. Do you wanna draw something? I can show it and I can describe it. Okay. So Graham’s now, for those listening, right now he’s pointing and he’s pointing to the mesial of an upper left central incisor. And what I would refer that to is the interproximal elbow, isn’t it?

[Graham]
Yes. That’s correct. You need to go into the interproximal elbow. In order to not break the contact. And literally it is just the contact you’re leaving.

[Jaz]
Yeah, you’re leaving just the contact area only. But even then, you know, contact areas aren’t huge often they’re just minimal there. But it’s important to prep that bit to allow you to cover that bit because if you don’t, you have that scenario where someone looks at the veneer, the side, they still see the prep and then they still like a discover-

And you get a discoloration over time from your bonding.

Yes. And you wanna hide that, that margin as best possible cuz yeah, margins do stain over time. So, yes. So great point well made about that. Now here’s just a technical question is if a dentist sent you some veneer preps and they haven’t broken the contacts and let’s say they’ve scanned it, then how do you create the digital dying models whereby they’re sort of you could take the prep on and off cuz don’t you have to then digitally make a split or something, right? And compared to when you used to this analog or is that also a nightmare to do it?

[Graham]
Yes, it’s a nightmare both ways. And it’s another reason why I’ve always chosen my method of doing things because with the analog, you’ve gotta stick your saw blade through, and by the time you’ve stuck your saw blade through, you’ve already taken off 10 microns of that margin.

So what I would do in this scenario is I’ll pour up two sets of die models and then I’ll just take every other and trim them out.

[Jaz]
Yep, yep.

[Graham]
It’s a bit of a prolonged process for me, but I know it’s right.

[Jaz]
But digitally it’s the click of a button. You just set your line and then it will just print it in that way.

[Graham]
It’s still difficult sometimes because if the margins are that close together, you’ve still got discrepancy there. But at that point, that’s when I’d switch to the solid model, single die thing and I would then do three designs of the models on exocad.

[Jaz]
Okay, cool, cool. Maybe if you’ve got some the show later, I can use my Sony camera and go around and make a extra feature to add to that.

But that’s a really good question. Thank you Bikram, best material for masking discolored teeth anterior. So your clients that send you photos of discolored teeth over the last few years, what material are you finding has given you good result? Like recently I sent you a case whereby we use MO or HO? Did we use HO or MO in the end for these crowns and veneers?

[Graham]
I do try not to use HO.

[Jaz]
Yeah, can you, I think you can use MO. What is HO for those dentist, dunno what is HO?

[Graham]
It’s high opacity. So basically-

[Jaz]
Lithium disilicate.

[Graham]
Yes. So it’s an ingot, high opacity ingot, Lithium disilicate. So basically it’s just masks things with very, very minimal thickness, but it kind of has a tinge in color that isn’t very nice to work with.

So the background itself. Should I say is not very aesthetic. So if you haven’t left enough room for some nice layering on top and the patient wants it to be in line with all of their teeth, then you’re not leaving yourself much of a chance to get-

[Jaz]
A set of compromise.

[Graham]
Yeah, it’s aesthetic compromise. So depending on how dark the actual tooth is, so unless it’s actually black or gray, then I tend to try and use the medium opacities and they can block out about 0.5, 0.6 mil. And then I’ll try to layer on top of that. It just allows me more scope. It’s much brighter, it’s more fluorescent and you tend to get nicer restorations using those.

So avoid HO if possible, it is the last possible resort for myself. And then also you’ve got zirconias, if you’ve got a crown and you can use the high opacity zirconia stones, which are quite old school now. They’re very hard. , but you can layer on top of them. But also now there are liquids you can use just to kind of opaque the internal surface of zirconias.

And as long as you’ve got a decent thickness, it doesn’t really affect the shade or the color of it because if it is thin still it can affect the shade because it just shines through the bright white.

[Jaz]
So the misconception that zirconia will block out everything underneath, you can still get some shine through with zirconia, right?

[Graham]
If done properly, no, but what I’m saying is you can get shine through of the O layer, so, which is quite bright. So if you are going for like an A three and you’ve put this white layer inside an opaque and block out your metal core, then that can then influence the A three and actually make it look more like an A 1.5.

Even though it looks A three on your shade tab, when you send it out, when you put it in the patient’s mouth with all the lights, reflect differently. It actually looks about a shade and a half lighter. So, it’s hard to get it right with any material, but yeah.

[Jaz]
What’s your bias? Zirconia, lithium disilicate when working with clients who send you discolored teeth in terms of you being able to deliver?

[Graham]
It depends on where it is in the mouth. Okay. So if it’s anterior, I prefer to use lithium disilicate as long as there’s not lots of space around the prep. So if the prep’s very small and there’s lots of space, I would probably say go for zirconia if possible. If there’s enough, you know, retentive sort of form there.

But obviously then you resort to emax, but then you looking at MO ingots, HO ingots in order to block out the light so that they don’t look gray.

[Jaz]
Well you mentioned emax, but I know that you’ve actually moved to LiSi.

[Graham]
I moved to LiSi a long time ago, so I used two types of lithium disilicate. I used the GC LiSi. I find it’s a bit more color stable. It’s got a bit more fluorescence in it than emax. And I also use, VITA AMBRIA

[Jaz]
okay.

[Graham]
Which is a zirconia-reinforced lithium disilicate can get finer margins using that material.

[Jaz]
But you’re no longer using emax product by Ivoclar?

[Graham]
I still use it certain occasions.

[Jaz]
Okay.

[Graham]
But yeah, it’s not my go-to.

[Jaz]
Okay.

[Graham]
So like if I’m gonna match in a restoration that’s already done in emax 10 years ago, I’ll use emax. If there’s a certain shade that somebody’s looking for, then I’ll order some emax in for it. You know, like if someone wants B4 and the patient has really high demands and they’ve chosen that color and they’re gonna want nothing but that color, then I’ll have to order that in because, otherwise I’m just setting this up for failure.

[Jaz]
Yeah. For those maybe younger dentists who, you know, the reason I mentioned this is because lithium disilicate is the material, but then you’ve got, you know,  Ivoclar does eMax. GC does LiSi. I didn’t know that. Vita with Ambria. There’s lots of different brands.

[Graham]
Yeah.

[Jaz]
Even with zirconia, there’s like lava. There’s Kanata, is it? Japanese?

[Graham]
Yeah. Katana

[Jaz] 
Katana. That’s it.

[Graham]
There’s vintage Press, which is a shofu

[Jaz]
so this is Shofu lithium disilicate

[Graham]
this is Shofu lithium disilicate

[Jaz]
I didn’t even know that.

[Graham]
This is Ambria

[Jaz]
That’s VitAmbriayo. Yeah.

[Graham]
This is LiSi Press.

[Jaz]
Oh, lovely.

[Graham]
And of course you’ve got your classic, original emax.

[Jaz]
Oh yes. The OG emax. Cool. All right. Love it.

[Graham]
There’s lots and lots to choose from, it’s a minefield and they’ve all got their pros and cons. Some are harder than others. Some have more fluorescence than others. Some you can fire more times than others without losing.

[Jaz]
But LiSi, I think you can fire more times without losing. I think Emax grays a bit, is that right?

[Graham]
It does gray. The microparticles are actually slightly bigger than with GC LiSi.

[Jaz]
Cool. Amazing. Okay, next question from Zhe. Zion’s got a couple of questions. So, Zik, man, I love you so much, man. I love your work that you do produce. It was great to meet you in Porter when he came to the vertical preparation course. You’re top guy. Thanks for sending this question in. So, just start with the easier one. What information, it’s kind of bigger picture. What information do you require for an upper anterior single crown?Just the basic information that you require and what other information that is desirable for you.

[Graham]
So I think at this point, photography is a must. You can’t just send me a shade unless, like, literally you take the shade and it matches exactly a shade tab. So if it matches exactly a shade tab, I will accept that A3

[Jaz]
the shade tabs are acrylic, right?

[Graham]
Yeah, but maybe not, because at the end of the day, this is where you still really need a photograph as a technician to start anything, because the enamel is always different. Where the enamel starts on the tooth is different on every patient.

So some tooth have got high chromatic content or high value content. So it’s the brightness and the contrast in the tooth of color and the light that goes through it. So the translucencies can be different. So cross polarized photograph.

[Jaz]
So this is a filter. So dentists out there, so firstly, apologies because I didn’t really make a big enough deal of this as I should have, because to match a single anterior, whether it’s upper incisor or lower incisor, is the most difficult thing in dentistry.

Right? That’s firstly, I didn’t build it up enough that this is really tough. And that’s why you know, Graham mentioned the importance of photography and cross polarizing filter is something that you can get on your camera. I’ve got one but I’ve got one by accident years ago. And it removes a specular of flash so you can see the details and so that is wonderful I think. Do you use the eLab protocol? I think I must ask you the last time.

[Graham]
I don’t use any protocols like that. I just haven’t got the business model from it.

[Jaz]
Yeah. But you see the different images that they’re saying and cross polaroid you find that helpful, so that’s good.

[Graham]
Yeah. Cross polarized is helpful. Try not to use a ring flash. Try to use a dual flash. Because you know, you get the shine back from the teeth. Especially with a ring flash. So try and use a jewel flash.

[Jaz]
Now if someone has a, done mentioning someone has got a ring flash only.

Like for me, I have my jewel flash, but it’s sometimes annoying to change. Might even get a second camera just for that reason. But, one thing you can do is you can detach your ring flash and just take a photo with the flash from the side. It gives a technician a different perspective.

[Graham]
Great tip. Yeah.

[Jaz]
It’s a really good thing. And a couple different sides from the bottom. From the side. Takes you a few seconds to do. We’re still using your ring flash.

[Graham]
Yeah. And it also helps establish surface textures.

[Jaz]
Absolutely.

[Graham]
And so, yeah, photography and the patient smiling, just how that tooth is looking in the mouth, how they smile is also a key, you know, where that tooth’s gonna sit on the lip line.

[Jaz]
Yeah. And to get the bigger macro features of the smile to get your hub, to get your anatomy right. So obviously the primary, secondary tertiary anatomy, so to copy everything in the adjacent teeth. But in terms of getting, cuz the real difficult thing here is the shape you can copy. Right?

It’s getting that shaded recipe correct, right? It is the trickiest bit. And, very often when we’re doing cases like these, tip to dentists is charge more. You just have to charge more for an upper anterior single unit crown. You must, must, must charge more. And I would imagine Graham, that you are charging more for that as well.

[Graham]
Well if I’m layering it, yes. Yeah, for sure.

[Jaz]
Yeah. And then the reason we need charge more is because we don’t do this as a one, you know, prep and fit you actually build into the, you know, call it business models. The term you used a few times now is you tell the patient there’ll be a first try and maybe even a second try and need to build that into the fee.

That’s why it takes a long time. Now, if it’s perfect that try and visit then fit it, great. But you know, I know that these can take 2, 3, 4 sometimes, depending on how demanding your patient is, it can take a lot of goes at it. So good photography, micro aesthetics and macro aesthetics, different flash settings, cross polarized photos.

[Graham]
Yes.

[Jaz]
Is that everything or is there anything else that you wanna pass on as advice a dentist who nail single anterior unit?

[Graham]
So your actual shade tabs. So your position of your shade tabs in the mouth, they must be in the light and you must be able to see the shade tab clearly against the adjacent to the one that you are gonna match is the one that you’re actually shade taking to.

So it needs to be close to that and not just one shade. Show me the closest two shades, which you think that match closest to the tooth. Now, so for some of my clients, I do actually provide a set of shade tabs that match my materials for high aesthetic work. And I ask them to kind of pick out what they see all of the colors that they see, send me the photographs and then I’ve got the basis for what I’m actually putting into them.

[Jaz]
It’s calibrated because you’ve got the same exact shade guide. So I like the idea of calibrating your shade tabs with your technician. I think that’s wonderful. I think we spoke about it last time as well actually, but it’s such an important topic. And, just to add onto that, if you’re using a shade tab photo, if you have the shade tab, two or three millimeters in front of the incised ledge like labial.

Right. And you’re taking a photo, the light reflects differently. So I make an effort to, whether it’s whitening photos or shade photos in general to make sure that my shade tab is at the same level as the tooth I’m taking photo of, so that the lighting is gonna have more chance of being similar on that tooth.

[Graham]
Mm-hmm.

[Jaz]
Just a little clinical point to make. Anything else on shade matching before we move on to the next question.

[Graham]
It’s a minefield.

[Jaz]
It’s tough isn’t?

[Graham]
Getting everything right all the time is impossible.

[Jaz]
Yeah.

[Graham]
It doesn’t matter who you are, how good you’re-

[Jaz]
Manage expectations.

[Graham]
Manage your patient’s expectations, you know, actually try and sell it as we might not get exactly right. You know, try and manage-

[Jaz]
I say, we’ll not get it perfect. There’s no such thing as a perfect, I’ve never done-

[Graham]
Make their expectations low. And then, if you perform highly, then they’re gonna be very happy.

[Jaz]
Yeah. Top tip there, Zahid’s asked another question, and this is because there’s a string between little discussion on the Facebook group between Cheng and Zahid about getting contact points, contact areas on like single crown. So he says, how do you overcome contact point issues with digital as opposed to stone, stone models for single crowns? And then Cheng was like, well, what issues are you having? And, Zahid was like, well, my lab having issues with sectioned printed model being a little bit more flexible than a rigid stone model.

[Graham]
Yeah. We covered this earlier.

[Jaz]
We covered that already. And then what he’s having is that when he’s getting things back. The contacts are too tight and he’s having to adjust the contacts a lot of times. Now, I’m not shy, I do a check with the floss and if it’s proud, if the floss not going through, and sometimes, I don’t tell you this, but a few times comes back and I do an adjustment.

I’m totally cool with that. I expect to do that because you are never gonna nail it every single time. A lot of time your work occlusion is brilliant and contact’s very, very good. So a lot of time I have to touch your work, but I think the worst thing for a dental student, especially young dentists, many years ago, you put it in and it’s not fully seating where you haven’t detected it because you haven’t checked with floss.

So these little basic checks are really important. But I guess the question I wanna pitch to you is any advice you have to other technicians or dentists in terms of getting the right contact points? Or what you do cause you do a good job, what are you doing differently that, you know, why are other tensions struggling maybe?

So basically you’ve gotta set yourself up for success from the start. So your models are the basis of everything that you do, get your models correct, print out a second set of dies, ones that aren’t gonna start wobbling. So have some that are fixed in the model and work on a master  for margination and anything that you’re gonna do off of the model.

[Graham]
So I know some technicians, they like to take the die out and they work around the die and they twist, you know, if they’re doing any layering or marginal work or anything like that, they like to take it in and out. They like to have that freedom and I used to like to have that freedom as a technician until I worked at it was Lab 39 in Harley Street.

And I started learning a lot about the model systems and they still work with split models themselves. But when I set up true form dental with a guy called Lee Stringer, it was mainly Lee at the time, but we set up on Harley Street and he taught me the way that I now use. And I just happened to agree with everything that he had to say about it.

And I was just like, do you know what? I’m gonna incorporate this. It saves me time, you know, throughout the whole procedure. So set yourself up for six success with the model system. And then once you’ve got your contacts right, polish your contact, getting them right and then don’t touch them.

[Jaz]
How do you check-

[Graham]
Every time you fired them, I don’t touch them. When you glaze things, glaze around it. Don’t touch those contacts.

[Jaz]
Once you’ve got the contact how you want, don’t touch it. Make sense. What are you doing to check that this is the level of contact? Because to floss through a stone model is different to flossing in the mouth. What kind of checks are you doing to see if you’re happy with your contact?

[Graham]
So I use shim stock.

[Jaz]
Mm-hmm.

[Graham]
I actually use a 32 micron shim stock.

[Jaz]
Okay. So what are you hoping to see when you put your 32 micron shim stock in? You put the crown on and they’re pulling, what do you wanna see?

[Graham]
So I want to see it, I want to feel a slight pole.

[Jaz]
Mm-hmm.

[Graham]
Just a very slight pole.

[Jaz]
Like a drag?

[Graham]
Yeah. Slight drag. Nothing too-

[Jaz]
It’s not too loose.

[Graham]
Not too loose. But not too tight either.

[Jaz]
Yeah.

[Graham]
It’s hard to gauge. But once you get some feedback from your client, that was nice, you’ll know exactly what it is you’re looking for.

[Jaz]
And I guess feedback, feedback, feedback, until you refine your protocols.

[Graham]
So find a couple of dentists who are willing to give you the feed for every single case for a few months. And then hopefully by the time you’ve finished that feedback, you’ve tweaked everything and everybody’s happy.

[Jaz]
Mm-hmm. Now, clinically, I’ll just talk for a minute. Clinically what I’m doing to check the contacts is firstly when I try the crown, is the margin seating all the way, the margin seating all the way. That, okay. The contact will not be a potential reason to stop your margin seating.

So if the margin’s meeting all the way, I know that, okay, it, it’s not necessarily that the contacts are so tight that it’s not allowing you to even seat the crown. So that is the first thing. Then I’m checking the floss. Can I get floss through? If the floss is too loose, which never happens. This rarely happens.

So usually with technicians I work with are not having this open contact issue, which is thank goodness for that. Am I able to take the floss through now? Sometimes so tight, I can’t get floss through. I know I’m too tight. Now what I used to do is I used to take off the crown. This is the way my consultant taught me at a hospital is I used to put I think it was like 40 micron arcticulator paper in red arcticulator paper, put the crown in and then pull just like you are on the model.

And then the problem with that is get gets really fiddly, you know, one hand in the mouth. Okay? And, you know, the first time the consultant showed me, the crown fell out into the patient’s mountain. And so my little joke I make with every patient is, if I drop it, don’t swallow it and they have a little nervous laughter, but I mean it to them.

[Graham]
Okay. Yeah, for sure.

[Jaz]
It doesn’t happen very often, but, you know, they need to know that. So, I switch from that to something else, which is what I created. A doctor, Ricky Bophal crosses on his top guy, and essentially, instead of now putting the articulating paper in and then seating the crown, the mouth and pulling, I’m actually coloring the red arctic paper on the floss.

And now I’m forcing the floss through. And wherever it’s too tight, the contact, the red articulating paper is rubbing off on the contact area. Bullseye. That’s where I’ve gotta adjust. So then I will usually get like a yellow stone or something, just polish a bit. I’ve got my ceramic polishing burs and whatnot as well. And I’m just checking. It usually takes minute and minute half to get it perfect.

[Graham]
Yeah.

[Jaz]
And then I move on. So just a little clinical tip for those dentist who may be struggling to find a way to check their contacts.

[Graham]
But obviously like from a clinical point of view, it could be coming from what you are doing as well, the way you temp things paramount. What material are you using? Has it got an expansion to it? Are you actually gonna be pushing those adjacent teeth further out so that when that comes off actually they spring back in and then you’ve got something that’s tight.

[Jaz]
Like clip clip and tell you that kind of stuff?

[Graham]
Yeah.

[Jaz]
Over time it can expand and especially if you’re doing like a quadrant of work, you know that. And then can you imagine that little bit of movement between each one?

[Graham]
Yeah.

[Jaz]
That might be the reason why you’re having contact issues really. It wouldn’t have happened if you use different material. So do you know of any materials that are safer or better to use? I couldn’t possibly tell you.

[Graham]
Yeah, I don’t really know clinical materials.

[Jaz]
Yeah. So with the clinical site, I just know that some materials have more, so if you’re having repeated issues, maybe it’s worth checking the expansion of whatever temporary material you’re using. I think it’s a great point well made, Graham. Okay. This is a really good one. Okay. The penultimate question, cause the last question is how to get bite spot on, right. The occlusion. That’s really important for me, as you know. But we’ll first cover the one from Victoria. Hi Victoria. Hope you will Victoria’s, someone who’s come to our splint course live before.

She’s a pleasant, dentist deal with. Thank you so much for being a Protruserati. Victoria said, I have noticed some labs are using only part of the quadrant to produce their work. Although full arch impressions are sent, I always thought that it’s best to use full models, even not mounting for better occlusion management, even in single units.

So essentially the first paraphrase question is essentially half an arch, top and bottom and bite check versus a full model and low model and getting the bite right. Which do you prefer and why?

[Graham]
Well, I prefer to receive a full arch, every time. Whether I use it or not for my models, depending on how I go about doing a case is questionable sometimes.

So if I’ve got a full arch, if I put it through a vertical articulator, if I design it digitally, for instance, I would be putting it through a vertical, call it vertical digital articulator as such. And I’ve got the excursions there, so I’ll design it digitally and then I know that those excursions are clear.

[Jaz]
How do you check your excursion? Is that digitally or by hand? How are you checking the excursions? Because if someone send you with no facebow, they’re just sending you an upper arch and a low arch scan. How are you checking?

[Graham]
So basically you’re just kind of set your virtual articulator to like an average values. So you just kind of check the levels of the teeth and you know, to where you think would probably match. And nine times out of 10 you’d get an excursion correct. You know, on a single unit. because all of the functions already there in the teeth.

[Jaz]
Yes. So you’re using, and this is really important, guys, is that you’re using the adjacent teeth and the angles and the slopes of those cusps-

[Graham]
Correct.

[Jaz]
As the reference on your virtual articulator. They’re-

[Graham]
So, the attrition, the articulator on the digital articulator, we’ll use that natural attrition to plot the function. So you then design your crown using that, and once you’ve designed the crown, you then design your models. So you don’t need all of that models because you’ve already done that procedure.

[Jaz]
Mm-hmm.

[Graham]
Now, some labs, they might just chop it off because their business model says we can’t spend that much money on the models, so they just chop it down, save money. Myself, I like to prudent at least the pre-molars on the other side, if possible.

[Jaz]
Oh, wow.

[Graham]
So if I get full arches, I will take from six to four or five, depending on where the contacts are. So if I’ve got a positive contact on both sides, I’m happy, but I need both canines in order to get an excursive process.

[Jaz]
But if someone’s got an anterior open bite and there’s no contact three three, and you’re doing even a lower molar crown, you want the full arch top and bottom right?

[Graham]
Correct.

[Jaz]
And in those cases, if it’s like very specific occlusal scheme there, then perhaps you probably want it on a physical articulator, or you happy to use the virtual one for more complex case where the occlusion isn’t really straightforward. How do you manage those cases?

[Graham]
I tend to hand mount a lot of things still on so yeah, I put a lot.

[Jaz]
And if someone doesn’t send you a facebow you’re just using average values to mount that. Right. But you’re still able to check things better, which makes a lot of sense.

So Victoria, I guess the answer is, the technicians would prefer as much information as they can. So they prefer the full arch and still send you a full arch. If that’s what you’re doing, that’s fine, but what you do in the model is your decision. And sometimes you might actually print it, but you seem to be in the mindset that you like to print it for at least to the other side pre-molars.

Whereas what Victoria seems to be getting back, she’s sending the full arches but she’s only getting half the mouth. And so that’s why her queer question stems from.

[Graham]
It should only really be an issue. If she’s having problems with excursions when it comes to fitting, then you need to talk to your lab about what they’re doing.

[Jaz]
Absolutely. So it is a conversation to have with your lab, but ultimately it should be results driven if you’re getting the right results in terms of your occlusion.

[Graham]
Correct.

[Jaz]
It doesn’t really matter what the lab are doing always matters what you are doing, but that kind of feeds into the results you’re getting I think, so great. Final question, big one is getting the occlusion spot on. You are very good at doing it. Okay. So I found that your shim holds, cuz what I like to give you often is I’ll tell you the shim holds and lower left four, lower left five, lower left seven. And I tell you to copy the sort of cuspal inclines of the adjacent for a single unit and you pretty much nail it.

But one thing I like to do now, I dunno whether you use this or not, Graham, but one thing I like to do is that quite often I’ll give you the pre-prep scan so you know what my temporary looks like or you know what the tooth look like before I prepped it. And if we’re doing conform dentistry, which mostly we are, then I try and get you to copy the features. Now do you disregard that and completely or starting? I’m gonna strangle, I’m gonna strangle you.

[Graham]
Off with that.

[Jaz]
Okay. So tell us about that then.

[Graham]
Mainly I disregard that because we’re looking at making something better at the end of the day.

[Jaz]
Mm-hmm.

[Graham]
So the tooth has failed for reasons whether it be like contact issues or occlusal issues. So this opens up a whole can of worms of why we do these single tooth restorations that tooth has failed for a reason and it’s normally because of something else.

[Jaz]
Mm-hmm.

[Graham]
Because they’ve got no guidance, they’ve got none of this. They’ve got no balanced force across their whole arch. So by replacing one thing-

[Jaz]
With an exact replica.

[Graham]
With an exact replica, we’re just setting something else up for failure or this restoration for failure. So I tend to disregard anything that we’ve had before. I might look at where the contact was originally and see if we can improve it or keep it where it was. But that’s it.

[Jaz]
The only time I would disagree with you, the only time I disagree with that is a time whereby and this is in your lab, there’s a different lab I used once and I had this patient on a temporary for many months. It was a very specific occlusion and I wanted to nail it, and I did and I got it working beautifully.

And I specifically said, you must do a copy of this cause I’ve nailed it. And they completely disregarded it. But what they sent back was completely outta the bite. Like it was completely shallow where I had these, and I sent them a photo of my temporary and their definitive and they saw that, okay, we kind of cocked up and you gave us that information.

You gave us the scan and we didn’t use it. So I think if you’ve test driven something in a temporary, and that temporary is not an exact replica before the temporary has been purposely built to serve this patient. Then I think technicians should use it if the dentist has asked.

[Graham]
Yeah. If specifically asked, sorry.

[Jaz]
Exactly.

[Graham]
Then yeah.

[Jaz]
Whereas otherwise I really respect the fact that you are wanting your conform to dentistry to actually add something rather than just be an exact replica of the thing that failed. So that makes a lot of sense. So Graham, this is Alexandra Kal.

Alexandra, thanks so much for being Protruserati. It’s always lovely see your engagements on the group and whatnot in the podcast. I love her question. It’s like, why on earth is the bite never spot on? Like, it’s a tongue in cheek thing. And I know Cheng was like, it’s slightly our fault.

Trust me on this. So Cheng is saying that it’s slightly the dentist’s fault, not your fault, but it’s good to hear your perspective. So what tips do you have for dentists to make to helping you to get the bite spot on?

[Graham]
Well, we kind of covered it earlier in some respects. So the way you temp is paramount because obviously if you’ve got a higher temporary, you’re gonna push that tooth further apart, and then you’re gonna end up with something that’s shy or if you, obviously you take too much off yourself, then the tooth opposing is gonna over erupt.

[Jaz]
Mm-hmm.

[Graham]
So then that makes your lab technician’s restoration high.

[Jaz]
Yep.

[Graham]
And you have to adjust obviously other things that can affect this is your temporaries is coming off. You know, you’ll be surprised just an overnight how much a tooth can over erupt.

I had it happen to myself. So this is personal experience. I had a crown prep done in an evening by a top dentist above where I used to work. His name is Ma Rashard. And I thought to myself, right, I haven’t really got the time to make a temporary and a crown for morning fit. So I thought, right, make the crown.

Don’t need a temporary, it’s only overnight. So I made a nice bonded crown, finished it in the morning, glazed it, went upstairs for a fit. It’s high.

[Jaz]
So you made your own crown high.

[Graham]
Yeah. Yeah. High, high, metal.

[Jaz]
Humble pie.

[Graham]
Humble pie. Yeah. So my tooth had actually over erupted about 0.5 of a millimeter.

[Jaz]
Wow.

[Graham] Just overnight.

[Jaz]
And so to me as a, with an occlusion background, what I’ve been taught by Rob Kirstine and these guys is that that tooth, perhaps the reason why it failed is that tooth was in chronic overload. And finally, now that there was no temporary anymore, it was able to passively release that pressure.

Okay. And restore itself. So it apparently takes about 17 minutes for the PDL just to recoil and get to where it wants to be. So it happens very quickly. Right. But in those cases, my predecessor whose list I inherited, he was famous for crowns, come back high and just cementing them and sending patients off and come back and everything was perfect.

And so I think lot dentists do this and we get away with it because we adapt.

[Graham]
Yes.

[Jaz]
The body is good at adapting. I’m not saying we should- it’s not why I teach either occlusal course, we should strive to be conforming the best way possible, but sometimes these things happen and you have to look at, again, lost temporaries is a good point.

[Graham]
Lost temporaries. So you’ve got temporaries impressions are a big thing as well. Like you look across the arch, like you say, about giving full arch impressions and only small impressions. Now these can make a big difference to the bite. If you’ve got any sort of distortions on your impressions, any drag on, anything, even on scans, you can end up with scan data that isn’t quite correct and you’ve got slight warp in it can affect the bite that the technician works from.

So that’s another reason why technicians sometimes chop a lot of your scan data out because it’s just not usable.

[Jaz]
Mm-hmm. It’s making it worse.

[Graham]
They’re trying to make well something work for you. Yeah. So yeah, it’s difficult. It’s a minefield. And then of course, You’ve got the lab technician side of things, and it could be a whole number of things in the laboratory as well.

Is that technician experienced enough? Has it been quality controlled by somebody? You know, depends on the type of lab you send it to. If you send it to a lab where you’ve got people working in a process, it goes through the ceramics last, he should do the quality control. So it basically comes down to that ceramics.

But everyone else have, they set him up for success to the point where he’s come to. So yeah it could point to a number of people.

[Jaz]
Well, I mean, with all the processes on the dentist side and all the person on the lab side, it’s a bloody miracle that anything actually fits. It’s a minor miracle.

[Graham]
It is a minor miracle.

[Jaz]
The occlusion’s even. And your occlusions usually very good. And we’ll take a few snippets some video content of the virtual articulator. I think everyone will be quite happy to see that. We’ll show that in a moment. But yeah, I think getting the occlusion right is a partnership between the dentist and the technician.

And another tip that I can give is, one thing you mentioned earlier, Graham, was that when we’re doing our scans, just take a second, just check the bite is how it should be. Cuz you know, one time of a hundred you might say to me, is this actually how the bite is? I’m gonna hang on a minute. No my photo show something different.

So at the time in haste you might have not scanned properly or the patients just shifted their bite a little bit as you’re scanning.

[Graham]
Yeah. Correct.

[Jaz]
Important to check that.

[Graham]
And it’s very detriment, especially if you are using like a quadrant scan. And your patients bit down in the wrong place.

You’ve got no real attrition to have any guidance with, even if you’re trying to put it in like habitual position and working with the attrition there. If you haven’t got enough surface area you’ve got nowhere to work from. And you’re just literally working off of excursions only, and that’s it. So you can make a crown that’s flat in order for it to fit. And that’s probably the best you’ll get.

[Jaz] The times where I struggles as a dentist to and I blame myself as a dentist rather than the lab is deep bite patients, right. Who don’t have much of an anterior stop. So they completely, they’re almost fighting onto a gingiva. Right. So, very, very deep bite that’s almost like an open bite in the sense that you’re relying a lot on the posterior anatomy cuz anterior isn’t really giving you much. And what I’ve found is that these crowns often come back very proud because of that deep bite element, the technician has perhaps not been able to control exactly what the bite is like because of the fact that it just over closes.

It’s got so much play at the front because the deep bite nature. So I’ve always found these cases a lot more tricky to get the occlusion right in. So I always go back to basics, get a full arch in that sense. Give a couple of different bites, use bit of you doing reference points and give as much information to technician as possible. I would never, in a deep bite case, give a half an arch only. Any other tips on that? To me?

[Graham]
None that I can think of. Continue.

[Jaz]
Okay, fair enough. Well I think we’ve covered a lot of ground there, Graham, I think we’ve covered a lot of top tips there and we answered a lot of the Protruserati’s questions. I’ve always enjoyed talking to you, but-

[Graham]
I do have a tip for digital dentists.

[Jaz]
Yeah.

[Graham]
Though about getting your bites right. Now, one thing that I do is when I receive a digital case, I will then go to design the models, et cetera, et cetera. I know dentists don’t do a lot of this, but if you go to a model design first before you then design your crown could be an advantage to yourself.

Now what I do, I always check for the contacts and where they are. Do they match up? You know, is it evenly balanced? Are they in the places where you thought it was? And if not, then I changed where the antagonist positioning is and I will bring it down as if the patient is actually biting. So I’ll bring it down like 10 microns and then another 10 microns until we’ve got contact.

[Jaz]
Digitally. You’re doing digitally?

[Graham]
Yeah. This is digitally. And then and only then when I’m happy with the way the patient is biting to know that when I build the restoration, that’s the position it’s gonna be when the patient’s biting down and it’s not gonna be high.

[Jaz]
But this is because the scan, the bite scan that you’ve been sent is kind of in deficient.

[Graham]
Yes.

[Jaz]
Yeah. And so what I appreciate about you, Graham, here, and it’s important to note this, is that you’re taking this time to check and, you know, do these pre-op checks rather than just make the crown fit in what you have and make it all just fit. You’ll actually taking time to check that which is wonderful.

So I think part of the reason why we get a lot of success, you and I with our occlusion is because you are doing these checks. I’m doing my checks and we work in synergy together. So now at this point people are like, okay, I wanna use Graham as my technician. So I’m gonna say piss off. All right. Hands off.

No, I’m joking. I’m joking. So I’ve already had this chat with Graham, and Graham is too busy. You could say what kind of work you are willing to accept. Cause I know you’re not taking any bigger clients.

[Graham]
I can’t take any aesthetic work on, I’ve got enough clients that are sending me that to keep me busy. I can perhaps take on some single units, mainly emax like onlays, overlays, veneer lays, kind of what we specialize in. And quadrant work, posterior quadrants, but yeah, anterior work and full arch is, I can’t take anything.

Jaz’s Outro:
Yeah, anything fancy buzz off. Yeah, he’s busy. Enough as it is. So, Graham, thanks so much, man. Really, really nice to see your lab today. We’ll take a few more bits of footage and stuff for the occlusion course, but also, just to add on to this video for the virtual articulator and that kind of stuff. And we’ll go around seeing some things. So guys, thank you so much for tuning in as always. And to the outro.

There we have it, guys. Thank you so much for listening all the way to the end. I hope it inspired you to pick up that phone and arrange to go visit your lab, see your technician eye to eye and GROW TOGETHER. Maybe even take them out for lunch, #taxdeductible. And if you’ve listened all the way to this point and you’re Protrusive Premium member, all you have to do is answer a few questions and get your one hour of CPD.

Because if you are listening every week, and many of you are, then by the end of the year, you would’ve got 30, 40, maybe even 50 hours of CPD by certificate ready to upload as part of your personal development plan, as part of your annual quota. Answering these questions super easy and it validates the learnings.

Make sure it’s all fresh in your head. In fact, one of the questions for this episode, I’m just gonna read it out, is, which of these is a cause for your crown being proud or too high in the bite at the time of delivery? So is it A, a temporary material that is dimensionally unstable, B, a lost provisional crown, see a distorted impression or scan D, a lab error such as a lack of quality control, or E, all of the above.

If you know the answer, you are pretty much almost there to get your certificate. So please do answer it. And if you haven’t already downloaded the app, that’s the first step. Either access the app online, on your browser, on your laptop by going to protrusive.app or downloading an Android or iOS.

If you found this episode useful, share it with your lab technician. That’s maybe one way how you’re gonna grow together, that one way that you’re gonna build a rapport with your technician or maybe send to a colleague that you like. I appreciate you listening all the way to the end, and I’ll catch you same time next week, same time, same place.