The Semi-Indirect Technique for Toothwear Cases – PDP187

Jaz’s Introduction:
So if you are earlier in your dental and occlusion journey, or maybe you’re not yet comfortable going beyond single tooth dentistry, then this episode may be difficult to grasp, but you should use these experiences as motivation and inspiration. It’s a bit like when you go to a conference and some of the stuff that’s being presented is so far beyond and above you at that moment in time in your journey where you are, but it’s still really important to pay respect and listen because that can be the spark that you need in your career sometimes.

But of course, if you’re into occlusion and tooth wear. And you love restorative dentistry, then this could be a really geeky discussion that you’re going to be able to apply on Monday morning if you’ve never used this technique before. Like, to give you a flavor of it, it’s essentially using the wax up to create your own composite restoration.

So you’re using the wax up to create your own, like, direct composite onlays, for example, right? Direct composite onlays that you’re making. So not indirect, it’s direct because you’re making them using the wax up and using the putty. And you’ll see later, our guest, Zohaib Khwaja. He’s going to explain why this has certain benefits and perhaps when he wouldn’t use this technique and go indirect. And from speaking to him, I do think that it’s a really nice trick to have up your sleeve, especially if you’re interested in the adhesive management of tooth wear.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to the Protrusive Dental Podcast. If you’re new to the podcast, welcome, it’s great to have you. And of course, if you’re a veteran on Protrusive, then it’ll be good to see you on Protrusive Guidance, our app, our platform, where we connect, where we share, where we learn and grow together. Before I bring on Zohaib to share the Protrusive Dental Pearl, the team have also made an infographic. So everything that we explain, Zohaib has kindly given his photos and we’ve made a little infographic so you can follow along to this episode and keep as a reference in the future for when you have that kind of case coming through.

To download this infographic, simply head over to Protrusive Guidance. Most of you listening and watching already have your login, but if you don’t, head over to protrusive. app. And make a free account. I’ll make it freely available to everyone. It’s kinda like a perk of being in the network. Of course, if you’re paying subscriber, you’ve got access to Protrusive Vault. It’ll be there alongside all the papers and infographics that are a fingertip away just for you.

The Protrusive Dental Pearl today, which Zohaib will explain, is all about finding centric relation, but actually what I love about what you said is the practice of it. Now whether you use a leaf gauge or you’ve been taught how to use bimanual manipulation and that’s what you choose to do, it is a skill. Finding the fully seated condylar position is a skill and so Zohaib’s tip is really good because it encourages you to practice it. So let’s hear it from Zohaib.

Today’s Protrusive Pearl is by our guest Zohaib. We’re talking about it a little bit and I’ll get him to say it, but I love what he’s going to say. I’m going to prime you guys now because it’s an idea of putting things into practice, even perhaps when it’s not necessary, but it’s building up those muscle skills. So when it comes necessary, it’s so much easier. It’s really like a, considered like a dark art, this part. So Zohaib, take it away.

[Zohaib]
So, I think if I’ve got a tip, it would be something that I found useful when I started first going on courses, learning about CR and kind of bimanual manipulation and things like that. I didn’t have any cases to do this on, but I would have regular patients for checkups. And if they were comfortable, I would maybe manipulate and try and find CR, find the first point of contact, make a note of it. I really just practice some of the things before I needed to use them. And you kind of constantly thinking when you’re seeing a patient for a checkup.

They’re not interested in kind of managing their tooth with it, but you’re having a look, where’s that weird facet, is that the first point of contact, is the mandible sliding, and you’re kind of, a bit of detective work, even when you don’t need to, and I found that kind of spurred my interest, because if a tooth fractured, I thought, why is that fractured, they’re already happy to have an onlay or a crown, but I want to kind of know a little bit more, and so you might look at their guidance pattern, and there might be a kind of non working side interference, And it was that kind of detective work that made me more interested in tooth wear and other bits and pieces. So, I think if there’s one tip, it would be kind of be interested in some weird dental things and you might find a bit of a passion that leads from that.

[Jaz]
I think you’re right, and especially with what we’re going to be talking about today. Tooth wear, tooth surface loss. When you’re treating these cases, you’re often raising the vertical dimension and often the joint position of choice that you may prescribe rather than just being arbitrary is central relation or fully seated condylar position or stable condylar position, call it what you want.

And it’s a skill to be able to find it, which is what you described. No matter how is that you’ve learned to find it. And we’ve got a webinar on YouTube all about this kind of stuff as well. I’m sure you guys teach it as well in your courses. But use that technique every so often, even when you don’t need to, to refine those skills. So when you need it, you nail it. Thank you, Zohaib.

Hope you enjoyed that Pearl. Like some of our younger colleagues may be like, ah, I don’t know anything about centric relation. In which case, check out the webinar that we’ve done. It’s called Finding Centric. And this webinar replay is available on Protrusive Guidance. There’s a whole section for webinar replays. You can check it out. Let’s now join Zohaib in the main episode.

Dr. Zohaib Khwaja, again, another fellow of Protruserati. It’s been great to interview Protruseratis recently. How are you, my friend?

[Zohaib]
Really good, Jaz. Thanks for having me on. I’ve watched the podcast and listened over the last few years. You’ve definitely kept me company on many of commutes, so really happy to be contributing today and really looking forward to our conversation.

[Jaz]
I’m very much looking forward to your contribution. It’s a great topic and I’m very excited to dive into it. We’ll be talking about managing vertical dimension, when to do DAHL technique versus when to go ahead and restore the posteriors and a little bit more about some of the things that you shared with me on social media, like the palatal backing.

So lots of geeky goodness to come tooth wear related, which I know is difficult to find good content on that. So I think we’re going to make it today. So let’s make it happen. I’m very excited to dive into that and extract as much as I can from you for the Protruserati and true protrusive style. But we were just talking before we hit the record button about your journey. It’s always nice to learn the journey. And so just to just summarize, you’ve got so many masters. I’ve lost track now. Just maybe you tell us what’s your journey been like?

[Zohaib]
So I graduated 2011 from King’s. I spent a year doing a MaxFax job. And then pretty much I’ve been in general practice since then. But kind of a few things happened to me early on in my career that were quite seminal I remember probably being about a couple of years post qualification and one of the professors at King sat me down. Prof Dunn who some of your your listeners will definitely know and he kind of sat me down. He was getting close to retirement himself at that point and he said he’d seen loads of dentists over the years and something would happen around about the kind of 10 year mark.

Very competent dentists who were seemingly very successful and they would kind of hit a bit of a brick wall. They were weren’t very satisfied. They kind of wanted out of dentistry and he was making the point that if you kind of find an area of special interest, find something that you’re passionate about in dentistry and really kind of go on courses, develop more learning around that.

That was a way to kind of stop you hitting that broke wall. I guess we would describe that as burnout. So that I guess I took to heart and that took me on a journey of first completing a master’s in primary dental care. I then went off to King’s did the distance MClinDent Prostho program. And I’m currently completing a master’s in dental implantology.

And that means that I’ve got quite an interesting varied week. And it’s also allowed me to take up various kind of teaching and academic roles. So it’s a nice way to spend my kind of clinical time, but very much kind of four days a week, very much in general practice.

[Jaz]
You pursued your interests and the kind of stuff you’re doing is day in, day out opening and managing vertical dimension, tooth wear cases, which obviously is your passion. You can tell straight away. The program that you did, the MClinDent distance learning. I know even some Australian dentists come and do that as well.

[Zohaib]
Yeah.

[Jaz]
What do you think is the difference between what you’ve done and taking the next step and actually being able to call yourself a specialist? I’m sure you would have considered it. Did you get enticed by that? And what do you think of that sort of equation to do the extra training to then have that specialist title?

[Zohaib]
Yeah, I think it’s definitely consideration for most of us when we kind of qualify in the first few years when we’re thinking about going on courses and maybe specializing or not. I think for me what appealed about the distance program was it was very much a GDP I liked doing a range of treatments I wanted to stay in practice. And the MClinDent allowed me to kind of pursue my studies as well as do general practice. I think the specialist definitely kind of a role for specialists in in private practice, but perhaps more so now in a hospital setting where specialists are really quite needed in tertiary care. So everyone’s got their own route. For me it was a really happy medium of being able to pursue an academic career as well as be very much in normal private practice. So that was kind of-

[Jaz]
Do you think you missed out on any skills training by, if you speak to your specialist colleagues, which I’m sure you have many of, do you feel as though they gotten more exposure to any elements of it that perhaps you missed out on, but obviously you’re seeking through the real world of practice, obviously getting more, more, experience in that realm. Any comments on that?

[Zohaib]
Yes. It’s an interesting one. I think there’s a bit of both, right? So I think for those of us who have been in normal kind of general practice and private practice, you get a lot of real life experience, you get to deal with your everyday dentistry, kind of the good, the bad, and the ugly.

And so there’s a lot of experience you gain over your hospital colleagues in that, but I think obviously in a hospital setting if you’re on a specialist program, you’re doing perhaps more complex care under the guidance of consultants. There’s definitely a different type of work that gets carried out. So I think both-

[Jaz]
More tertiary care.

[Zohaib]
Yeah more tertiary care and so both have their role and I think actually they work in harmony I don’t think it’s conflicting as kind of everyone seems to think that that perhaps it would be. And I think even within those specialisms, you’ll find an area that you’re interested in, and then you’ll continue to develop. So most of my specialist colleagues up, continue on courses and gaining more knowledge as well. And so dentistry rates so fast, fast changing, fast paced.

I think whatever path you take whatever kind of qualifications you have you still have to continually learn you’re still always on that journey. I’ve definitely found myself kind of once I finish this course I’m constantly thinking about the next one and that’s part of the fun of it as well.

[Jaz]
You’re so true. Like I have plenty of my friends who are specialists and sometimes my colleagues that look at specialist think, oh, once you’re a specialist, you made it, you’re there. You’re done with the learning, right? You put the books down kind of thing, but actually no, sometimes that specialism sparks that niche, that interest.

And then, we need to go on more courses to develop it and broaden it. So the learning never stops. So if you’re out there thinking, oh, if I just become a specialist, I won’t have to go on X, Y, and Z course anymore. I can just focus on my day-to-day care. It’s not quite as simple as that.

It gives you the bug to learn more and the learning never stops. That’s a great lesson you mentioned there. The other thing I want to highlight is the great advice you were given by Professor Dunn because of the element of finding your niche, finding your niche and having that purpose and that desire and the hunger for what you do is the antidote for burnout.

And I think that is great that you have that. And the passion is very obvious. So on that note, let’s talk about some things that you’re passionate about, right? Looking at comprehensive dentistry in comprehensive cases. So that we can narrow this episode down a bit. One of the ways to manage tooth wear, tooth surface loss, tooth wear, call it what you want, is we’re always needing space.

We’re always fighting for space. And so one of the accepted techniques is to open the vertical dimension or raise the vertical dimension. And in the UK and Europe, especially over so many decades, the DAHL technique has become very popular. In fact, I always say, I always see the DAHL technique is a really great technique for a younger dentist as a stepping stone to into full mouth dentistry. And one of my earlier cases when I qualified that really inspired me to learn more and look and look further into comprehensive dentistry was actually a DAHL case as a dental core trainee.

Can you just for the younger listeners and those who are in certain countries where they’re unfamiliar and they don’t believe in the dial technique, explain even though we covered it, I’d like for you to, in this episode, start fresh. What is the DAHL technique and what percentage of your tooth wear cases, day in, day out, are you managing with this technique?

[Zohaib]
Really interesting introduction and kind of conversation. So DAHL’s predominantly kind of been spearheaded in the UK and across Europe. And it originated, I think in the 70s, there was a Scandinavian dentist by the name of Dahl, and he made a cobalt chrome appliance, which went on the anterior upper six teeth.

And he used it to bring the posterior teeth out of occlusion. And he found that over a six month period, six to nine month period, the posterior teeth extruded and then when he took off this cobalt chrome appliance, he now had space on the anterior teeth to restore those worn teeth. So we tend to use DAHL in very specific cases of localised anterior tooth wear, so If you imagine, if we’re the patient with upper 3 to 3 palatal wear, and there’s no space, now they’re biting in ICP, and they’re biting on those worn palatal surfaces.

You have to think, at that point, what options do I have I could restore in ICP, so that would require me to drill those already worn tooth structures. Maybe a bit of crown lengthening, so that’s quite, quite an aggressive approach. I could reorganize the entire occlusion. I could reorganize in CR, open up the OVD.

And that’s a suitable option in certain circumstances, but then, again, that’s quite a lot of wear. I’d have to restore a whole arch or both arches. And then that leaves me with one of the options, which is to do DAHL restoration. So I can restore the anterior teeth high in a very specific way and control the occlusion, leave the posterior teeth.

Open to the out of occlusion and then I can closely monitor and expect over a six to nine month period. The posterior teeth will extrude, and the anterior teeth will intrude slightly, and so the teeth will come back into occlusion. We’ve got to be very specific about the cases we want to use DAHL on, because otherwise you get uncontrolled posterior movements, and that’s why in some countries it might be frowned upon, or in some cases it might not work.

So I will consider DAHL in cases where the teeth are quite nicely aligned posteriorly. So if I’ve got posterior crossbites, missing teeth, bridges. I don’t really want uncontrolled posterior movement. Anteriorly, if I’ve got a nice class one occlusion and I know that I’m going to be able to control the anterior loads in an axial direction, that’s when DAHL will be favorable.

But if I’ve got a class three or a deep bite, the big Class 2, then I’m not going to get that axial loading in a favourable manner. So I might want to avoid DAHL. If I’ve got a reduced periodontium, if I’ve got TMD problems. So again, in those instances, I might want to avoid DAHL. But when it works in effect, you have to imagine you are in essence, giving the patient a fixed Lucia jig.

You’ve got resin composite on those anterior teeth. You’re controlling the occlusion. So it means that the muscles of mastication aren’t firing off as much because it’s just the anterior teeth that are meeting. That allows the mandible to relax and to distalise slightly. And then in effect, the patient finds their own CR position.

And then, over a period of about six to nine months, you get posterior extrusion and anteriorly you get intrusion. So, for me, it’s very case specific. But in certain cases it’s a very conservative way of managing patients with localised tooth wear.

[Jaz]
Thanks. That summary. I’m just going to mention that a common mistake that a youngish dentist might want to do when they’re starting out with a technique and they get a little bit trigger happy. Oh yeah, this looks like a DAHL. Oh yeah, no, what, let’s do a DAHL here. And all the things that you mentioned of as contraindications with DAHL, and it’s very specific, localized anterior tooth where describes it. Amazing. But one instant I remember is mentoring a colleague and he showed me a case and he asked me, is this suitable for DAHL?

And whilst there was a good amount of enamel anteriorly, enough that you can still bond to and get that vertical dimension, which is great. But posteriorly, we were into dentine. We’re into dentine. There was some leaking restorations. There was crowns that needed replacing. That’s not a DAHL case.

You need to go in and treat those posterior teeth. Don’t do DAHL because it’s going to be cheaper for the patient or it’s going to be easier for you. If it really needs, if the posterior teeth really need attention, they need attention, you got to really do a full mount approach.

[Zohaib]
Yeah, absolutely. That’s a really important point because DAHL is actually the worst thing to do, if you’ve got generalised wear like that, because what will happen is those posterior teeth will come into occlusion. And now that space that you’ve created, that you could have used for restorations in quite a conservative way, you’ve now kind of lost it. So absolutely. So it’s really important to be case selective and generalised, where it should typically be kind of, you’re thinking about a full arch and restoring in CR.

[Jaz]
What percentage of your cases are you doing DAHL? Like, obviously it depends on what walks through the door, but if you look through annual, your audits and your photos and stuff, how much DAHL versus how much you’re doing, how much localised interior tooth wear you’re getting, is the question really, versus how much generalised tooth wear you’re getting that you’re doing other, other approaches, which we’ll discuss.

[Zohaib]
I love that question because I’ve never actually thought about it. I’m thinking, off the top of my head, I would say about, I would imagine about half of the cases I see are localised anterior wear we’re going to manage them as localised anterior wear because the posterior teeth, I can get away with a little bit of composite. I don’t need to restore the entire arch. I’ll definitely look out for what proportion, actually. That’s quite an interesting question.

[Jaz]
But it’s good to get an idea, which I think you’ve given us quite fairly there. It just gives us an idea.

[Zohaib]
We did a study a while back at King’s, a couple of years ago. And it looked at restorative referrals. And what was really interesting was the majority of referrals were for tooth wear. And in those referrals, I think most significantly it was for erosive wear and typically you’ll find that kind of localized anterior pattern in erosive wear. I usually be thinking kind of patients under 40 presenting with erosion.

[Jaz]
Yeah. And I think the patient age has got something to do with it as well. Now, we don’t want to make it all about a DAHL episode here. So we talked kind of about what is DAHL and you kind of talked about the scenarios where perhaps you shouldn’t be considering a DAHL and have a look at a full mouth approach.

And part of doing a full mouth approach often is once you’ve got your, I don’t know, anterior provisional restorations, or you’ve done some composites anteriorly that could be transitional, for example, and now we have that space posteriorly, which you don’t want to leave because you want to use that space.

There are techniques to be able to restore the posterior teeth and some things that you’ve shared with me in the past is these injection molding stents, ExaClear, for example, and that is one way to restore the posterior teeth once you have the space. Can you give us a breakdown of some of the techniques that you use, being an interest in this field of managing tooth wear, what are the different techniques you’re using nowadays and what are you favoring to restore the posterior teeth?

[Zohaib]
Yeah, great question. It changes for me over time. So if you think about it, once you’ve opened up the patient anteriorly, in effect, I’m thinking I’ve got them in a fixed Lucia jig. So they found CR and I’ve got this space at the back. My options are really direct or indirect. So if I’m going directly with composite, I could go injection molding.

I could go freehand and kind of just play some composite. I could use a semi indirect technique, which I really like and hopefully get a chance to describe. And then indirectly, we’re thinking ceramic or then composite, and actually I think composite and tooth wear indirectly has quite a good material because composite is adjustable.

There’s a certain amount of elasticity to it as well. It’s a bit more forgiving than ceramic. When I’m looking at the posterior dentition, once I’ve opened up, I’m looking at the amount of wear, what’s the size of the defect, the age of the patient, what the patient’s expectations, finances are. So if I’m going directly.

I don’t particularly use injection molding, but I know there’s some great clinicians who do. I think injection molding for me would be if there are smaller defects and I can get away with a little bit of flowable composite. I quite like a semi indirect technique, so I will have a wax up from the lab and that will give me the planned final position. I will take, make a putty stent of that diagnostic wax up in that putty stand.

[Jaz]
This is like standard putty and not some of the clear stuff? There’s like normal putty, yeah?

[Zohaib]
At this stage, just normal standard putty. I will then cut a window in that putty and then inject some clear silicone into that putty stand. And the reason for that window is it allows me to light cure through that putty stent. So if everyone’s following me so far, I’ve got a putty stent that’s essentially an impression of my diagnostic wax up. There’s a little window with clear silicone that allows me to cure through it. So with that putty stent, I can then place some heated composite.

I can take it to the mouth, so the worn posterior dentition. I can put some PTFE on that worn posterior dentition, heated composite in my putty stent, pop it on the tooth and cure it. Take that off, and in effect I’ve got a semi indirect composite onlay. I can then adjust that. Get the rubber dam on the patient, isolate them really nicely, air abrasion, and I can cement that into place.

And that’s just a way of copying and pasting my wax up into the mouth using what feels to me a more rigid paste composite rather than a flowable composite. And in medium sized defects, while I’m opening up the OVD, that seems to be a good alternative. The options beyond that would be indirect. The composite will then ceramic

[Jaz]
Amazing. What a summary, but let’s dive deeper because I’ve never used this technique. So I’m very interested. So once you’ve got the putty for the posterior, let’s say you’re doing the lower left quadrant, right? You’ve got a sectional putty. You’ve got it over your wax up the putty and it’s setting. Okay. Once it’s set, are you at that point using a scalpel to cut out the window?

[Zohaib]
Yeah, absolutely.

[Jaz]
And then you’re then injecting in the ExaClear?

[Zohaib]
Absolutely.

[Jaz]
So now you’ve got part putty, which is the opaque stuff, the blue, the green stuff, for example, and any guidance as to which areas you found work well as a window. Should it be completely occlusal, occlusal buccal, occlusal lingual?

[Zohaib]
So, actually, if you’re just completely occlusal, that’s enough, because all you need is the light cure to give it initial set. You can then take that off and then you cure it properly, obviously, and then you’ll polish it, do whatever you want, and then the rubber dam goes on. And then you’re going to bond that onto the tooth. So actually, just the window, kind of covering most of the occlusal surface doesn’t have to cover the entire occlusal surface is enough for the light to penetrate so that you can take it off the actual the mouth or the model and then cure it completely.

In the past, I’ve done it on the models. So I’ve taken impression of the wax up. And then use the pre op model as the patient’s mouth and create them before the patient’s even got in the chair. The advantage of that is efficiency and kind of you feel like you take some of the pressure away. However, the kind of inaccuracies you get probably aren’t worth it. And so doing it inside the patient’s mouth instead of the pre op model means that you’re going to get a really nice accurate snug fit. You can cement it on with heated composite and then you’ve got kind of a monolithic composite block which works really well.

[Jaz]
I like the idea of using heated composite here because you might have a few more voids here and there which the heated composite can can fill in. I quite like the idea of that. Now when you actually, that putty that you have which is a part opaque putty and part clear putty, when you transfer that to the mouth you’ve obviously got paste, composite, heated, I imagine, in the putty, right?

[Zohaib]
Yeah.

[Jaz]
Yeah, so it’s in the putty. You’ve isolated, you’ve dried the teeth. You’ve got PTFE on all the teeth that you want to cover because you want a separating medium. You don’t want to stick to the teeth. But at this point, is it too soon to use a rubber dam or using rubber dam now anyway?

[Zohaib]
No, so when I’m creating the onlays on the teeth, I’m not putting my rubber dam on yet because it’s getting in the way. So I’m going to go tooth by tooth. So I’ll put PTFE on the lower left six. I’ll have composite in my putty index on the lower left six. Pop it on the tooth, cure it. Take it off and then cure it again. And so now I’ve got a composite onlay. I can then neaten that, kind of polish it, adjust it. And then once I’ve done the rest of the teeth in that quadrant, I’ll isolate that quadrant, air abrade and then go through my bonding protocol.

So here’s the tricky bit. I think you probably might have a few tricks up your sleeve here. Once you’ve done the first molar and then you find in the contacts area, maybe the contact’s too wide. It’s kind of slipped into the premolar and the second molar. And then, do you have to sort of do a fair bit of adjustment to make sure that they all sort of sit together passively?

So you have to check all of that, obviously. And I think the important thing to kind of factor in, in a lot of these tooth wear cases, you’re not going interproximally. The wear hasn’t been significant enough to kind of get into the mesiodistal box.

[Jaz]
So you still have the natural contacts preserved?

[Zohaib]
Exactly. So ideally you’ve got your own natural contacts and I’m literally covering the top surface almost like a hat so I can get bring the occlusion back to where I want it to be and get get contacts on restorative material. Once I’m into those mesial distal contacts then I start to think more about indirect materials. I probably want to prepare those margins properly. Or, if I’m not using indirect materials, then I’m typically getting a sectional matrix and they’re building that up and then kind of doing it in stages.

[Jaz]
That was a real good pearl there. I mean, I think if anyone is multitasking to listen to that bit again, because that’s a real good pearl in terms of case selection and consideration.

[Zohaib]
Hopefully I can share, Jaz, I know sometimes you do lecture notes and things like that, and I can share some images that might be helpful to show some of those steps a little bit clearer.

[Jaz]
Yeah, and of course, your social media is very rich in this kind of stuff, so we’ll definitely be able to share that, as well as some of those photos you could share with us, brilliant. So I’m just wrapping it up for those people who are trying to get their head around it, and I think we’ve described it well so far. Do you ever do them linked? Like, for example, can you think of a reason why you might want to them linked as a transitional, so you’re linking that entire quadrant, for example, is that something that you’ve ever done?

[Zohaib]
So, I haven’t done it. I’ve seen it described, Francesca Vailati, who describes a three step technique that some of you guys would have heard of, describes linked posterior interim composites and actually I can’t see a necessarily bad reason for doing that as long as you get the TePe brush in between.

It’s a simpler method of linking everything together. I think you probably then want to transition to a more definitive material sooner. I think in a lot of my cases. Those composites are lasting for a decent number of years for those patients, actually they see them as a good medium term restoration rather than just a short term restoration. So having actual proper contacts makes sense. It’s easier to clean. But yeah, it’s definitely been described and I can see some benefit. It would be an easier technique to just to link them together.

[Jaz]
When would you consider perhaps going indirect? Well, I mean, the semi indirect, it sounds nice, and then we like to get creative and do this, and the indication of already having preserved contacts makes a lot of sense.

And the great point you made that actually the contacts need a helping hand, and to have an indirect material can help us here, because what you don’t want to be doing is playing technician on your patient, right? You’re doing all the hard work of the occlusal, and then doing the contacts for each one, the contacts are already there, which gives us the edge. So other than the contacts, are there any other reasons which you might consider going indirect?

[Zohaib]
Yeah, I think if the wear is quite significant, then I’m thinking actually it would be better off just to prepare some margins and go indirect. I think there’s certain patients who want a more definitive solution.

Maybe you’re older patient who isn’t interested in kind of composite chipping and wearing and constantly requiring adjustments. So I think those kind of factor in, but in your younger patients, someone’s in their 30s and you’re thinking, I’m going to have to kind of restore all of those posterity.

If you’re committing them to indirect restorations in my hands, which would mean kind of preparations with mesial and distal boxes. So, they’re conservative, but they’re not that conservative. That’s something that you perhaps want to do later on in the restorative cycle rather than earlier on.

So yeah, I guess those are some of the factors that I’d consider. One of the things I’ve mentioned, if I’m going indirect, actually a material that gets quite often overlooked with, with kind of tooth wear cases is indirect composite. So the big advantage of indirect composite is you can adjust the occlusion a lot easier.

There’s often a little bit of adjustment that’s required. So actually as an indirect material, indirect composite, which has better wear kind of characteristics than your normal composite, is actually quite a nice material. You don’t have to immediately think you’ve got to go emax in all these cases.

[Jaz]
Well said. And does the patient’s occlusal risk come into it? Like, for example, if someone’s got really large masseters and they’re more parafunctional, would that sway you more towards a different technique? Does that also form a decision making factor in terms of which way you’re going to go?

[Zohaib]
Perhaps a little bit, but actually I’ve been surprised over the years of doing this. Once you start to restore kind of anterior guidance, once you give them those favorable contacts. Actually interesting-

[Jaz]
In mutually protected occlusion.

[Zohaib]
Yeah, mutually protected occlusion. Interestingly, they don’t, at least for the years that I’ve been following them, don’t seem to wear their teeth in the way that you think that they might do. And maybe it could because they’ve got a second chance they’ve got a splint, wear monitoring them. So actually it probably doesn’t swim me as much as I kind of think it may do. I think I’m looking at the size of the defect. I’m thinking about what we want as an outcome for the patient, what age they are, and that kind of helps make my decision a bit better.

[Jaz]
Okay, we’re very happy with that. Let’s switch our focus to the anteriors. You talked to me before about palatal backings. Can you tell us more about what they are and then when we should be considering using palatal backings, and again, whether they should be indirect or direct, and how you do them in your practice?

[Zohaib]
Yeah, so actually very similar to what I described with the kind of a semi indirect posterior restoration. So if I’m doing a DAHL case and I want to restore the anterior occlusion high, I’m looking for a very specific type of occlusion. I’m looking for even anterior contacts, heaviest, I guess, on the canines.

Maybe shim slides on the lateral side. So I’m quite perspective about how I want that occlusion to be. So I’m trying to copy as accurately the wax up and then make some careful adjustments inside the mouth and so I’ve found over time the best way for me to do that is I will get a wax up made I’ll check that I’ll mock that up inside the mouth.

Make sure I’m happy with it and to transfer that into the mouth, I will make a putty stent again of my wax up. I’ll cut a little window politely and put that clear silicone back into it. And then I can use that again either in the mouth or I can do this off of the models. And typically I’ll do it on the models because anteriorly there’s less play.

I’ll put some PTFE on a pre op model, heated composite on my silicone index, pop it onto the pre op model, cure it. And then I’ve got a little composite backing, which I can then adjust. And I can take that to the mouth, get my rubber dam on and then bond that into place. That palatal backing will have a little tag, which covers over the buccal surface.

Almost like a locating sprue or locating tag and that allows me to quite accurately position them. Once I’ve bonded everything into place, I can then trim them back and then I can lay a free hand. So for me, that takes two appointments. The first appointment will be cementing on palatal backings. I can send them away for a couple of weeks, make sure they’re happy, they’re coming back comfortable.

And in my mind, what’s happening at that point is in the first couple of weeks, they’re getting a little bit of destabilisation of their mandible because they’ve got even anterior contacts, almost like that fixed Lucia jig. And before we start to get extrusion and intrusion, I’m then coming over to the front of the teeth and I’m layering over freehand like I would do for a normal composite case.

If I’m then planning a full mouth case and I’m going to be restoring the posterior teeth to prevent the DAHL movement on those posterior sextants, or posterior quadrants, I’ll put some GIC in the posterior teeth to stop them from, from over erupting. If I’m aiming for DAHL, then I can keep, I don’t need to put anything there, and I’m waiting for those posterior teeth to move.

So, for me, that’s a really handy technique, whether I’m doing a generalized case, whether I’m doing a localized case. Because it takes some of the thinking away from the surgery. I can get quite neat palatal backings and I can quite actually mimic what I’ve wanted to do on my wax up into the patient’s mouth.

Other techniques of doing it. You can do it freehand and I think there’s nothing wrong with that. It’s quite a simple approach. You have to be confident and competent that you can then adjust the occlusion accordingly. You can do it injection molding. Again, I just feel less comfortable with the mess, but definitely under capable hands it’s very possible.

And then you can go indirect and I’ve done indirect composite palatal backings. What works less well with indirect palatal backings are, because that composite is so heavily cured, there isn’t that methacrylate layer, it tends to de bond easier, so you can bond those indirect composite backings into the mouth, but they have a tendency to de bond, at least in my hands, I’ve found it.

Actually, I’m far more successful if I’m making those backings myself. Also, I don’t have to tell the lab, keep it away from this margin because I can’t get my rubber dam that deep. I’ve got a little bit more control. So I like having that control. So yeah, that’s a technique that I use quite a lot, actually, whether I’m going to localize or whether I’m going to generalize.

[Jaz]
Okay, so a lot of the lessons from the posteriors that you described move to the anterior, which I quite like. I’ve got a couple of questions here then for you. The method of, let’s say, using a putty of your wax up, but without the window, just the normal putty, seating up on the anteriors, and then putting, usually when we’re doing these cases, there’s a fair bulk being added back palatally.

What do you see as a disadvantage of doing it? That more traditional direct way? That led to you to you favor? I can see it myself. I just want to spell it out for everyone. What do you dislike about that that moves you to actually doing it in a semi-indirect way?

[Zohaib]
Yeah. So two things. One, you’d have to have a clear stent. ‘Cause if you’ve just got a normal putty stent, you’re not going to be able to cure that palatal surface properly. So you can get your lab to make you a kind of a clear stent. And I definitely have over the years, what I didn’t like over time was just interproximal areas and getting kind of contacts being closed and I’m shaving things through being irritating when the dam’s in place and then I’m kind of pushing at the map.

And actually what I didn’t like was the unpredictability of it again in my hand so sometimes it worked really well and sometimes I’d just be fiddling around for ages and I just find it really difficult so it took the stress away kind of when I was doing those cases because I thought well I can do all of this beforehand and I may even get the patient in for a review before I bomb them in just to check everything fits nicely. And once I know everything fits nicely, I’m just, it’s an easy appointment at that point.

[Jaz]
Brilliant. And when you’re forming these anteriorly, are you doing every other tooth? And then going back and doing every other tooth so that now you have now six, for example, canine to canine, for example, is that a way that you’d like to do it?

[Zohaib]
Yeah. Every other tooth is a good way. What you want to avoid is having to put the stent. Often on too often because then every time you’re pushing it on, you’re compressing a different amount and you can kind of get a little bit of defamation when you’re doing all the study ones. It’s easier because you can kind of control how much you’re pushing and not.

And if you’re finding that that’s creating errors, then another way is getting the lab to make that stent so they can make a clear silicone stent with an Essix over the top, and that would be quite rigid. And then you can you can do that off of the model. So usually it’s every other tooth for me. I’ve done it every, just one tooth at a time as well, if you’ve got plenty of time, because again, you’re doing this right when the patient’s not in the chair, you’re doing this in your own time. I have very sad lunches.

[Jaz]
Like, I mean, I know, you’ve done your MClinDent prosthodontist, anyone who’s got that extra prosthodontist training, you guys, every free bit of time you get, you’re like stroking articulators and playing with wax and stuff. Yeah, you guys love doing that. I just want to ask on that element of describing all these things that you do and the additional stents that you could make.

So in those cases where you’ve got the anteriors all set up and you’ve decided that you are not doing a DAHL and you said already that you do not want to lose that space. So after that long appointment, once you’re done, you want to stop the teeth from meeting posteriorly and you use GIC for that, which is also something I’ve used as well.

Can you just talk a little bit about that? A couple of clinicians I’ve spoken to, they like to do put like a blob and make a dot on each tooth. Others make like a sausage all the way along. What technique are you using for your posterior stops?

[Zohaib]
I like the blob. The blob works well for me. So just a blob on each tooth, nice and flat. Put a bit of Vaseline, kind of get them to bite down so they’ve got something.

[Jaz]
Is it just one arch that you’re choosing to do? Or are you doing a little bit on the top, a little bit at the bottom?

[Zohaib]
Usually both. So a little bit on the top and a little bit at the bottom. And nothing artistic. It’s literally just a blob on the occlusal surface for the back teeth. Yeah, and it just works. It prevents the teeth from over erupting. Be mindful if you place it too early, it prevents the mandible from distalising as well. So actually, sometimes it’s favourable to get a little bit of distalisation because you might be close to CR, but I think you’ll be a lot closer if anteriorly you’ve got the composite in place. And you leave them for a week or so, the mandible will find that kind of comfortable CR position, and then you can place those GIC dots on those back teeth and kind of keep them permanently there, until you go in to restore.

The big advantage with having GIC then, is you can break it down quadrant by quadrant. I’m not having to think I’ve got to do all of the lower teeth at the same time. I might think, well, today I’m on the lower right hand side, I can take off those GIC blobs, restore those teeth and then bring them back a couple of weeks later to do the other half.

[Jaz]
Okay, well Zohaib, you described the semi indirect technique, both posterior and anterior. What’s the biggest mistake you’ve made using this technique?

[Zohaib]
What’s the biggest mistake? Gosh, I’ve probably made-

[Jaz]
Can you think of a blunder where you thought, oh, bloody hell, this is going to take me a long time to fix? Or it could be maybe a mistake that you’ve seen the wax up maybe? Any tip you can give us there?

[Zohaib]
Probably loads, probably loads of mistakes that can, I think useful ones are remembering that, there’s a mistake that I still make actually. A lot of these tooth wear cases are more functional than aesthetic. So, obviously, aesthetically we want things to look good and function or follow form. So, that’s quite important. But I think sometimes, I definitely fall forward to this, is you spend a lot of time working on the aesthetics and you’re trying to layer things and add tint. Actually, you’re wasting a lot of time doing things that are potentially unnecessary.

You want to get the form correct first. You want to get the occlusion correct. You want to make sure you’ve got the composite in the right place. You’ve got contact points, you’re not blocking things out. And then you can come back later on and make things look good. You’ve got a functional occlusion, you might want to come back and re layer anterior.

You might want to cut back and re layer and do some lovely composite veneers. You can, as the kind of three step technique that Francesca Vailati described, you may even come back and go ceramic veneers on those anterior sixteenths. So, I think probably one of the mistakes that I make is, these are cases where actually the function is going to be more important than the aesthetics.

At least initially, you can always come back to the aesthetics. You don’t have to kind of kick yourself about why is everything not looking completely perfect straight away, because you’ll have plenty of time to do that.

[Jaz]
Great. It’s always nice to ask about nuances and mistakes and stuff. And it’s nice to remember that the main reason is to recreate that function on that patient and make it, you can always come back. You can always come back. If you’re trying to do a nice, neat job initially, and manage those contacts well, like you said you can always go back and neaten things up and redecorate the kitchen as they say another point. I know we had a Zahid on recently. We talked about IDS. He was brilliant, he came to Porto as well as I first met him vertical crowns and stuff. Are you on to verti preps yet?

[Zohaib]
Yeah, absolutely, Zahid’s got me on to VertiPrep, it’s got me out of quite a few difficult situations, so yeah, love it, still learning, still trying to push the boundaries, but yeah I think really useful technique.

[Jaz]
Well, next time come to Sicily with us, we’re going with Marco Mailino in Sicily, in June, actually, on his course. Maybe next year consider coming as a Protrusive Gang Trip. That’d be good. Tell us about the teaching that you’re doing with Zahid. I saw some dates in Manchester, London, that kind of stuff. Tell us a bit more about what kind of program you got.

[Zohaib]
Yeah, lovely. So we’ve got a two day restorative masterclass and it covers everything from kind of anterior posterior composites to rubber dam, onlay. And really for us, it’s a taste of kind of two days of pretty intense, a very broad spectrum of restorative things that we think what we’ve learned over the last 10 years of practice, it doesn’t compensate for a year course or a three year masters, but it’s meant to give you a flavor, give you a taste of some of the things that you can do go off and develop them.

For us, it was really important to give aspiring dentists, young dentists and kind of dentists who’ve been around for a long time a flavor of what’s available coming new adhesive approaches to dentistry. And actually, I think we also touch on the idea of of trying to make dentistry.

For us, kind of meaningful, enjoyable, sustainable, tho those kind of being able to work in an environment and create protocols that allow you to do that. So it was bringing not just the clinical side of things, but also developing a network and a community of dentists that can all kind of grow together. That’s all.

[Jaz]
Lovely. Well, what’s the website? I’ll stick on the show notes anyway. What’s the website?

[Zohaib]
The website is coming. So website is coming, but anyone who follows us on Instagram, we will get kind of regular updates with the next courses.

[Jaz]
So what’s your Instagram just so everyone can follow along and also put in the show notes.

[Zohaib]
DrZoKhwaja, Z O K H W A J A.

[Jaz]
Okay, brilliant. Everyone follow Zo and also Zahid as well. Great guys. Zo, it’s been amazing to have you here. Thanks for describing the semi-indirect technique. I think it’s always good for those who never use it for like myself to think, Oh, You know what? This is a good way to get me a hole.

And sometimes not every case is suitable for injection molding. And so it gives us another trick up our sleeve and allows us to work with our hands. And I really see the benefit and you’ve explained it well enough to me that I’m really happy to now give that a go. And I encourage everyone to check out the educational channels that you have at least for sure. Go on the Instagram, check out, be inspired by all the lovely work, adhesive work you guys are doing. I really appreciate you coming on my friend.

[Zohaib]
Very kind. Jaz, an absolute pleasure to be on. Love what you’re doing. Keep on doing it because massive service for the whole dental community. So, hopefully we’re going to cross paths again.

Jaz’s Outro:
Thank you. Well, there we have it guys. Thank you so much for listening all the way to the end Once again, don’t forget to go on to Protrusive Guidance. The website is protrusive. app and you can then download the infographic so they can actually visualize. Maybe if you finished your commute, you’ve got home and you can download it and visualize it and keep it as a reference. If you ever consider using this technique.

Please do follow our guest Zohaib Khwaja on Instagram. I’ll put his handle in the show notes. It’s always great to speak to Protruserati just like him and all these clever guests that have so much to share with us. This episode is eligible for 50 minutes of CPD, you just have to answer the quiz.

At the time of publish, it’s already available for you alongside the premium notes and the transcript on, you guessed it, Protrusive Guidance. I just want to end by saying thank you so much to the team. Erika, the producer. Nav Bhatti, who recently joined us. He did the premium notes for this one and made sure that the infographic is just perfect.

And also I always thank Mari, our CPD queen, who will be responsible for making sure you get your CPD certificates. Thank you for listening to the end once again. I’ll catch you same time, same place next week, bye for now.