Steps for Increasing the Vertical Dimension of Occlusion with David Bloom – PDP232

Teaser: We’re probably not gonna be prepping the teeth at all, but patients need to be aware that whilst there’s gonna be less cost, I’d consider it as a long-term provisional. Because-

Transitional, almost.

Transitional. Yeah, absolutely. I mean, ideally, if I’m doing restorative, I’d rather not whiten first, because if we have our super thin restorations and our whitening result, over time will fade. It’s much harder to top that up. If you have a restoration.

The first step in a collaboration is to be able to manipulate someone into centric relation. And 90% of the population have a slide from CR Central relation to CO centric occlusion habit by whatever your terminology and the first step in a equilibration is-

Jaz’s Introduction:
So we’ve talked about this big topic before, vertical dimension and restorative dentistry. Me and Mahmoud did an episode basically reassuring you that you can safely raise the vertical dimension and that we shouldn’t be so scared of it. What I do in this episode with Dr. David Bloom is really lean on his decades of experience.

Comprehensive dentistry to delve deeper into the intricacies of opening the vertical dimension, the staging, the phasing, the planning, and a full walkthrough of how Dr. David Bloom does it. And you know what? There’s many different ways to go about it. In fact, for those of you who can see me who are watching this, I’m a bit more formally dressed.

I’m not wearing my hoodie. I was actually at an occlusion symposium today, and you had these great speakers and inclusion like Paul Tipton and Koray Feran, Tif Qureshi. And these guys were talking about the importance of canine guidance. And then you had Ken Harris, also a legend in occlusion. And one, the mentors on Kois.

He did not care for canine guidance. It was irrelevant, it was not important. And if you go back into the Archives of Protrusive podcast, you remember two episodes we did with Dr. Andy Toy. About the posterior guided occlusion where actually we don’t want canine guidance. So it goes to show my friends that in the world of occlusion, there’s many ways to do it.

Learn one way, learn it well, it will serve you well. And then the benefit of learning the other ways is that sometimes you’ll find a patient that really fits into that box a little bit better. For example, for many years I didn’t use a Kois appliance. I had my ways of deprogramming that I was very happy with, and just a couple of years ago, I did my first Kois, and I’ve done a few more since then.

And there are certain patients and characteristics that just are very amenable to that way of doing it. But then for most of my patients, I use a leaf gauge. There’s two types of patients. There’s loosey goose and tighty whitey. The tighty whitey patient, we all know this patient, right? It’s the one where you’re trying to do some manipulation, you’re trying to seat the joints and their mandible is just so stiff.

Whereas you have, they’re much nicer loosey goosey patients where you don’t have to work very hard to deprogram them or get everything nice and relaxed and hinging. And these two patients will need a different type of deprogramming. So I say learn one school, one occlusal religion well, and then start looking at the others.

And I think there’s so much to learn from all the occlusion camps. Just like I said, two polarizing views I was listening to today on canine rises and whether canine guidance is even important at all. And you know what? I subscribe to them both. And you are thinking Jaz. That’s not possible. How can you serve two masters?

Well, you can because our patients are so variable. They’re so unique. That’s what actually makes our dentistry fun. If every patient was the same, it would be boring. But our patients come with these unique challenges, these unique presentations, and we have to sometimes be very creative in how we treat someone, how we arrive at treatment decisions.

And lemme tell you, learning about the different occlusal religions has made me a better, more rounded clinician. But for many of you listening early in your career. Honestly, just pick one religion, whether that’s the Kois religion, who don’t believe in canine guidance and certainly don’t believe in anterior guidance.

In fact, the anterior teeth should hardly touch. Or you might go more Dawson, whereby anterior guidance is very important. And you know what the secret is that both these camps work? So pick one, lean in, learn it well, and eventually critique the others. Learn about everything and that my friends is the Protrusive Dental Pearl for today, if you don’t really have an occlusal philosophy, learn one.

If it’s from me and Mahmoud and the OBAB philosophy as a foundation of occlusion, great. If it’s from Kois, amazing. If it’s from Dawson, super. Pankey, whoever, learn a school of thought. But then the second degree of this pearl is that once you’ve learned a school of thought and you’ve got some cases under your belt, then be willing and respectful for the other sides. Listen and appreciate other views. They will make you a better clinician.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast once again, David Bloom is back on the podcast today. We covered minimal preparation of veneers last time, and today we talk all things vertical dimension. I hope you enjoy this deep dive and I’ll catch you again in the outro.

Main Episode:
Dr. David Bloom. Welcome back again to the Protrusive Dental Podcast. Last time we spoke about veneers, something that you’re so experienced in. This time, we’re talking about something similar. ‘Cause quite often you’re doing veneers, but you are also doing, as part of a full mouth rehab, you are opening the vertical dimension and there’s so much we can talk about.

But in this taster today, we’re gonna ask some really key restorative questions from someone who’s got so much experience in yourself. For those people who didn’t listen to that episode, can you just tell us about yourself, your passions, David? 

[David]
Yeah, well I’ve been qualified 36 years now. I’m A GDP. I was in the same practice for 24 years, which teaches you about failure, what works long term, what doesn’t work long term.

And having done that passionate about cosmetic dentistry, but also about doing it as responsibly as possible, which means as minimally as possible. And so we talked about an additive wax up and how that can allow a visual, trying to confirm the aesthetics and then allow us to prep only where we need to.

[Jaz]
So guys, if you haven’t checked out the episode we did on minimal preparation of veneers, David, as I joked on the Protrusive guidance app, David has Graham for Graham, done more veneers and I’ve consumed peanut butter and I’ve consumed a lot of peanut butter. That was my silly joke at the time. But, you’re very humble.

David’s also ex BACD president and big time educator as well. So I’m gonna, at the end do encourage you guys to do checkout this stuff, which is amazing. Let’s get the little details of restorative, right. It’s such a big topic in a way, David. It’s actually quite a challenging one to record.

But I’m just looking forward to just geeking out with you on such a awesome topic when it comes to restorative of my own personal journey, David, and you may remember this as well, when you’re starting out the level of training that you accumulate from dental school and stuff like everything is conformative.

And then when you have an opportunity to open the vertical dimension, like your first you’re learning just to deal with caries, then you’re learning to deal with, you know, the very foundations. It seems like a big step at the time to open the vertical dimension. And I remember the first few times I did it, is the patient going to survive?

Is their head going to pop off? Are they gonna be able to chew? And that kinda stuff. And once you do it a few times, you almost become a little bit blase about it. But you kind of need to do it a few times to realize that actually the human body is amazing at adapting, providing we conform to a few rules. So we were gonna come onto that, but just at the macro level, David, how do you explain to young dentists, okay, how do you arrive to the decision to open the vertical dimension? 

[David]
Well, I think first of all, you have to have a thorough understanding of occlusion, as I’m sure you’d agree. And if you think about it, when we do occlusal appliances, flat plane appliances, we are opening their vertical.

And as you say, the body is remarkably good at adapting as long as we stick to our occlusal principles. And I think once you also know how to do an equilibration, which I think is essential. It gives you the confidence to be able to move on, and it’s a reorganized approach as opposed to a conformative approach, as you say.

But once you have the confidence in occlusion and you know, you can open verticals, it becomes less of a step. And what it does allow is us to be a lot more conservative because we’re giving ourselves space. So when do we do it? Well, it’s always an option when we’re treating the lower arch to consider.

And one of the classic times to do it is if we have a deep bite and a deep bite. And I think we alluded to this in the last episode, especially what I see as I practice more and more class two div twos, we see a lot of wear going on because they have effectively a restricted envelope of function, an increased overbite, maybe a restricted overjet.

And opening the vertical simply gives us space to add here and to add occlusally. So certainly a deep bite. I think wear cases, historically, we’d have done a lot of maybe crown lengthening, conventional plastic crown lengthening. But that’s obviously quite invasive. And with wear cases, obviously crown lengthening is still in our armamentarium and with additive composites, we may be looking at DAHL, which is maybe an interim, it’s maybe a different conversation again, but we can be additive and again, open the vertical.

But with DAHL, I wouldn’t want to go straight to porcelain. I think it’s probably too abrasive in that situation. So I’d be looking at composite. And composite is gonna have less longevity. So composite will obviously be non-invasive. We’re probably not gonna be prepping the teeth at all, but patients need to be aware that whilst there’s gonna be less cost, I’d consider it as a long term provisional. Because-

[Jaz]
Transitional, almost. 

[David]
Transitional. Yeah, absolutely. Because longevity may be five years, maybe longer. But it’s not gonna have the same longevity of porcelain where we’re talking maybe 10 to 15 years. So again, first few times I was doing it, I might have been happier to do it in composite stage, but if we know we’re going straight ahead, a wear case is often a case where you may open a vertical as well.

And obviously small teeth is a time we may do it out and I’m not concerned too much about the size of the teeth in that sense, but it gives us the possibility. But even a classic Class one case, it’s always something we have in our armamentarium, and I suppose it’s considerate, but I’m not advocating it for every case. But it can be very useful to have in our toolbox. 

[Jaz]
I think if it was just so many different things that we could talk about in terms of arriving in that decision and a flow chart and stuff. But I guess if there was one overarching theme or one word to use, I would say, it’s space as the primary thing, right?

You need space to solve a problem. You need space because when the patient bites together, there’s no space to restore their missing lateral. You need to open ’em up to give ’em that tooth. You have completely worn teeth. You need to open it up to actually get aesthetically looking teeth as well as potentially looking at the gingival stuff.

But I think that is a primary driver and a lot of the principles we can learn like with aesthetics, as you know, David, complete dentures. We learn so much about that and we actually forget that actually we’re change, we’re moving very fluidly, dynamically the vertical dimension in complete dentures and sometimes we forget that.

Now you mentioned a few really interesting things. I just wanna just talk about that ’cause I think it’s really important. You mentioned a word equilibration. And I’ll tell you something David, you mentioned a word equilibration to anyone who’s maybe less than 10 years qualified and like they are trained in an era where that’s a dirty word.

So can you just clarify what you mean when you say, as part of opening vertical dimension, you should have a skillset of equilibration? Just ’cause I think it is a lot more simpler than what can be interpreted. Just explain that part. 

[David]
Sure. First of all, I mean, if the dentist can’t say equilibration, they probably can’t do it. That’s something I’ve learned over the years. But an equilibration is a way of idealizing someone’s occlusion to eliminate the interferences. And the first step in equilibration is to be able to manipulate someone into centric relation. And 90% of the population have a slide from CR Centric Relation to CO Centric Occlusion habit by whatever your terminology. And the first step in a collaboration is removing that CR CO slide. 

Interjection:
Okay, guys. Interjection number one. What is deprogramming and how do you get someone, how do you manipulate their jaw into this centric relation? What is centric relation, right. Let me just break it down. Centric relation is essentially a stable position of your condyles.

Nothing to do with your teeth. If we imagine very crudely that your condyles are like balls, right? You’ve got the left condylar bone and you’ve got the right condylar bone that roughly look like two potatoes, right? And we’re essentially seating them into the cups. Which cups are the fossae? So balls into the cups.

It’s like your shoulder being seated into the shoulder socket. I say that ’cause I’ve got history of shoulder dislocations, but I remember one time they were relocating my shoulder and like boop, it just slip right in. The ball of the joint just goes right into the fossa. So crudely speaking, we wanna get that into position because it’s a repeatable position, it’s a comfortable position, and it’s somewhere we can keep going back to If we lose our way, if we’re confused, hmm, where are the teeth supposed to be?

Then if you keep taking the balls back in the cups, then you have a point of reference. But to be able to do that, the muscles are always fighting you because the muscles have learned this existing bite, which is not in centric relation, your condyles are, the balls are not in the cup. So to manipulate someone, you first need to release their muscles, you need to relax their muscles to allow the condyle to seat, to allow the ball to go into a cup.

And that’s all to do with the joints, not the teeth. But then certain teeth will hit when you go into centric relation. So there’s lots of different ways and what we teach our occlusion course is there’s hands-off approaches and there’s hands-on approaches. Like hands-on is like, imagine like bimanual manipulation, right?

So you get your hands and its awkward way around the mandible, and you try and manipulate the condyles into the fossae. That can be quite tough, especially for a beginner. That’s not an easy thing to learn. And also when you get the patient to curl their tongue all the way to the back, that’s kind of like a forced position.

Whereas I like hands off approaches. This is using things like a leaf gauge, something called a lucia jig, which will have another interject for coming up, or an occlusal appliance. Essentially, it’s allowing the back teeth to separate and allowing the muscles to guide the jaw into this repeatable position centric relation. So hands-off approaches and hands-on approaches. Let’s listen to the episode and let’s build from there in the other interjections. 

[David]
Once someone’s in CR, they’re obviously much easier to manipulate. They tend to have relaxation, neuromuscular release of their muscles, and then we are looking at eliminating any interferences in our lateral movements. And so it’s a process of learning how to do that. I know I shouldn’t use my hands ’cause those people who are listening. 

[Jaz]
Just describe what you’re doing. 

[David]
But when you are going back, you tend to find the contacts are on the mesial slopes of the uppers. The distal slopes of the lowers. And by adjusting those contacts, you’ll get to a point where CR and CO are coincidence. Then the next stage is to ensure we have anterior guidance, so anterior disclusion in lateral excursions. So we’re then removing our- 

[Jaz]
Do you mean posterior disclusion in lateral excursion? 

[David]
Sorry. Yes. I mean exactly that. Posterior disclusion in lateral excursions and removing those interferences. And if we’re going laterally that if we’re going to the right. That’s then gonna be on the palatal facing slopes of the uppers and the buccal facing slopes of the lowers. And I use this terminology to help patients understand as well. And so we’re getting to a point where CO and CR coincident and we have immediate anterior disclusion and excursions.

[Jaz]
Excellent. And I just wanna just add to that as well, in terms of the equilibration, like sometimes to young dentists, like what you described is a classic approach to equilibration, but much more fundamentally on a day-to-day basis, how can we make it more relatable day-to-day? Imagine that class two div two patient that you described, and you are going to do all the steps to open the bite a bit to fill in the space posteriorly.

When you fit the restorations, there will be some adjustment to do right? The left side might be heavier than the right side. Even just to get that degree of balance between the left and the right, something just so foundational. We just do it. You do your composite and the composite’s proud.

When you are adjusting that composite, you are in a way equilibrating if you like. You’re trying to achieve harmony and balance, and so it blends in with the rest in dentition. And when you think of it like that and then you think, okay, what are my objectives and goals I’m trying to reach. So when we’re doing a class one composite.

If that composite that you just placed take the rubber dam off bite together, that’s the only tooth in the bite. Well, your goal is to go back to how you were at the beginning and have every tooth biting. If that was a case of your patient and you know your goal and the equilibration is the means to get there.

And it’s important to remember that, that is it. And then when you’re doing these bigger cases, then we have our goals that we want to be in centric relation in many schools of thought, it’s a utility position, it’s a repeatable position, as you said. And so a equilibration allows us to get there.

And on that topic again of the class two, div two patient, David, when you have that deep bite, right, when you have the wear and the incisors. Here’s a good question, right? Opening the vertical dimension versus orthodontics, how do you arrive at the decision that, okay, I’m gonna open the vertical dimension, versus actually, let’s just intrude those incisors, level out the curve of spee orthodontically, and give this patient a result by ortho.

[David]
Will you bang on? And I’ve made just a couple of notes and I will answer that. But going back to equilibration, what you were describing is an occlusive adjustment when we fit a restoration. Absolutely. We are adjusting the occlusion, but in a conformative approach. So we’re working in centric occlusion.

I suppose the biggest difference for an equilibration is that we’re going to a repeatable position CR, because that’s our go-to point, but we’re working it as a reorganized approach rather than a conformative approach. And you mentioned something earlier about dentures and vertical dimension.

Ironically, I’m probably a little bit more concerned about opening the vertical in an edentulous patient than I am in a Denate patient because it’s much more harder for them to adapt because they don’t have the proprioception. So just a couple of points to cover there. Going back to the class two, div two, I think we do have to be very aware that whilst we may be giving ourselves space in a situation like that, we are not actually addressing maybe the fundamental issue, which is the restricted envelope of function.

And if we don’t correct the reduced overjet because we can correct the increased overbite by opening our vertical. If we’re not correcting the retrocline nature of the upper anteriors, we are potentially inviting more wear, especially if we’re treating the lowers in porcelain, because porcelain can be more abrasive.

So absolutely there is a case to be made for pre aligning patients, especially with a class two div two, because we may be solving one problem, but swapping it for another. When it comes to the leveling the curve of spay, that’s less of an issue for me, restoratively, because actually we can add to the occlusals of the lowers without doing any preparation.

And so that’s what I wouldn’t be so concerned about, not doing pre-restorative orthodontics. But for the restricted envelope of function, I think it is important you may be choosing to go full coverage on the uppers, in which case that wear is potentially gonna be less of an issue.

But if you’re leaving the palatal of the uppers, then we may be not causing wear on the lowers, which is what we tend to see in an aged patient and a class two div two, but we’re gonna then have palatal wear on the uppers potentially moving down the line. And again, I think in any of this- 

Interjection:
Okay, interjection number two, restricted or restricted envelope of function to what it simply. It’s like there’s a lack of chewing space. Like if you go back to basics, there’s a certain like movements that the jaw can make.

That’s the envelope of motion, i.e. Your lower incisors can go all the way forward. Protrusion all the way back, protrusion all the way left, right, opening. So there’s only so many different places your jaw can go. But chewing only happens in like a small, classically teardrop shape, right? It’s a teardrop shape.

And that’s where magic happens. That’s where chewing happens. That’s where speech happens. But if this envelope is constricted or restricted, it’s like you don’t have any space at all. So like there’s a lack of overjet and your lower teeth are like right behind your upper teeth. There’s a real lack of overjet.

And as you’re chewing, these teeth are like rubbing together. So it’s high frequency and low intensity. So it’s not very forceful, but it’s happening several times a day. Every time you close your teeth together, your teeth are potentially rubbing. So classically you get wear of the palatal of the upper surfaces and the incisor facial of the lower surfaces.

And you see patients all the time like this where they just don’t have any chewing space. And so that’s the consequence of trying to work with a restricted or a constricted envelope of function. And these cases often need orthodontics primarily, or at least raising the vertical dimension, but primarily orthodontics ’cause it is a tooth position problem, a jaw position problem. And so really important aspect to grasp a night guard is not gonna fix this. It needs space. So there we are. That’s that interjection. Done. Thank you. 

[David]
When we’re opening the vertical, what we’ve got to be aware of is the length of the lower incisors, because that is gonna dictate whether the uppers can just be facial as in veneers, or if they then have to be full coverage.

And then when they’re full coverage, we can’t call them veneers because they’re not veneers, they’re crowns, and therefore not gonna be maybe as conservative. Ironically, if we’re going full coverage. But all of this is worked out pre-preparation with, again, our visual triad. So we’ve got an additive wax up, one has to think three dimensionally.

Are we gonna have to cover the palatal of the uppers? That depends on the length of the lower incisors. And we spoke last time about our smiling teeth on the uppers and our talking teeth on the lowers. We don’t want to have especially long what? Extra long, lower incisors because that’s gonna be too visible.

But with our visual tryin, we are working this all out preoperatively. And we shouldn’t be afraid to be equilibrating our visual, try-in, making adjustments, you should be able to contour because it all needs to be worked out. But when we are adjusting our visual try-in, I may even equilibrate that and at that point I’ll take new putties because I don’t want to have to go through that process again.

But we know that we are one step closer. We’ve checked the aesthetics. We’ve checked the occlusion and so again, it’s not a quick fix, but it’s in a logical pathway, a very useful item to have in our toolbox, but done in the same predictable diagnostic manner. So working out the length and lower incisors, that’s gonna determine what we have to do with the plate of the upper incisors.

And going back to your question, we need to be aware that we may get space, but we don’t want to be causing a separate problem, which would be where, so absolutely a class two, div two, I would think of some pre restorative orthodontics to correct the retroclination 

[Jaz]
I think sometimes, in those cases it’s a bit like if orthodontics would completely solve their aesthetic and functional demands, then that probably might be the best way to go. However, if they have crowding. That’s gonna mean that you’re gonna have to be more invasive, all right? Or I sometimes find it helpful to tally up which teeth actually genuinely need restorations, and if that number is getting higher and higher and higher, I’m thinking, well, if I have to do orthodontics and then restore these teeth anyway, can I bypass the orthodontics and just restore these teeth and achieve the shapes and aesthetics that I want?

You made a great point about the retroclination of the upper incisors. Sometimes, you know that is gonna be the main killer of your case. Sometimes it can be good ’cause it gives you so much space to come labeling and be minimally invasive. But if that torque is wrong, that loading after your restorative is gonna be problematic.

And so sometimes that’s the reason. And then even things like if they’ve had ortho before and now they’ve got root resorption, then you wanna try and, and they’ve relapse and you wanna maybe avoid ortho and therefore restorative is more favorable. So you gotta really look at globally. But I’m glad you mentioned those points. Have you got something to add there? Sorry. 

[David]
Uh, yes, I have. I mean, I think we have short term orthodontics. It doesn’t necessarily have to be comprehensive ortho to give an ideal class one result, and we spoke before about anterior tooth alignment. I think the days of instant orthodontics with veneers is gone.

It’s something we maybe did because we thought everything took 18 months or more of comprehensive ortho. But to correct those retrocline upper incisors really doesn’t have take a long time. I said a lot of the times, class two div two leveling. The curve of spare, as we said, is also not an issue and also is a great option.

But ortho is not gonna correct size and shape and also isn’t gonna deal with heavily restored teeth. And so as you say, it’s planning it. And if we’ve got virgin teeth, then we’re probably gonna look up more orthodontics than if we’ve got heavily restored teeth, but orthodontics can’t correct size and shape and whitening is a great tool, but if patients, as we touched on before, live in Essex or or Liverpool, they may want to be going significantly lighter than B one.

And again, that’s a time where a restorative solution may be necessary because B1 is quite a bright shape, but not for everyone. And sometimes we can whiten beyond B1, but I’m not gonna guarantee it. I’m fairly confident most of the time to get to B1, but not beyond. So there are times where orthodontics alone is not enough for very many reasons.

[Jaz]
Great point. And just on that whitening, I mean, I’ve noticed over the years that patients, despite me trying to manage their expectations and stuff, patients are less and less made up and overjoyed from the results of just whitening. I think the more I’m realizing is I actually, if I listen carefully, then perhaps I should have said, the whitening is a stepping stone to the shade that you want.

Or perhaps we should go for the restorative. And then when they have the veneer done, they’re like, yes, this is what I wanted, kind of thing. And so I’ve noticed that the expectations and trends and desires are definitely increased for patients. 

[David]
Yeah, I mean, absolutely. I mean, whitening is predictable, but we are gonna have darker cervicals, however we look at it, because that’s what actual teeth have, and if people want a different look from that.

But I think we should also, whitening is very safe. It’s non-invasive, as you say, potentially an entry level, but from a cost perspective is much lower ticket item. I mean, ideally, if I’m doing restorative, I’d rather not whiten first. Because if we have our super thin restorations and our whitening result over time will fade, it’s much harder to top that up if you have a restoration.

So if I’m doing, and if I think it’s important, we know if the patients have whitened, so the lab can maybe factor that in than using maybe a more opaque ingot if we’re using Emax for example, because as a result fades, it’s harder to top it up. Whereas I’d rather get the color shift knowing that the foundation shade was darker.

We are gonna get that color change into porcelain rather than whiten first. But as you say, whitening isn’t enough of a change for some patients and we can’t always whiten the cervical as much as they want to, whereas porcelain gives us a few other options. 

[Jaz]
I think nowadays I’m a little bit wiser from my experiences and I will show patients realistic photos. Like, look, this is what to expect, among patients who are I treat a very aging population in a village type practice. And so you, I’ll show them photos of cases where, yeah, there’s been a moderate improvement. Like this is what I can get you, but if you want to go for this, then maybe it’s looking at a different approach.

And then just like you said, the cervical is not the same as the enamel. That’s more in the body and they’re not gonna whiten the same way. Going back to vertical dimension. When I was starting, and you know, DAHL was like, is like a gateway drug into occlusion. DAHL is like a gateway drug into opening the vertical dimension.

And you do with DAHL for the first few times and the patient survives, it’s like, oh wow, okay, maybe I could just restore the posteriors now. And then you can suddenly realize you’ve done a full mouth rehab, right? And so the next thing I was afraid of was, okay, how much can I go here? I think once you overcome the fear of raising the vertical dimension, the next thing is have I done too much? And so what guidelines do you use David to kind of figure out the anatomical limits of raising the vertical dimension? 

Interjection:
Okay. Interjection, DAHL technique. One of my favorite things, it’s like a gateway drug into full mouth rehab. And I know a lot of our colleagues in America are against it or they don’t believe in it, or they call it unpredictable orthodontics, as I call it as well, but it works and it can really serve as an interceptive treatment for localized tooth wear.

So essentially localized anterior tooth wear classically, and you build up the teeth and now you’ve raised the vertical dimension. The back teeth are separated, but like magic. After about, three months, sometimes a year, the teeth reestablish. They, the dental alveolar compensation takes place and then the front teeth intrude. Or maybe they flare out a little bit, maybe, I don’t know the exact mechanism, like we think it’s intrusion, but it’s pure intrusion always happening.

Who knows, but essentially you’ve now created space before you did not have space, and then you managed to create space. So it’s a wonderful way to treat localized anterior tooth wear. But it’s important to also know when you should not do this treatment and it’s better to do a full mouth treatment. So the reason I say DAHL treatment is like a gateway drug to format rehab is in DAHL, you do the anterior six to eight teeth and you let the back teeth sort themselves out.

Sometimes do the front to six to eight teeth, but then soon after just sort the back teeth out as well. It just makes sense. You’ve just, there we are. You’ve done a full mouth rehab. It’s not as tricky as what they say and the kind of case not to do DAHL on is when you’ve got like dentine exposure posteriorly.

If you’ve got dentine exposure, posteriorly, do you really want to leave those teeth to DAHL into contact? No. You want to cover those teeth. So a full mouth rehab is more appropriate. ‘Cause actually you are being additive and you’re being more minimal in that scenario. Other times you want to avoid DAHL is if someone has an anterior open bite, then they’re usually not gonna have anterior wear.

Usually it’s the people with AOBs that have their mamelons still, or their incisal halos. So usually they’re not gonna have wear anteriorly, but let’s imagine they did, and you want to now add in restorative material and open the vertical dimension.

So they go from having no contact at the front and actually having a space between their teeth to now having extra contact on the front. The reason why that might not be a good idea is because these people, they might not have that much eruptive potential. Think about it, if they had eruptive potential, wouldn’t the front teeth have kind of erupted and adapted back into the occlusion?

They would’ve, right? So that’s why we say, okay, let’s avoid it in anterior open bite patients. Let’s avoid it when you know what? This patient just needs orthodontics. If they’ve got crowding, why are we darling? Just align the teeth and sort the space requirements out during your pre-restorative orthodontics and intracapsular issues.

If they got major joint issues, they got like history of locking, jarring of their jaw joints, significant pain from the TMJs. That’s not the kind of patient we wanna be doing any sort of reorganized dentistry. And last few is, if you have someone who’s got a reduced periodontium, i.e., they don’t have periodontal disease anymore, but they used to, but now they have recession and they have some mobility, which you’d expect.

But now do you really want to overload because DAHL treatment is like a controlled overloading of the front teeth to allow them to intrude and the back teeth to erupt. I like that term, right? Controlled overloading. But do you really want to overload, even if it’s in a controlled way, teeth that have less bone support to begin with.

So really, try and avoid when you’ve got someone with the history of periodontal disease. And lastly, imagine you wanna do a DAHL treatment, but your anterior teeth have all got like root canal treatments and posts inside. Do you really want to do a controlled overloading on structurally compromised teeth? So there we have it guys. A quick overview of when not to DAHL. 

[David]
Well, I think again, we need to think of it in terms of a rule of thirds, and by that I mean that if we are opening the vertical, a millimeter posteriorly, we’re probably looking more like three millimeters anteriorly because of the nature of the V, if you like that it’s less space. How much am I opening? Prosthetic convenience, so really the space that I need, and therefore we’re never gonna be opening more than really, maybe two to three millimeters maximum. It’s possible you could open more, but being realistic, we’re probably not having to go beyond that, and therefore that’s always okay in my experience so far.

So there is a natural limit that occurs because we don’t need to open beyond that. And I’m not opening vertical to change someone’s face shape. That’s more of an orthognatic approach. So for me it’s prosthetic convenience that gives us a space. And again, we are working that out with the technician and I’m sure we’re gonna come on to how we do that.

But I’m quite comfortable that I can open as much as I need to for prosthetic convenience without causing an issue. And that isn’t gonna be any more than probably three millimeters max. 

[Jaz]
There’s a really good paper by, Abduo, which I’ll link again. I think we spoke about on the podcast for about vertical dimension. I link that paper. It’s just a fantastic review. I’ll post it again in the show notes here, but that paper had a good guideline of up to five millimeters is fairly okay. And so keeping in line what you said there, measured anteriorly and then interesting when you measure that anteriorly.

Let’s say your lateral is worn down to a two three millimeter stump, right upper lateral worn two three millimeter stump, and then you want to lengthen that by four or five millimeters, you open the bite, four or five millimeters there, and then in different people it’s can actually give you a different amount of space posteriorly. You mentioned a rule of thirds, very universal, but sometimes in a class three patient you’re getting a lot less in a class two skeletal patient, you’re getting a lot more, and sometimes in the past that’s given me some challenges whereby, yes, I’ve got the right space anteriorly.

But I’ve got these great big spaces posteriorly, and now you are almost like doing a vertical cantilever. You’ve got like an onlay that’s like more height than actual existing tooth there as well. And so I kind of worry about that, David. Should I worry about that? Should I not worry about that? What have you, in your experiences long term, seeing these patients come back? 

[David]
I think to a large extent, aesthetically driven because if we’re bonding to enamel posteriorly, given that that I’ll be using a dual cure cement and not a like your cement. Again, I’m not concerned. I would like to have vertical loading.

Sorry, actual loading wherever possible. But another tip, and again, you’re working it out and you’re right, it can be different in class three and class two patients, but we’re working it out in advance. I’m not concerned about the thickness. I’m concerned about the length of the lower incisors. And then a tip is sometimes I will leave the sevens out if they are fully dentate, because that’s the area where they may have issues.

And those sevens may erupt, but it’s unlikely. If that’s an issue, you could then always add them in at a later date once the patient’s adapted or even put some composite on the occlusal surfaces to just give some light contact. So there are other options, but the extent of the opening, as you say, you are not really gonna ever need more than five minutes.

I find actually this very, very rare that you need up to five millimeters. So in that sense, I’m not concerned. But you have to have the experience. You have to have the comfort of being able to equilibrate. But because we’ve gone through the whole process of the diagnostic try-in, I’m comfortable that I’m not opening excessively and that I’m marrying that functional side with the aesthetics anterior.

[Jaz]
Great. And I think this leads onto the next bit where you’ve mentioned about doing the visual try-in and then potentially considering testing this, right. Nowadays, we also touched on the fact that composites can be transitional, can be provisional, can be transitional, and we’re seeing a boom in injection molding.

I think it’s a fantastic treatment modality to increase vertical dimension and give a transitional, let them adapt. And then potentially in the future, at some stage, the patient knows that, okay, we convert this in ceramics. I’m a big fan of that, but there’s is a couple of schools of thoughts here. A really good post by Lukasz Lassman will also be coming on the podcast soon.

He’s a bit of a superstar, and this guy has posted some, the Markus Blatz of occlusion on Instagram kind of things from wonderful posts. And one interesting post was when you are testing the patient, takes about 90 days for neural circuits to adapt. And so he was suggesting that perhaps for the experienced clinician like yourself, David, that because in your hands, you know what’s worked, what’s what hasn’t worked, that perhaps, in your case, your judgment and the fact that patients do adapt quite well, you can almost go too definitive without that testing stage. Because when you’re testing in composite and then when you’re delivering in ceramic, for example.

The two different materials, the brain has to adapt twice and sometimes it may better for the brain just to have to adapt once. So interested to know, in your years of experience, how often you might feel that it’s safe and best for you still to do the testing and that’s working well for you.

Or do you sometimes go over the vertical dimension, go for the definitive, if you like, and let the patient adapt on the definitives. What’s your stance and philosophy at the moment. 

[David]
So historically when I was less experienced, and to be fair, it was less common that we might open a vertical, we would maybe test drive it with a flat plane appliance, so a Tanner or a Michigan.

And I found that there was no one that didn’t adapt and I was doing a lot of flat plane appliances back then, and therefore, more experience than people that might be having a rehabilitation. They may have been having an occlusal splint for TMD reasons. But we have a few other staging points, so we are gonna test drive it.

Remember that your visual try can be spot bonded to the teeth and the patient can wear that as long as they can clean incidentally, that is a test drive and so we can test-

[Jaz]
And that’s a bisacryl material, that kind of stuff. 

[David]
Where we do the visual try-in, but we actually spot bond it rather than just shrink wrapping it onto the teeth and the patient can go away with that to test drive it. And we are gonna test drive it. 

[Jaz]
How long for typically, ’cause people are thinking, how long was it reasonable longevity to expect from something like that? 

[David]
Well, I’m not a big fan of doing that, but it’s an option that we have. And if I do a  visual try-in and as I think we touched on last time, I like to be able to take it off to show the patient, but I think you could expect to do that for a week.

But also the important thing is that’s before we’ve prepared the teeth, but even if we are preparing the teeth or when we prepare the teeth, we’re still gonna test drive it in our trial smile, in our prototypes, in our provisionals, and then you have the option if you are concerned about lab made provisionals.

But those are definitely gonna be on for a month. And could be on for longer if you want to test drive for longer and the transitionals as you say, absolutely, I’m happy to do it in composite, but it’s gonna add more cost to the patient. So if you are idealizing the occlusion and you know through your diagnostic steps that we can give them an ideal occlusion.

In that sense, I’m then not concerned because I know that I’m down a very predictable path. But for our colleagues who are be, aren’t maybe as experienced, we have those stepping stones to use along the way. But I know that if I’ve got my diagnostics right, I’ve proved it to myself as much as to the patient, but proved it to myself with my visual diagnostic trying that I know with my bisacryl that I can get to where I want to.

It’s then a question of being able to execute that, which I’m quite comfortable I can, so I’m not so concerned, and I think you make a good point that it’s less adaptation and less cost, but we have those steps or those interim steps should we feel there’s a need for them. I’m not advocating always rushing to final restorations. But in my hands, I am actually comfortable proceeding to final restorations most of the time, if not all of the time. 

[Jaz]
One thing I didn’t actually mention, which actually, may relate to when you’re testing with the visual try-in and you gain from when you hear them speech and whatnot, but we’ll talk about do’s and don’ts at the end, but one relative contraindication to the limit of increasing vertical dimension is if you open the vertical dimension and then they lose their lip seal. When the patient close together. Lips must touch together first, then the teeth exactly. And so, kind of anatomical that long face patient, right? If you get a patient who’s got a long face, they’re not so amenable to opening vertical dimension.

And I’m sure we’ll talk about that in the do’s and don’ts, but I just remember that. I think it would be a good point now, David, to maybe discuss a typical case and then, because I know you wanna bring in the fact that how it’s planned with a technician and then at what stage do you scan. If you just talk us through a typical case journey as an example, obviously the example you’ll give us can’t incorporate every single scenario, but it’ll give us a bit of a flavor.

[David]
Absolutely. So we’re obviously gonna do a diagnostic wax up, and we’re waxing up at the open vertical. So the first question is, what extent of the vertical are we opening? And we really want to be taking a CR bite record because once we’re in CR we’re on a hinge axis, and then we can open the pin quite comfortably knowing that we’re in we repeatable grounds. So ideally I’d have someone deprogram, so they’re in CR. And then- 

[Jaz]
What’s your preferred web poison of choice for deprogramming? 

[David]
I find that a lot of the time I can, with bimandibular manipulation, get a patient into CR ’cause actually what I’m after is their CR contact. And if I can have a record at that CR contact, then that’s enough for the lab to be able to mount the models in CR and then open the pin. But that isn’t always possible. So then we are looking at a few different options. We’ve got- 

Interjection:
Hey guys. It’s Jaz here with an interjection, right? So these interjections have been designed, we’ve been going for about maybe five or six episodes. Now, as per your request, just to, sometimes I don’t want to disturb the guest.

I also feel like we just need to explore a topic a little bit more to make it tangible. That’s the mission of Protrusive, right? To make things tangible. So he mentioned lucia jig. Some of you already know what it is. You made some before. But to a lot of people, they might not know what a lucia jig is. So let me describe it, right?

Classically, it’s like something acrylic, that you make and like you make it to a right shape and you put it on the central incisors, like for example, the upper central incisors and you create like a flat plane. And then when the patient bites together, now the back teeth are separated and they’re sliding around the front on this, what we call lucia jig.

So it’s made out of acrylic. Classically in the past, something like Duralay could be used, which is like a red acrylic. You can use any type of acrylic. But actually you can actually get these preformed ones whereby you inject the bite registration paste into, and then you can pop it on the teeth.

It’s got like this little plastic unit that sits on the front teeth, and the whole purpose of it is to separate the back teeth and allow the lateral pterygoid muscles to release and relax and allow the patient to find centric relation i.e. the joints, the condyles will seat, the balls will go into the cups as my analogy of the condyles seating into the fossae.

And when you get the patient to go grind left and right and grind forward and back, they’ll keep returning back to the same place. It’s kind of like a gothic arch tracing if anyone knows that from complete dentures. But essentially we’re able to find this repeatable position that’s comfortable and then we know that the muscles are relaxed and this is essentially their centric relation.

Now, for those of you who are watching this, then you’ve seen me like kind of play in the background a clip showing a lucia jig in action. It’s not so important ’cause a lot of people listen to this while they’re running chopping onions, whatever they’re doing. So I hope that made sense. But if you want like a videos of different ways of deprogramming, then one of the lessons we have in OBAB, our occlusion online course is a deprogramming masterclass.

So I show you all these different ways of deprogramming the patient including the leaf gauge to a lucia jig using a chin point lift technique, which I think the best is a hands off approach, right? So lucia jig is great. Leaf gauge is good, and there’s different times you might consider each one.

Potentially, the goal is to seat the joints and find that repeatable, reproducible, and comfortable position, AKA stable condyle position, AKA centric relation. There we are. Let’s return back to the episode.

[David]
Leaf gauges. We’ve got a lucia jig, or we have the Kois de programmer, which is effectively an upper removable appliance with a flat bite plane just on the palatal of the upper anteriors, which is similar to a lucia jig.

It’s gonna deprogram the muscles. So of those probably I most prefer a lucia jig, but alternative in my next would be a leaf gauge. So the two different ways is that if they’re deprogrammed, then you can use, the fact they’re in CR to then open them up to the extent that you want. And certainly that’s when a leaf gauge becomes useful because you know you’ve got them at that first point of contact and can put by registration pace at potentially the desired opening.

But the flip side of that is we don’t always know how much we’re going to open. So the most important is that you have a bite record at CR and then the technician is going to work out what space they need. And anything I provide them with is an estimation until they start waxing up the case. Whether that’s a typical analog wax up or absolutely a digital wax up. And so two different ways, but for the less experienced, the safest is to give the lab a bite record at your proposed increased vertical by making- 

[Jaz]
I write that down now, that is that exactly. 

[David]
But that isn’t always possible. And if, but as long as they’re in CR, the lab can adjust that because they’re gonna work out what is needed. And then they’re gonna make a bite jig at that increased vertical. Effectively, I like to think of it as almost like a lucia jig at the front. And we’re gonna come onto- 

[Jaz]
On the articulator? 

[David]
On the articulator. Yep. Before they wax up or after they’ve waxed up. I need that jig because when it comes to the technique that we’re using, that’s my most important part, apart from the putties that I have to make the bisacryl.

So it is a question of how we decide on the extent of the opening or in CR. So they’re in hinge access and then our anterior jig. And we’ll come onto that in the techniques of how we then use that. But that’s gonna give our extent of opening. And then the lab, we’re gonna wax up, we’re gonna do our visual try-in, and we’re gonna check that we’ve still got an oral seal.

And that goes back to what we were saying about making sure we don’t have overly long, lower anterior teeth. And so we’ve worked it all out and then we could sort of come onto how we do it. Unless you have any other questions about the balance. 

[Jaz]
No, no, no. I’m happy for you to just talk, ’cause that’s a good point about the jig. And then importantly how you then use that in the clinic once the technician made it. 

[David]
So assuming we’re doing a upper and lower full mouth, I’ll have the anterior jig in and that’s gonna tell me my occlusal clearance because that’s what we’re trying to work out. The preparation facially, whether it’s full coverage, something we touched on in the previous episode.

But I wanna know the amount of opening now when it comes to doing an increased vertical. Some colleagues prefer to do one arch one day, the other arch the next day, and that’s fine. I’m quite comfortable going through a very long appointment. That’s a full day appointment, and the advantage for me is that I can work out which is upper and which is lower.

[Jaz]
What do you mean by that? Sorry. 

[David]
So how much I’m adding to the upper, how much I’m adding to the lower where the distribution between the extra occlusal coverage between upper and lower, and doing that as a same day case. I find that easier to work out. But basically the anterior jig goes in and I’ll do a posterior sextant on one side.

Let’s say it’s the right hand side. I’ll then work out the distribution of that increased vertical or how much we’re adding occlusally to the upper, how much we’re adding to the lower on our prep upper and lower  sextants. And I’ll make temporaries for those upper and lower  sextants with the jig in knowing that I’m in the correct vertical, I’ll then prepare- 

[Jaz]
This jig. Sorry, one thing, David, like this jig way of doing it, so I imagine this is not flat plane, this is indexed ’cause it guides them into the exact position you want, right? 

[David]
It is indexed, but I want to be sure that that is at CR and ultimately what you can do is once you’ve got it indexed, once you’ve removed the posteriors, you can remove those indentations and you’re effectively convert it from a jig that’s actually physically indenting into the teeth, to a lucia jig. 

[Jaz]
And then you’re observing that they’re literally biting together, and that gives you so much confidence.

[David]
Exactly. So it’s effectively acting as a de programmer as well as a jig down the line. But I’m not using it until I’ve made posterior sextants right hand side and then left hand side, because then I actually want to equilibrate those posteriors, and if you then flatten that anterior jig out to remove the indentations, it’s acting as a deprogram so that your posteriors are in the ideal position vertically, but also equilibrated. So that may we know the patient’s in CR. We can then take out- 

[Jaz]
Interested to know the following. Actually, sorry for interrupting, but think there’s so many questions, which I think will be helpful to everyone, is what percentage of the time do you put the posterior in?

So you’ve got the left and right posterior with the bisacryl from your temporaries, provisional. Basically within bis-acryl ’cause in our pretend full mount scenario, you’ve got the anterior jig, you’ve now flattened it out, and then you find that, whoa, the lab have nailed it. Your CR record was amazing.

The patient’s occlusion is spot on. Versus I need to do some adjustment. So is it that 99% of time there is a bit of adjustment needed or more that actually there’s not adjustment needed? I’m just trying to give those young dentists to know what to expect when they come onto this kind of dentistry.

[David]
You’d be surprised how much the lab often do nail it, but I would expect some minor adjustment, but not significant. 

[Jaz]
Yeah, if a significant adjustment, that means there’s a huge issue with your bite record. 

[David]
Yes, absolutely. But again, having gone through the diagnostic process, I’m already a step ahead of that because I know that isn’t the case because I’ve already done a visual try-in to confirm where I’m up to.

[Jaz]
So yeah. And then like you said, you did the visual try-in and you took a putty and then that guides lab for this provisional stage. Very important. 

[David]
So yes, if I’ve made more adjustments, I’m making new putties, but I’ve gone through that process, so am I expecting some adjustments? Sometimes that isn’t necessary, but often some very minor adjustments, very, very rarely, if not at all, if never to have significant adjustments.

[Jaz]
I think this reminds me of something that Ian Buckle taught me, which is centric relation is like playing golf, right? You’re not gonna get a hole in one, right? So sometimes you get like a little bit closer, like with your bisacryl, visual try, you get, there’s a bit adjustment to do then, right? And then you take a putty, and then on the day of personalization, you’re a little bit closer still. And then at the delivery you’re a little bit closer still, potentially, so, or there, you wanna be in the, you definitely want the ball inside then. 

[David]
And that’s a very good point ’cause even when I fit, I’m not expecting to have to do no adjustments. There are always gonna be some adjustments, but they get less and less.

And I mean, we’ll touch on how we record that for the lab. But yes, not expecting a lot of adjustments. So we’ve rated our posterior sextants, sorry, left and right. Then we can take out our anterior jig. And we then have our clearance anteriorly so we then know how much we’re preparing. We’ve already done the diagnostic of whether the uppers are full coverage.

And certainly in an unrestored case, I’d be ideally not wanting to go full coverage. So my amount of vertical opening would be to give me the length of the lower incisors that I want to, because I don’t want to have to prep the political of those uppers ’cause then technically they’re crowns. I’m talking about a new case.

A full mouth rehab will be a very different situation. So effectively we’ve prepared and we have six lots of temporaries, three upper sextants, three lower sextants, which are all removable in their own right. 

[Jaz]
At this stage, you tend to favor using acrylic like shells or you like bis-acryls. What do you prefer? 

[David]
I’m still very comfortable with bisacryl. If it’s palatal uppers, then we are less concerned about the upper anterior temporaries because it’s our lower anterior temporaries that give us the extent of the vertical against the upper palatal. If the uppers are full coverage, then bisacryl is gonna work fine. So in that sense, with the uppers as veneers.

It’s maybe harder to have a temporary, you can take on and off, but it’s less of an issue. Ironically, in that situation and when they’re full coverage, I will have six anterior crowns that I can take on and off because the next crucial aspect is how do we record that vertical for the lab? Bear in mind, I’ve equilibrated my posteriors.

That’s allowed me to equilibrate my anteriors so my bisacryl are all equilibrated at my new vertical. I will then take out my posteriors for my bite registration, and I’ll have my anteriors upper and lower or certainly lower if it’s just an upper veneer case in place. And then I can just put bite registration paste in my posterior.

And I’ll do that both sides, and I’ll do it three times because I want three bites. So we’ll do that and keep those separate. And then I’ll take out the anteriors and I’ll fill that in. So I have a full occlusal registration equilibrated in CR at our new vertical dimension. And I’ll do it three times. And when it goes to the lab, we hope, and most of the time, all three of the same.

If not, you’d hope that two are the same. If all three are different then, then maybe, but you’d be amazed that all three are often exactly the same, but certainly two of them. So we have our prep to prep bite registration at an increase vertical. 

[Jaz]
And what I love about this is that, sometimes our concern about using stone bite Futar D whatever you’re using, at this stage you have plenty of thickness and rigidity of that because of the space we have and that gives you so much more confidence.

[David]
Absolutely and bite registration material. There are many around Futar D is is a great material for me. It’s a little bit hard. I prefer blue moose, but I get extra fast ’cause otherwise it’s a long time to set. But speak to your lab technician. Often they will be trimming that down because they only want the very cusp tips in there.

So the rigidities, less of an issue because you are gonna have a quite a thick, sturdy bite registration. But I mean, it goes back to, not on topic, but when we do a single restoration, you won’t really wanna do a bite registration over the other teeth because that’s when it gets in the way. But we are talking a different scenario where we have a much thicker bite registration and so therefore the material for me is less, less of an issue.

But I’m comfortable with Futar D, blue Moose, DMG, do a great product O-Bite. Not to be confused with LuxaBite, which is too hard for a bite registration pace, but is great as a splint or a sort of a liquid Duralay that we can inject and splint together, implant impression coping. So certainly in full arch cases.

So we’ve got our bite registration material as a full arch, and that would be our prep to prep. I will also do a prep to template registration. And a temp to temp bite registration, which is allowing our lab to cross mount our preparation models and our provisional models so that they can work out the space distribution and work out everything is the same when it comes to making the permanent restorations. 

[Jaz]
And at this stage, you are taking a new face bow record for your technician? 

[David]
Absolutely. Onto the prepared teeth. So that’s my workflow, to do the preparation and to get the bite registrations. And we’ll have three lab bags, and inside one of those lab bags, there’ll be another three bite registrations. So there’ll be three prep to prep, there’ll be just one prep to temp and there’ll be just one temp to temp bite registration. 

[Jaz]
Your assistant has to be so switched on to make sure the labels are there, and then everything has to be nice sealed boxes. Not in like flimsy Ziploc bags. You need everything protected. You don’t want things to be shattering by the time they get into the lab. Do you ever use custom incisal guidance tables? 

[David]
The answer is, I have done, and I’m quite comfortable with using them. If you are reproducing the guidance that you have. And the lab may choose to make one from your temporaries to help them reproduce it.

And again, it’s a way that we can record our, the steepness of our incisal anterior plane for the technician or for the technician to be able to reproduce that. Whether that’s from something you are wanting to copy in the patient’s natural dentition, or wanting them to copy from your provisionals. So it has a place, but if the technician’s done the digital wax up and it’s all in house, that they’re probably gonna be able to copy what you have.

But it’s always an option as an extra tool to confirm that they’re copying what you have. But I think we must always remember that we have to be able to be adjusting in the mouth because the best articulator is the mouth. And so we don’t wanna give patients overly steep incisal guidance because, but it needs to be steep enough to give us posterior disclusion. And a custom table can be useful to help confirm that if nothing else. 

[Jaz]
Wonderful. Those are my main questions. Wanna just talk about any do’s and don’ts that you wanna just come to mind on the clinicians who are starting their journey to just remember to save them for getting in trouble? 

[David]
I think it’s a fairly classic one. Don’t try to run before you can walk. And absolutely don’t be doing work that’s beyond your scope of knowledge. And so, initially, get a good foundation in occlusal training. And if you are used to doing equilibration, if you’re used to adjusting flat plane appliances, I think that’s a very good start because it’s gonna give you the confidence to be able to move forward, be comfortable and confident in your restorative and your preparation skills.

Going back to Schellenberg, knowing how to prep is definitely very important and don’t do anything beyond your skillset. But going through the pathway, especially if you’ve had your occlusal training, you are comfortable doing equilibrations, you’re comfortable adjusting your flat plane appliances. We’re not doing anything massively different from that.

And with the whole planning stages that we have gone through, we are not taking steps into the dark because it’s a very predictable process. We’ve gone through that. We know the aesthetics, we know that we can achieve the function. It’s then just a question of taking your time. For me, this is a full day appointment.

Patients are instructed, wear company clothes, have a good breakfast, bring some music in to listen to. It’s gonna be a long day, but you can have a break and be aware that you can split it into two days if you’d rather and fully inform your patients about what’s involved would be my list.

[Jaz]
And the last thing you want is a patient like, what the hell just happened? You couldn’t imagine that. Oh, David, thanks so much for, so sorry. Go for it. 

[David]
We just, with the dahl process, the patient is aware of what’s happening. They’re fully invested, they understand their level of dental knowledge has gone up because they have to be aware of what they’re going into.

And it is a long day and patients invariably get very, very tired at the end of the day, but the results, that memory fades very quickly When you give them the mirror and you give them the functional aesthetic result that they’ve wanted. 

[Jaz]
You forget about the flight and the ear pain that you had when you have your pina colada at the beach. 

[David]
And our wives and our female colleagues, if they have gone through labor, they will probably tell us the end result is worth it.

[Jaz]
Well, that’s a great point to end on. David, thank you so much. But there’s early morning session. We covered a lot of ground there and I think, kudos for really covering a complex topic like, wow, like this is such a big topic and I’m really happy with the rabbit holes we went down. David, please tell us more where can we, what are the channels that I can get Protruserati to learn more from you, my friend. 

[David]
So as we touched on last time, there is gonna be a website, ppcontinuum.com. Sorry, I can’t let you have that one on chat as you asked last time. But there will be some resources on there for myself, but from other colleagues and Kushal Gadhia at ace, I do run the additive program for veneers and minimal invasive dentistry. And you’ve inspired me, Jaz, that I’m gonna put together a program for doing the open vertical as a course as well. But I haven’t got that completed yet. 

[Jaz]
But let me know when you do. I’ll put it in the show notes, my friend. someone experiences you, you know that it’s a great skill to learn and to have that will be wonderful.

[David]
Thank you. And I’ll be doing that I think as a hands-on with Kushal Gadhia at. Ace and obviously you can Google me. I’m happy to help in any way I can. And another point that is not just with me to find a mentor because one thing we didn’t touch on is that you can do this sort of a case with someone as a tag team.

So you’re both clinicians together and working it out with your mentor where you treat the patient together and your mentor might treat one side, you might treat the other side and that would give you the extra confidence to- 

[Jaz]
That is a rocket fuel. That is rocket fuel for your career. Honestly, great point.

[David]
And I know you are working on the mentoring program and I think doing the case together will give you the confidence that it’s the first one, the first few that obviously, understandably anyone’s gonna be concerned about, and to give you the confidence to get through that, that’s also an option. 

[Jaz]
Amazing. David, I’ll put the links there for you. Got for you guys to learn from. David, thank you for your time again. 

[David]
Thank you very much, Jaz, and well done to you. 

Jaz’s Outro:
Thank you. Well, there we have it guys. Thank you so much as always, for listening all the way to the end. What I did do in this episode is I put in a few interjections. I don’t always do this, but when you have a very confusing topic, like vertical dimensions, multifaceted, I hope those interjections were useful, and if they were, if they weren’t, please could you comment? Please could you let me know whether you’re watching this on Protrusive Guidance or on YouTube, or maybe you’re gonna go on Instagram at Protrusive Dental.

You’re gonna DM me. Let me know. Were those additional injections, were they’re helping you or are they hindering you? We love your feedback on Protrusive. This episode is eligible for CE or CPD depending where you’re on in the world. We are a PACE approved education provider and on our platform, Protrusive Guidance, you have access to over 350 hours, including our masterclasses and on-demand webinars.

And our mission really is to make dentistry tangible. So check out www.protrusive.app and maybe start a free trial today. As always, any links that we promised, I’ll put them in the show notes. So scroll down if you want the premium notes, which is like a PDF summary of everything we discussed. It’s like revision notes, like really good revision notes for every episode.

Again, they’re accessible under the episode. If you’re watching on Protrusive Guidance or in our Protrusive Vault at the time of recording today, we have over 3000 strong community of the nicest and geekiest dentists in the world. And so Protruserati, thank you so much. I appreciate your support and for returning.

And if you’re new to the podcast please do hit that subscribe button. It really means a lot to us. I wanna take a moment to thank my team. Our CE queen is Mari, who’s the one who issues your certificates, and this episode was edited by Gian with collaboration from Krissel and Nav. Thank you to my lovely team for doing all that work so I can be a father, be a dentist, and be able to watch IPL Cricket on Sky Sports.

As always, I’ll catch you same time, same place next week. Bye for now.