Protrusive Dental Podcast

Can you apply the Dahl technique to localised POSTERIOR wear? Spoiler alert: hell yeah! How can the Dahl Technique help when there is posterior wear and NO space to restore? How predictable is building up posterior teeth (rather than the usual worn anteriors)? In this episode, Jaz dives into the ‘Reverse Dahl Technique’, a twist on the classic method typically used for localized anterior wear. Dr. Hans Kristian Ognedal from Norway shares his insights, explaining how building up posterior teeth with composite can lead to occlusion magic!  If you’re curious about this technique and want to see a real-life case study, this episode breaks it all down, with a special visual breakdown for those watching on YouTube or Protrusive Guidance. https://youtu.be/V8MTFfXmdlw Watch PDP235 on Youtube Protrusive Dental Pearl: Jaz shares insights from Hold On to Your Kids by Dr. Gordon Neufeld & Dr. Gabor Maté, emphasizing how modern children lose parental attachment too soon, turning to peers for guidance. This shift can lead to anxiety and emotional disconnection.  Takeaway: Kids thrive when their primary attachment remains with parents, not peers. Strengthening this bond is crucial for healthy development.  Key Takeaways The traditional Dahl principle focuses on creating occlusal space for anterior crowns. The reverse Dahl technique is a direct method for treating worn POSTERIOR teeth. Diet plays a significant role in tooth wear and dental health. Taking photographs of patients’ teeth can help track wear over time. Understanding the etiology of tooth wear is crucial for effective treatment. Building up dental anatomy is essential for successful restorations. Occlusion should be viewed as a dynamic system rather than a static one.  Patients can adapt well to this treatment modality “Patients that wear their teeth, they don’t usually have TMJ problems.” Highlights of this episode: 02:22  Protrusive Dental Pearl 04:50 Guest Introduction: Dr. Hans Kristian Ognedal 07:06 Understanding the Original Dahl Concept 09:31 Exploring Reverse Dahl Technique 13:30 Etiology and Patterns of Tooth Wear 23:46 Facial Patterns and Occlusal Traits Linked to Wear 24:44 Clinical Approach to Posterior Wear 30:26 Patient Comfort and Staging Treatments 32:11 Cuspal Planes and Guidance 34:21 Review Schedule and Observations 38:44 Longevity of Treatments 44:04 Contraindications and Patient Selection  45:24 Case Studies and Practical Tips 49:30 Night Guard Use 53:06 Final Thoughts and Education Opportunities If you want to learn more about Dahl Technique, be sure to listen/watch: Why do some Dentists find Dahl Distasteful? – PDP016 Dahl Part 2 (The Spicy Bit) – PDP017 Dahl Technique and ‘Maryland Bridges’ – GF001 This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes B and C. AGD Subject Code: 180 OCCLUSION (Occlusal functional concepts) Aim: To explore and understand the Reverse Dahl Technique, focusing on its application for patients with localized posterior tooth wear. This technique provides a solution when posterior teeth are worn, and there is insufficient space for proper restoration. Dentists will be able to – 1. Understand the principles behind the Reverse Dahl Technique and how it differs from the traditional Dahl Technique. 2. Identify the clinical scenarios where the Reverse Dahl Technique can be applied. 3. Comprehend the role of composite build-up in restoring posterior wear and its impact on occlusal reestablishment.

Do you feel confident managing patients with TMD or oro-facial pain? Are you clear on when to treat conservatively—and when to escalate? What’s the best SEQUENCE of care for TMD patients? Emma returns to Protrusive Students fresh from her finals, joining Jaz for an insightful episode on the basics of TMD management. Together, they explore the foundational steps of TMD care, from proper diagnosis to the logic behind a structured treatment hierarchy. They break down conservative versus aggressive approaches, share clinical tips for muscle and joint assessment, and highlight common mistakes to avoid—especially during palpation and history taking. Whether you’re a student, a dentist returning to practice, or just want a refresher on TMD, this episode will help solidify your approach and boost your clinical confidence. https://youtu.be/p5VJzwSka94 Watch PS016 on Youtube Need to Read it? Check out the Full Episode Transcript below! Key Takeaways TMD is a complex topic with various treatment approaches. Patient education is crucial in managing TMD effectively. Physiotherapy can significantly aid in TMD treatment. Different splints serve different purposes in TMD management. Bruxism can be a silent issue that affects many patients. Identifying the source of pain is essential for effective treatment. Stress can exacerbate TMD symptoms in patient cohorts Continuous learning and resources are vital for dental professionals. Highlights of this episode: 02:35 Emma’s Finals Experience and Advice 05:16 Deep Dive into TMD: Clinical Insights 09:59 Common TMD Disorders and Their Presentation 18:31 TMD Treatment Options 28:00 Medications and Appliance Therapy 34:25 Practical Tips for Managing TMD 37:19 Addressing Bruxism and Patient Communication 41:00 Protrusive Pathways and Future Plans 43:46 Protrusive Students S2 🔗 Protrusive Resources OPPERA Study Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group† TMD Therapy Hierarchy of Management Effects of occlusal splint therapy in addition to physical therapy on pain in patients affected by myogenous temporomandibular disorders: A pilot randomized controlled trial Splints Decision-Making Flowchart  📚 Protrusive Pathways Structured playlists grouped by topic (e.g., TMD, bridges, onlays): TMD Content Playlist 📝 Crush Your Exam Student NotesDownloadable summaries by Emma, covering TMJ anatomy and function, are available inside the Protrusive Guidance App (request student access via Mari) If you loved this episode, be sure to watch TMD New Guidelines! Evidence-Based Care – PDP213 #OcclusionTMDandSplints #BreadandButterDentistry #Communication This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes  C – Maintenance and development of knowledge and skill within your field of practice. AGD Subject Code: 200 – Orofacial Pain / TMD Aim: To provide a practical, evidence-informed framework for the conservative diagnosis and management of Temporomandibular Disorders (TMD). Dentists will be able to – 1. Describe the three major categories of TMD and their clinical features. 2. Differentiate muscular from joint-related symptoms using simple chairside tests. 3. Explain the rationale for a conservative, staged approach to TMD management. Click below for full episode transcript: Teaser: TMD is one of those things, which is like so debated, so hotly contested, so controversial. Right. Teaser:Taking these broader categories, like how do these typically present in practice to during an exam, or does it chop and change for every patient? I tell ’em, I’m not a guru. I don’t know what’s gonna work. But can we at least try things that are conservative and then we can always escalate to more aggressive things?  Jaz’s Introduction:Welcome back to another Protrusive Student episode. Emma is back after finishing her finals exam. So, in Glasgow where she studies you do the finals exams in your fourth year. And so she’ll be soon heading into her final year, which is fifth year. So it’s strange that they do their final like academic exams in their penultimate year, but I guess that’s how it works there. And I’m pleased to say she passed. She passed, and she’s back again for this series called Protrusive Students. Now it’s not just for students, it can be provision for someone returning back into dentistry or validation for many clinicians. Or maybe you are feeling that TMD is not your hot point, and so this is a great basics episode to lift up your foundational understanding. Now, it’s very tough to cover TMD in this short episode, but the main takeaway I can tell you now is the hierarchy of treatment or management is probably a better word than treatment. We do talk about a few clinical gems and a few pertinent points in someone’s history. Or the common mistakes we make when we’re palpating the joints and the muscles. But if there’s one thing that you’re to take away from this foundational episode on TMD management is the hierarchy of treatment and why it exists. What are the modalities included in conservative care and what are the modalities that are deemed more aggressive? And why we should have a bit more logic and sequence to how we treat our patient. You’d be able to download my hierarchy underneath the link if you’re on the app. And of course, for the students out there who have exams coming up or want some really good revision notes, Emma regularly updates the Crush Your Exam section. So in this section on the Protrusive Guidance app, you can access it on your phone or on your browser, anywhere you like, and you can download revision notes. For example, PS006 was indirect restorations, a really good overview for young practitioners and students. And for this episode, you can get everything about TMJ anatomy, which is so important. How can you understand what pathology is if you don’t understand what normal anatomy is? So to access that, just head over to protrusive app. Make your free account and join the ‘Are you a student?’ section. If you can verify you’re a student, you just need to DM Mari on the app. Her name is Mari Benitez. She’s like our CPD Queen, also student lead. She’ll just need some proof that you’re a student and she’ll let you access the Protrusive vault, which has got like all our infographics and papers. It’s our way of like supporting and nurturing you students. But like I said, this episode’s also useful for those who have a bit more experience, who are qualified, and you can even get CPD or CE credits for this episode. We are a PACE approved education provider. For that, you need one of our paid plans, and you scroll down, you answer the quiz. And Mari, our CPD Queen will arrange your certificate. Let’s now join Emma the Protrusive Student and welcome her back for this episode. Main Episode:Emma, welcome back, the Protrusive Student. Congratulations for passing your finals like in Glasgow. You do it in the fourth year. Tell us how was it?  [Emma]It was intense, but I made it through. I think anyone that’s done final exams before. You’ve just gotta keep your head down for a bit and get through it, really. But I survived. So here I am.  [Jaz]Never in doubt, Emma. Never in doubt. I remember we were chatting before you getting results and it’s sometimes difficult to gauge how you’ve done, like I was convinced, I failed. Like it was that one of the OSCEs went that bad. But actually I did end up doing very well and so it was a bit of a family joke now about how I catastrophize. That kinda stuff. But yeah, it was all good. And now that you’ve been through it, what’s the number one advice you can pass on someone who’s gonna be maybe doing finals next year, for example, or coming up imminently?  [Emma]I would say don’t underestimate anything ’cause they will just ask you anything question by-  [Jaz]You’re supposed to make it, like you’re supposed to make them calm and reassured that, that’s gonna overwhelm them like to the nth degree. But it is what it’s.  [Emma]I think you can either be one of two people. You’re either gonna be someone that knows a little bit about everything or a lot about certain subjects. So for me, I’m one of those people. I like to know a little bit about everything. There’s not one specific topic that is my absolute ride or die or something that I’m bagging on on coming up in the exam. I’m one of those people that like to try and cover everything-  [Jaz]And that’s strategy, right?  [Emma]I would say for me, definitely. Yeah. But I know some of my friends, they pick the topics that are quite common year after year, and they will know them inside and out, and they’ll compromise on the other topics that they just don’t have time for. Because you’re never going to know absolutely everything unless you’re you and you get a hundred percent in your finals.  [Jaz]That was one exam. But with you, what’s the pass percentage?  [Emma]I think like in Glasgow, I think it’s around about 60%.  [Jaz]In Sheffield, it was 50%. If you get 50%, you can be a dentist. Which coming into it like from a level, right? And like as a 19-year-old and going to dental school and then you get told that, hey, you just need 50% to become a dentist. And I was like, wow. Okay. But it’s tough, right? Yeah. That’s why honors is 65% and then you get your 50%, you’re like, whew, phew. That was hard kind of thing. Right? And it really puts you in your place. But I think the most important thing is they wanna see that you’re a safe beginner and that you are gonna go out ’cause epitomizes the fact that dentistry is something that you really learn once you qualify rather than in dental school. And so good. I’m glad you got through that. Today’s episode, we’re talking about something that I like to talk about. We’ve done episodes for dentists in the past, but today we’re gonna make it very student specific for you. TMD, TMJ. How much of the previous episodes on TMD have you listened to? How much, how much information about TMD have you consumed? I know you’ve got a really good tutor in Glasgow, Dr Ziad Al-Ani, who does wonderful work with occlusion, TMD. So I imagine you, your knowledge is better than the average student, I imagine.  [Emma]I think Dr.  Al-Ani is absolutely amazing. We have him a lot in first and second year, and then when we come back to do a lot of TMD and oral medicine and fourth year we go to Dr. Rob Riley. He’s an oral medicine specialists, so I think they teach us a lot. How much is examinable and relevant for new graduates? Unsure, but it’s all things that you need to be aware of. We go pretty in depth for TMJ, TMJD, big topic in Glasgow for exams and things.  [Jaz]I’m thinking that you probably know more than the average student about TMD. So like how much background knowledge, is there something that you are lacking confidence on or you are feeling confident on? Like where’s your head space around TMD?  [Emma]I would say for TMD, it’s one of those ones I quite enjoy, especially working for Protrusive. Like it’s something that you like to talk about, you talk about quite a lot. So working with you for the last few years and editing those episodes and doing all the notes in them, it is something that I think I have a bit of more of a background on, but it is a big topic, big, big topic.  [Jaz]But like it’s one of those things, right, where, yes, you learn about it and then you read them articles about it. You go to the books. But then when you have that patient and they give you this history, and then you are like, whoa, what’s the diagnosis? And then, you think, okay, how do I manage this? It’s actually, it’s one of those things that I think is one of the most difficult things to apply. And Jeff Okeson. The Jeff Okeson. I’m literally staring at his textbook in front of me. He says that TMD is a thinkers game. Right, very much is a, it’s a bit like ortho, right? Like it’s all the planning, the bracket’s fine, they go where they go. But it’s all about the planning and the sequencing and the diagnosis and that kind of stuff. So really, I want you to ask away any questions that you think will genuinely help you and students everywhere and we can, yeah, I think it’s nice to go back to basics, but here’s an interesting, I’ll just set the scene a little bit, right? TMD is one of those things, which is like, so debated. So hotly contested, so controversial, right? And I say this to my patients when they come to me and they expect me to be this like, or, you know, this guru that’s gonna cure them. I’m very quick to educate them that, hey, if you go to seven different practitioners, they’ll give you radically different. So it’s not even like slightly different. Like if you have a broken tooth, it’s either gonna be a crown or a filling. Very rarely. Or someone might say it’s restorable, not restorable, right? But like it’s gonna be a crown or filling. For TMD though, you have jaw pain. You can go to someone, they will say, you need ortho. You can go to someone and say, you need botox. You can go to someone and say, do you know what? Just go physio only. You’ll be fine. And so it’s a really tough space to be a patient in general anyway, it’s a very debilitating disease. It’s very, very debilitating. Has a huge impact on the quality of life on our patients, but it’s also more troublesome because as a patient that you are trying to read up on it and you are like, whoa, like I’m so confused. There’s so much out there, and then also gets carried through as a clinician. Because we then, there’s not just two polarizing camps. It’s about five different polarizing camps. If you listen to Daniele Manfredini, one of my friends, Morten, he went to his like a live thing in Italy, and he will get rid Italian hand gestures and he will bang the table and he says, occlusion has nothing to do with TMD. Right? And then he will put the splint in and just send the patient away saying, because why? Because occlusion doesn’t matter. Right. Whereas I’m training with Dr. Rob Kerstein, who’s coming to the UK in September. Hopefully we’re organizing that and he’s gonna give me hopefully, what we call DTR certification, which is basically Disclusion Time Reduction therapy, which is basically adjustments of teeth, of their own teeth to get them onto canine guidance as soon as possible. And you monitor it using these EMG things. And so what he’s saying is occlusion is everything to do with TMD and so I’m looking at these two camps and I’m like, whoa. And then the other three camps are lurking in between. And then there’s a bazillion, gazillion different types splints. So no wonder, Emma, it’s confusing. How can I help? Where do you wanna start?  [Emma]So, as students, as we get so much thrown at us, just information to remember and to recite and exams. But in dental practice, and I understand you probably see a lot more TMD patients than the average big time, but what are the most common temporomandibular joint disorders seen in dental practice? [Jaz]Okay, so if you can just categorize them broadly into three main categories, there are lots of subcategories. So TMD is an umbrella term, right? It’s a bit like I give the analogy of like, for example, if I say someone has perio disease, we automatically think of like pocketing and chronic perio disease, but actually, perio disease encompasses like a traumatic occlusion causing mobility. That’s the type of perio disease. It could be periodontal disease around an implant like perio-implantitis. It could be perio disease in the form of recession. They just have, they don’t have any like mobility. They don’t have any pockets, but they’ve got loads of recession. That’s the type of periodontal disease. Periodontal disease has lots of sub classifications and diagnoses. And so TMD has lots of sub diagnoses. So if you look at the actual, official, research diagnostic criteria of TMD, there’s like 13 or 15 different sub classifications. But broadly speaking, it’s muscular. Okay, so it’s extracapsular. So basically the capsule is that piece of anatomy that sort of encompasses the ball and the socket, i.e., the condyle and the fossa, so everything that happens in that space to do with the disc, and that’s intracapsular. Extracapsular, everything outside of that. So we’re thinking muscles, right? Yeah. And then there’s osteoarthritis. So this is like classically bone on bone. It’s like a wear and tear disease. So if you look at those three, then the most common is muscular, right? 70%. And then, it’s like a 25% intracapsular. So this is like clicking, locking, clunking popping, that kind of stuff. Very similar terms used on purpose. And then there’s osteoarthritis. There’s like degenerative, right? So there, over the years there’s been wear and tear. And classically you get crap as they open and close their mouth and you feel this like crunching and their jaw joint. But classically, they don’t have any pain. And so yes, there’s crossover, right? You have all three at once or you have muscular with intracapsular. But those are the broad ones, and muscular is the most common.  [Emma]The most common, yeah. So I suppose this is also a very broad question, but taking these broader categories, like how do these typically present in practice to you during an exam? Or does it chop and change for every patient?  [Jaz]Yeah, it can be. So TMJ right? It’s called the Miracle Joint, which is Dania Tamimi came on the podcast and said it so elegantly, but it’s also TMD is called The Great Imposter. Did you know that? So you can have like-  [Emma]I’m sure I’ve heard you say that before. [Jaz]Yeah. Yeah. So you can have like many other issues like tinnitus and headaches and vertigo and all that kind of stuff. But actually it’s a TM joint is a main culprit. So, it’s a great imposter for that reason. So how does it present? We’ll put it this way, because I get referrals for TMD and patients seek me out for TMD and actually as a clinician, I’m happy to say this, I know patients watch my podcast, which I wish they didn’t, but they do, and I’m happy to say that I’m happy to help. I’m empathetic. I’m a sympathetic, but I’m no guru. Right? I try and follow the best evidence available, which isn’t that great anyway. So I try and do things in a way whereby, okay, let’s do the most reversible and basic things. Safest things first, and escalate from there. And the peak of that would be surgery. So very few people need to escalate to that. Lower down is botox. Anything that’s irreversible, like orthodontics. We say that until we’ve exhausted, like, education, physiotherapy and appliance, that kind of stuff. Now, going back to your question, how do people present? And the reason I mentioned why I just mentioned now is when I used to be a purely a general dentist and I would just do a TMJ examination and I would diagnose, did you know you have a click? Or, oh, your muscles are quite sore, aren’t they? And so, that was not a symptom. It was a sign. A sign is something that the we find. But the patient hasn’t quite yet. It’s like subclinical and so success rate was through the roof because actually it’s not become a big problem yet for them. But now when patients seek you out for this care, then quite often they’ve had it for a long time. It’s very debilitating. It’s like trying to help someone when they’ve got small caries lesion and that it’s completely asymptomatic. Asymptomatic, so you know that the risk of root canal is so low. Versus they come in and they’re already in pain. And so, you know, pulpitis has started, there’s a higher risk of root canal treatment ensuing. And so it’s more difficult to treat, it’s more difficult to preserve pulp vitality. So I’m making that comparison because when I now see my patients, they have very clear like headaches, jaw clicking, jaw locking. Whereas when you have general patients, they often have have zero issues. A really good study to look up, Emma, for all our colleagues listening. So it was the opera study, I think it followed like 3000 or 4,000 healthy people who did not have TMD. Right? It followed them up then they saw who got TMD and who didn’t. Really fascinating, right? Prospective study. And then they kind of looked at these, they studied the people who did get TMD and they found like commonalities. Now they didn’t really go into the occlusion kind of things, but it was like genetic testing. They were often quite in a high state of stress. They had a few other things. Like they had like tummy issues like IBS, their gentle symptoms. They had other, like back pain, muscular aches around the body. So there was a common trends in these patients. So what that can teach us that it can affects a very specific kind of person. And in my practice, and also according to literature, it’s like eight to one females to males, eight to one. So we know it must have a genetic or hormonal component if that’s the case. So it’s that kind of a patient that can come to you. And I think one thing, one tip I can add is that if that patient comes to you and they’re complaining of a jaw issue, then Schiffman found a really cool way to figure out, okay, is this patient’s concern more muscular or more joint? So is it intracapsular or extracapsular? Is that you get the patient to say, can you point with one finger where the source of pain is, and if they point right by their ear, then it more than likely probably is intracapsular something to do with the capsule, the disc, the clicking clunking, that kind of stuff. Or if they’re pointing all over their face or lower down, then it’s probably muscular and that can help you to kind of figure out where to delve deeper into in their history.  [Emma]Okay. Yeah, that’s some good, like the clinical tips because just when you’re starting out as a student, you’re just feeling and you’re kind of blind at that point. You don’t really know what you’re looking for. So that’s some good-  [Jaz]What you mentioned there, what you’re looking for that, I mean, the top tick in this basic episode is classically when me and Krina are the physiotherapist I worked with and taught with in the past is when we’re calibrating dentists on palpating muscles and palpating the joints classically for the TMJs, we are too far anterior. We’re like feeling the zygomatic. We’re you’re kind of feeling your cheekbone, right? You go a little bit closer to the ear, right? And then when you get the patient to open a bit and wiggle side side, you should feel the balls of your condyles. Can you try that for me, Emma, right? Can you put your fingers, put your middle fingers that say just in front of your ear, and then open a bit and wiggle your jaw side to side. Did you feel the balls of your condyles, like against your fingertips, you’re in the right place now. Right? Okay. Whereas classically, if I don’t do that, wiggle bit classically, dentists are too far forward. The other thing I found is that when dentists are palpating the muscles, and we’ll talk about that if it leads that way, we’re being too gentle. We need to really be a bit more thorough when it comes to muscle palpation. And so it’s very difficult to talk about something that I wanna talk about so much about, but I’m also mindful about keeping this in tune with relevant for early career. People or students, or actually, this could be a good revisiting for someone getting back into practice or someone who actually feels though, you know what? They ought to just get the foundations of TMD. And so far what we’ve said is it’s an umbrella term. It can present in loads of different ways, but classically, muscular is the most common. But obviously there can be like clicking popping. We can talk about the mechanism of that as well. And just to like calibrate, like make sure you are palpating the right place and you’re able to at least locate the condyle and check the mouth opening. And I guess we can talk about the key things to record, but I want you to lead the show, Emma.  [Emma]Yeah, I mean the next question I was going to ask you was, we start basic patient education and you can go all the way up to surgery for treatment options and it obviously depends on the diagnosis. Should we dive into that sort of treatment options?  [Jaz]That sounds great. Let me share my screen. So if those of you are listening on Spotify, don’t worry, we’re gonna describe it. But there’s a really cool thing that I want to show, which is like a really nice pyramid, that we’ve been working with, which I also share my patients that I show them, okay, this is where we’re at and this is where we’re heading, and this is how we manage temporomandibular disorders. We don’t treat TMDs. We help to manage TMDs. And they kind of get it and they understand why. A really good thing that Jeff Okeson teaches is that, okay, there’s things that we know are like evidence-based, even though the evidence-based quality can be poor. And one of the reasons it can be poor is because there’s so much variability, Emma. Like your joint anatomy will be different to mine, just ethnically, genetically, you are a woman. I’m a man. Your tooth contact time, how many minutes a day your teeth come together is different to mine. Your incisive classification is probably different to mine. And so one of the reasons why the research is so different is ’cause it is difficult to compare. And get good research quality basically in that regard. But it is nice to be able to educate in terms of, okay, why we follow a certain hierarchy. Because as Jeff Okeson says, okay, let’s try and focus on the things that are reversible. But then, if you are treating someone and you’re doing what we call fringe treatments, treatments, which are, are not really evidence-based, they may be perceived that maybe be a little bit naughty, bit irreversible like orthodontics, but at least you’ve tried all the basic things first ’cause that could have helped. But then also at least, you know, okay, what I’m doing is on the fringe and to know you’re doing it. The worst thing you could do is do hocus pocus dentistry that isn’t evidence-based. But you’re not, you don’t really know that you’re on the fringe. You know, that’s the one of the worst places to be is what Jeff Okeson teaches, and I really respect that. Okay, so where we start is patient education, right? One of my mentors, Jamison Spencer, he taught me that TMD patients are nuts. Okay? They’re NUTS, okay? What I mean by that is, is not what you think. It’s NUTS means Not Understanding Their Symptoms. That’s what NUTS means. So we owe it to our patients to educate them, okay? About their anatomy, about what’s going on ’cause believe it or not, there’s a handful of patients every year. I see that just by education, I don’t like to use the word Cure, but I Manage them. They literally are really help. And even like sometimes telling the patient that our teeth shouldn’t be touching together during the day, and they’re like gobsmacked. They’re like, what? I thought our teeth should be touching together the whole time. And once you tell ’em that, and then they’re there in the chair, they’re clenching away. And when you tell them that, hey, this is pathological, this is not good. And then finally, after so many years of their life, they’re able to give their muscles rest. That’s it. They’re essentially managed, right? So we owe it to our patients to give them an explanation. Sometimes the patients are just, they’re not really, are not in pain. They’re just scared. Like, wait, what is this clicking? What’s happening? Am I gonna need surgery in the future? If you just explain to ’em what a click is and we can talk about that, then this is why this education is the foundation. Okay. So, any questions on that before we move to the next bit?  [Emma]Well, in terms of education, sorry. Not in particular, no.  [Jaz]Okay, so the next thing is, soft foods because we have to remember that the temporomandibular joint is indeed a joint, right? So if you have it as something dodgy, a dodgy knee, well you’re gonna go crutches or put less load on it, or not do strenuous activity. So when people are having a flare up of their TMJ, so for example, their joints themselves or the muscles, it just makes sense to eat as we had recently on an episode as well. Dr. Suzy Bergman said eat smaller, eat softer. Eat slower, right? Smaller, softer, slower, the three S’s. So it makes sense ’cause it gives the joint rest. So we educate our patients to do that. As part of education we also say, our teeth shouldn’t be touching together. And like I said, that can be very curative for a lot of patients. We tell them what a click is. So a click, Emma, do you know what a click is? Like what is that click sound? What does that mean? What’s happening to your disc?  [Emma]Is that in the disc displacing?  [Jaz]So when I open-  [Emma]Or reducing it?  [Jaz]Let’s, okay, so what does reducing mean?  [Emma]So reducing means it’s going back into its original position.  [Jaz]Lovely. And so, what Dania Tamimi came on the podcast maybe a few episodes ago, and she had this wonderful way of explaining it, is think not of disc displacement with reduction ’cause reduction is confusing term. Think of it as disc displacement with recapture. By using the word recapture, it really is like a light bulb moment, don’t you think?  [Emma]Mm-hmm. Yeah. Yeah.  [Jaz]So when you open and that click comes, that’s not what a lot of people think. Even Prosthodontists, I know of the thought this is, that they think that click is bad and that, oh, your disc is dislocating out of position. ‘Cause that click sound means it’s dislocating. No, that click means that the disc is already out of position and that click is the disc returning back onto the condyle is the sound energy of that motion. And so actually it’s a disc displacement with recapture. And so just going back on the education bit there, the next bit in the hierarchy is so TMD education, soft foods, and then ice and or heat. So, heat is really good for muscle, but sometimes they need to experiment and they do like hot and cold or just cold. Whatever makes ’em feel good is a simple, cheap, minimally invasive evidence-based way to help sore muscles and reduce inflammation. The next one is gentle stretching, because a lot of times your muscles can be in spasm and when muscles are in spasm to allow them to have stretching is really good. And to actually go forward towards jaw exercises like very specific exercises. Then in tandem with physiotherapy. Physiotherapy has got some decent evidence base when it comes to TMD. Chiropractors on the other hand, don’t have it. So like a patient the other day asked me, should you know I’ve found a good chiropractor? Should I go for them? I’m like, yeah, you can, because if it’s gonna help my patients and if my patient thinks it’s gonna help ’em, then that’s great. I’m happy for it. But if you have to spend good money, then why not do the more evidence-based thing first? Try the physio first. Knowing that the chiro is probably a little bit more in the fringe. And so it makes sense. And so physios can be incredibly helpful. Like my physio, I use Krina in central London. She does dry needling, she does red light therapy. She does very carefully targeted exercises. And that can actually improve their range of motion. So initially they might be opening 32, 35 millimeters without pain. And then after her physio, they’re able to get a 20% improvement in their range of motion. So, that’s there. Anything there before I escalate to the next two, which are more conservative?  [Emma]I was going to ask about like, all these stages and about soft diet. So are these things that you would do, the first two in tandem and then you would review after a certain period of time? Or would you just take it step by step by step?  [Jaz]Yeah, really good question. I think it depends on who’s in front of you. But most patients. Most patients, right? Because these are all basic things. Like you can do TMD education on everyone. If they’re actively in pain and the one that complaints is that it hurts to chew hard foods, then soft foods, it will be a mainstay ice and heat for those in pain. But sometimes the patient’s not in pain. They’re just like, they’re getting lock without any pain at all. There’s no pain. They’re just locking down. And again, so for that patient, you may not be necessarily saying, okay, put ice and heat ’cause they don’t have any pain. But it’s more about them giving them specific exercises to strengthen certain muscles to help their coordination, to help them unlock themselves at will. So, like you can’t go wrong by knowing these. But you might that pick and choose a few of these and emphasize more on certain facets of this, on certain patients than others. And that kind of depends on the micro diagnosis or the problems that your patient presents with. [Emma]Okay. That makes sense. Yeah. And about the physiotherapy as well. How, like just out of curiosity, how often are you sending patients to physio?  [Jaz]I would say 80% of my patients would benefit from physio.  [Emma]Okay.  [Jaz]Because it’s like a lot of times if I send a physio, then we may not even need to do an appliance. It just makes sense. And finding a good physio is really tough because there are physios who dabble in TMD and so they’re taking knowledge from other joints and applying it to physio, to the TMJ, which can help. But I encourage patients to try and seek out specifically TMJ specialist physiotherapists and ’cause in physio school, you don’t learn above the neck actually. So, you need to seek out physios who are specialized in TMJ. So it’s actually not just like seeing a physio, but specifically a specialist, really helps that. [Emma]Okay, that makes sense. Yeah.  [Jaz]Next one is medications. So, NSAIDs, ibuprofen, for example, if the patient could tolerate it, maxillofacial surgeons may recommend baclofen, which is like a muscle relaxant, something I don’t re-prescribe, but it can be used as well. So medications have their place. And the last part of conservative care is an appliance, in fact, a random, and there’s mixed evidence when it comes to appliance therapy. But the most recent randomized control trial, this was literally published, June, 2025. So this is like two weeks ago. So it’s in CRANIO, which is a highly respected journal, and its effects of occlusal splint therapy in addition to physical therapy on pain patients affected by muscular TMD. This was a randomized control. So diagnosis was extracapsular muscular TMD and the patients were allocated into the experimental group, which is basically education, physiotherapy, and splint. That’s the educational group, and the control group is education and physiotherapy. So you always have a control and then you have an intervention. So the intervention, the way we testing here is, does the addition of a splint actually help? And actually, this is not the first time this study has been done. I’ve seen previous studies done like this, and they found the splint made no difference. So again, evidence-based really varies, but this is a really recent one in a highly respected article, so let’s talk about it. The primary outcome was TMD pain intensity, and all outcomes were assessed at baseline, at the end of physio, and after six months at the end of physio as well. So there were 27 subjects, 7 males and 20 females. So 27 is not a huge amount, but in these randomized controlled trials in TMD, it’s difficult to recruit. And this is quite often in TMD lecture, you find that the N numbers are quite low. So let’s go to the conclusion. Findings from the present study demonstrated that pain NDI, which is Neck Disability Index and health related, quality of life improved in both groups. So that’s good. So we know that if you just do education physio, you’re gonna improve your muscular patient. But only in the experimental group, which was the splint group, these outcomes improved significantly further after six months. So like a few months, they’re both working, but at six months then actually there is a lot of merit in having an occlusal appliance. Thus, our results show that adding occlusal splint therapy to the physical therapy may produce higher positive effects in patients affected by myogenous TMD. So there we are. That’s hot off the press research. Happy that you asked me that because I’m able to talk about this, and hats off to authors. And then I’ll put that paper, link that paper in the show notes. So that’s why I think it has a place because if there’s bruxism happening, if there’s wear facets right, and they’re overloading their joints, then it sometimes makes sense to put something in between their teeth to prevent that load being transferred onto their joints. And they’re kind of like protecting the joints and protecting the muscles.  [Emma]For sure. And I know you mentioned there about splints and bite therapy. What do you offer, because I know there’s so many different types of splints and a lot of opinions on different types. So what do you use in practice?  [Jaz]I think in the interest of time, I think I’m gonna say if anyone’s really interested in this, it is a rabbit hole to go down, right? The evidence-based will say that there is no one splint that rules them all. I feel as though I’ve refined some protocols and I’ve got enough patient data now of my own that I do think certain splints are better suited to others, but this is not high quality evidence, obviously, but remember that when it comes to N equals one case studies. In the world of adhesive dentistry, you have all these like benchtop studies, in vitro studies. Something that one of my mentors, Lane Ochi taught me is that even if you just have one case report, N equals one, one case report. Okay? Involving a real patient that’s already better than any in vitro study ever done. Because that’s involves a real patient, right? So I think there’s a lot to be said about that. But if anyone’s interested, going down this rabbit hole, two resources I can link to this podcast. One is a flow chart I made, which pretty much summarizes my decision making in appliance therapy when it comes to permissive spints. These are splints that are not guiding the jaw anywhere and the jaw goes wherever it wants to go. Think of soft bite guards, think of Michigan splints, thinks of hard occlusal, flat splints, that kind of stuff. So I’ll link, I make sure, Emma, that we link that flow chart. And also we did, I did a couple of episodes, which is, Which is the Best Splint? There was actually a whole episode about that. So I think let’s direct our listeners to go down this rabbit hole. I think everyone needs to do their due diligence. But in a nutshell, if it’s a muscular patient, I find something like a B splint quite helpful, which essentially the back teeth are not able to touch. So if you try it on yourself, Emma, can you clench on your back teeth and put your fingers on your, like forehead region overhead? Just side ahead. Lovely. Bite together on your back teeth. And tell me what you feel on your hands.  [Emma]You could feel like your muscles portrayed in there.  [Jaz]Did you feel a bulge? Did you feel a bulge on both sides or just one side?  [Emma]Both sides.  [Jaz]So you have already a, more than likely a healthy masticatory system because a dysfunction patient is basically that bites so off that when they bite together one side bulges and the other one doesn’t. Or it bulges asynchronously. So one side bulges and then, then like a second later, the other one goes. Okay. So if they bulge at the same time, that’s good. And then feel your masseters. Can you go and feel by like the angle of your jaw a little bit lower down for me? A little bit lower down? Yeah, a little bit. Yeah. And now bite together and feel the bulge there. Do you feel that?  [Emma]Mm-hmm.  [Jaz]Okay, good. So a certain type of splint that when you are clenching together, you are not able to contract. It’s a bit like if you hold a pencil in between your front teeth and you try checking those muscle contractions again, you’ll feel a small fraction of that power. So I find splints like that are really good for the muscular groups, basically to just to give some sort of value to that. So after you’ve done all that conservative care, conservative non-invasive care, so conservative once again, TMD education, soft foods, ice and heat, gentle stretching, jaw exercises, physiotherapy, medications, and an appliance therapy specifically appliance that does not aim to change the bite. Then what you do is you evaluate. Okay. And then after the evaluation, and then you see, is the juice worth a squeeze? Are the risks of aggressive treatment worth it? And then the aggressive treatments, which we’re not gonna go to go into in this more basic episode, but is bite adjustment orthodontics, crown and bridge work and surgery. Okay. And then encompass within that as well is botox and stuff. Right? That’s a little bit more aggressive. It’s like the interface between conservative and aggressive. I would say botox somewhere in the middle which kind of paralyzes the muscles, but that’s kind of the mainstay of how we can, in the absence of high quality data manage TMD. Any questions on that?  [Emma]Yeah. So you show this to your patients, don’t you?  [Jaz]Yeah. I basically talk ’em through it. I talk ’em through it, because the problem with- I say the problem with TMD patients, I bless them, they’ve often been fobbed around and they are, like I said, they’re NUTS. They’re not understanding their symptoms and they’ve been down this dreary pathway or researching everything and they are really confused at what’s going on. And so they already have like preconceived ideas and unfortunately there’s so much marketing to these TMD patients and then messages like, Hey, you need ortho. Hey, you need this approach. Hey, you need a misalign to cure your TMD. And so bless ’em. They’re so confused. And so I say that, look, maybe that is the right way. I don’t know, but this is what I believe in because I tell ’em, I’m not a guru. I don’t know what’s gonna work. Can we at least try things that are conservative and then we can always escalate to more aggressive things. And that to me goes, that for me is a rational way to explain it. And my patients understand it. I think the way I explain that, they get it. They understand that I’m on their side. I don’t want to go straight to surgery unless it’s genuinely needed. I don’t want to go straight to botox unless we can do patient education and physio first before we escalate. And I think my patients have received that really well.  [Emma]And I think we learned similar in Glasgow. You know, start off with the basic things, the obvious things, and work your way up. But, even for me, I’m struggling with, or was more so when I was stressed during exam, struggling with grinding and a sore jaw and things like that. It’s calmed down a bit now, but even then it was just me as a dental student still just didn’t really know what to do about it. So there’s so, so many opinions in TMJ and TMJD, so it’s a hard one. But yeah, definitely that flow chart as well, that you were talking about, just lays it out nice and simple as well. [Jaz]Great. So we’ll make sure we reference all those. And I think one more nugget I can give to make it as valuable for everyone spending time listening to this, but like you mentioned, you are stressed, right? And so stress is something to do with it as well. You are probably clenching your teeth some more. So muscular overload. And then a really cool clinical tip I can give you is if the patient says their pain is worse in the mornings or the pain is worse in the evenings, that gives you a clue. So if the patient’s waking up in pain, then that could be the overwork, the dental gymnastics happening in the night. But if this pain, like they feel great in the morning, but by the end of the day their muscles are really burning, then that could be something that’s what we call awake bruxism. And the interesting thing about bruxism is that fascinatingly bruxism is not even linked to TMD. We haven’t even established those links, so let’s not even go down that rabbit hole just yet. But for some patients it can be a big deal. Because muscles get overloaded. But if someone is even thrusting their jaw forward, like holding their jaw forward without touching their teeth, yeah, that’s still bruxism. That’s still a pathological thing. So what we end up doing, especially as dentists, we’re like in this strange posture. And I speak to dentists all the time that jaw is in this funny position, and as dentists, we suffer a lot with TMD, muscular TMD ourselves. And so it’s about making sure that you are respecting your jaw posture, you’re keeping everything relaxed. You’re not keeping holding tension in your jaw because that could be a big part of your TMD story because even you transiently, you had TMD. Yeah, muscular TMD by the sounds of it. [Emma]Yeah. And it wasn’t until recently that I really noticed it. We were doing intraoral scanning at uni for like at the end of our exams. We go back for a few weeks. Dr. Maddison said to me, he was like, oh, hundred percent you grind your teeth in your sleep. And then, I have a partner now. We’ve only been together like a few months, and he was like, you grind your teeth and your sleep. I woke up one night and I was like, what the hell is she doing? And I was just like, chomping my teeth away. So that is not actually something that I was ever aware of either. But I notice it now, so I’m trying to stop.  [Jaz]Wow. Okay. So interesting. Let’s talk about that. Because when you tell patients, right, it’s like, well, we call it Grind Scene Investigation. Okay. GSI. Okay. Not crime scene, Grind Scene Investigation. Because when I was a newly qualified, I say to a patient, Hey, you grind your teeth, and you know what patients say? Like, no, I would know. I would know if I grind my teeth. Yeah. I would know. My partner would’ve told me. Kind of thing. But here’s the thing, right? I think it is like kind of like catching a solar eclipse. Seeing your partner grind, right? You have to wake up at that exact moment in time. It’s dark. Okay? You wake up that exact moment in time. You often don’t make any sounds when you’re grinding. And then how many minutes night are we actually grinding? It’s like 8 to 15 minutes for a severe bruxist. And so to catch that, the few seconds of burst of grinding activity. And that’s why the patient, like when you ask patients. If you grind your teeth self-reported, then the instance is low. But if you look at the wear sets, the instance is high. So actually go by the grind scene investigation. So you never say to a patient, you grind your teeth? You say this, you say patient, did you know that you had the signs of teeth grinding? So you as a dentist, we take control because either they don’t know that they had the signs of teeth grinding or they do know that they had the signs of teeth grinding. It’s not like a blame thing. It’s like, hey, you’ve got the signs of teeth grinding. Okay. This is the grinding scene investigation, therefore you have been right. So it may not be active, but I can see evidence of it kind of thing. So maybe we have to, to do an appliance for you, Emma, and we can talk about that. One thing we’re introducing to Protrusive is Pathways, right? Because I noticed we got so many hours of content on our podcast now, and I feel as though we want to invite everyone. Like if you wanna go down the TMD rabbit hole, we probably have like 12 to 15 hours you can consume just on TMD and have like a mini diploma in that, right? And be able to help your patients. So what we’re gonna do is, I’ll link below the playlist for all the splint and TMD type bruxism type episodes that you can go down the rabbit hole. But similarly, like everything around bridges, everything around onlays and crowns will have its own pathway. So we’ll release these Pathways. By the time this is published, this will be out there. And so I would encourage everyone to delve deeper and hopefully this is like a nice little, wet your feet and an introduction to TMD. We could go days and days talking about this, right? But it is one of those things that it’d be a nice to have this conversation, but I think it’d be a disservice if we try and just distill all of it, but now we can lead them to the Pathways which are available for free. Obviously if you wanna get CPD, then join one of our paid plans, help support Team Protrusive and what our mission, but. Any burning questions, Emma, based on our chat just now?  [Emma]None at the moment. I think that was good for me as well to maybe learn a bit more at the end there about my own possible problems with my TMJ and my pain that I’m having at the moment. But no, it was good. Good to be introduction, definitely.  [Jaz]Good, good, good. And maybe you can do a part two next year and build on this. What else, do we have any student notes? Like you, obviously you’ve been uploading your student notes in the Crush Your Exam Section of the app. [Emma]Yes. So I’ve made some student notes for TMJ, not so much TMJD, but more just about the TMJ cavity movement and-  [Jaz]Anatomy. Perfect. I was just gonna say that the top tip I’d give to everyone starting out is learn the anatomy. Like it’s so, so, so, so crucial. The muscle insertions and origins, what the disc looks like, because once you understand the anatomy, you can understand disease. [Emma]Yeah, for sure.  [Jaz]When mechanical disease is relevant to TMD and sometimes it is. So that’s a really key one. Also, in the future, if you’re doing bigger cases, reorganizing the bite. It’s important to have this knowledge to be able to assess a healthy joint, which will allow you to proceed to give that level of care.  [Emma]A hundred percent. Yeah. So a lot of anatomy and then just at the end, there’s a very small, like, basic understanding of TMJ dysfunction. Just a very small bit there.  [Jaz]Amazing. So if you guys wanna catch that, check out the Protrusive Guidance app, the website, protrusive.app. It’s free if you message Mari on the app, um, then she’ll be able to get you onto the secret student section, which gives you access to Protrusive Vault as well. But Emma, what have you got planned for the rest of the, I guess the version two, season two of Protrusive Students now that you’re a free woman.  [Emma]And so again, yeah, a free woman at the moment. Again, just going through, I actually have a list of potential topics. I know that we just did one on communication and we’ve got a lot of episodes on oral medicine, but maybe just some a student version, oral med, oral surgery, medical history. We’ve not done anything on endodontics yet, but just some basic understanding of those kinds of topics, so-  [Jaz]It sounds great. Okay., I’m excited. Let’s do it. So, whatever you decide, I mean, whatever serve the students the best, we will do it. And thanks for the wonderful notes that you make for us. And I’ll see you next time. Thank you so much.  [Emma]See you next time. Thank you.  Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Like I said, you can download the PDF of the TMD hierarchy on the Protrusive Guidance app. Just head over to protrusive.app on your browser, and then once you sign up, you can then actually download the Android or iOS app. But it’s really important to make your account first. For the students, you’ve got your own space, but for everyone, we’re a very inclusive community. As long as you’re a dental professional, we are here to support and grow together. We are the nicest and geekiest community of dentists in the world. That’s like our tagline. And if you listen all the way to the end, like you have done, and you are a real qualified dentist. I use the word real because recently in the news there was like this check dentist who was like fake and he was like YouTubing procedures, and he got away with it for a few years. That’s absolutely crazy. But anyway, if you are a real dentist and you wanna get CPD and CE credit, this episode is eligible. You can get over 350 hours of CE on the Protrusive Guidance app from clinical walkthrough videos to our bread and butter episodes. So do check it out and remember to share the love if you find that this podcast is helpful to you, your colleagues, your associate. Your mother-in-law, if she’s a dentist, might find it helpful as well. So please send it to everyone. And I thank you once again for sticking with us all the way to the end. I’ll catch you same time, same place next week. Bye for now.

Have you heard of Photobiomodulation (PBM)? Or are you thinking… ‘photo-what?!’ Is red light therapy just voodoo science—or is it already part of mainstream healthcare? Can PBM really help with wound healing, pain relief, and even reduce the risk of dementia? In this episode, Professor Praveen Arany joins Jaz Gulati to break down the science and clinical relevance of PBM in dentistry. They explore how this light-based therapy works, its applications in managing oral lesions, and why it’s already standard care for cancer patients undergoing chemotherapy. They also discuss real-world cases, practical protocols, and how PBM could shape the future of dental care. Whether you’re a skeptic or just curious, this episode will open your eyes to an emerging and evidence-based treatment modality. https://youtu.be/lQrawr3-YQA Watch PDP234 on YouTube Protrusive Dental Pearl: SHEEP Scoring as a practical tool to assess the prognosis and restorability of compromised teeth. 🐑 SHEEP stands for: S – Structure: Amount of remaining tooth structure H – History: Patient’s dental and medical history (e.g. caries risk, trauma) E – Endodontics: Endodontic prognosis (ease/difficulty of root canal treatment) E – Expertise: Your personal skill and experience with managing such cases P – Periodontal: Periodontal condition and bone support Each category is scored out of 10, and the total is doubled to give a percentage-based prognosis. This structured approach supports clinical decision-making, encourages honest reflection on the clinician’s own skills, and enhances patient communication during consent. The method is backed by literature, including a paper co-authored by Martin Kelleher. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Photobiomodulation can significantly improve patient comfort and healing. The treatment is standard for cancer patients undergoing chemotherapy. There are no known adverse effects of PBM when used correctly. PBM can be used effectively in various dental procedures. The future of PBM includes personalized treatment protocols. Research is ongoing to optimize PBM applications in dentistry. PBM is distinct from other laser treatments and has unique benefits. The technology is becoming more accessible to practitioners. Awareness of PBM’s benefits is growing in the wellness industry. 📚 ResourcesProf. Praveen Arany shares papers on: Light buckets and laser beams: mechanisms and applications of photobiomodulation (PBM) therapy Photobiomodulation therapy: Ushering in a new era in personalized supportive cancer care Photobiomodulation Therapy by Prof. Praveen R. Arany Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022 For full PDFs, you can check out Protrusive Guidance. 📖 You can find more of Prof. Praveen Arany’s scientific papers on Google Scholar 📢 Two Upcoming PBM Courses! ADA PBM Course – A dental-focused program by the American Dental Association.📧 Contact: Sherie Tynes – tyness@ada.org PBM in Supportive Cancer Care – Held at Gustav Roussy Hospital, Paris.📧 Contact: Dr. Camelia Billard – camelia.billard@gustaveroussy.fr If you liked this episode, check out Medication Related Osteonecrosis for GDPs – What You Need to Know (MRONJ) – PDP215 #PDPMainEpisodes #OralSurgeryandOralMedicine #BreadandButterDentistry #CareerDevelopment This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B & C. AGD Subject Code: 135 – Laser Therapy/Electrosurgery Aim To introduce dental professionals to the fundamental science, clinical applications, and emerging potential of Photobiomodulation (PBM) therapy in dentistry. Dentists will be able to – Define photobiomodulation (PBM) and explain how it differs from surgical laser applications. Describe three key mechanisms of PBM at the molecular level. Identify clinical situations where PBM can enhance patient outcomes (e.g., mucositis, ulcers, TMD). Click below for full episode transcript: Teaser: I did not think that you could use light in a therapeutic manner on people. We are not plants, we don't do photosynthesis. So how can you do light treatments on people? Teaser:People used to use a point and shoot approach. They just switch on the light pointed at the patient and hope that they get better. And hope is not a scientific strategy. So- In a 30-second soundbite, are you able to just describe the actual molecular mechanism or the physiology of how it actually gets the results it does? So our current understanding of photo biomodulation mechanisms is-  Jaz’s Introduction:Did you know there’s something called PBM, which stands for photo biomodulation and I know what most of you’re thinking. Photo what? Listen, I was as confused as you are and I thought, what is this mumbo-jumbo voodoo science? But then I found out that photo biomodulation or light therapy is already the standard of care when it comes to cancer patients undergoing chemotherapy. And then it reminded me of my physio who uses red light therapy for pain. And today’s guest, professor Praveen Arany, who does a wonderful job on educating us on this treatment modality explains about the mechanisms in wound healing. So, dear Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. I’m so excited to share this episode with you today for so many reasons. Number one, a lot of the guests I have on, we talk about restorative dentistry or occlusion, things that I really have an interest in and I know a fair amount about. But then this episode, I came in with nothing. I purposely didn’t do any research ’cause I wanted that magic and the aha moments to be alive. And I enjoyed this. I enjoyed learning about PBM very much, and I know you will too. Number two is our guest has no financial interest at all. He is a pure academic for the love of it, for the love of research. I even asked him to recommend specific PBM units ’cause trust me, by the end of this episode, you want to know. And he directed me to like guidelines. And scientific websites, which I absolutely love. So I think you really enjoy this, what I feel is really unbiased and it focused on an emerging technology, which I’m so excited to unpack today with you. So on Protrusive guidance, our community group. I asked a question a few weeks ago, do you know anything about or actively use photo biomodulation in practice? Okay. And 74% of us were like, what? What is that? We have no idea. 7%, just 7% use PBM. And only 18% have actually heard about PBM and its use in wound healing and in dentistry. And you know, interestingly, one of our members, Lindsay, she said there’s a lot of research being done on PBM at the moment, which you’ll see today. And then she wrote something fascinating, which is also something that was DMed to me on Instagram when I talked about this on the story, is how it can help you in pain. So for example, with Lindsay’s case, it cured her ruptured vertebral disc symptoms we’re using her laser, and she managed to avoid spinal surgery. And there’s also some great insight from our resident implant geek Doctor Pav Khaira, like research on PBM to reduce the risk of Alzheimer’s and Dementia. But why I can promise you in today’s episode is that we’re gonna make it very relevant for dentistry. You’ll learn about how PBM works and what indication should it be considered, and what are the protocols and what does the future hold. Dental Pearl:Now, before we unpack this topic, I’m gonna give you a Protrusive Dental Pearl. If you’re new to the podcast, welcome, it’s a good one to join. And every PDP episode I give you a tip, a pearl, a hack. Something you can use, you use straightaway. A lot of times’ clinical. Sometimes it’s mindset and nonclinical. Today’s is very clinical. So Dr. Jack, as he likes to be known on Instagram, DM me this pearl. He noticed that sometimes I mentioned on these episodes that, ah, I’m struggling to find a pearl for today. And so he rescued me. He said, listen, SHEEP, he said, SHEEP, remember the acronym SHEEP? When you want to find out the prognosis of a tooth, you can use SHEEP. And so let’s talk about this for a few minutes. From his DM, I was a little bit confused about its application. Then I saw Googled it and I found out that actually it’s a legit thing. And there’s an open access paper and the primary dental journal co-authored by the legend, that is Martin Kelleher, which reminds me I need to invite him to podcast, absolute hero, in UK Dentistry. He’s the guy who wrote the famous article like porcelain pornography and that kind of stuff. And he also famously wrote about the daughter test when we’re considering doing veneers, for example. Anyway, back on topic, SHEEP scoring, a practical tool. So I’ll make this paper available to everyone. But essentially a practical tool for evaluating the prognosis and restorability of compromised teeth. SHEEP stands for Structure, History, Endodontic, Expertise, and Periodontal. So the way it works is that you look at that tooth in question, let’s say, is a heavily restored lower molar, and we want to inform the prognosis of, let’s say, saving this tooth or keeping this tooth long term. You can now apply SHEEP. So S stands for Structure and for this particular scenario, because it’s heavily restored, let’s say we give the S a 3 out of 10. So for example, if it’s really low amount of structure, you give it a like a one. If it’s a really good amount of structure, like a virgin tooth, you give it a 10. So we give a heavily filled molar, for example, a three. The next one is H, which stands for History. So what the paper talks about is, is this the first time this problem has come, like a freak accident, or is it a recurring problem? So for example, if someone is a high caries risk, and like every six months they come with a high, they come with a new caries lesion, and now this tooth has been affected by caries, then you are gonna give it a low rating for history because this patient is a high caries risk patient and history is not on your side here. Also, the medical issues of this patient, like let’s say they have Xerostomia or something, would also count as history. If this is, let’s say a crack tooth and it’s a painful crack tooth, then that would score lower than an asymptomatic crack tooth. So that’s where you can score on the history. Then for E, you score the Endodontic prognosis. So is this tooth easy or difficult to treat endodontically? And actually what I like about this system is that it says how easy or difficult is it for you, the treating clinician? Because what I respect is that prognosis varies, right? Like the prognosis of an endo with me in my hands might be 80%, whereas with a specialist it might be 95%. So that’s interesting. I’m glad they touch on it on this paper. So let’s say, that same lower molar, it’s got really simple canals, nice big pulp chamber. You might give that an eight or a nine because the endodontic prognosis is pretty good. The next E is Expertise. And again, I really like this because it allows us to reflect honestly on your skill, like your individual skill. So when you are applying this E of Expertise, it’s like based on your skill, how much experience and expertise do you have to be able to do this? So for example, I’m going on a course soon to extrude, broken down premolars. I haven’t done many of these yet, so I would score my expertise on this very lowly. Maybe in a few years I’m gonna increase my score and therefore my expertise for this tricky implant case or tricky endo, or a tricky wear case will hopefully increase. And so your expertise directly informs the prognosis, right? So this is really, really cool. And the last one is P, which I’m sure you guessed it, is Periodontal. This is fairly easy because like the less bone support you have, the bigger the problem. If you’ve only lost a little bit of bone, let’s say you know, 10, 20%, then you might still give something a 7 out of 10 prognosis. But if you’ve got significant bone loss, then you might give that like a two or a three for the periodontal aspect of that prognosis. Okay, so what do you do with all those numbers? So let’s say there’s 1, 2, 3, 4, 5, 5 letters in sheep. Each one you score at 10, maximum score is 50. You double it. So if someone scores 10 in each letter, then 50 and you double it, it’s a hundred percent prognosis for this tooth. In our made up example, let’s say we get something like 31, you double that, you get 62%. It’s like a rule of thumb. It’s a nice way to give a number to it. Sometimes you go by our gut, but I like the idea that now we can go through this logical sequence and give it a percentage, which I think is useful in your consent procedure and also allows you to reflect on that case. So, Jack, thanks so much for bringing that to my attention, and I will make that paper available in the show notes. The best place to grab all these things is on the Protrusive Guidance app. Wherever you’re looking at this episode, scroll down. The PDF will be there, the link will be there. Team Protrusive, like to look after your geeky side, and we’ll make that available to you. Thanks again, Dr. Jack. Hey, enjoyed this episode on PBM. I’ll catch you in the outro. Main Episode:Professor Praveen Arany live in Barcelona. You are right now at the IADR. So, absolute privilege honor that you’re able to make time for this podcast whilst you’re on your travels, and spreading the good word about something that I tell you, I just don’t know anything about. And I refrained from doing a deep dive ’cause I wanted to just hear from you and be a very candid learner today. So Professor Praveen, tell us about yourself.  [Praveen]Thank you, Jaz. Thank you for having me. And I’ve heard a lot about this podcast and the popularity, so I hope we can get the word out on this really innovative treatment that has so much promise for healthcare, not just clinical dentistry. So I guess when I start talks like this or you know, introductions like this, I always point to the fact that I began in this field as a disbeliever. I did not think that you could use light in a therapeutic manner on people. We are not plants. We don’t do photosynthesis. So how can you do light treatments on people? Although you will notice, and I think all of us are aware that the ancient civilizations were aware of the therapeutic effects of light and specifically sunlight, but there was never a medical or a therapeutic manner in which they could do these treatments. So if you look at the absolute basic fact that the human body does not have a photo sensor, but we can see there is no camera in our eye, right? So the fact that the human body has evolved to have rhodopsin in your eye, that enables vision, it is not too much of a stretch to imagine that there are other non-visual ways that the body can use light. So if you start with that basic premise that there are certain biological molecules that can interpret light and use light. Then the extension to using light as a therapeutic agent doesn’t seem so farfetched. So I always like to start with this because I think it gives people some orientation and I remember when I was first introduced to it, I was very skeptical. I’m like, come on. How can people ever-  [Jaz]I have to say since we were introduced by email, I was also a little bit like, hey, wait a minute, is this legit? Is this like some woo woo stuff? But then, the source that connected us, he’s so credible. He’s so good. And I saw about your institutional role, professorship. So to tell us more about you as like your journey, your professor in New York?  [Praveen]In Buffalo, New York.  [Jaz]A little bit about you and how you fell into PBM, being a non-believer initially, and now presenting in Barcelona and talking about it so much. How’d that happen?  [Praveen]So, I think, like I said, the story began when I was looking at using light in a therapeutic manner in dentistry and in dentistry-  [Jaz]But is this something that was just like assigned to you as like a trainee and you were like, oh, have to do this, or was it like you chased it? Like how did you even fall into that?  [Praveen]Right. That itself is the fascinating story that I think began my journey in research. So you don’t hear of many dentists, especially, people who are focused on clinical to be thinking about research and molecules and molecular mechanisms. So it all began actually when I was doing my residency in oral pathology. I just finished dentistry. And all of us want to do something cool, right? We wanna distinguish ourselves. And so I was reading this book on pathology, and I think we all do in our dental training. But as a resident, I think you take even more interest right on what you’re reading about. And very interestingly, there was this book chapter on wound healing in pathology. So, most of us have trained on Shafer and Sook Bin-Woo, right? So when you look at the textbook of oral pathology, there is a whole chapter on wound healing. And intuitively you would think that wounds should be thought in physiology, not in pathology. So why is this chapter in wound healing? And I kept digging into that and I think, oh, that’s pretty cool that you have wound in our textbook of pathology. And interesting enough, if you put a piece of wound tissue under the microscope, it looks exactly like a tumor. It has the same number of disorganization, vascular inflammatory components that you see in a tumor that you would see in a wound. So I began my research career in a very naive manner. I was looking for a way to improve wound healing. Because people had made parallels between wounds and tumors, and the idea there was if you can control wound healing, then maybe someday we could control tumors at the molecular level. That’s how I started my journey, and I came across this fascinating paper by Endre Mester in the late sixties that had shown that using low par laser light, they could stimulate wound healing. And again, I told you about my disbelief and my skepticism about that. Interestingly enough, this work has been around for more than 60 years now. And when you think about what people have noticed in the clinic, you always talk about a clinical human phenotype, right? So people who have actually experienced something in the clinic is telling you something that is real. And that’s why I began my first clinical study looking at extraction wounds, tooth extraction wounds, and I was doing light treatments to see if I can replicate this phenotype, this phenomena that people had noticed. And surely enough, again, as a dentist, and as a beginner, I wanted to obviously be, look at the lucrative part of that, which is can we put implants faster? Can we do dentures faster? Can we rehabilitate faster? So that was, I’m gonna admit, was part of my motivation. But when I started looking at the molecular aspect of that, I was so fascinated that light could be used in such a therapeutic manner. [Jaz]You mentioned the sort of almost comparison, like we are not plants, right? We don’t photosynthesize, I’m just imagining like this study you’re doing and these patients, these poor patients are like staying open while there’s like a, some sort of a light beam on their socket and so how did it actually work and for how long did they have to have this light therapy to actually have clinical effect? [Praveen]So I think the best parallel is to think about how we do curing of composites, right? You remember how we, I mean I’m sure we do that actively even now. So you use a blue light, you shine it at the composite that you’re stuck into the prep and then you cure it. Think of it very similar to that. So it takes between three to seven, maybe less than 15 minutes to actually do that kind of treatment. And most of the treatments are less than five minutes. So in our study we did five minutes of infrared, 810 nanometer light that we were painting the socket with so that when you pull out the teeth, you have a complex, three-dimensional socket, right? So there’s a soft tissue, there’s heart tissue inside. So we were painting that for five minutes with light, with infrared light, and we were able to show that the healing was significantly improved in the socket that was treated. And we randomized it. So not always the lower jaw, not always the upper jaw. So we randomized that in our-  [Jaz]And you had a control group that had no light therapy or placebo light- [Praveen]That was the key part. So in that study, we used the patient as their own control. So these are full mouth rehabs that come from multiple extractions. So you assign one randomly to the control, which is non-treated, and the other one you treat. So one of the key parameters of wound healing, because all of us have different oral habits, nutritional demands, and parafunctional, oral functions. So, it is always appropriate to compare healing within the same person to get a true measure of whether a intervention is helpful. So we use-  [Jaz]So kind of like a split mouth?  [Praveen]Kind of like a split mouth. But this was upper lower jaws. Yes. So we found-  [Jaz]What I’m thinking of now is, what actually did you see that and also what benefit above normal wound healing did you get? So, for example, in the medicinal world, I read somewhere that if you take, if you have a cold and you take zinc supplements on average, you’ll like heal or get better one day sooner than if you didn’t. And so for them, some people are like, yeah, that’s great. It’s evidence-based. You’ll heal one day sooner. So is your socket less likely to get dry socket? Are you seeing that the wound maturation is like, two days ahead, three days ahead, any conclusions you’re able to draw in terms of what actually it tangibly does? [Praveen]That’s a great point, Jaz. So the most important part that we pay attention to is the patient comfort, right? Is there any way we can reduce the chances of infection? Can we reduce the number of swelling and pain that the patient has perceived? Now that’s a little subjective because everyone perceives pain very differently. What is a little more objective, unless you’re doing research, in the clinical scenario, what is very objective is how many pills are they popping, right? How many painkillers are they popping? And surely enough, if you take a drug history very carefully, you will find, and we found that there was less intake of analgesics. If you also look for swelling in the area as well as healing scores, you can look at healing in many different ways. And in the end, we ended up doing radiographs to look at the bone healing as well. We found that all these parameters were at least 30% to 60% improved. And again, that range is because all of us heal differently. But in every case that we did, we found that this improvement was consistently better when you did this light treatment compared to no light.  [Jaz]Amazing. And are there any, I mean, I know I’m jumping ahead now, but I’m actually getting very excited to hear about this. In terms of side effects and negative stuff, like for example, when we look at MRI versus CBCT, we think, okay, well MRI is great because there’s no radiation, but it’s like the fact that you are in a claustrophobic area, the cost of it is prohibitive. There are still downsides, but maybe not so many huge risks when it comes to MRI. What are we finding with this kind of therapy that purely, let’s start very small where we are now, I’m sure we’re gonna expand into different uses and indications, but purely to improve someone’s wound healing prior to implant therapy, for example. Are there any risks or has it been studied enough to see there’s any adverse effects?  [Praveen]So this is a great question to go to. The highlight of, I think this talk and this treatment, which is in cancer patients who are getting chemo and radiation, especially head and neck cancer, this treatment called photobiomodulation is standard of care. Which means every patient who’s getting chemo or radiation should be getting this treatment before they get chemoradiation and even transplant. So bone marrow transplants, right? So why should they get this? This is based on a systematic review and meta-analysis by three major scientific global organizations called the Multinational Association of Supportive Care in Cancer, the International Society of Oral Oncology and the World Association of PhotoBiomodulation. So these guys looked at 35 placebo controlled, multicenter, blinded clinical human clinical trials, and found that this treatment was very effective at reducing pain and incidents of oral mucositis, which is the condition that we all, unfortunately the patient get because of taking chemo and radiation-  [Jaz]Pain, ulceration, dryness, right? That kind of stuff.  [Praveen]So all of that incidences of the severity and the incidence period can be reduced by this treatment. In this study, what they also did was they looked at the tumor incidents that occurs. And remember, these are head and neck cancer patients. So if you do this treatment, do you at any, is there any possibility that you’re increasing recurrences or secondary tumors? In fact, they found that because you were doing this treatment, everyone was getting almost the complete dose of the prescribed onco treatment, radiation and chemo. That in itself enabled them to get better clinical outcomes, but none of them actually reported any increase in secondary tumors or recurrences. So in the human studies, we know that this is very clearly safe and effective. People have done more elegant animal studies where you put tumors into the animals and then give them different doses of light, and have also found that the tumor growth is actually reduced. Now, could this be attributed directly to the light or the effect of light on the host immune response remains to be fully investigated? But the bottom line is there are less tumor burdens in animals that were treated with light.  [Jaz]Like with radiation, there’s deterministic and stochastic effects. So for example, if you pump up the radiation, you know that you’re gonna get some local damage to cells, for example. Or there is like a stochastic, like random, they, it could cause mutations. Sounds like what you’re saying is that with this therapy, it didn’t seem to increase any cancer risk on these patients. But if you like pump up the time spent under this PBM or you pump up the sort of, I don’t know, the dose of light, I dunno what the correct term is. Do you get any like deterministic, local side effects, burns, that kind of stuff?  [Praveen]Right. So because this treatment can be done both with lasers and LEDs, this has become a key question whether we should only be promoting one versus the other. And unfortunately we don’t have an answer right now, whether we should be doing one or the other. We know that both are equally effective, but the lasers, as you can imagine, have a lower dose threshold. So they have a smaller therapeutic window before which they can get cause those thermal injuries that you were referring to. But the LEDs, it’s very subtle, so you don’t actually see burns, but you can neutralize your benefit if you increase the temperature too much. So, although both of them, if used in the right dose range, do not cause damage, the laser obviously has the potential to cause damage even when you’re using a defocused beam. So we have to be careful, but there is no evidence that there are off target or side effects of light. If you do end up dosing overdosing in your patients, especially if you’re thinking deep tissues like TMD or trigeminal neuralgia, these treatments have been shown to neutralize their benefits. So one of the biggest problems with this field of photo biomodulation has been the inconsistent clinical outcomes. And we believe and I think there is data to back this up now, that unfortunately the motivation of the clinician and the motivation of the patient is to get better sooner, right? So this is one case where too much dosing is actually detrimental and we have to be careful that we don’t overdose the patient.  [Jaz]Are you at a point now where you’ve figured out what that sweet spot is in terms of protocolization and so that it is information that can be disseminated to practitioners and primary care and they know which settings to use to get the best outcomes? Has it been studied enough or is this still like, we’re not sure exactly for how long or what intensity to use this technology?  [Praveen]So we do have a good handle on a specific application. So one of the problems with this treatment, I would say one of the benefits of this treatment, which is also a problem with this treatment, is there’s a very broad range of applications. So there are things like mucositis, TMD, trigeminal neuralgia, aphthous ulcers, lichen planus, pemphigus, and you would wonder, even in dentistry, and again, we are not talking about medicine because we have all these major chronic diseases like Alzheimer’s, Parkinson’s, multiple sclerosis, fibromyalgia, where this treatment has been shown to be effective. So even within dentistry, the fact that it has so many broad applications raises a very important clinical and biological question. How is this possible? How can one treatment be effective? It turns out the way-  [Jaz]And I guess the delivery also matters, right? The way you deliver the light in for TMD will differ to a different part of the anatomy. And then therefore, I guess working out what is the best for each disorder for that patient. And so that must be, ’cause it’s such a wide application, I’m already thinking, well how can you protocolize this and how can you then also tune it or make it bespoke for that individual? And I mean, I dunno, does the patient’s weight or their skin color vary and cause a change in how you would treat someone? [Praveen]So these are the intuitive factors that you would imagine as a photobiology with, with 101 basic knowledge of photobiology that we would want to optimize. So these are the concepts that are coming in now, unfortunately, I would say, like, three, four years ago, and previously, people used to use a point and shoot approach, they just switch on the light, point it at the patient and hope that they get better. And hope is not a scientific strategy, right? So that is one thing that I find as we show more and more of our molecular and non-linear physical phenomena work, you mentioned stochastic and deterministic reactions. So those kind of very precise dosimetry concepts are still, I think, in the research interface, but they’re coming rapidly to this treatment and that’s gonna significantly improve many of the clinical outcomes that are unfortunately still lacking.  [Jaz]Well, the questions I’m getting now, by the way, I’m really enjoying learning about this, but, lasers, right? So lasers are a topic that is actually we need to discuss on the podcast more. But what I get from speaking to people who are into laser. And also what I’m seeing from the people who sell lasers, right, is like, again, very similar to what you’re saying, very widespread application though you can use it for perio, you can use it in the root canal system. You can use it for these effects. And you can obviously use it in a different way to cut tissue or soft tissue. So it’s such a wide thing. So can you just like dumb it down for me in sense of, okay, you’ve mentioned PBM and you mentioned that laser is one way of delivering that. When we talk about lasers used in perio lasers used in root canal, how does that differ to what you are talking about in terms of PBM or is it the same thing? [Praveen]Excellent question. So I think, there are two major topics here. One is lasers in dentistry and lasers in clinical use, and the other one is photo biomodulation. So I think many of my, at least academic talks and my courses that I’d actually end up trying to bring this information to people have focused on differentiating them. So there is, if you think about light as a physical form of energy and you transfer that energy very quickly into biological tissue, it has nowhere to go, right? That light ends up evaporating or ablating tissue. This is how a surgical laser works. And this is exactly the property we use when we are trying to cut tissue, either heart tissue or soft tissue, and in some cases biofilms, right? So you can do disinfection with biofilms by simply abating them, evaporating them. Now, there are two other forms of light use, which is not well understood or well talked about. It is well understood, but it is not as much popularized in the media and I guess in our training. One is photodynamic therapy where you’re using a color dye and light to destroy its target, and that comes in two flavors. You can either destroy tumor cells or you can destroy microbial, polymicrobial films. So this is photodynamic therapy, which is disruptive in nature, you’re trying to destroy your target. In contrast to these two treatments, the surgical laser and photodynamic therapy, another form of light treatment is photo biomodulation. Now, how is photo biomodulation different? It is a non-surgical, non-thermal way of modulating the biological response. And this very nicely circles back to why is it working in so many diseases? When you use the right amount of light and the right, and you evoke the right molecular mechanism or the signaling pathway, you end up modulating pain and inflammation. You end up reducing pain and inflammation at the same time. With a different protocol and a different delivery system, you can stimulate wound healing, tissue regeneration, and a positive immune response. And that is why the term photobiomodulation is very appropriate. There are about 350 different terms, everything from low level light treatment to cold laser therapy to infrared or red light therapy, which is becoming a very popular term. [Jaz]So these are all the same things because I was gonna ask about red light therapy for TMD, and also low, is it low level laser? How do you say it?  [Praveen]Low level light therapy. Yeah.  [Jaz]So these are all the synonymous with the photo with PBM?  [Praveen]Photo biomodulation, PBM. So if you look up, you know how in academia how we organize stuff, is PubMed, right? So National Library of Medicine at the NIH indexes, the entire scientific literature. So photo biomodulation now is a catchall term that includes all the 350 odd terms that are present for this literature. So all of them, if you look at the science behind it and the mechanisms behind it, is photobiomodulation or PBM. [Jaz]Okay, that really helps actually in understanding. Is there like one machine which you can just twist the dials and then you go from it being a cutting laser to then you twist the dial and then it becomes in like low level light and PBM or is that yet to be invented?  [Praveen]That is actually one of the most popular questions we get Jaz. So when people, when I give these talks and lectures, they’re like, tell me one laser that I can buy and I can solve all my other problems. And I rightfully so, because these are expensive technologies. So you would like multi-functionality out of them. So when I get that question, I usually ask them a question. Name one bur or curette that you can do everything in your -. And the answer usually is, I cannot. Right? So you have to think about lasers like that. So every wavelength, every device has a very specific application. There are people who are trying to develop multiple units and there are people who are trying to adapt. Surgical lasers for PBM and they have had some success. But like everything else in life, you have a sharp pointy thing. You can do a lot of different things with it from, you can remove calculus, you can remove caries, you can reshape soft tissue or hard tissue. But would you be able to do everything effectively with one tool? And the answer is probably no. And similarly, I think laser technology has evolved like technology, I should say. And you may not need a laser in many of these things. It might be even more, I think one of the big questions in our field is, is it as effective to use an LED as it is to use a laser? And there are pros and cons to that, but I think that question is still very relevant as we are evolving with this technology. Right now, I can tell you both are very effective if you are in the right dose range.  [Jaz]Okay. That’s very helpful. Now my own personal experience is like once removed, the physio I work with for TMD patients, her name is Krina, she works in London, she’s brilliant. And she uses, I think she calls it The Velvet, I dunno if that’s a brand name, whatever. So it is low level light or it’s a red light therapy. And she says she’s getting good results with that. And so that was my first, like, me thinking about it. And then when I started emailing you and stuff, it was very interesting. It reminded me of that. And then someone in the US, Dr. Jamison Spencer, I did his course many years ago and then he was emailing me about it as well. So I was like, ah, I’ll remember this for when I speak to Prof Praveen. So what are the applications that you see dentists using it for? Yes, for myself, for example, if I was to get it, I would like to use it to help patients with their joints, but I also want my physios to have some role in that, for example. But should we be using it for wound healing prior to implants? Should we be using it after implant surgery to get better outcomes? Should we using it for, I don’t know, any other acute pain? So, it’s starting to sound like there are so many indications, but can you name, like, make it tangible, some real world indications that you think that general dentists should be considering, if at all? [Praveen]So if you’re talking about a laser, I think we have a list of applications. But if you’re talking about PBM specifically, photobiomodulation. I think your question is more directed towards that. Any clinical scenario where you are anticipating pain or inflammation or a lack of healing, that’s the definition of photobiomodulation. We find that we can use it very effect. Is it the only thing you’re gonna use? Absolutely not. So it would be an adjunct to your standard of care, but PBM has a very important role. Every time you anticipate pain or inflammation or a lack of healing. So the most common scenarios that we see, for example, are areas where you’re going to obviously anesthetize, right? So, which is pretty much every clinical procedure if you irradiate that site, I shouldn’t use the term irradiate, I should say treat that site with photo biomodulation.  [Jaz]Should you not say illuminate? Is that not the correct term?  [Praveen]Illuminate is a better word. I mean, we try to avoid irradiate because that normally brings in concept, thoughts of ionizing radiation and this is not ionizing. So that is the big misconception that we try not to promote. So we use the term illuminate or treat, which is a better term. Yeah, absolutely. So, I think if you can use your, if you use the PBM before you do anesthesia, that’s I think absolutely 101 in every clinical procedure, you’ll find that the patient is much more comfortable and will recover-  [Jaz]During anesthesia. So I’m thinking like a palatal injection, which is commonly, we think that that’s gonna be a painful one for our patients. Are you suggesting that by doing some PBM, the perception of pain from that palatal injection, which is just moments away is gonna be less? Has that been proven?  [Praveen]That is true.  [Jaz]Am I thinking correctly? [Praveen]That is absolutely true, and I think we have the strongest evidence with wisdom teeth, third molar extractions, where you do the light treatment for the biomodulation and then people find that you have to give them less anesthesia. They are more comfortable during the procedure. And then you come back after you finish the procedure, which is the extraction, and then you do the healing protocol. So one of the nuances I think, of what we understand now is that the pain control is a slightly different protocol than the healing protocol. So even though you might end up using the same device and maybe the same handpiece, you’re gonna do slightly different protocols for getting different biological responses. So in the first case, you wanna reduce pain. The second case, you wanna reduce inflammation and promote healing. So it’s gonna be slightly different. So that is pretty much, I think 80% of things we do, which is either anesthesia or some kind of a surgical procedure. And then of course there are these patients who come to you with aphthous ulcers, pemphigus lichen planus is very common, right? These are situations that unfortunately are very managed very empirically, right? And it’s effective. I mean, the reason we are still practicing dentistry is because our treatments are effective. But there is always that odd 5%, 10% cases that are not responsive. And if you go-  [Jaz]So anything surgical, it just makes a total sense. How about this scenario? I’ve just thought of like a patient who’s keeping their mouth open for, let’s say a root canal treatment or a crown, but they’re the kind who just is getting a lot of tension in their masseters, in their jaw joint. They’re feeling like they’re in a lot of pain, perhaps before the treatment, using that. And during, is that a protocol that you guys, that you’ve studied?  [Praveen]Absolutely. So there’s actually a whole term for that in physical therapy called DOMS. Right dos, which is basically the muscle fatigue that you get because of continued strain. And obviously you can imagine the masseter and the temporalis and all the other masticatory muscles are subjected to a given position. And when you do a procedure like, you know, keeping your mouth open for a filling, you are obviously putting them in a lot of stress and fatigue. So, if you do the treatment photo biomodulation before you start the procedure and even during the procedure, you will find that the patient is much more comfortable and you really feel the difference in the following day, 24 to 48 hours after the procedure, that’s when the real pain kicks in, right? So in the initial fatigue I think, they can manage because usually they’re anesthetized and they don’t, they’re paying more attention to the procedure, but the next day they start feeling the discomfort. And that’s what I think you will find if you start taking histories or even a lot of people now have apps where you can report things like this. A quick text saying, you know, are you comfortable? Do you need more treatments? If you wanna come in for another dose of PBM. And now there are so many of these PBM devices that are available to take home as well, the LED ones at least. So you can potentially, you know, have them take it home and take it home and treat themselves. So that’s also becoming a larger and larger possibility. [Jaz]Okay. And I’m just thinking of like the various, like if you do a really like deep crown and you had to remove some tissues and to use it then to help with their recovery. But let’s talk about ulcers, right, because I think that’s gonna help me help to make it tangible. If someone has an aphthous ulcer and it’s a very nasty one, and often they might come in and show you, or sometimes you notice it at that checkup, right? Do we have any data on how many days of difference it actually makes or any sort of perception of pain reduction or quality of life improvement surrounding the use of PBM on an absolute ulcer, which is not the worst thing in the world, right? It’s the first like, first world problem in a way, but it’s still unpleasant. It ruins your appetite. It can be very painful to eat certain foods and just annoys you, right? So how does it actually help?  [Praveen]Yeah, so that is one of the biggest practice builders, if you will, if you’re trying to bring this technology in, the ulcer is not going to disappear. You’re not actually zapping the ulcer out of existence. That’s not happening with PBM. Right? But when you do the treatment, your patient will tell you in the chair that they’re feeling better, right? So you can actually perceive the improvement within seconds. And this has been a major part of my lab’s interest in trying to understand how are you getting local anesthetic effects with light, which is non-ablative, non-surgical. These patients are comfortable in your chair, right? And there have been several studies looking at both perception of pain and what pain does, it heightens other perceptions. So hot, cold pressure, you know, hyperalgesia. So we can actually measure this very, very objectively with thin to thick filaments of metal, right? So we poke the patient just like we do, probing after anesthesia. You can actually probe this in a very scientific way and precisely measure how much pressure you’re doing to evoke a pain sensation. So people have done very, very careful measurement. What is still lacking, I think, is at the level of functional MRI kind of studies where we are looking at integration of central signals of pain perception. But the peripheral signals and peripheral perception of pain has been very well studied. And there are several ailments, including fibromyalgia, which just recently got the US FDA approval. So there is actually a device on the market now that is FDA approved for fibromyalgia, which is again, a generalized pain condition. You can imagine things like burning mouth syndrome, trigeminal neuralgia, and other fines of atypical pain, which are extremely painful. And unfortunately people resort to very severe surgical interventions. Could be at least avoided or prevented for, if you could get symptomatic relief. So I think it’s worth exploring. And unfortunately there is not like a precise device and a protocol that works. So you’ll have to look at the primary research literature to actually find that right device and the right protocol. But they do exist and there are some very, very good studies for each one of those applications.  [Jaz]With that ulcer patient. Again, just to make it really tangible, right? If that patient has an ulcer and they’re at the peak of it, during the laser delivery, sorry, during the illumination delivery in the practice, let’s say five minutes, wherever it might be for the protocol for that ulcer, they’re gonna be feeling better then and there. Do we know if that ulcer is gonna end up healing actually faster or the percentage improvement in quality of life? Or do we not have that data yet?  [Praveen]It does resolve faster. So if you have a painful ulcer and you do nothing to it, it usually takes 48 to 72 after ulcer. So 48 to 7-  [Jaz]But major ulcers are real and my mother-in-law gets em right and they’re really nasty. And they can be there for a while. I can really think of a good application for major would be something like this, right?  [Praveen]So not only is the immediate pain relief evident, but the resolution of that inflammatory response is also quite well documented. So you will see, the problem with these things is it keeps coming back. So you wonder if the treatment is actually not just laser treatment or photo biomodulation, but any treatment will it work. So I keep emphasizing when we talk about photo biomodulation that you cannot substitute standard of care. You do need a good diagnosis and the right prescription of the standard of care where PBM can either be used as the main treatment or as an adjunct. It is not magic. I think that why, I think a lot of people you will talk to try to palm it off. As you know, it’s magical light and it does cool things. It does cool things, but there is a rationale for that. So it’s not going to omit your good practices, and we give this great example. I’m sure you’ve heard this literature on lasers in perio, right. You know, that lasers have been used in perio for a long time. It’s rather controversial because people thought they could do everything with the laser. Everything from scaling root planing curettage, to disinfection, to healing. Yeah. [Jaz]I feel like those who are laser converts, they’re a bit like vegans. If they have a laser, you’ll know. Right? And so sometimes I feel like, and no offense to anyone who uses a laser, ’cause people swear by it and they love it. But I just feel as though, like, is it really that good? It might be, and maybe I’m missing out here, maybe I’ll eat my hat. But and soon to be discovered, but yeah, you tell me more about that.  [Praveen]So, lasers in dentistry is a rapidly evolving field, and the great news is, although it has existed from the LA you, the 1980s, it has been formally recognized by the ADA in 2023. So there is clearly a lot of good scientific literature supporting the use of a laser compared to all of our mechanical and rotary tools. So there is clearly a lot of more understanding and information about the superiority of a laser device for any procedure compared to a blade or a scalpel, which arguably is way, way more cheaper. So why would you buy a fancier tool to do the same job? But the laser does do a lot more. So this is a whole separate discussion on what are the advantages of the surgical laser. But there is nothing like PBM, so there is no tool, maybe the closest you would think of is trans electrical neural stimulation tends right where they use microcurrents to stimulate the analgesics response. Or there is a little bit, I think, overlaps with ultrasounds, when you’re trying to do photo acoustic signals. But there is a non-invasive way of doing something in the clinic that there is no other alternative to. And photo biomodulation is very, very uniquely placed in that. In fact, we think not very far away, given all the advances in optical diagnostics, that every dental chair will actually have a laser or a light device on your chair, right? It’ll be one of the things that you pull out and you can do either a light curing is an absolute easy thing to think of, right? But it can also do other things like diagnostics, maybe potentially PBM and maybe some of the PDT stuff.  [Jaz]I can just imagine like, those intra oral scanners that we use, they could probably just bolt one onto there. Maybe, it’s a good size head, isn’t it? Like maybe they should have a separate head or combine. It just makes sense that, that I think that kind of access could exist in the future.  [Praveen]The form factor Jaz that you’re pointing out is turning out to be the biggest barrier, right? For entry into a clinical market. We are all trained as clinicians. We are very comfortable with certain technologies. It’s very difficult to move a field if you bring in something which is very different, right? So, you will see that even most of the surgical lasers have handpieces, which look exactly like our surgical handpiece. You look at any of the major manufacturers, they look exactly like a manual. Okay, you don’t have the tactile feel. That’s definitely a limitation, if you will, from laser surgery, but like every other skill that we have learned, this is something that you get better at practice, right? One of the funniest thing I should mention here, Jaz, is that we hear this thought about, why bother with a laser? I can pull out a blade or a curate and you know, do this in 10 seconds. Why do I need to set up my laser and do all of this? Lasers are very slow, right? The laser procedure is very slow. Whether you’re doing a class two prep or anything, class one mini prep, class five preps, there is nothing faster than light in the entire universe. So how can you tell me that the light tool is actually slow? That doesn’t make any sense. So it’s basically your technique, and I think that’s one of the things we keep pointing out. Yes, there is some setup time, but there are so many advantages of this technology that you would not get with a mechanical plate. And I think this is coming to the forefront. I just came back from another meeting, you can imagine this is really catching on and there’s a lot of interest in different societies and professional organizations. And I just came back from the American Academy of Oral Medicine and the American Academy of Pain for very different workshops. One, obviously for the pain. We were just discussing how is this thing working? Is it, how is it doing? And I just effect how is it reducing Inflammation has become a big key because once we understand how it works, we can obviously develop protocols that are consistent and reproducible. So that is the motivation there. Well, the thing-  [Jaz]Well, just in terms of circling back to how it works though, like I just feel like you mentioned at the very beginning, the wound healing in a 30-second soundbite, are you able to just describe the actual molecular mechanism or the physiology of how it actually gets the results it does?  [Praveen]So our current understanding of photo biomodulation mechanisms is threefold. We have identified three separate molecular pathways that light can induce, just like you need to induce rhodopsin, right? You need to change the cyst to trance. If you remember our 101 physiology classes, it has to change its confirmation. Nightmares. I’m sure, but nonetheless, we made it through, right? So, there has to be a change in the biological system, whether it’s shape confirmation or it’s biochemical change, right? It has to be modified. So when you think about photobiomodulation, there are three well understood mechanisms. The first one, which is usually the most talked about, is the mitochondria, right? You have cytochrome C oxidase, which is present, which is an enzyme in the mitochondria that’s responsible for electron transport. And when light is absorbed by this molecule, it transiently increases the electron transport function, which makes the cell more resilient and more fit. It improves the fitness of the cell. You can imagine better mitochondria. Sounds great, right? You would want a better mitochondria no matter what. So you can, so this is one of the most talked about mechanism. It makes a lot of intuitive sense. You’re putting light energy, you’re improving energy in the cell, energy metabolism in the cell. And that for the longest time that used to be the most cited mechanism, it still is Tiina Karu and Harry Whelan actually showed this mechanism very elegantly in biochemical models. The second mechanism, as we were talking about earlier, is the pain relief. And that’s almost instant, right? So when you do light treatment, you instantly see the improvement in your patient. So this cannot be long term, transcription translation changes in the signaling. It has to be something as simple as what we get with local anesthesia. So there is something disrupting the neutral conduction instantly. And lo and behold, there are light sensitive receptors and transporters. So if you shine light at the right intensity of the right color and the right wavelength, right? So you can actually disrupt transiently and reversibly just like local anesthesia, neural conduction. And there has been a lot of very elegant work on different receptors and transporters. Some of the famous names are Opsin and TRPV1. These are molecular targets. So we have a fitness or resilient mechanism, which is the mitochondria. And then you have the pain mechanism, which is a transporter or a receptor. The third mechanism is the one that I described to you in the beginning, which is the wound healing mechanism. Turns out that there is a growth factor that is present outside the cell. And this growth factor is called TGF-β1. And that growth factor has very specific amino acids that are light sensitive. So when you shine light of the right wave angle and the right intensity, this amino acid actually senses light. And it changes its shape, just like rhodopsin and causes biological signaling. So activation of this growth factor, TGF-β1, has been shown to be a pro healing and it can actually recruit local endogenous stem cells to do tissue regeneration. So yeah, more than 30 seconds, but hopefully I give you a load up. [Jaz]No, no, it helps. And automatically I’m thinking of something really far fetched. Okay. Something really crazy. You know how people, some people, they will like sit in a chamber that is highly oxygenated, right? And so then in the chamber and so they’re getting more oxygen. They feel like, okay, I’m performing, gonna perform better. I’m having better oxygenation in my body. Do you think, I dunno if this applies. Is there like a red light chamber they can sit inside at very low level to just gain the health benefits to your total body for no reason, just for preventive medicine? Is that something that exists?  [Praveen]A preventive medicine and longitude. So I think the question now is no longer improving lifespan, which I think a lot of people are trying to do, but let’s improve health span. Where you are more functional at least at similar level, if not better. There is so much interest now and not just improving the length of life, but the quality of life really. Unfortunately, the reality is in the last decade of your life, you are not as functional as you are in the rest of your life. So can we use light along with exercise, nutrition? As well as the right structure. Human beings are social beings, right? So we can’t discount the others, but it is being very rapidly recognized that light in its many forms can be another supplement, if you will. It can be another part of this health and wellness protocol. And-  [Jaz]Dammit, I thought I invented something there.  [Praveen]The chambers is something that I think a lot of saunas have been modified to do. Very interestingly, there are beds that are available, like beds, just like the tanning beds and- [Jaz]That’s exactly what I had in mind actually. But there we are. It’s already been done.  [Praveen]Absolutely. So the beds are becoming extremely popular, both the athletes, right. A few microseconds of improvement of their performance is millions of dollars and lots of trophies and wins for them. And you pretty much name any peak athlete right now in any sport, whether it’s swimming, whether it’s cycling, whether it’s football, soccer, all of these guys are using it as a part of their regimen. So you will be shocked that, how many of them-  [Jaz]I had no idea. So this has been very educational for me. Not only just dentistry, but it’s in general. If you were to get your crystal ball out, Prof, you get your crystal ball out, right? Where do you see- I mean, it sounds like there’s enough evidence based now you are very enthusiastic about it. I’m liking what I’m hearing, but where do you see the entry point applications? Where do you see it overcoming the barriers that exist and at what stage you think is gonna take five years, 10 years? What’s your guess? Prediction.  [Praveen]I think where it’s going to immediately make an impact is wellness and longevity and better health spans. So the cosmetic and aesthetic and wellness applications are already on autopilot right now. So if you have not already, and we point to the fact that almost every smartphone that we have, smartphone or a digital device now has a blue light filter, right? It is a different part of the research and biology where we talk about circadian rhythm, but the awareness that light has a role in your physiology is very well understood. So we think PBM will become something very standard in regular wellness. Even when you fly, commercial airlines, you can see that they don’t switch on the light anymore. They actually cycle through red, blue, green, and then switch on the white light. Right? This is just coming from awareness that you don’t want your cranky customers in your home after a long flight, you want to actually cycle them and then the mood gets better. So, simple things like that, which we may not think of as PBM, have already established light as a critical role in our physiology. So I think the more awareness come everything from the desk, digital screens we are looking at to our digital displays, to the light that is eliminating in our rooms, they will all adapt this technology much, much they are, I think I should tell you, they’re already adapting these technologies. No lights are no longer just eliminating a space. You can actually have additional wavelengths that come on at a very particular amount of time for a particular duration, to improve your moods and elevate your performance both neurocognitive and skeletal muscular. So there are some, and Jaz, we can talk about this all day, but, there are these assisted living homes where they install these special PBM lights and they found less depression, less falls skill, falling over, which is the number one reason why these people pass away. Unfortunately, once you have a severe fall, unfortunately it’s downhill from there. So just switching the lights for 15 to 30 minutes of treatment every day has significant health benefits. So I think the wellness and of course you Google, I don’t know, Amazon, Alibaba, you’ll find a thousand different light marks that are available right now. And if you have children, like I have a teenage daughter, she loves a light mask, so she’ll do all her facial creams, but she loves the light mask as well. So, and there is a lot of cosmetic and aesthetic use that is already very prevalent. I think there’ll be increased awareness that will occur. In terms of the clinical adoption, which I think we are more thinking about. There are very well done studies, systematic review, meta-analysis, clinical practice guidelines, but they are restricted to specific applications. So, although we know that there’s a lot more that can be done, TMD, trigeminal neuralgia, BMS, all of these ailments, pemphigus, lichen planus, things that we have difficulty managing in our patients. Those studies are unfortunately not yet fully done, but mucositis is where we have the most evidence. And you need one thing, right, to get the field moving. So we think mucositis is going to be a big break.  [Jaz]But, like you said, the cancer world and mucositis sounds like there’s a big tick there, but I think what you’re saying is that the research is on the way to then have clear protocols and guidelines for ulcers management or wound healing after extractions or prior to wisdom tooth surgery, but that’s the next phase of research, you think? [Praveen]Yeah, I think those are primary areas for future research and optimization of these protocols. So when we started speaking, we talked about differences in skin color, time of the day, whether you’re a male or a female. All of us respond differently, so the fact that even in medicine now, we largely acknowledge that we can’t do, everyone is not a cookie cutter kind of treatment. We have to personalize and optimize. This particular treatment is very amenable to that, right? We don’t have to do too many things to change the intensity, change the treatment time. So I think this might actually to in many ways begin our precision, medicine, precision photo medicine, if you will, that would allow us to optimize and personalize for optimal outcomes. [Jaz]The Protruserati that listens to this podcast are all over the world. They’re a very geeky bunch, prof. Right? Would you be willing or happy to share some papers that they can just read in their own time? ‘Cause I think when something new like this comes along and naturally everyone’s skeptical, but then, you’ve presented it really well. But I think everyone always needs to do their due diligence to learn about things. I think it’s a wonderful thing to be able to read and assess literature. Are you happy to send some papers over that I can put on for a while?  [Praveen]More than happy. It would be a pleasure. So people, I think, don’t realize that in academia, the reason we publish papers is that people read them, right? So it is something that a lot of people don’t realize that, that that’s the whole point of doing research, right? You may not be able to convert it into a treatment. We all play to our strengths, right? We are dependent on the clinicians and the companies, the stakeholders, to actually convert that into a device or a product or a protocol. So I’m more than happy to share it. And I think the latest paper that forms the foundation for the ADA approval of photobiomodulation as a discreet kind of treatment. That paper probably is the most updated. And for those of you, like you said, are interested in the molecular mechanisms, I’m happy to send two or three papers across. [Jaz]That’d be great.  [Praveen]The more view of the field  [Jaz]Amazing. I can put that on the app for everyone to download. That’d be great. There people will be screaming and typing and say, okay, like, should I just wait and watch as I’m a general? Let’s say you’re a general dentist. You do everything from children to root canals to surgery. Is it the time to maybe dip your feet in, like everyone’s talking about 3D printing, should I buy a 3D printer now or should I wait a bit? Do you think dentists, are there any obvious products in dentistry that they should be looking at or they should be holding off? What’s your thought on that? [Praveen]No, I think, the fact that the FDA has cleared many devices, not approved, but cleared many devices should speak to the safety and value of adding a PBM device to your practice, right? So if you already have a surgical diode laser, you might just have to invest in a handpiece that makes that surgical device into a PBM device. But if you’re really interested and you’re new to the field and you’re seeing a lot of these patients, you will be amazed at how many devices are available right now that are more-  [Jaz]Do you have any financial interest in any of them?  [Praveen]None. I don’t endorse any of them. And I think that-  [Jaz]And that’s why I appreciate you very much. So, someone might listen to you today and think that, hey, this guy has got a big stake in, in PBM . But I love that. Yeah, you wish, right? But like, look, that’s why I appreciate you so much, as a professor who’s just, your enthusiasm and dedication to this topic, it just shines through. Are there any brands that you like that, that you think, that have been working well that perhaps a general dentist somewhere should consider as an introduction into PBM?  [Praveen]So I think, our yardstick for that has been who’s involved and supporting the field, right? There are many, many devices on the market. You go on Alibaba, Amazon, you’ll find like a hundred thousand devices. But the people who come to our scientific meetings and are contributing to promoting the field, those are devices and people that we know make good, good protocols and good devices. So my recommendation actually would be to go to the World Association of Photo Biomodulation website, or the North American, all the academy of Laser Dentistry or World Federation of Laser Dentistry, these scientific organizations are supported by several companies that it’s almost like a self-reinforcing prophecy, right? These are people who we trust to come to our meetings and bring good devices. So those are the units that I would say you should look into. And there are several manufacturers who are very well established and have a good following and are very responsive. If you’re new to the field, after you buy the device, the first thing you wanna do is get the training right. And that becomes unfortunately many people don’t pull that. They try it themselves and sometimes they don’t get good results and they give up on that. So that is something that we feel, if you’re active about seeking the training, you will benefit a lot more. And these organizations actually are, they don’t endorse any of the manufacturers, but the fact that they are supporting them and they’re being supported by these organizations is a fantastic place to start. And again, I can call out the names of different manufacturers, but that is not, I think the, I mean, I’m sure your readers can very quickly look at that.  [Jaz]Well, we’re gonna put the papers on, as you said, and then we’ll put the websites that you mentioned.  [Praveen]That would be awesome.  [Jaz]That clearly state those manufacturers. And I think it’s a very elegant way to convey that message. And so I’m very grateful for that. Prof, I’ve really enjoyed our time together. We’re coming to the end of the hour mark. Thank you so much for all the research you’re doing, for everything that you are sharing out there and this conversation that we had to really make things tangible for me. I’m glad I didn’t do any research beforehand ’cause it meant some of the questions I was asking was very much candid and fresh. And so thanks for playing so well with that and engaging so nicely there. Is there anything else that you, I mean, do you have any channels that you want people to support your research or reach out to you or anything like that? [Praveen]No. So, I think you will face the book papers, right? So the papers I think has major resource. I think that’s our best advertisement, if you will. And that’s the best kind of advertisement because it gives us a platform to show people where we are and what we are doing. The contact information is on that paper, so you can definitely get in touch it. We are easy to find on Google as well. The one thing I would say Jaz is, you mentioned this in the podcast today, that people need to differentiate between laser applications and photobiomodulation. And unfortunately because lasers have been around for the longest time, so has PBM. People get confused with, can I buy, the question we were talking about, can I buy one device that does everything? Unfortunately, I think the answer is no. And when you learn what else it can do. I think that that gives you a better platform. So, PDT unfortunately is not well understood, even though it’s been around for the longest time. It won the 1903 Nobel Prize in medicine and we don’t know much about this treatment, right? So, if there is interest from your audience and your forum, I would love to come back and talk about surgical laser applications and why it is different than the mechanical ablations. And PDT can be a whole, I may not be the best expert for that. I can recommend some of my colleagues. I think this is the kind of granular information, if you will, for someone who’s bit being bitten by the bug of curiosity in this space.  [Jaz]Oh, I think you’d be a most welcome guest again, but I do like engagement when it comes to this. So those who are watching on YouTube or Protrusive Guidance, I want you to comment below. If you’d like to see Prof Praveen again to talk about surgical laser applications, which I would personally love, but I want you to love it as well. Please comment below and then we can do that. I’ll, of course make the papers available. And yeah, thank you so much. Enjoy the rest of your trip time in Barcelona, presenting for the IADR, yeah, onwards and upwards, sir. Keep up the good work.  [Praveen]Thank you, Jaz. Thank you for having me. I really enjoy it.  Jaz’s Outro:Thank you so much. Well, there we have it guys. Thanks so much for listening all the way to the end. Look, you’ve done the hard work. Why not get some CPD or CE credits? Protrusive listeners who listen to a new episode every week, they easily get 40 CPD or CE credits every year just from listening to the podcast while they’re on the treadmill or on their commute. You can just satisfy all your targets. And now we’ve got like core topics like oral cancer, medical emergencies, that kind of stuff as well. Not only do you get the certificate, but you get to answer the quiz and validate your learning and reflect ’cause it’s important to be a reflective practitioner. Of course. If this sounds good to you, but you all have time for is the podcast, then you should join our podcast CE plan. If however you want access to the podcast, CE Plus all our masterclasses, then you want the ultimate education plan that’s got Sectioning School, VertiPrep for Plonkers, RBB Masterclass. And now recently Splint Course Online. And how could I forget? The Premium Clinical Videos, step-by-step walkthroughs, you name it. So the best place to check it out is protrusive app. Select your plan and hey, we have a free plan. All you need is to join your tribe, join your community. There’s so much value to be gained. We do have a manual application procedure, is important to us that only dental professionals join our network is how we keep it a safe space. So check out protrusive.app. I want to thank again, Professor Praveen Arany, who will definitely be inviting him back. But please comment below if you’d like that as well. And don’t forget to hit that subscribe button. It might sound like a small thing, but it actually really helps us a lot to get the right reach and help more dentists. I wanna thank Team Protrusive for the wonderful work they do in the production side. And thanks to you once again, Protruserati for choosing us for your dental education. I’ll catch you same time, same place next week. Bye for now.

Should you be re-treating that root canal—or referring it out? What are the red flags that scream “specialist only”? How do you confidently remove GP without compromising disinfection? Dr. Ayman Al-Sibassi joins Jaz in this endo-packed episode to help you navigate the tricky world of root canal re-treatments. From solvent selection and GP removal techniques to assessing case difficulty, they break down everything a GDP needs to know to make smart, confident decisions. You’ll learn how to spot the cases you should be tackling, which ones to send to your endodontist, and what tools and techniques will make the re-treatment process smoother and safer. Because not all re-treatments are created equal—and some are surprisingly simple once you know what to look for. https://www.youtube.com/watch?v=apMtcuNTLqI Watch PDP233 on YouTube Protrusive Dental Pearl: A crack in a bonded ceramic restoration isn’t necessarily a failure! Just like we accept cracks in natural enamel, we can also accept cracks in ceramics—as long as it’s been properly bonded. Shoutout to Dr. Pascal Magne for this powerful mindset shift! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Specialist training in endodontics includes a variety of surgical skills. The complexity of root canal retreatments varies significantly. General dentists can perform some retreatments, but should assess complexity carefully. Patient consent is essential, especially regarding potential unrestorability. Communication about fees should be clear and upfront with patients. Red flags for retreatment include poor coronal seal and previous treatment quality. CBCT imaging is becoming increasingly important in endodontic practice. Collaboration between general dentists and specialists enhances patient outcomes. Many referrals stem from straightforward cases that are poorly managed. Using solvents can aid in GP removal but should be approached cautiously. Single visit treatments are often preferred for patient convenience. Adequate disinfection is crucial, sometimes necessitating a second visit. The survival rate of root canal-treated teeth is comparable to implants. Patient age and overall health should guide treatment decisions. Understanding the difference between success and survival in endodontics is essential. Highlights of this episode: 00:00 Introduction 05:02 — Protrusive Dental Pearl: Cracks in enamel vs. dentine  06:34 — Guest Introduction: Dr. Ayman Al-Sibassi and his journey into Endo  11:03 Assessing the complexity of re-treatments and when to refer 15:21 The role of CBCT in diagnosis and treatment planning 17:47 Ethical and financial dilemmas: charging for unrestorable teeth 22:05 Red flags in root canal re-treatments 34:55 Techniques for GP removal and file selection 47:07 Cost vs. predictability: re-treatment vs. implants and long-term outcomes Take a look at this Endodontic Complexity Assessment Tool to help you evaluate how challenging a root canal case really is. If you enjoyed this episode, you’ll definitely want to check out: Stop Being Slow at Root Canals! Efficient RCTs with Dr. Omar Ikram – PDP163 This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B and C. AGD Subject Code: 070 ENDODONTICS (Non-surgical treatment)  #PDPMainEpisodes #EndoRestorative Aim: To provide clinicians with a structured approach to diagnosing, planning, and executing simple Re-Root Canal Treatments (Re-RCTs), while recognizing case limitations and improving treatment outcomes. Dentists will be able to: Identify clinical situations where Re-RCT is appropriate and distinguish them from cases requiring referral or alternative treatment. Describe the potential challenges such as canal blockages, separated instruments, or apical complications, and know when to refer. Communicate effectively with patients regarding prognosis, risks, and treatment expectations, including the need for possible referral. Click below for full episode transcript: Teaser: So if it's higher up on the attached gingiva, I'm thinking more about a root fracture. If it's lower down in the buccal sulcus, then it's more likely to be coming from the apex. And that is a, I'm not saying it's less, probably less likely to be a fracture, whereas if it's really high up, you're thinking maybe a furcation, sorry. Teaser: Fractures somewhere in the root essentially. If we come back to what I said about why most these more straightforward cases, why they fail a lot of the time. As I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be- so the reason I say that is ’cause they’re handfull, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well.  Jaz’s Introduction:I used to think that root canal re-treatments were only for specialists and that GDPs should not touch them. Well. How wrong was I? When I entered my training post in Sheffield, it was a a dental core trainee post. Now the rest of the world is kind like a residency. It was like one year attachment with the restorative department, and this was in a dental hostel. I remember seeing a case, it was a central incisor and it already had a root filling, so it was up to me to do the root canal re-treatment. Now, I was scared. I was, oh my God, I’ve never done a re-treatment before. I’ve never had to remove gp. And also I was learning how to use the scope of the first time. So for me, I was nervous. I was thinking, this is very much specialist treatment. Will I be able to carry it out? Now, when the case actually came in front of me and I saw the radiograph, it literally was like a GP cone floating in this big wide canal. Just that one sultry master cone. Plenty of air and fluid if you like around it. No wonder it failed and I accessed the tooth. I literally, with my tweezers, could see so clearly that GP cone, I picked it out and I carried out the root canal treatment and that was the easiest root canal re-treatment ever. And it just made me realize that had this limiting belief that not all re-treatments are the same. So I guess the point of this episode and what we’ll learn with my guest Dr. Ayman Al-Sibassi, is how to know which re-treatments GDPs should totally get involved with and how to know where perhaps this is one to refer to our specialist colleagues. You’ll find out the best ways to remove the gutta percha. Is it gutta percha or is it gutta Perker? Honestly, endo is not my thing so much anymore, so I don’t even know how to say it anymore, but you know what I mean. The GP. Which is the best instrument, which is the best solvent? And interestingly, how much solvent should he actually be using? Like should you be flooding your canal with solvent or should you be just using tiny drops on your instrument? And related to what I just said earlier, I want you to understand more about risk and predictability of re-treatments. What are the red flags that you should not pass go? We cover all this and so much more in this episode. Now, if you’re new to the podcast, welcome. My name is Jaz Gulati, and therefore you are called affectionately the Protruserati. We are the community of the nicest and geekiest dentist in the world. So if you wanna join that community, head over to www.protrusive.app. The idea is that we don’t want anyone to feel isolated, that they can’t ask for advice. If anyone’s feeling nervous or unsure about certain treatments, well check the whole backlog of all the episodes we’ve done. But also having peers, like-minded Protruserati to support you is exactly what you’ve created on our app. Now those of you who are returning viewers and listeners, please do hit that subscribe button. Dental PearlAnd as you know, every PDP episode, I give you a Protrusive Dental Pearl. Now by the time episodes come out to publish, it’s actually probably been a few months sometimes what I’m kind of doing now is like early spring now, and I’m kind of getting ahead so that I can enjoy my summer with my family. But you guys all get an episode once a week. That is the dream. And one thing that you guys ask me all the time is Jaz, how do you do it? How do you stay motivated with your podcast? How do you get it done? How do you balance family, children, clinical dentistry, and of course watching cricket, which I love doing. How do I make it all happen? Well, I’ll tell you something guys. Something just from the heart. I have a big team now and they help me so much. It is a real team effort to get every episode out. Every episode that has CPD or CE especially, has probably been through about four different people and about three of those are dentists before it actually reaches publication. That’s so that we can actually quality control the CPD questions, the learning outcomes, and produce the best done for you notes ever. Like our premium notes are just such a brilliant summary. The key takeaways are summarized so nicely in our PDFs and to actually make that happen takes a lot of effort. Now because I have a team on board that rely on an income from Protrusive, it is so motivating to make sure I don’t let my team down. So I guess I’m trying to say. Thank you so much guys. Thank you so much for supporting the podcast. I’m feeling in a very grateful mood today ’cause yesterday I was at Dr. Pascal Magne lecture live in London, and I met so many of you that came up to me and said thank you. Like literally I was just amazed. Like I was, I was almost getting very emotional. You guys were coming and saying, hey Jaz, I just really wanna say this. I wanna get this outta my chest. And you said to me, Jaz, I just wanna say thank you.  Thank you for all you do and honestly, I’m passing this straight to my team. I really appreciate your kindness and all these years you’ve been listening and our channel’s been growing, thanks to you and for you recommending your colleagues. So if you still know people who haven’t heard a protrusive, please do send them episodes like this. The Protrusive Dental Pearl today is taken from Dr. Pascal Magne’s lecture yesterday, right? It’s very fresh in my head. Sometimes I get anxious about, oh, which pearl will I share today? Like the first few episodes, it was easy had loads of pearls I could pull out. You know, 300 episodes in now is difficult to actually think of a protrusive pearl to give you. So it was a really cool one yesterday from Pascal Magne. He says that when we see a crack in enamel, how do you feel? What do you think? Do you think that this tooth needs to be extracted? Hell no. Okay. Cracks in enamel are not a big deal compared to cracks in dentine. Cracks in dentine are serious stuff. Cracks in enamel are common. A crack is how the stress has dissipated. So the real pearl here actually is when you see a crack in your ceramic, don’t think that it’s failed. Don’t think that you are a failure. Don’t think that ceramic needs to be changed just because of a crack. And that was really eyeopening because sometimes when you place a ceramic and you see it a few years later and you start to see a crack inside, you think, oh goodness, this has failed. But actually, we shouldn’t think that if we accept it in enamel, why can’t we accept it in ceramic providing, providing that’s been bonded properly. A bonded ceramic is a completely different beast to a cemented ceramic. So in bonded ceramics, a crack is not the be all and end all. And please don’t interpret that as a failure is our tip for today. So turban tip to Dr. Pascal Magne for sharing that in his lecture yesterday. Anyway, let’s dive deep into root canal re-treatments for GDPs and I’d catch you in the outro.  Main Episode:Ayman Al-Sibassi. Welcome to the Protrusive Dental Podcast. Can’t wait to geek out endo stuff with you. But tell us the story, right? You just literally told me, that you have a baby. Congrats at 10 months old. But he or she, sorry?  [Ayman]It’s a he. It’s a boy.  [Jaz]Okay. Boy. Name?  [Ayman]His name’s Suleiman.  [Jaz]Okay, so Suleiman was born a day before your specialist exam, is that right? For Endo?  [Ayman]Yeah. Yeah, basically, yeah.  [Jaz]What was going through your mind and like how did you cope? Did it affect your exam in anyway? [Ayman]Yeah, well I think it was probably made it up to be more than it was. Only because, you know, the day before the exam you’re kind of like, you’re not getting any more information in, at that point anyway. You’re kind of just like bugging out at that point. You’re kind of stuffed with information. So in reality I couldn’t take any more information in. It was more just the panic of how am I gonna do this? Is my wife gonna be okay? I was thinking a little bit more about my wife, my son, not about like revising more, but just is, are they okay? That kind of thing. Basically it’s just, I had good support, to be honest. I had like a lot of good support. Like my parents, my mother-in-law and like my supervisors were, was super helpful as well. One of my supervisors even came and like dropped a bag of stuff at the hospital to help out and stuff.  [Jaz]Wow. Wow. That is a real special story. Where did you do your specialist training? [Ayman]University of Liverpool.  [Jaz]That is really cool man. I love that your supervisor was supportive like that. That is, you know, we need more of that in dentistry.  [Ayman]Dr. Marwad(?) Yeah.  [Jaz]Okay. Okay. Well I’m glad you name dropped. Buddy, look, I’d love to know a little bit more about you. Firstly, my listeners are gonna love like those listening on Spotify treadmill. You have this lovely years deepest voice, which is just the podcast listeners are gonna absolutely love this, by the way. So that’s a great plus. They’re gonna get through the end of this one, which is great. Tell me about yourself, mate. How did you get into Endo and, and the usual stuff.  [Ayman]So essentially, fourth year of uni when we kind of started do an undergrad, this is under undergrad, I mean undergrad sort of endo. We started like around third, fourth year, and I did a couple of endos and I just thought, yeah, that’s me. That’s what I’m gonna do. So I kind of knew since towards the last couple of years of undergrad that that’s what I wanted to do, and I always kept telling my colleagues. This is what I’m gonna do. So kind of when I left, I focused on that a little bit during my FD year. Did a little bit of it, well I didn’t really do any of it ’cause I went into DCT over a year after that. Did a year in Maxfax and then came out two years in general practice and then straight into specialist training. So I probably did in total a little about three years in general practice, one year of Maxfax. And then, yeah, went in specialist training three years full time, basically up in Liverpool. But yeah, I just liked it. I felt like it was a bit of a dark art. I liked all the gadgets. I like the instant results that you see as well, and I thought it was just quite niche. Not many people like it, and that kind of drew me into it as well. [Jaz]No, we need more endodontist on the register, there’s not many, I mean, the last I checked years ago, maybe nine years ago, if you know this number, it was something like 264, 9 years ago. I remember that number of, especially endodontist registered in the UK.  [Ayman]Funnily enough, part of my sort of doctoral thesis at Liverpool, which is part of the research we have to do there, attached to our specialist training. I had to actually look into how many there are. So there’s still around, I think around 300. But the thing is a lot of them will be like restorative consultants who don’t necessarily do endo mono specs. There’s probably a lot less than that.  [Jaz]Yeah. Okay. No, that’s a good point. And just about your training, I think it’ll be very useful for our colleagues who are in earlier stages of their career decision making. You knew you wanted to endo right? And you did. Almost like a distraction year when, if you think about it, it was a distraction year when you did MaxFax, ’cause it kind of, you, one might think it took you away from your goal, but maybe you needed it to actually reach the endo hand on heart. When you look back at it, do you think, ah man, I regret doing that year. I wish I did private practice, or I wish I did more endo. Or do you think back saying, you know what, you’re so glad ’cause it made you a more rounded clinician. What’s your take on that?  [Ayman]I don’t regret doing it. No, definitely not. Number one, because I felt like the year itself was quite full on, so I felt like it made me a little bit more resilient in terms of like doing things, working, just working hard basically. So that was one. And then the second thing is we did a fair bit of oral surgery on that rotation, so it kind of gave me some more surgical skills, which nowadays and endo are becoming a lot more important ’cause endodontists nowadays. Historically it might have been maybe more, a little bit more about the endo with like apisectomy and stuff like that being done by oral surgery. But it’s becoming a lot more within the remit of Endo to do things like, you know, apisectomies, auto transplantations, intentional replantations, root resections, and then even like resorption repairs, perforation repairs, stuff like that is all kind of coming within the remit endo now. So I think for that, it’s quite useful. [Jaz]Yeah, that’s good. It’s probably a stepping stone. I can see those surgical skills being useful later on. Thanks for talking about your journey, Ayman. I really wanna get into the topic of today, which is re-treatments, root canal re-treatments. I remember when I was working under my consultant as a DCT, when I used to type it, when I used to like write in the notes re RCT, he was like, no, you must write root canal re-treatment. ‘Cause what is a re-rct? Like, it was one of those pedantic things. But anyway, I remember I mentioned my DCT because I remember I had this limiting belief, Ayman. Yeah. I had this limiting belief ’cause I was a GDP. I was a DCT. If anything, right. And I was like, I can’t do a re RCT, I can’t do re-treatment ’cause I’m not a specialist, therefore I cannot do re-treatment was my limiting belief that I had. And so I remember doing this one case, it was a re-treatment, right? And it was like single central incisor and it was like, the thinnest, skinniest GP point, right? In this widest canal, like probably every time the patient walks, the GP point’s probably moving side to side in the tube. You can just imagine it, right? And so when I accessed that and I literally got my tweezers and I pulled out the GP. And I treated it and the sinus tract went away. I was like, holy moly, I just did a root canal retreatment. And then you realize, okay, hang on a minute. That was just a limiting belief that actually they’re not all the same. So my first question to you on that remit is what do you think about the scope of re-RCT for GDPs versus should it be referred to specialists?  [Ayman]Well, I definitely think they’re on a spectrum. So some of them, as you said, like will be a lot more straightforward, like the one you described versus some others, which can get complex depending on what you know, what they are. So you’d always have to kind of do a complexity assessment. So there’s different tools available.  The one I’ve used and the one I’m most familiar with is one called ECAT. It was developed by a couple of colleagues at Liverpool. It’s essentially an online tool that you can click through and it just basically gives you all the factors which will give you how complex it is. So things that I would look at just in terms of what would make it a very simple case, I’m usually thinking about patients medically fit and well. No sort of complex medical conditions.  Things like sort of bisphosphonates, not very anxious, mouth openings quite good. That would be the sort of patient factors I’d be looking for. And then tooth related factors to make it simple. Usually you’re looking at like an anterior tooth, usually a one to three. Premolars can get a little bit tricky sometimes. Not always, but the anatomy, I find that my clinical practice always get kind of fooled sometimes by how complex premolars can be. But yeah. So one to three is usually, as you said, GP points kind of floating around. Those would be kind of simple cases in my mind.  [Jaz]And then what about when you see one and you see that it’s been like there’s no voids and it looks like it was a decent job. And I look at it and I’m like, hmm, I know the radiograph. The problem is the radiograph doesn’t tell you if rubber dam was used. The radiograph doesn’t tell you if hypochlorite was used. So much information you miss when you look at radiograph, but sometimes you see. And it looks fairly good quality in a radiograph. At that point, I’m very happy to refer because I’m like, okay, well there’s something else going on here in addition, and I just think, our specialist friends need to eat as well, so this is the kind of stuff they should be eating. I’m just gonna do the cherry picking as a GDP should do. But of course, some GDPs, they love endo and they kind of like have a special interest. They do extra courses and then they, they know if it genuinely gives you excitement and a challenge, then do it. But for most GDPs it’s like, okay, that’s a point where I see a well. Filled canal. There’s no voids. It might be a little bit more challenging to remove the gp, which we’ll get into. Is that a, a fair way to think about it for a GDP?  [Ayman]Sorry, can you repeat that last question again? I did just cut up there for a sec.  [Jaz]Is that a fair way to assess a tooth as well? When you look at the, how well it’s filled on the radiograph.  [Ayman]Yeah. So that would be one of the things that I would say would make it more complex is out of one of many factors. So if it’s already like, like there’s certain quality standards that we look at for endo. So the main things would be, is it filled to within two millimeters of the radiographic apex and is there root filling walk condensed? And then also like coronally you’re looking to, so is there any obvious corona leakage there or anything like that? So if there’s nothing obvious you can identify on the x-ray, that could be the reason why it’s failed and you can’t see, for example, any cracks in clinically that you’re picking up as well. Then yeah, I mean those cases tend to be a little bit more complex. There might be like missed anatomy inside that you can’t see. Again, you don’t know what happened previously, and there could be a lot of leakage. So a lot of the times, if the root canals are old, there’s studies that show that a lot of the restorations, or almost all of them have some coronal leakage to a certain degree around them as well. And that can cause sometimes failure. I mean, in those kind of cases, I would always kind of be thinking about CBCT because there’s no obvious cause of what is causing it to fail that you can see. So that would usually some give you some more information. I mean, that’s what I’m thinking.  [Jaz]That’s fine. So, Ayman, how common is CBCT becoming in your practices as endodontist now either at the consultation appointment, or, are you really happy when a GDP sends a referral with a CBCT and gives you just more information? Is that becoming more common in practice now?  [Ayman]Yeah. Yeah, it’s definitely becoming a lot more common in practice, and especially as with CBCT, the machines are going in the direction of the doses becoming, or the radiation doses becoming reduced over time. So as that happens, I think it will become a lot more used. To be honest, the doses at the moment, they are not. I mean when you look at them in relation to like what you do in Maxfax, for example, remember we used to take full mouth, full face CBCTs of everything, for example, when the patient came in. So dose is actually like way, way lower than that. So yeah, and those doses are only gonna come down with time. So as that happens, it will become more common. In terms of when a GDP-  [Jaz]Can you gimme some examples of like, you saw the CBCT and it completely changed your treatment plan, it completely change your perception. How often does that happen?  [Ayman]Well, I can think of a case that happened actually a couple of weeks ago. So it was lower molar, it was re-RCT case. A patient came in and the root canal filling just looked like void. The big PA lesion, void the root filling. So anyway, I just, I started the root canal filling, re root canal treatment just based off of the PA. I didn’t really suspect anything, and I opened the tooth up. I was getting quite early apex locator readings much earlier than I expected. So then I took a CBCT of the tooth, and I found that actually the mesial roots, that sort of danger zone, that distal concave aspect of the mesial root was kind of completely resorbed away. So the gps were half sticking out into the fication area, which wasn’t obvious on the pa. So that means that the-  [Jaz]So this was a resorption and not like a strip perforation. How can you tell? [Ayman]Well, yes, it was difficult to know, and my suspicion is it probably was resorption because there was a massive lesion associated with it into that vocation area. So sometimes you can get something called external inflammatory resorption, which kind of eats away at that area of the tooth as well. But it may well have been a strip perforation. I’m not entirely sure just looking at that. Yeah, I mean that made in my mind the tooth on restorable. There wasn’t really much that I could do about it, so I had to tell the patient, you know. I can’t really do anything with it. Whereas previously I was about to go and reroute, can I treat it? [Jaz]I’m gonna get into removing GP and that kind of stuff. But now that you’ve mentioned this point of a very niche scenario, one of the questions we had from the community, I asked last night, I said to everyone, hey, I’m recording tomorrow about re-RCT. And so one question was, is it tricky question? Ayman, not in terms of like tricky endodontically, is tricky more in terms of ethical dilemma and charging of patients. Let’s talk about this before we go into the details of re RCT further. You have this scenario, just like you described, right, invested time in treatment. You’re now time committed. You do the CBCT, and now the tooth is unrestorable, okay? Does the patient then leave and they haven’t paid any money to you, right? Because now they’ve just been told that they can’t do it. Is there a fee that was agreed in terms of the consent and the consultation that you do? Is that okay if it can’t be saved? You’re gonna be charged this much and you’ll have that information because imagine as a GDP, you trying to, like the example Julia gave, Julia Tully, example she gave is that she opens up a molar and she can see the three main canals, upper molar, and then she just about sees the MB2, but she gets stuck at that stage. She can’t get into and navigate MB2 properly. And now she’s like an ethical dilemma. She feels though, well, okay, to get the best result. I need to refer you to the endodontist, but I’ve just spent an hour and 15 minutes accessing, removing caries, and then now, and that was all part of the endo, and now I have to refer, is it fair that I’m now charging my patient for my initial fee? So there’s no right or wrong answer, but I’d just love to know your take on that.  [Ayman]So two things. So from my perspective, I always would consent in a patient that the tooth is might be unrestorable. It’s almost like for almost every single case, unless it’s like, you know, no belly restoration is minimal or anything like that. But even then I’ll say, look, there might be a deep crack in there that we find or something like that. So I’ll always consent the patient for it being unrestorable and I’ll quote them a fee for an investigation fee if we don’t go on to completing the full root canal treatment. So, that’s, for example, that’s how I manage the case that I just mentioned. So I still charge them the investigation fee charged for the CBCT as well. Obviously, I didn’t charge for the full root canal treatment. In terms of if they can’t, for example, they can’t find their MB2, a lot of the times the patient for the GDPs, the patient, a lot of the time will come in in pain. So you’re still getting the patient out of pain, for example. And I would still, for example, charge maybe half a root canal fee because you still have done something with a patient. You’ve got them out pain, for example. You don’t necessarily always need to find MB two to get the patient outta pain. And I would assume that also it’s part of your consent process sometimes to say. Sometimes we can’t find canals, we might need to refer you. So if you need to do that, I would again, just consent the patient for potentially taking maybe half the fee or a third of the fee, because it’s still your time. At the end of the day, you’re still helping the patient out.  [Jaz]I agree with you so much, and I feel as though what we don’t wanna do is I feel bullied or curse that, oh, because I missed one canal or I can’t find it. Like you’re still doing the right thing. You’re thinking okay. I think someone else can navigate the deal, but you know, you would’ve got ’em out of pain. You would’ve done the hard work of caries removal, access removal. Sometimes you do a pre-endo buildup, you do all that. That stuff is valuable, but I think you just nailed it. You know, as long as you have this standard spiel in these situations, if we can do the root canal and everything goes well, this is defeat like you tell your patients your fees before you do the treatment. But sometimes things are really, really tricky. If they’re really, really tricky, I need to refer you. Don’t worry Mrs. Smith, you won’t have to pay the full amount. You have to pay a third of X or a half of X. And at least that way we’ve done some of the work and then the endodontist who may charge this much will do the rest. And now you’ve just been like super clear. And if you had that patient who doesn’t consent to that, then that’s the whole point of the consent conversation. Don’t think that if I tell the patient this, they won’t go ahead. Well, that’s actually the point of consent, right? And so you wanna have a patient who’s on board and who’s very reasonable and understanding of that, right?  [Ayman]Yeah, a hundred percent. Yeah. I would say like for example, you made a good point as well in terms of the caries. So a lot of the time root canal treated teeth, the majority of them are quite knackered to start with anyway. So you’ll almost always do like a restorable assessment as part of your root canal treatment. You’ll be stripping out amalgams, old amalgams, old composite caries, and that obviously, it’s still valuable.  Me as an endodontist, if you refer a patient to me and it’s already had the pre endo buildup, I’m like, thanking God at that point in time ’cause that actually saves a lot of time. So you’ve obviously done that service for the patient, it’s something that you’ve done, you’ve helped the patient out and you’ve saved me having to do it as well. So yeah, I would definitely still charge for that.  [Jaz]I think a really good way to do it ’cause this is obviously a real world issue. And then so there are some colleagues who would do the following. They would charge a fee for the restorability assessment and pre endo buildup. And that would come as a one fee. And then the second fee would be the root canal. And then at that point it was like, oh, you know what? I’m not charging you with the root canal ’cause I didn’t do it, but I did all this stuff. And it makes sometimes sense for the patient’s head. And so that might be a model that some practice may wish to use as not the main thing is that the conversation is had beforehand, so totally.  I’m glad we’re on the same page there. Just going back a bit before we talk about removing gp. Any like red flags that GDPs when they look at root filled teeth and they’re thinking, hmm, should I do a re RCT? Like, the one I mentioned was like, if you see that it looks like a reasonably good root filling, that is kind of like a little bit of a red flag that, hmm, should I be doing this? Another one would be like, if you see a separated file in there, then obviously. That’s one for you guys, not for us unless you are that way inclined. But I’m just giving like an easy guide to GDPs. If you see, I mean sinus tract for me is just a sign of infection. I know that can reduce the prognosis of your re-rct. Would that come as a red flag for you?  [Ayman]Just a sinus tract by itself?  [Jaz]Mm-hmm.  [Ayman]No. ‘Cause as you said, it’s just basically an external sign of the infection. Sinus tract by itself doesn’t mean too much. Although what I would say is depending on the position of the sinus track, that can sometimes indicate a fracture in the root. [Jaz]Tell us more. Where are you worried about?  [Ayman]So if it’s higher up on the attached gingiva, I’m thinking more about a root fracture. If it’s lower down in the buccal sulcus, then it’s more likely to be coming from the apex. And that is a, I’m not saying it’s less, probably less likely to be a fracture. Whereas if it’s really high up, you’re thinking maybe a furcation, sorry, fracture somewhere in the root essentially. Not always.  [Jaz]That makes sense.  [Ayman]It’s not like, it’s not fracture-  [Jaz]It’s the rule of thumb.  [Ayman]Yeah, I’m just a little bit more suspicious at that point, basically. And I think there is some research, I can’t remember the name of the paper, but there is actually some research on the position of the sinus tracts and how related they are to the presence of a crack. So yeah, which also confirms higher up on the buccal attached gingiva. More likely to be a fracture.  [Jaz]That’s a good one. And then obviously if there’s a post in the tooth, which actually one of the questions was, we’ll come to later, any tips on post removal, but I wanna save that for later. There’s a post, right? And unless you’re really into that kind of stuff as a restorative dentist and you get a kick outta that stuff, then I’d probably say that’s the one to refer. I’m sure you don’t get a kick out removing posts.  [Ayman]Is a question do I get a kick outta removing both?  [Jaz]Yeah, yeah. That’s the one where you’re cursing your referring dentist and not saying thank God.  [Ayman]Yeah, exactly. Yeah. I mean they can take a long, some of them come out in like two minutes and those ones are fine and you can kind of tell which ones those are gonna be ’cause they’ve got loads of space. But some of them they can take up to like an hour, like the long ones, well adapted really fat posts. But in those cases, a lot of the times you’d be thinking about a vasectomy and those teeth a lot of the time as well because yeah, I mean you might take the post out at the end of it and see that the tooth is actually unrestorable. Because it’s already been prepped to death to actually get the post in there in the first place.  [Jaz]And we’ll talk about some tips to remove posts, but any other last few red flags before we move on to GP removal?  [Ayman]There’s a few. So, kind of, yeah, if anyone is interested to see like this in a bit more detail, again, that ECAT tool goes through every single factor that you could kind of consider. So if you have application-  [Jaz]I’ll link it. I’ll link it.  [Ayman]Yeah, I think that that would be useful for anyone listening. So yeah, that it basically goes through every single possible factor. So just made a note of a few. And again, like I always kind of divide it into patient mouth, tooth related factors. So patient related factors, again, so for example, bisphosphonates, because there’s always a small risk that when you’re doing patency filling, for example. Potentially not always, but not a high risk, but that you could stimulate some kind of MRONJ reaction. Something like that. That’s one. Again, if they’re really, really anxious, you don’t wanna be sort of faffing about with taking a long time for root canal treatment as well. Limited mouth opening as one as well. That’s one we get quite commonly in referral practice too. So tooth related factors, I would look from the crown down. So number one, if there’s really, really deep restorative buildups required, so if you’re looking at like the margins on almost on bone, that’s one ’cause you wanna make sure you’ve got a good coronal seal. So that’s one that I’d be looking at. Any crowns or posts that you’re looking at there, especially if the crown or the post is in a different angulation to the tooth on the x-ray cracks is quite a big one, especially becoming more common nowadays as well. Cracks specifically as also associated with periodontal pockets. ‘Cause often with isolated periodontal pockets, ’cause often that means that the crack is extending down the root surface. Now those teeth, to restore them effectively, you often need a microscope because you’ll be bonding, composite down the canal orifice. And to do that without microscope is quite complex. So if you see an isolated periodontal pocket associated with a crack, a lot of the times, that would be quite a complex case to manage previous RCTs. As you mentioned, if the RCT looks good on the periapical radiograph, well condensed within two millimeters of the apex. That would be, you’re thinking why has this failed? So that might be something more complex. And also it’s well condensed. The GP is gonna be a lot more tricky to actually remove as well. It’s not gonna be straightforward. Fracture files you mentioned as well. And then more niche things I’d be thinking about are things like developmental anomalies. Sometimes you get like to taurodont, palato-gingival grooves as well. Which can sort of mask as endo problems. Well, C-shaped canals as well. Those are sort of things, fast breaks as well. That’s quite a, quite a common one that you see. So it’s kind of difficult to explain without an x-ray, but usually you see it, for example, on premolars, it comes back to our premolar while I was mentioning about premolars. So you see the canal, the canal, canal canals there, get to the apical third and then it just disappears. And then often that means that you’ve got some sort of deep apical split. So that would be quite a big red flag as well ’cause obviously you need a microscope to actually see all the way down there and actually help you to navigate around that apical complexity. Resorption, resorption cases as well. So depending on what the resorption, especially like cervical resorption, which is probably becoming more common nowadays. So resorption cases, ’cause a lot of the times they will need like surgical repair to actually access and fix history of trauma on anterior teeth. Sometimes they’ll have trauma to multiple teeth, which needs quite complex management. A lot of the times as well on the PA radiographs, you won’t see root fractures. They don’t necessarily turn up and that might need a CBCT to actually reveal that perio status as well. So perio endo lesions as well, which is actually, yeah, the topic of, that’s what I spent three years sort of researching at the University of Liverpool. Perio endo is quite a big one because a lot of the times the endo might be straightforward, for example, but to manage it appropriately, you’ll need a lot of the times regenerative surgery, which will become more complex in those cases as well.  So you might see, for example, an anterior tooth re-root canal in our treatment might be quite straightforward, but then to actually get the bone to regrow and the mobility to stop and the pockets to come down, you’re actually gonna need like bone grafting, membrane, stuff like that. So perio endo, especially like there’s a new classification. It’s by the, I think it’s the European Society or European Federation of Periodontology. [Jaz]Perio people, they love a classification. Like they’ll love bus one every six months, like they are the kings of classification.  [Ayman]So there’s a perio-endo lesion one. So they’ve divided it into grade one. There’s grade one, two, or three, basically. Grade one is if there’s an isolated pocket associated with the tooth. Grade two is one pocket on one surface, but not isolated. So it’s a wide base. And then grade three is wide or pocketing on more than one surface. So grade two and three, often those cases will require regenerative surgery, bone grafting, or enamel matrix derivatives to actually help them along. So those would be quite complex cases to manage too. I mean, I’ve been through quite a lot. Yeah. Sorry. [Jaz]You have, I mean, over, over the last two minutes you shared so many red flags there and so the general dentist listening to this like, wait, wait a minute. Like, are there gonna be enough cases left for me? So my question then for you is, how many re cts do you do and think, you know what, the GP could have done this. [Ayman]A lot. Yeah. So the good news is a lot of the cases that I do that are RCTs then these things have, are the red flags that I mentioned. They are there, but re-RCTs fail for common things. What’s that phrase? Common things happen for common reasons, so, the most common thing that I see with root canal treatments failing is poor coronal seal and poor apical seal.  So the GPS floating about, or this caries or some kind of leakage coronary, and those are the most common things that I see in terms of why that those kind of referrals come through. Probably, or maybe not common, probably about 50% of them are like that. Yeah. I mean there is a lot of cases like that. So while there are a lot of complex things, there’s also a lot of simple things that are easily managed. [Jaz]I think-  [Ayman]Easily. Probably sounds-  [Jaz]Easier.  [Ayman]So easier. Yeah, that’s the idea. Easier, yeah.  [Jaz]I think, Ayman, people might be thinking that, hey, why is the endodontist telling a dentist that, no, you could do a re-RCT, and I think it’s because you have enough, you guys are not gonna go hungry if the easier re-RCTs are done in general practice to give you the stuff that you’re actually trained to do. The things that actually are trickier. So let’s talk about when you are a general dentist and you are learning about doing retreatment is something that little bug bit me and I was about two years qualified and the first thing was actually DF1 actually had my first one. And I was like, how do I remove the gp? And so then you look into it and then you think about different oils and stuff. At the time I had bought, ’cause obviously chloroform in practice was difficult to get. So I used eucalyptus oil. I remember using it and then like a drop of it went to rubber dam and I forgot which dam it was. And a huge hole appears in rubber dam. I’m like, wait, no. No one told me this would happen. This wasn’t the playbook kind of thing. So it’s a lot of things that learning. So it takes us nicely to the question, okay, what are the tips that you can give to general dentists to remove GP effectively and safely and efficiently. [Ayman]Yeah. Yeah. So if we come back to what I said about why most these more straightforward cases, why they fail a lot of the time, as I said, it’s because the gps already not that well condensed to begin with. So in terms of removing the gp, my first go-to in those kind of cases would always kind of be headstrong files. So the reason I say that is ’cause they’re hand files, so they’re probably a lot safer than using sort of rotary files. You can control it a bit better as well.  Interjection:Hey guys, this is Jaz with an interjection. Just a really quick one, right? H files. K files, and C plus files. This just briefly, really quickly go through the differences, like going back to basics. So K files are the workhorse, right? These are the main files we reach for. They are triangular or square in cross-section. They use a rotational or a push pull watch, winding kind of way. Very versatile, and they cut to dentine both on insertion and removal, but not as aggressively as H files, which stands for Hedstrom Files. Now before we talk about Hedstrom Files, we just have to point out that whilst K files are like a workhorse and they’re so versatile, they’re not as aggressive as debris removal as H files are. And when you get a calcified or sclerosis canal, then you know what? K files are not as good as the C plus files, which I’ll explain in a moment. So H files, I was always taught in dental school that they look like a Christmas tree, and once they’re circular in cross-section, they do actually look like a Christmas tree to me. Now, they shouldn’t be used in the same way as you use a K file. Absolutely not. These are specifically push pull, and they don’t really do much when you push into a canal, but when you pull, they are very aggressive and very efficient. They’re good at removing debris. They’re good at cutting, and they’re even good. Very relevant to this episode at removing gutta percha, which is why they’re used for re-treatment cases. So whilst they’re efficient, you have to be careful because you could break them if you misuse them. So please do not rotate H files and use them like a K file if you misuse them, you can cause all sorts of errors within the canal like transportations and ledges and that kind of stuff. Now, mostly the C plus file. I don’t have much experience myself in using these files, but they have a very active, so they’re really good for sclerosed canals or calcified canals. That active tip allows you to get really good tactile feedback, and it’s just ideal for the negotiation of sclerosed canals. The main thing is to use the file for its intended purpose in its intended way. Don’t go using a H file in a curved canal in the wrong kind of manner. ‘Cause that’s asking for a file breakage. Now let’s go back to the episode.  [Ayman]So I would probably go for like a size 35 to 45. Nothing smaller than a 35 because when you screw it in, I find that they are more likely to fracture. So yeah, I would go for like a size 35 to 45, something in that range. And yeah, you kind of just ask, get your estimated working length off the radiograph and then you’ll kind of go into the top of, say the most coronal portion of the apical thirds. I’ll try and get the file down there. Screw it in just very gently. If it’s not go in, I wouldn’t force it ’cause you can end up lodging and stuff like that. But oftentimes you’ll literally feel the headstrong file. It’s passing down quite easily into space, or you’ll feel it screwing into like stickiness, and that will be the gp. So get it down there, make sure you got your length, and then you just kind of, it’s basically a pulling motion essentially. And a lot of the times in these cases you’ll find that the GP just comes out with one or two pull of that and it kind of just pops out with it. If it doesn’t, then you can use a second hedstrom file and like a braiding technique. So you can kind of put them both in together, wrap them around each other, but again, very gently, don’t wrap them around too many times ’cause you can fracture a file inside.  [Jaz]For this braiding technique. I’ve seen it been recommended for removing separated files and stuff, but in this instance, if you’re using two H files, are you now using thinner ones to allow both the files to go in at the same time? [Ayman]No, I would still probably be using like 35, something like that again, because often if the cases we’re talking about they’re gonna be one, two, or threes and the access in those cases, currently is quite big and it can accommodate two hedstrom files. I don’t find that it’s that uncommon for me to get two hedstrom files into these coronally. Obviously apically won’t be able to pass those files down, but coronally, coronal third, mid third, you should most of the time be able to get it in there. I’m not sure if that answers your question.  [Jaz]That does, it’s just reassuring. And so obviously you’re saying 1, 2, 3, for our American colleagues, we’re talking about upper centrals, laterals, and canines for our American colleagues. And then, so when the braiding technique, and correct me if I’m wrong, is you put in both the files and then the handles, you literally start like twisting them around and then braiding them. From the top and then on the inside the files are like wrapping, intertwining together. Which we are hoping will latch onto the GP, is that what we’re hoping? [Ayman]Correct. Yeah. So ideally you want to look and see if you can get one file on one side of the GP and the other file on the other side of the gp. And then you kind of just wrap them over each other a couple of times and then you kind of pull again, like if you’ve pulled a couple of times with a single hedstrom, it’s not coming out. You’ve tried a couple of times, the braiding technique, and it’s not coming out. You probably need something a little bit more. And I probably wouldn’t push too hard because obviously the more you put stress on the files, the more likely they are to fracture. So braiding, obviously you are bending the files to a certain degree as well, and if you are putting motions, bending it is putting a bit of stress on the files. So if you keep trying to do that again and again and it’s not working, I would probably move on to the next thing after that just to reduce the risk of the file fracturing essentially.  [Jaz]Okay, so GDP has tried those two things, and what’s the next call of action?  [Ayman]Yeah, so then I would be looking at essentially using a file, so a file system to basically remove the GP at that point. So the file system that I would use often, I’d go to something which we call rake angle. So if you look at the axial section of a file, you cut it down axial sections. Axial sections, like a bird’s eye view of the file. So when you’re looking at a bird’s eye view of the file, the way that the teeth of the file points, they kind of curve in a way which they end up biting into the GP rather than brushing it in a way, if that makes sense.  So it scores a positive rake angle. So often I’d go for a follow with a positive rec angle. The most common one that you see nowadays is Reciproc Blue. So that’s the most sort of common one that has a positive rec angle. And the use of that is that bites into the gp so when it reciprocates and bites into the gp, it kind of grabs hold of the GP a little bit and that can help to pull the GP out as well. So, that would be sort of my next step and my next go-to if the headstrong files aren’t really working. But again, you need to- [Jaz]And so when you are using the Reciproc Blue, ’cause I’ve never used this one before. Are you trying to take it to length and just allow it to sort of take you to length and then give up? [Ayman]Yeah. Yeah. Just so I’m on the same page. I’m not saying that Reciproc Blue is the only file that you can use for this. Of course, you can use things like -. Yeah, you can use WaveOne and stuff like that. In my hands, I just feel like it’s more efficient because of that positive rake angle. WaveOne will work fine as well, but it’s just a little bit less-  [Jaz]Glad you said that.  [Ayman]Essentially, because I think WaveOne usually in GDP practice, that is my understanding is that that’s the most commonly used file and it’s a really excellent file system as well. I actually use it quite a lot as well. For GP removal-  [Jaz]Well maintained the ties with Dentsply there. Good man.  [Ayman]Well, you know, I think Reciproc Blue is now owned by  Dentsply as well. They’ve been bought by, used to be, they’re both very good file systems for GP removal. Yeah, my go-to would be  Reciproc Blue . Sorry, I forgot what you were asking me now.  [Jaz]I was saying, so are you gonna take it to lent? Is it safe to take it to Lent at this stage?  [Ayman]Yeah, so, I wouldn’t go all the way with the rotary file. I would probably, again, look at the estimated working length and I would take it up to like sort of apical third top of the apical third, or alternatively to within a two, three millimeters where you think the GP ends. And the reason for that is if you keep trying to go past that, you can end up leveraging. And a lot of the times the GP stops at that point because there’s a ledge or there’s some kind of blockage in there. So if you try to keep pushing the file down there, you can make that worse or fracture a file or make it a problem that would be irretrievable at that point, basically as in a lot more difficult to negotiate, to patency to negotiate the canal. So I would stop at there where there’s still two to three millimeters of GP left. And then that last apical bit, I would probably be navigating using hand files. So 10, 8, 10 hand files with lots of irrigation. There’s a lot more control that way.  [Jaz]So I can imagine if you get lucky, you go towards the apical third with the Reciproc Blue in this example. And then you pull it out and then ideally the whole thing, the apical bit comes with it, but sometimes imagine it breaks up and so it’s left like an apical third plug of gp. At that point, you’re then using the files again?  [Ayman]Yeah, I would use, probably be using K-Flex hand files essentially at that point to try and get through. So like eight 10, those were, would be what I’d be using to negotiate the equal third. I mean, if the GP is really still, if you get to that point and the GP is feeling quite hard with the hand files. I remember when I started doing re RCT cases. You put the hand files in and you’re like, okay, it’s hitting a stop. Am I, is it blocked? What is it? So the main thing that you need to, you are feeling for at that point is to feel for that spongy feeling. And that’s how you know you are actually biting into gp. You will hit a stop, but it’ll be a spongy stop and that’s the gp. If you are hitting like a hard stop, like it feels like it’s like kind of pinging off the wall or something like that, then you know there’s maybe a ledge. Or there’s something else that’s more complicated. But if you are biting into something that’s a little bit spongy, you should be okay basically to keep, keep trying. And often I would be using like, sort of watch winding motion just to keep it, well keep the file well centered or like a 90 degrees, small, 90 degree pull motions to try and pick out the GP bit by bit. [Jaz]At what point are you thinking get that, grab that bottle of eucalyptus oil? Is that, Olbas, was it Olbas, was it, maybe it was Olbas oil actually. But I used it. Are you using those little oils, essential oils and stuff?  [Ayman]I use them very occasionally. Very occasionally, and the cases that I use ’em to are kind of limited to if I’m really struggling to get through the apical third of gp. But oftentimes I would find those are cases which are quite complex to start with. So the GP is already like super well compacted or it’s a really, really old re-treatment. So like for example, the GP has set rock card and I tend to find that when the root canal’s already been been in place for like 10, 15, 20 years, if it’s like relatively fresh, then the GP will normally still be quite soft and easy to pick up. So yeah, I would leave it in there for a few minutes and then pick out a bit more. And the reason I don’t go to it that commonly is because it smears, like with the rubber dam example, is it tends to smear the GP over the walls of the root canal. And when we think about the sort of biologically, what we’re trying to achieve with the root canal is adequate disinfection. So if you’ve got layer, layer of rubber smeared over the dentine or tubules, you’ve got a lot of bacteria a lot often hiding inside those dentinal tubules, which then becomes a lot more difficult to access with your irrigation. So although you might have got to the bottom of the canal, you’ve then just blocked access to a bunch of other bacteria, which could be in the apico ramifications and the Dentinal tubules. So yeah, you might be getting through one problem, but then causing yourself another one. It’s a little bit controversial. I mean, I think in America it’s a lot more common that they use it. In the UK, I see people, my experience is that my mentors and what I’ve seen people do is a lot less common in the UK because of that reason. [Jaz]It makes a lot of sense because if you think about how to remove once that GP has made, we know that a file system, you’re only really touching 40% of the canal space with the file. Most of it’s left untouched, right? And therefore, how are you gonna mechanically remove that without then actually over preparing the canal itself, right? Which is obviously the last thing you wanna do. So that makes a lot of sense. Now, for those getting a little bit stuck and they want to use some sort of solution. Can you just name what is it that you use? Is it Olbas or is it Eucalyptus? Is it something else that you have access to? And then what’s actually the best way to use it? Like do you dip your file in it and then put it in, or do you actually syringe it in like you would do hypochlorite and leave it there? What’s actually the accepted way to use it?  [Ayman]So there, in terms of what I use, there’s a few that you can use. Orange oil, eucalyptus oil. Orange oil is one, Eucalyptus oil and there’s Endosolv as well. I’m not sure if the Endosolv original is on the market now. I think they’ve changed it to Endosolv R I’m not sure. I’m not sure. I’ll have to double check that. But there’s a few. And these all basic kind of work on different arbitration materials. So for example, if you’re finding out to get down one, you might experiment with the other one and see if you get any further with that. But again, oftentimes if you’re having to resort to-  [Jaz]I didn’t know that it was interesting.  [Ayman]Yeah, I did know when I was sitting my exam exactly which solvents were good for which materials.  [Jaz]Baby brain. Newborn dad.  [Ayman]But yeah, so, you might go through a couple of them, but oftentimes if you’ll get into that stage, I’ll be thinking of the reroute treatment is obviously probably a bit more complex at that point anyway, so you might at that point be thinking about a referral if you’re really stuck in that apical third and none of the solvents are working. In terms of-  [Jaz]And how to deliver the solvent.  [Ayman]How to deliver it. So, in terms of delivering it, I would usually use it in a syringe. Basically. It’s the same way that I deliver the hypochlorite and I’ll just leave it to sit in there for a couple of minutes to do its work. Just kind of, have a little break, just let it sit. And then once it sat there for a couple of minutes and it’s done, its work, I would go back in with the hand files basically and just slowly start to pick away at it with the hand files.  [Jaz]Okay. I mean, I’m kicking myself now because I remember, years and years ago doing it and I was like literally dipping my file in it a little bit, dipping in the canal, dipping my file. Like it just makes so much sense. Just leave it to do work.  [Ayman]Yeah. It needs a little bit of a reservoir to kind of work. And if you imagine as well, it’s kinda like the hypochlorite, it reacts with the gp, so if you’ve got a reservoir of it, it’s of sort of continuously reacting. Whereas if you just put a little bit down there, then you are limiting that sort of reaction process in a way. [Jaz]Okay, great. And so in the interest of time, I’m gonna ask you my friend, when you’re doing these, firstly single versus a two visit, the endodontist that works in our practice that I work at, he is adamant, he swears by a two visit. The previous endodontist we had, younger grad, newer specialist. He liked one visit. Okay. And obviously sometimes they’d find a reason to change patient factors, tooth factors, whatever. Right? So what, firstly, I’d like to know what is your general preference? When you look at your diary, like a retrospective. When you look back at your diary, are you tending to do primary root canals in one visit or two? And then does that change because it’s a re-RCT and how you manage that in terms of timing?  [Ayman]So you’ve kind of touched on quite a controversial topic in Endo, to be honest. There’s actually quite a big divide in Endo among single visit and two visits. So depending on who you ask, they’ll probably give you different answers. [Jaz]That’s cool. But I’m literally generally interested in what you do. Okay. ‘Cause you can do it either way. And I just wanted to hear from you. What do you do?  [Ayman]Yeah, yeah. I mean, I would try where I can to do things in a single visit. ‘Cause I think that’s a lot of the times that’s a bit more patient centered in terms of what the patient wants. So the patient would obviously prefer for you to have things done in one visit rather than two visits. But having said that, if you think about the main sort of biological rationale or root canal treatment, you’re trying to disinfect the canal space. If I feel that I cannot adequately achieve that in one visit, then I think the patient would much prefer me to do a second visit rather than increase the risk of it failing. So things that would then push me to doing that second visit, if I think I can’t get that adequate disinfection process is number one, if I run out of time and I can’t find all the anatomy that I think is there. So that’s one. Then I’d be doing it in two visits. Number two would be if there’s a lot of discharge from the canal, so the canal is just weeping continuously. That would be another thing that would make me probably dress the canal as well. And then another thing would be perio endo lesions as well, that would be one that would dress the canal too. So there is some research to suggest that with peroneal lesions, if you dress the canal, although it this kind of controversy for endo, it might not have an impact necessarily on the perio apical healing of the tooth, which is the endodontic outcome. But in terms of the periodontal pocketing, dressing the canal with an interim dressing can improve the periodontal pocketing side of things as it sort of diffuses through the dentinal tubules into the periodontal ligament space. And then also in terms of teeth with cracks as well. That would be another thing. So if it’s got a crack with an isolated pocket, that isolated pocket a lot of the times is where the crack is leaking bacterial leakage, basically through the crack. And that’s manifesting of the periodontal pocket. So if you, for example. Do the first stage root canal. You clean everything out and then you dress it. Oftentimes, I’ll get the patient back in a few weeks later to see if the periodontal pocket has improved and reduced in depth. If it has, then I’m thinking that crack is probably a crack tooth worth trying to save if it’s not really improving or it’s basically getting worse and I’m thinking, is this really gonna work for the patient? So you can use it as a kind of diagnostic tool in that way as well.  [Jaz]A stepwise, careful approach, basically.  [Ayman]Yeah. So I’d be thinking exactly. Yeah, so the other thing is probably really, really significant swellings as well. So if the patient comes in with a massive swelling, that would be another thing that I would sort of be looking at as well. [Jaz]But you haven’t mentioned re-RCT. So what I’m trying to get to is, is the fact that it’s a re-RCT. Should that push our colleagues so GDPs now, right? So not the kind of specialist, what you do just because of re-RCT. Is there any reason why they should be thinking, oh, it’s gotta be two visits now, or is it still okay to do it in one visit? [Ayman]The fact, as I mentioned, I find that they occur just as much for re RCT cases as they do for primary cases, if not more for re-RCT cases actually. ‘Cause often the tooth has already been through that restorative life cycle for many, many years. At that point, the fact that it’s a re-RCT case in and of itself is not enough for me personally to do it over two visits. Maybe if it was a really good quality root canal treatment, that would be an indication. ’cause then I’m thinking as there sort of more virulent strains of bacteria. But that’s not really that evidence-based to be honest.  [Jaz]Well, I’m gonna just take a few questions from the community now, buddy. In the interest of time, right? Let me just head to the community here. There was some questions we had yesterday. Okay? So I posted yesterday saying, I’ll be talking about this topic. And James, oh man, James got some awesome contributions and he put up a radiograph of these post crowns and have a look at this, look at this central, which like complete destruction, caries, post, root filling, that kind of stuff. And he makes such a real world point here. He says, I’d love to hear us, your thoughts on value for money in re-treatments, right? So if you have a molar with an old crown, poor margins failing, inadequate root treatment, right? The total cost of doing a root canal, re-treatment, new core, new crown, okay? Possibly pre endo restorability assessment, okay? Can be so high that I sometimes question whether XLA and implant. Will be more predictable option for the patient. For example, the radiograph he posted was his father-in-law’s, and then if he’s doing the re-treatment, et cetera, and he’d be, even if he’s only paying the lab bills, that’s still coming up to a significant amount. So what do you think about this, cost versus predictability dilemma, especially in this world of titanium.  [Ayman]Yeah, I think that’s, it’s actually quite a common scenario.  [Jaz]Great scenario, isn’t it?  [Ayman]Yeah, really good question. It’s a conversation I have a lot with my patients actually. So the first thing to sort of note is that the survival for root canal treated teeth on average at around the sort of eight to 10 year mark is still in the like 80, 90% range. So it’s still quite high, which is at probably comparable to implants as well. So that sort of 80, 90% range is, yeah, not too far off what an implant’s survival rate might be at that, that stage probably a little bit higher for implants. But the other thing to consider as well is probably their patient’s age. So ultimately we’re trying to get the patient through their whole life with a functioning set of teeth. So if, for example, you get that 10 years out of the tooth, even though the patient’s paid a lot of money for it, granted you get that 10 years of life out of the tooth, you then pushed the need for an implant back potentially by 10 years. Whereas if you start off with the implant, obviously you haven’t got that lifecycle out of the tooth. And to replace a sort of failed implant, if it was to fail at 15 to 20 years, which is a reality of implants, then that becomes a lot more tricky than replacing a tooth. So I’m thinking of it not just isolated, how long will this tooth survive? It’s also how are we gonna get this patient through their life for the functioning set of teeth. And yes, a lot of the teeth that we treat are re root canal treat are very compromised, but it doesn’t mean that they won’t work into the future. The other thing to sort of consider is how you are assessing the outcome as well. So a little bit into the sort of nuances of endodontics, but in terms of you wanna look at success or survival, which are two completely different outcomes. So success is when you’re looking at the x-ray is the perio apical lesion actually. You know, reducing in size, is it getting smaller? That is a lot more of a stricter criteria than cervical, which is, is this tooth still in place in the patient’s mouth? So you might have a lesion, is the tooth still in place and functioning okay in the patient’s mouth? So how many patients do we see that have massive perio apical or big perio apical lesions, or not big, but as in like, you know, periapical lesions, but the tooth is asymptomatic and functioning fine in the patient’s mouth. [Jaz]So as a GDP, I had this conversation a lot. And the patient’s like, well, you know what? And we had that informed consent and that, look, I really, I’m doing just fine. I appreciate his infection. And we had that conversation and the patient has opted for that. I can live with this. I’m okay with it. And I just say one thing, which is what, what Dave Winkler taught me. He says, look, that’s fine. As long as you understand it’s like a dormant volcano. It can blow up any point. And I say, just don’t call me at Christmas. I just say that point and they get it. Like I said, don’t call me at Christmas. Okay. And then they get it. I was like, okay, fine. Yeah.  [Ayman]So if you are going by success, yeah, correct. You might find that more of these cases are more likely to fail compared to an implant. But if you’re looking at cervical, then you know, it might be that, and I mentioned survival rate at the beginning was 80 to 90%, not success rate. That is because a lot of these patients have these PA lesions, which are just sitting there completely asymptomatic, and those cases can last many, many, many years into the future. What’s interesting as well is the implant literature. A lot of it, if you compare their outcomes for like with what a tooth outcome would be, it’s actually closer to survival. So the implant could have like threads exposed, that kind of thing. But actually what they’re looking at in the implant literature is the implant still in the mouth. That’s commonly what’s looked at.  [Jaz]There could be a lot of, yeah, bone loss. There could be several prosthetic failures, which are very common.  [Ayman]And when you look at that, that 90% success survival rate that’s coated for implants is actually quite similar to the tooth survival rate. So yeah, you can have a compromised implant and a compromised tooth, which is surviving many, many years into the future. And that rate of survival is pretty similar for these compromised teeth into the future. So yeah.  [Jaz]I like that ethos of delaying implant as much as possible So I’m definitely with you in that. My friend, in the interest of time, we’re gonna wrap up. My wife has to go to a some sort of a pediatric dentistry conference, and I’m gonna get killed if I don’t be there in two minutes to help out. But, Ayman. As we wrap up now, firstly, thank you. Thank you so much for spending some time with me today and sharing and helping GDPs just overcome this obstacle. And hopefully, a lot of those people who had a limiting mindset like I did, you’ve helped out but also helped to identify which are the easier cases which we should be doing. And actually lots and lots of good reasons to make sure our endodontist colleagues. Don’t go hungry. Now, Ayman, can you tell us about any, either education involved in or how to follow you or how to reach out, how to thank you. All this kind of good stuff.  [Ayman]So, the main place I’m on is on Instagram, so it’s ayman_endo. That would be it. I’ve just recently started posting. I’m not like a big account at them or anything like that. That’s one. And then, yeah, just any of the practices that I kind of work at. If you have any questions you can kind of ask for me there or message me on Instagram basically. So the practice I work at, there’s a few one in Norwich. So they’re all listed on my Instagram anyway. If there’s any questions, just ask ’em on Instagram. That’s fine.  [Jaz]Well just, you know, Ayman. And I were touching base on Instagram, so thanks for all your applies and stuff. So, having helpful, friendly specialists to liaise with on a social platform that we’re so used to is just amazing. Ayman, if you’re interested in community, come and join us on the app Protrusive Guidance and be a resident endo geek on there. But, wishing you all the best hope Ramadan, Kareem and all that stuff as you were recording in the middle of Ramadan at the moment. Thank you. So wishing you all the best for that, Ayman. Thanks so much for making this time and making re-RCTs a lot more tangible for us.  [Ayman]Great. No problem. It’s my pleasure. Thank you.  Jaz’s Outro:There we have it guys re-treatments for GDPs. Thank you, Ayman. Once again, our fantastic guest with a lovely deep voice, a nice little feature for those who are listening. Now, listen, wherever you are, please do hit that subscribe button. It astounds me how many of you listen and yet have not subscribed? It does matter to us. 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Are you confident when increasing the vertical dimension? How do you plan, stage, and sequence a full-mouth case safely? What’s the right deprogramming method—leaf gauge, Kois appliance, or something else? Dr. David Bloom joins Jaz in this powerhouse episode to demystify the real-world process of increasing vertical dimension. With decades of experience in comprehensive dentistry, David shares how he approaches diagnosis, bite records, temporization, and final restorations—with predictability and confidence. https://youtu.be/gAaP0VYP84s Watch PDP232 on YouTube Protrusive Dental Pearl: Pick one occlusal philosophy and stick with it until you understand it well through real cases. Once you’re confident, stay open to other approaches—hearing different views will make you smarter, more flexible, and a better dentist. If you are looking to get started with the foundations of Occlusion, check out our comprehensive Online Occlusion Course. Need to Read it? Check out the Full Episode Transcript below! Highlights of this episode: 00:00 Trailer 00:55 Introduction 04:43 Guest Introduction: Dr. David Bloom 10:25 Equilibration Techniques Explained 11:18  Interjection #1 15:50  Opening Vertical Dimension vs. Orthodontics 18:06 Interjection #2 23:05 Whitening and Restorative Solutions 25:27 Guidelines for Raising Vertical Dimension 25:52 Interjection #3 29:28 Midroll 32:49 Guidelines for Raising Vertical Dimension 36:06 Visual Try-In and Adapting Vertical Dimension 40:16 Case Planning and Execution 41:16 Interjection #4 43:42 Case Planning and Execution 50:23 Material Preference for Provisionals 52:00 Bite Registration and Final Adjustments 55:06 Do’s and Don’ts for Clinicians 57:15 Conclusion and Resources 58:59 Outro Key Takeaways Vertical Dimension and Adaptation: Opening the vertical dimension in dentistry can be challenging, especially for edentulous patients who lack proprioception. However, with proper planning and understanding of occlusion, the human body can adapt remarkably well. Occlusal Philosophy: It’s important to learn one occlusal philosophy well, whether it’s Kois, Dawson, or another. Understanding different approaches can make you a more rounded clinician, as different patients may benefit from different methods. Equilibration and Deprogramming: Equilibration is crucial for idealizing occlusion by eliminating interferences. Deprogramming helps in achieving centric relation, a stable and repeatable position for the condyles, which is essential for successful equilibration. Orthodontics vs. Vertical Dimension: Deciding between orthodontics and opening the vertical dimension depends on the specific case. For example, pre-aligning patients with orthodontics might be necessary to address a restricted envelope of function. Testing and Adaptation: Testing the vertical dimension with transitional materials like composite can help patients adapt before moving to definitive restorations. Experienced clinicians may sometimes proceed directly to final restorations based on their judgment and diagnostic steps. Get CE/CPD for this episode only on the Protrusive Guidance App. 🖥️ A new website is launching soon by Dr. David Bloom — ppcontinuum.com Also, Dr. David Bloom’s hands-on courses on veneers and minimally invasive dentistry If you found this episode valuable, you’ll definitely want to watch PDP197: Vertical Dimension – Don’t Be Scared!, part of Occlusion Month. #PDPMainEpisodes #OcclusionTMDandSplints #BreadandButterDentistry This episode is eligible for 0.75 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes B and C. AGD Subject Code: 180 OCCLUSION (Occlusal therapy) Aim: To provide clinicians with a comprehensive understanding of how to safely and predictably increase the vertical dimension of occlusion (VDO) for restorative cases, using a diagnostic-driven, conservative, and patient-centred approach. Dentists will be able to:  Describe the indications and contraindications for increasing VDO. Differentiate between conformative and reorganized approaches to occlusal rehabilitation. Identify the steps involved in diagnostic planning, including CR bite records, wax-ups, and visual try-ins. Click below for full episode transcript: Teaser: 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 composite will obviously be non-invasive. 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.

How do you manage patients that have ultra high expectations? What’s the best way to communicate cosmetic outcomes before the final result? How do you balance your aesthetic vision with what they see? Dr. Brandon Mack joins Jaz for a deep dive into the realities of cosmetic dentistry—from subjective perceptions of beauty to practical tips that make or break a case. They discuss how to navigate aesthetic stress, manage patient expectations, and even go into Brandon’s favorite veneer cement and occlusal philosophy. Plus, Brandon shares key failures that shaped his journey—and how you can avoid the same pitfalls. https://youtu.be/s7puDNP3d7U Watch PDP231 on YouTube Protrusive Dental Pearl: When discussing smile design with patients, especially in high-end cosmetic cases, set the right expectations early by using this memorable “Eyebrow Analogy”: Central incisors = Twins (they should be as symmetrical as possible) Lateral incisors = Sisters (not identical, but related) Canines = Cousins (more individual) This helps patients understand that perfect symmetry isn’t always natural or necessary — especially for lateral incisors! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Cosmetic dentistry as a lens through which all treatment should be approached—balancing patient autonomy with ethical care. Managing expectations begins before the patient sits in the chair. It continues through structured checkpoints: from initial consultation to provisional feedback and final delivery. Temps aren’t just placeholders—they are test drives. They align expectations between the dentist, patient, and lab, reducing surprises and improving satisfaction. Some dentists may under-diagnose due to fear of rejection—not out of true minimalism. Thoughtful planning can make “more treatment” actually less invasive. Patients often want teeth that are both ultra-white and natural-looking. Brandon developed the concept of believability—a visual balance that delivers a wow-factor while still appearing real. Creating a mathematically perfect smile can make natural facial asymmetries more obvious. Dentists must weigh beauty against harmony. Social media and filters have distorted patient self-perception. Dentists must learn to identify signs of body or tooth dysmorphia and respond ethically—not just clinically. Building relationships with ceramists over time—expecting 15–20 cases before finding synergy. Each technician has unique strengths and should be matched accordingly. Composite veneers are accessible and beautiful—but extremely technique-sensitive. You become the ceramist. Brandon admires them but uses them selectively due to long-term maintenance concerns. Panavia Veneer Cement – Translucent for its predictable handling, strength, and minimal risk to thin ceramic restorations. Highlights of this episode: 01:35  Protrusive Dental Pearl 03:11 Dr. Brandon Mack’s Journey and Philosophy 09:19 Managing Patient Expectations in Cosmetic Dentistry 14:23 Choosing the Right Technician 21:13 “Undersell and Overdeliver” Philosophy 25:12 Conservatism in Cosmetic Dentistry 26:48 Overcoming Failures 33:15 Body Dysmorphia in Dentistry 37:28 Occlusal Philosophy and Techniques 38:30 Fake It Till You Make It? 40:38 Veneer Cement  42:07 Composite Veneers 44:17 Upcoming London Event and Final Thoughts 🌴 Coming Soon: Occlusion in Dubai 🌴A luxury course experience at Atlantis, The Palm — yes, the one with the famous waterpark! 🦷 Learn practical occlusion during the day👨‍👩‍👧‍👦 Bring your family for a fun, relaxing getaway📍 World-class location, world-class content 🎟️ Coming Soon: Brandon in London (February 6th and 7th, 2026) – Soho Hotel Two-day immersive aesthetic experience aka ReturnofTheMack Rewire how you think about cosmetics with Dr Brandon Mack Participants will learn how to create personalized smile transformations that harmonize with each patient’s unique facial features, moving beyond generic smile designs to achieve truly customized results that enhance overall facial aesthetics. Bigger picture and smaller details in 2 days: transition zones, light interaction, surface modulation For new grads and seasoned dentists alike→ “It’s like re-reading a great book. The content didn’t change — but you did.” Discount Code: PROTRUSIVE for £100 off (case sensitive) If you enjoyed this episode, don’t miss PDP129: 4 Rules of Planning Aesthetic Dentistry (Ortho-Resto) #PDPMainEpisodes #AdhesiveDentistry #CareerDevelopment This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, B, C, and D AGD Subject Code: 780 ESTHETICS/COSMETIC DENTISTRY (Tooth colored restorations) Aim:  To enhance the clinician’s ability to manage patient expectations, communicate effectively with labs, and deliver predictable, high-level aesthetic outcomes in cosmetic dentistry through philosophy-driven protocols and reflective case-based learning. Dentists will be able to – Understand the importance of managing patient expectations in elective cosmetic procedures. Recognize the role of provisional restorations as communication tools between dentist, patient, and lab. Reflect on how personal failures can lead to clinical growth and stronger aesthetic outcomes. Click below for full episode transcript: Teaser: What is cosmetic dentistry? It's not really a specialty. The way that I look at cosmetic dentistry is essentially a philosophical approach to dentistry, and that's it. Like a lens that we look at everything, how can we be comprehensive? And at the center of that lens, there's two things that need to be balanced. Teaser:Number one, why people don’t want to take more creative risk. It boils down to fear. And this idea as dentists we’re so type A that we feel like everything is a Super Bowl. We have to get it right on the first attempt. When you are in the process of doing this, you have to understand the level of anxiety that comes with it on the patient’s part, because everything that we’re doing is semi-permanent, right? Nothing lasts forever, but this isn’t a hair dyeing or a haircut. When a patient says, I want really white teeth, but I want it to look natural. That is a horse with stripes. It’s not a zebra. It is a horse with stripes. I think that for the young dentists embracing every failure, no matter how big or how small, and understanding that every one of those lessons are an opportunity to put you in a better position to treat the next person better, it’s going to make the next person’s case better, every single failure. So there’s always five checkpoints for patient expectation. Patients are demanding certain things, and so how much do we balance patient expectation and autonomy, what a person wants for themselves? I think it all boils down to one thing.  Jaz’s Introduction:Cosmetic dentistry is tough. Think about it when you’re removing caries, is there a way to make that objective? Like some of caries removal is obviously subjective because how much I would remove is different to how much you might remove. But with something like caries detector dye, we know that we can turn this procedure and add a degree of objectivity to it, and we have some guidelines that we all work to. Now, in the world of cosmetic dentistry, there is the lens that the dentist wears, and then there’s a perception of the patient. And as they say, beauty is in the eye of the beholder. Now, add to that the ultra high expectations that patients can carry today and the very nature of cosmetics and beauty being subjective. This is tough. This is what makes cosmetic dentistry tough. So I’m absolutely honored toast today, Dr. Brandon Mack from Florida. He is one of the biggest names in cosmetic dentistry and we have a really geeky session today. I asked him how he manages those ultra high expectations patients, so big level stuff. And I also ask him little details like what’s his favorite veneer cement? What is Brandon’s occlusal philosophy? And one thing I really love is I ask him to tell us about his failures. And I always appreciate colleagues that share their failures and what they’ve learned along the way. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. If you’re returning to the podcast, maybe you’re watching this on the Protrusive Guidance app. Thank you so much for coming back. If you are new to the podcast, you picked a really awesome one to join us. I said on the podcast, I actually really enjoyed Brandon’s flamboyant vocabulary. He’s full of energy, and these are the kind of episodes that really get you feeling good before a day of work. Dental PearlNow, every PDP episode, I give you a Protrusive Dental Pearl. Today’s Pearl is actually inspired from this episode. It was actually something a patient taught me that I’d like to teach you that very much goes in tandem with a theme of this episode about ultra high-end cosmetics and meeting expectations. And something I talked to Brandon on the show so you’ll hear it later, but I had this situation where I’d done some ortho and bonding and I was really loving the result. Okay? I was actually genuinely happy that I had delivered a nice aesthetic result, but my patient was hung up on one lateral incisor, and yes, it was not symmetrical to the other lateral, but laterals aren’t usually symmetrical, and so this is what you should say, right? You should remind your patients right at the beginning, at the consultation when you’re gauging expectations, is that central incisors are like twins. They should be pretty symmetrical as much as possible, and they should be the dominant part of the smile, right? Having that central dominance. Now, lateral incisors should be like sisters or siblings. They should not be identical twins and canines are like first cousins or something like that. Now, when I said this, my patient finally got it. And yes, I just did some adjustment and I tweaked it and I think it did look better. But when I described it this way, my patient says, ah, it’s like eyebrows. She said that when you get your eyebrows done, something I know nothing about obviously, apparently you are told that eyebrows are like sisters. They’re not twins. They’re like sisters. And I was like, yes. It’s just like eyebrows. And so happy patient in the end. And a nice little way to communicate with your patients and to get across the correct expectations. So feel free to use this eyebrow comparison analogy. Call it what you want. And hey guys, enjoy this episode. It’s really good. And look, be sure to hit that like button, hit that subscribe button. If you’re on Protrusive Guidance, do drop a comment. Catch you again the outro. Enjoy the episode. Main Episode:Dr. Brandon Mack. I wish this wasn’t your first time on the podcast. I wish it was your second time so I can play Return of the Mac Song, but it’s the first time for Brandon Mack. Welcome back my friend. Welcome to the show. All right. It’s so, so cool to have you. I’ve recently discovered your presence online world, thanks to Barraj and oh my God, I’m blown away by the standard of your work. The episode, I called it provisionally Ultra high-end Cosmetics. And my goodness, what you deliver on a day in day out basis is very inspiring. So I’m very excited to learn from you. So for our guests all around the world, Brandon, please tell us about yourself.  [Brandon]So my name is Dr. Brandon Mack. I practice here in Tampa, Florida. We also travel to New York a couple times throughout the year to do cases. And one of our focus is on understanding cosmetic dentistry and its impact, I guess, a world with an egregious appetite for instantaneous gratification. And we are trying to carve out a particular niche where we’re guiding patients to optimizing aesthetic outcomes while looking through a scope of comprehensive dentistry. I love what I do. I’m having a good time doing it, and I’m really just trying to change the narrative for tapping into a sense of authenticity and really tapping into a passion for what we do. [Jaz]Nowadays, so many clinics offer cosmetic dentistry. What do you think when the nature of the clientele, you see, they hand pick you, they carefully seek you out. What is it that they see from what you put out there that think that, okay, for all the dentists I could choose, I’m gonna travel all the way to see Brand Mack. What is it that you think that they’re expecting, why do you think they’ve picked you? What is the promise that you try to deliver? What is your USP?  [Brandon]You know, in a world where there are so many options. I feel like what speaks to a patient the most is gonna be a multitude of things. When it comes to social media, most of our patients are gonna find us from other people talking about what it is that we’ve been able to do for them. And social media has also been a huge marketplace for people to discover us and discover the body of work and what we put out to the world essentially is focusing on a sense of transparency on how we craft the product and how we put passion into what it is that we do. So patients that are selecting us, while there are so many good cosmetic dentists across the world. I have my list of favorites, but I think more importantly, what they are coming here for is an alignment of energy and an alignment of who we are as people and what we’re putting out to the world. Not necessarily just the work, but I do think that our work speaks to a particular population of people who are seeking someone who focuses on the micro details. I always have this saying that, a patient or a person can never have higher expectations than we have for ourselves. So people who are aligned with that concept or that principle, or they want someone who is gonna deliver energy and love in the work that they do, and have that translate into something that they can enjoy, I think those are the people that are selecting us and what separates us from the pack. [Jaz]I mean, making it relatable to general dentist. Some advice I’ve always received, Brandon, is people never buy treatment. People never buy the dentistry they buy you. I see that very much in when the kind of stuff you put out there and what I’ve seen of you. But your rise to the top of cosmetic dentistry from what I’ve seen, I’ve been very impressed. Can you just describe your journey? Have there been any blips along the way? Has it been very linear or have there been a few curve balls along your journey?  [Brandon]You know what? All started out when I had a friend, we were hanging out in my building and this kid was from Abu Dhabi. He was like, hey, my dad has a finance company. We’re looking for dentists to come over. And that was my initial push to seek out CE at a high rate of acquisition. I wanted to just do as much see as possible because there were certain requirements from the Ministry of Health that they required for dentists to come over. You either needed two years previous experience or you needed to have a certain certificate or specialty, and I had neither one of those ’cause I was just starting out my journey. And so I went on this quest to consume as much continuing education as possible. And I ran into a couple of people that changed my life forever. And one in particular, this guy named Miguel Ortiz from Argentina. He was a Harvard trained prosthodontist. I went to take a photography course with him and this lab named Midwest Dental Arts with Justin McCroy down in Sarasota. And when I saw these guys and what they were doing in dentistry, it completely blew my mind and opened my mind up to a whole nother world of possibilities. There was this guy, Eduardo De Agüiar from Venezuela. I saw he had this picture. It was a needle and thread, and the name of the picture is when the pictures really matter. And that sat with me because I had never seen dentistry photographed at such a high level, at such an artistic way. I had never seen it in dental school. None of my friends were doing it, and it intrigued me. And you get on a journey where passionate people are passionate about everything that they do. But I was lucky enough to also discover my passion through this journey or quest to seek out continuing education to try new opportunities. Now, my career, it kind of went in a different way, but it really came down to being very passionate and being compelling, which is a quote from Joe Plumeri, this guy who comes to aesthetic advantage to speak on occasion. But he always says there’s two things about people who are gonna be successful, is that you have to be compelling and you have to be passionate. You have to be obsessed. And so those things, I would say catapult to the next level.  [Jaz]You don’t fancy going to Abu Dhabi anymore?  [Brandon]Man, you know, I still wanna go. Abu Dhabi, it seems so incredible. Are you kidding me? Everybody wants to go down Abu Dhabi.  [Jaz]Well, you know what? This really cool thing that we’ve set up, I haven’t advertised or anything, or put it on social, it’s just through our email list, but we’re setting up this, we call it the Dubai excursion, right? The deluxe occlusion. We’re doing an inclusion course in Dubai, but it’s like I’ve seen it in US. A lot of educators, they do this, their courses at Disney World, right. And then they encourage everyone to bring their family along, right? And so we’re kind of making this thing happen in Dubai. We’re encourage at the Atlantis who’s got the waterpark and stuff, and a mixing family and passion. So if you wanna come and join us next year at April, man, come to Dubai with us. You can-  [Brandon]I would love to.  [Jaz]You have the whole seminar day yourself.  [Brandon]I’d love to.  [Jaz]I digress. You already mentioned some mentors. You already mentioned the role of being inspired by someone, so that’s great. The next thing we wanna tackle with you, Brandon, ’cause there’s so much we could talk about. I just wanna really understand the mindset of someone operating in the way that you do. Some of the cases you do, some of the themes of meeting patient expectations, right? This thing really keeps up dentists at nighttime like that, sleepless nights over it. This is a source of anxiety for dentists and when I look at your kind of work you do, like your patients must have high expectations. They’re coming hundreds of miles, they’re coming see you. Exactly. So my question to you is, what systems or techniques do you employ to help with that? For example, some dentists might have a very strict selection criteria, so they’ll actually dismiss a lot of patients and they pick the home runs other one, the most classic one. Since day one of dental school, we are taught undersell over deliver. Okay, so I wanna know, how do you manage the crazy high expectations that you must get?  [Brandon]Man, you hit a lot of points. Make sure that I come back to that undersell over deliver concept. Expectation management, I think is the key of cosmetic dentistry. And if you really think about it, what is cosmetic dentistry? It’s not really a specialty. The way that I look at cosmetic dentistry is essentially a philosophical approach to dentistry and that’s it. Like a lens that we look at everything, how can we be comprehensive? And at the center of that lens, there’s two things that need to be balanced. Number one, patient autonomy, and also doing the right thing, right? We took a Hippocratic oath in order to become doctors, and so there’s a certain balance, as we know in the world of social media, and now people are taking a accountability for guiding their own oral health and their total health in general. People want to be in the car seat and drive the car. Patients are demanding certain things, and so how much do we balance patient expectation and autonomy, what a person wants for themselves? I think it all boils down to one thing, having a very clear and dry practice philosophy that governs every decision that you make. Okay? And so when I think about meeting a patient’s expectation, I wanna first sit and be a very good diagnostician. I wanna be able to understand exactly what I’m dealing with so that I can communicate with a patient in a way that’s very digestible so that they can understand. But we put it in the framework of their expectations and it starts with just listening and understanding how can we become a translator? And that is the biggest challenge. And I think we are equipped with certain tools that allows us to communicate effectively. Not just with the patient, but once the patient does accept treatment with the labs and creators that we collaborate with. And one of these things are tools that are the center of everything that we do is being able to handcraft temporaries that tell a particular story because now the patient has an opportunity to test drive what it is that you did for them, but they also have an idea for direct feedback. Did you translate the vision that I have for myself? One of the things that we have in place is that 24 hours after doing a case, I bring a patient back. I sent them down in a new environment. We take photos, videos, same records we do in the beginning, and we analyze ’em. We give the patients an opportunity to give feedback, so there’s always five checkpoints for patient expectation. When a patient comes in and fills out the paperwork and tells you their chief concern, the patient isn’t usually involved in a mockup or digital design. That’s more for inter-office communication to verify, hey, are we on the right path? Is everybody on the creative team on board with this? The temporaries day one, when you’re doing the preparation, this is an opportunity for us to deliver the vision that we’ve aligned ourselves on, that the patient has told you, this is what I expect from a functional and aesthetic standpoint. After that, the fourth checkpoint is when the patient is gonna give feedback, did we deliver? And if we did deliver, fantastic. Now you have to manage that expectation again because it is very difficult, as you know, even with the tools and technological advancements in dentistry to copy a set of teeth, one-to-one. And so over the years, I have changed my language. I don’t say that we’re gonna copy the temps. What we’re doing is we are creating a framework for aesthetic and functional interpretation from the partners that we work with. And so we have a lot of different labs. And one of the difficult things is when you’re working with different creators, different ceramics from Romania, Brazil, Los Angeles, New York, London. If you’re working with those team of people, how do you have a unifying body or a certain aesthetic voice that communicates to the patients? That consistency is going to give you trust from the patients. And that is going to help manage the patient’s expectation. Their expectations are being managed before they even meet you. Are you consistent? Do you have a consistent aesthetic voice? And what is your philosophical approach? Are you a doctor that I do what the patient wants? Or are you a doctor that says, hey, let me hear what it is that you expect and let me translate that into something actionable within a framework of what I’m comfortable doing. And so there’s so many different approaches that you can take, but I think managing the expectation starts with listening, communicating and being aligned on an agreed upon vision.  [Jaz]Let’s just talk with the lab, ’cause you said it’s a very difficult thing to do an exact replica, which is why creating a framework, it makes sense. Do you choose the technician based on who’s a good match for the patient or like some other clinic, what they do is they kind of give the patient a brochure. It’s like, here are the five labs I work with. You pick the menu of the day. You pick the signature dish, you pick the ceramics that you like the most, and their work. Like how do you become that decision?  [Brandon]First of all, I love your energy, brother. You got me fired up this morning at 8.45. It is a delicate dance when it comes to choosing the technician, and I heard this thing on social media the other day, and it was about being magical, right? And so when you have talent, and you do something and it just comes out great, those people who have talent that they’re just born with and they’ve fostered over the years, they’re able to be magical. But when you can take that and apply science or an algorithm to it, now you have something that is just undeniably exceptional. And so when it comes to selecting a technician, we’ve boiled it down to, alright, this particular technician, he does color very well. He works on preps with homogenous prep shades very well. His interpretations of shapes tend to have more sharp line angles as opposed to another interpretation of the temporaries tend to be a little bit more soft or rounded. And when you have a certain vision for a patient, the final result, the beginning, you have a ceramics in mind. Who is going to maximize their skillset to deliver that kind of interpretation of the product. And so I’m always thinking from the beginning consult from first meeting a patient. It’s like, oh wow, this is a great case for Chris. Oh, this is a great case for Rico. Oh, this is a good case for Calvin. Danny. Boom. And so we selected based on which ceramist has the skillset to deliver on that particular case type? Some of my ceramics are very, very good at mixing different material selections. Feldspathic, mixed with layer zirconia, or some are really good at using lithium disilicate. Some are very good. When we start talking about changing vertical dimension, which we’re gonna talk about later on the pod, I believe. It really depends. All of my ceramics have a particular thing that they do very, very well, and I like to connect with them so that we can exchange energy. I believe in having two sets of creatives on a case versus me being the only person there and they work for me, so I like to have feedback, and we’re gonna talk about that in the future.  [Jaz]And when you were discovering these technicians to have that flow, who aligns with you? I mean, you’ve named about four or five different locations. You must have been through at least 20 different technicians until you settle on the five of your A team or whatever. Tell us about the journey of working with many technicians or going about to discover who best aligns with your practice or your values of aesthetic dentistry?  [Brandon]Investing energy and risk, and building genuine, authentic relationships. That’s what it’s all about. The first thing that I do when I reach out to a ceramic or they reach out to me, I tell ’em about my approach and how I like to work, and I ask them, is this something that you would be interested in? And what is your vision for yourself? How do you like to work? Some people, they want to be the artist. They wanna have a lot more creative control of contours. When you’re early in your career, it’s nice to have ceramics that can guide you through the process and kind of, be the training wheels for the case to make sure that it goes as you plan, as you progress in your skills and your aesthetic vision and your functional capabilities to deliver, you start to wanna have more creative control over the case and then you wanna match that energy with someone who can deliver what it is that you see. And so the conversation changes over time. The cost change over time. And as you vet different ceramics, it’s more about who is the most willing to communicate in a way that I like to communicate. The minimum standard is, is the work good? Do they do good model work, and are they passionate? If they have those three things, they can come to the table to work. Now, from there, how do we communicate? What’s the energy? What’s the alignment? Do we enjoy working with one another? Are we on the same wavelength? What is it that you see? Am I learning from you and are you learning from me? All those things are very, very important. But yeah, we’ve gone through at least 20 ceramists and some really good ones too, and you kind of settle in the people that you actually enjoy working with, not just because the work is good, because you enjoy the energy exchange that happens there in creating something special, and there’s a certain power that comes with that. I love that part of it.  [Jaz]That’s brilliant. Now, when I talk to many dentists, younger colleagues, they always ask me, oh, how do I choose a lab technician? Or which technician do you use Jaz? And the mistake they’re making there is that, we’re very sheepish in dentistry. Like, for example, you start working in practice and whichever lab that practice has been using for the last 15 years, he just said, oh, this is who we use for dentures, and this is who we use for crowns and you just go with that. But to go through that uncomfortable period of actually having a conversation with a new technician and actually seeing that A, they are communicative. And they are responsive, which is what we need in this world. And then eventually you will find someone who is similar to you, really great denture removal process specialist Dr. Finlay Sutton in the UK. He recommended once in a podcast to find a technician who’s kind of like a similar age to you. And that you wanna like bounce off each other and then you grow like together over the years. And that always really resonated with me. And it’s really nice to have those open communication channels. Like sometimes my wife will look through my phone and the WhatsApp messages and exchanges and or voice notes between me and the technician. She’s thinking like, what’s going on here? You speak to him more than you speak to me, kind of thing.  [Brandon]Yeah, I know that. Listen, I’m up at like four in the morning sometimes talking to the ceramists because we’re at different locations. I think that you said something there, and I think it really boils down to the fear why people don’t want to take more creative risk. It boils down to fear and this idea as dentists we’re so type A that we feel like everything is a Super Bowl, we have to get it right on the first attempt. What many people don’t understand is that even when I’ve identified someone that I would know as being the best in the world, it takes a minimum. And I don’t even think this is an overstatement. I think it’s an understatement, a minimum of 15 to 20 cases to dial in a particular language until there is a certain homeostasis that’s happening there where you are just in the zone oscillating back and forth. And a lot of people have to be okay with taking that risk. They have the fear that we’re not gonna get it right this first time. It’s like there’s certain indicators. How do they fit, how is the communication? Are they open to feedback? Do they give you feedback? Because if you have that type of relationship, exactly, like your mentor told you, that the prosthodontic technician, it is about getting with someone that you can grow with. And I think it takes 15 to 20 cases to build a body of work. And now you can reference those cases when it comes to color and texture and design. That’s really important.  [Jaz]Brandon, you have a very flamboyant vocabulary. I love it. I just wanted to put that in there. Now we mentioned undersell over deliver and I wanna hear what you say on that, but before I let you go off on that, another thing it reminded me of eight, nine years ago I was, there was lecture. And this dentist, he was teaching us that when you try in a crown, let’s say you try and crown on upper premolar, okay? And then you show the patient in the mirror to check the crown. And then he was saying never say, what do you think? Because his thing was, you’re just inviting feedback. They say, oh, it’s a bit fat. Or is the color okay? Then he was like, you’re setting up yourself up for failure and revisions and that kind of stuff. Now that was, you have to understand the context where that was coming from, Brandon. That was coming from someone who’s head of a corporate and he wants the fits to go in the first time and therefore less remakes. Therefore, profitability is highest in his corporate chain practice kind of thing. Whereas what you described was like multiple checkpoints, multiple times of checking for alignment and accepting feedback and hearing feedback and trying to get there. And so going back then to what the opposite of that, but also going to undersell and over deliver, which is what we’re taught as, what we’re taught in dental school is undersell over deliver. What is your philosophy on that approach?  [Brandon]I think confidence comes through humility. And what I mean by that is that you have to have the humility to analyze your work and know that there’s space to get better. And by getting better consistently, you become confident through time. And that confidence comes off in the consultations. And so with me, my approach is being very aware, self-aware about one’s own’s ability is very, very important, and it’s okay to communicate that and be honest about that with the patient, whether it’s good or bad. I think that it is a tricky thing. I talk to my team about this all the time. When you are in the process of doing this, you have to understand the level of anxiety that comes with it on the patient’s part, because everything that we’re doing is semi-permanent, right? Nothing lasts forever, but this isn’t a hair dyeing or a haircut, what we’re doing, we intend for it to last a very long for time. And just about everything that we do in dentistry, even if it’s a zero prep veneers irreversible, the surface of that tooth will never be the same again. And so what I talk to my team about and everybody in the process is that our job is to control. What are we controlling? Their trust in the process and everything that we do, it is geared towards that. Number one, did we give them the space to talk in the consultation, did we listen? Thoroughly? That way the body of work is gonna procedure you. They’ve seen the work already and so I don’t like to get into the weeds about what they want things to look like in the beginning because now you’re introducing the opportunity for the wheels to fall off of the thing. Their feedback comes from that post-op, and I don’t like to just give them a mirror when they sit up because that is a very intimate thing when they look at themselves for the first time. I don’t wanna be involved in that process. I don’t wanna be involved and I don’t want my team involved. I want that to be something intimate that they experience. Over the course of 24 to 48 hours themselves where they don’t feel judged and now they can have honest feedback with themselves and come the next day or the next two days and give that feedback. And so what I’m doing is I’m taking the photos and I’m studying the case so that once we come to post-op, I want them to speak first, to make sure that we’re aligned. We’re seeing the same things. If they see what I see, this is a home run if you can execute. Right? But if they’re seeing something different, it’s like, let’s take a step back. Let me understand where you’re at. And then now you go in there and you deliver. Oh, that answers the question. It is a very tricky thing. It is tricky, especially when you are asking a patient, what do you think? One of my mentors, he always said he would do one side of the temps one way, the other side of the temps another way. It’s like, what side do you like best? So the answer is always positive. No, I’m just kidding. But he did say that. That’s one of my mentors. This is Dr. Larry Rosenthal. He’s a funny guy.  [Jaz]Okay, that’s interesting actually. I like that. But I mean, I think the undersell over deliver concept, therefore, in your practice you don’t really practice that ’cause you are prototyping everything and you are, you are checking every change and so they’re gain to get what you see is what you get to a large degree because you’ve tried everything in the prototype. Is that fair to say?  [Brandon]Well, I have a question for you. This is why that resonated with me. How do you feel about this concept of conservatism for the sake of being conservative? Undersell over deliver. I know where you’re going with it, but this is why it struck a chord with me. And it goes back to kind of understanding occlusion also and functionality. I think a lot of the problem in cosmetic dentistry is that we’re not given the patients the opportunity to explore what is possible. A lot of times we undersell a patient by under diagnosing because we don’t want to hear no, we’re afraid they may say, no, maybe this is too invasive, but what is really invasive? Think about a patient who has wear from, let’s call it bulimia, and they wanna explore the concept of cosmetic dentistry, and a new dentist recommends doing 10 teeth on the top and then 10 lower veneers on the bottom. How invasive does that have to be? How much tooth structure do you have to cut if they already have acid wear and now the occlusal surface have the little acid dimples on the cusp tips. Now, if we were to consider opening the vertical dimension or the bite by mounting the case in CR for prosthetic convenience, how much more conservative could we be by treating a few more teeth in terms of saving the total amount of enamel that’s being cut for this case? And the amount of time that we can preserve the entire system, you know? And so I think about that a lot. I know you were going a different place with that question, but that’s what popped into my mind when you talked about, I guess the under promise, over deliver.  [Jaz]No, but I like it. That gives it a very good perspective. We are afraid of rejection.  [Brandon]Oh, very much so. [Jaz]No, that sits perfectly with me. When you were going to like, through process of setting everything up in your systems, obviously everything that you’ve been doing over the years. It informs your system and you’re gonna make this tweak and you’re gonna do it like that, and eventually it takes years to build these systems and therefore, managing expectations over the years. Are you happy to share a couple of hairy scenarios where expectations work difficult to meet for whatever reason? Or some failures along the way that you can pass on some lessons to us. Seeing you where you are now, it’s nice for the little guys to say that, hey, you know what? We can still all mistakes and learn and grow together.  [Brandon]This plays in the why it’s great to have amazing mentors and be very open to helping your community. Because I remember a particular case was referred to me from a periodontist. This sweet lady came in and she was in the process of doing some other cosmetic surgery, facial enhancements and such, and we were gonna do her teeth. And at the time I thought that I understood the nature of where we were from a cultural standpoint with aesthetics. Meaning when we talk about natural teeth, what does that mean for people? What does that mean for dentists when it came to color, what white teeth meant to patients versus what it meant to dentists? And we did this case where a patient, we thought we hit a home run. The case was like an 0M1–0M3 at the time we showed it. We didn’t show the shade tabs because that’s what was taught to me. That is what I learned is that, oh, we don’t show a patient a shade tab, but we have them select a color based on the temporaries. It’s this good. Is it too white or is it too dark? That was what I learned. And so in this particular case, it was one of the best cases that I thought that I had treated, and she came back to me and we mismanaged the case so poorly. When she asked, she said, hey, do you think these teeth are white enough? And I remember looking at the centrals thinking, it’s like they do look a little warm, and we tried to convince her. I wanted to convince her because I was so attached to the amount of work that was put into delivering the case. And that was one of my best lessons for me to remove myself. If you put in so much work and you hit 99% of patient expectation, you know that you put in the 99%, but that 1% is what it took to meet that expectation. You have to be in a position where you can stomach that level of failure. And be okay with saying, hey, you know what? I see what it is that you’re saying. I’m gonna go back and we’re gonna replace this case. Now, when you’re getting into a game of elective dentistry, it can get a little hairy. You have to be okay with understanding that everyone’s opinion about what is beautiful or what meets their expectation is gonna be different. And if you don’t manage the patient well throughout the entirety of the process, their expectations can shift at any point. And you can be upside down on a case, meaning it doesn’t matter what you do technically. If you mismanage the patient and meeting their expectation, it can go sideways, and you have to have systems in place to predict when that’s going to happen. Understanding personality types and patient psychology when you meet somebody and really respecting your decision, am I going to take on this patient? Can I help them get closer to what it is they want to access? Or am I not the provider to guide this patient to meeting their expectations? Should I recommend that they have a second opinion? I think those are things that I learned early on in my career. I also remember there were cases when I used to think that OM3 was the whitest that I would wanna go because there was this, certain dentists were regarded in a way if they made the teeth too white and too opaque, and patients were asking for it. Early on I was a little bit fearful of going wider and wider. I didn’t want to take those type of risks from thinking that I wouldn’t like it. And so as you go through your career, you start to understand who you are. It’s like, is it about me pleasing myself and feeling like, oh, I did a great job and I love it. Or is it about pleasing the patient? Where is the balance? And I felt like that was the, at the center of a lot of my early failures as well. And that’s something that’s very difficult to talk about-  [Jaz]That the patients wanted to go whiter?  [Brandon] Correct. You know, you have some dentists that say, hey, the patient wanted this, so I did it and I think we leaned, I used to look at dentists who said that as like, hey, that’s just an excuse for accepting a low standard of what should be done. Patient standards are so incredibly low, you could do just about anything and make them happy. But if you don’t have a high level of standard for yourself, then at least that’s what I used to think. Right? And that was the excuse that I would make. And now it is a little bit different. I’m more open to taking more risk and understanding how can I achieve what it is that they want by doing what I’m comfortable with. And I’m talking purely aesthetics. Now, is it possible to give an unrealistic level of whiteness or value to a set of teeth and still have it have elements of believability? And because of all of those failures early in my career for color, that’s where the concept of believability came from. It’s not natural when a patient says, I want really white teeth, but I want it to look natural. That is a horse with stripes. It’s not a zebra. It is a horse with stripes. These are two conflicting things that I felt like, it didn’t exist. And so it forced me to have more open lines of communications with my lab partners to ask them how can we press the boundaries of giving something that could be believed as being real, but also have elements of wow factor? And so over the course of like two to three years, I was able to develop that concept, and it came directly from failures to communicate expectations around color, opacity, fluorescence, reflectivity, absorbing teeth, and all of these concepts you learn along the way. And it modulates how you prep a tooth based on prep, shade, material, thickness, material choice, all of that stuff. And so I think that for the young dentist, embracing every failure. No matter how big or how small, and understanding that every one of those lessons are an opportunity to put you in a better position to treat the next person better, it’s going to make the next person’s case better. Every single failure.  [Jaz]In this case, it’s all about just doing right for the patient, but the two words that, I’m just screaming in my head based on everything you said there. And the whole mention of the psychological status of the patient and everything is some clinics, they may employ a initial screening form for I know, psychometric analysis or something like that. You know, the two words I’m thinking of, right? Body dysmorphia. Have you had body dysmorphia patients? ‘Cause I can imagine, that can drive you up the wall, right? Because you want to do your best. But they keep changing their mind. They don’t know what they want themselves. And then you end up in this perpetual cycle and that’s very toxic for everyone involved. So do you have a way of screening for that so that they can get the correct medical help potentially before you do the other element of it? Or has your experience been otherwise?  [Brandon]You saw how hesitant I was to say the words body dysmorphia or tooth dysmorphia because that is a very real thing. And we have to ask ourselves as dentists, are we contributing to it or are we making it better? So I think that also boils down to that personal practice philosophy. In my office, I think about that when every time I sit down and do a consultation, does this person have body dysmorphia? Can I meet their expectations and are their expectations realistic? Yesterday I had a patient come in, she says, hey, my friend treated me with orthodontics. And this lateral won’t move. It won’t turn. And they did Invisalign go on me. And then they told me, oh, we should have done Invisalign comprehensive care. And now they’re telling me I need 32 more trays. And I sat down with the patient and I told her, I said, listen, you’re gonna walk into 10 offices. Out of 10 offices, and every one of us is gonna tell you, wow, your dentist did a phenomenal job. I see what you are saying about the lateral being tucked behind the central. But these teeth are gorgeous. They look absolutely phenomenal, and they were stunned. She had a stunning smile, very natural, had very nice depth, central dominant lateral setback. But she was looking for this perfection that it doesn’t even exist in nature. And I heard something once that there are no straight lines in nature and I’ve been very pressed to find one. And so I was trying to explain to her this concept of balance and embracing asymetry and embracing the characterization of the teeth because I think she was suffering from body dysmorphia or tooth dysmorphia where she was looking for a level of perfection that does not exist. And if we were to introduce perfection into her smile, it’s going to introduce a certain level of aesthetic stress because her face is asymmetrical. And now with that perfect smile, it’s gonna have us focus on, look, the interpupillary line is off. This eye is a little bit low. This side of the jaw is a little bit longer and more prominent. So I think it’s something that’s very difficult to deal with. And I don’t think we talk about it enough in dentistry because I think a lot of the world profits on body dysmorphia, and it’s something that we should be talking about a lot more to help pick populations of people, and I think social media has a lot to do with it. We are more self-aware of how we look. Filters has a lot to do with it. Us being able to change and modulate the way that we look, and then if we see ourself through filters over and over and over again. And then we have to juxtapose that to what we see in real life. It can create body dysmorphia and then who has to deal with it. [Jaz]I loved your use of the word aesthetic stress, the whole concept of facial flow and aesthetic stress. And I really like that, it reminded me of an interaction with a patient a few weeks ago. Similar issue, like I did her Invisalign, I did her a bonding, and I was in love with it. It’s very important for the operator to be in love with it because though if you are like fitting something right? And you’re like, you are not in love with it. Then the two years later they come back and they say, I don’t love it. You’re like, yeah, okay. Yeah, I see what you mean. Now you can’t, you have to fall, you have to be in love with it yourself. And so I was in love with it first year, so it ticked the first box. But she was saying this lateral and that lateral and the thing that saved me, I guess, or but got her to understand, okay, because I was really liking this, right, is something that apparently is used eyebrows, women’s eyebrows, right? They say eyebrows, they’re not twins. They’re like sisters. Okay. They’re slightly different, which I really liked because I always explain to the patient, look, the centrals should be like twins, right? The laterals should be like siblings, and then the canine should be like cousins, first cousins. And she was like, oh, so it’s like eyebrows. Eyebrows should be like siblings. I’m like, there we are.  [Brandon]I love that. I’ve never heard that about eyebrows, but I do. I see it. I use something very similar, except I say the essentials are like fraternal twins. They don’t have to be boy and boy, but man, I love it, man. I love it. Yes. I bet you bring a high octane energy to your patients brother and I know they love you for it. [Jaz]I appreciate that very much. Means a lot, coming from you. Okay, cool. We’re now into the occlusal philosophy. So, Brandon look. You do all these cases. You mentioned already about raising the vertical dimension and that bulimia case. It’s a tough question to ask someone, and so good luck. What is your, in a nutshell, what is your occlusal philosophy? [Brandon]My occlusal philosophy is I look at a patient, is the bite stable or is it not? Is it a destructive bite or is it stable? If the bite is stable, then we should consider restoring them in their comfortable bite or MIP. We leave the vertical dimension the same, and we’re gonna shoot for canine guidance on a case so that the back teeth disclude when they go in the lateral excursive movements. If the bite is destructive, we have to decide a starting point and mounting the case and CR, and then understanding how do we alter the vertical dimension based on prosthetic convenience and occlusion. And so it really boils down to that.  [Jaz]I love it. And let’s just keep it back. ‘Cause I love the simplicity. Occlusion is this thing that’s over complicated. Just having a few, ’cause we can talk for like seven hours on one topic of vertical dimension stuff, but I’m happy with that. So Brandon, I appreciate that very much. I always want to ask a cosmetic dentist this, right? To what extent do you agree or disagree with the following statement? Fake it till you make it. [Brandon]Next question. No, I’m kidding. I disagree because I did my career in reverse. I tried to put in the work first and then I wanted to make it. Now you see a lot of the young dentists, they come out celebrities, and they’re very, very popular. But there’s a lot of pontification that happens, and I, I don’t think it’s pontification because they want, I think it’s pontification because they don’t know that they don’t know. Some of the things, and I don’t believe that we should fake it till you make it, because there’s a lot of harm that could be introduced in this industry to patients, and we are dealing with something that is very powerful. And I always say this, if you have a product or service that is so powerful as hope, love, and something is addiction, right? Those are magnetic forces. And the power that we have to change a person’s life or the idea that we can change their life, it is a magnetic force that must be approached with responsibility. And I think that the fake it till you make it is something that’s very prevalent in our industry, and I think people should focus more on getting the proper training and building up a certain skillset before we try to jump out and have that type of approach because it is very dangerous. Patients, they don’t know better in some instances, and they want a product because it is powerful. We are unlocking a level of freedom for people. They wanna explore, experience, empower, and express. And the teeth is the cornerstone of facial beauty, or it can be. And it’s also connected to how we look at ourself, our self worth, our value. And so if you have the power to deliver that to somebody, or they think that you can. Faking it till you make it can be a very dangerous concept in my personal opinion. That’s why I said, hey, next question. This may have to be edited out because hey, I’m the dentist. Dentist and I’m here for us.  [Jaz]Last couple of questions. Very like technical geeky kind of stuff, right? Because obviously we’ll talk about your London visit. Very exciting next year, and we’ll talk about the kind of things that we’d be talking then, but everyone will probably want to know like such a stupid little thing, like what’s Brandon’s favorite veneer cement?  [Brandon]Panavia veneer cement, translucent. And it is something about when you do a wet trying with a veneer and you have a very nice prep shade, all right? If you are doing ultra thin veneers, we all know that both the ceramic, the substrate and the cement are gonna contribute to the final color. If you have a veneer that’s thicker, it’s really the material and a little bit of the substrate that contributes and the cement has a little bit less of an effect. But with these ultra thin veneers that we’re doing, the cement has a certain effect on the final result. And I love using the Panavia veneer, translucent cement, and I tell all of my labs, this is a cement that we use so that they can do these little custom prep tabs. And then they can do a veneer, and now they’re gonna know how the cement influences the ceramic and have like a little bit of a standard. And so I love that. I really like using the same cement for a case so that I don’t have to modulate the final color with the cement, that translucent cement from Panavia, it handles well, cleans well, and it has a really good viscosity that doesn’t fracture thin veneers when you overly pressure to it. Sometimes with something like a RelyX veneer cement, it’s a little too thick, and so if you have too much pressure on a ultra thin veneer, it can be susceptible to fracture before curing. So that is my ultimate favorite of all time.  [Jaz]As a Panavia fanboy myself, I’m very happy to hear that. What are your thoughts on composite veneers? Because they’re all the craze, right? And I know a lot of American dentists, they say compo-sh*t and so they don’t believe in it and stuff. Whereas other people are really, that’s all they do right? Day in, day out. They’re doing resin veneers. What’s your stance on that? You are looking at all this happening. What’s your philosophy on this?  [Brandon]Everybody wants to be a bodybuilder, but no one wants to lift the heavy weights. The best cosmetic dentists in the world either start on or they know how to manipulate composite extremely well. You have to be talented. An extreme level of talent to use composite, well, composite veneers, in my personal opinion are one of the best things that has hit dentistry because it offers a very nice solution at a little bit lower of a price point. The challenge is, and why a lot of Americans don’t do it is because it is technically demanding. For most, it requires that you have a high level of skill. There’s no one to save you. There is no lab or designer to save you, even though we have digital design and you can do the suck down method where you do every other two TEFLON it off. But they have some very talented dentists that are working with composite veneers, and I’m a huge fan of it. Now, in my hands. I don’t like to use it just because from for long-term maintenance. And being the level of you gotta be really good. And I love working with composites. I feel like my experience with doing composite veneers or class four restorations early on, learning from Dr. Adamo and Dr. Amanda Seay out in Charleston, that is what gave me my initial boost and getting fired up about cosmetic dentistry because you are essentially the ceramics now. It’s up to you texture, the layering, looking how colors interact, understanding the achromatics and how teeth look when they hydrate or dehydrate. I mean, composite is amazing. I think it’s a wonderful material. One of my closest friends, Jeff Trembley outta Nashville, he plays with the composite veneers. Dr. Marshall Hanson in Utah’s good. Felipe Verde. I don’t know how to pronounce his name properly, please forgive me. Huge fan kidding monsters in a good way. Rhodri Thomas, Australian, I believe.  [Jaz]Rhodri Thomas?  [Brandon]Yes.  [Jaz]He’s Welsh. He’s from the UK.  [Brandon]Yeah, he is stellar.  [Jaz]Look, you’ve answered all these questions brilliantly. The time has really flown with you, my friend, but we need you to tell us about your trip to London. Baraj connected me with you. He says, you know, Jaz you gotta check out Brandon’s work. And I’m so glad he introduced me. I know it’s a two day, it’s quite intense two day thing. He showed me the images of like the cinema type thing. I dunno if I’m allowed to say the venue and that kinda stuff, but the photos look amazing, but more importantly, you are putting on an educational package. You’re doing a live demo. What is that the dentist gonna gain from this experience with you over two days in February, 2026?  [Brandon]I think the biggest thing that I want to communicate is changing the way that they approach cosmetic dentistry. Changing and unlocking their mind and what they think about how they communicate with the patient and with the lab, and equipping them with tools to focus on understanding the impact of provisionalization and what it means to use that as your primary tool between A to B and B to C, meaning between me and the patient. And then me in the lab and the patient in the lab so that the flow of information is consistent. And then taking those concepts and figuring out how do we actually execute on it? Taking the information that we know, how do I do what you do? How do I create the transition zones? How do I communicate the stroke of a line angle? What does texture and modulation of surface anatomy do to how it interacts with light? I think using these tools, I think is gonna be one of the biggest takeaways from the course. Changing and unlocking the way that we think about how we approach dentistry and then giving them actionable items to actually execute on the biggest communication tool that we have. [Jaz]At what level are you pitching this in terms of are you gonna be able to serve dentists who are like, brand new, or people who’ve been in the game and doing some aesthetic dentistry for the last five, 10 years? Like, who’s the ideal dentist?  [Brandon]For the new dentist, it’s going to unlock what is possible. And for a dentist that has dabbled, either in some cases or a lot of cases, especially someone who’s dabbled, in some cases, in a lot of cases, there are going to be certain takeaways or AHA moments that every time that I go to a lecture, I can go to the same lecture three times and there’s always a new takeaway because my level of work that I’ve seen is increased, and there’s always nuggets or pearls that are like, wow, this is massive. And now I can put that connection together. I think it’s gonna serve both populations, especially the younger dentists. And people who have already dabbled in doing aesthetic cases and aesthetic dentistry.  [Jaz]It’s like reading a good book, right? And then when you read it again the next year, like it hits you completely differently. Now, the book didn’t change, but you changed, right? And so some people will come into a course like yours and if their practice is built around cosmetic dentistry, right, they’re gonna be like seeking validation, but also, oh wow, Brandon does it this cool way that I hadn’t considered and introduced these technicians that you might use or workflows. And then sometimes it’s about those tiny nuggets that make a big difference to your practice, whereas a new grad might come and just be like, wow, how do I make sure that in the next five years I can make a treatment plan and trajectory to get to some way towards what you’ve achieved? And so I’m very excited for this. I’m gonna put all the links. Now that you’ve been on the podcast. The link will be protrusive.co.uk/returnofthemack. So I can remember it and that will take him to the website to do the booking. So we will do that ’cause that’s fun to do. Brandon, thank you so much for spending some time with me. I know you’re a mega busy guy and I’m so glad our calendars could align in this way. You brought a lot of value. You’re very real. It’s been an absolute pleasure to talk to you. Any last words for all the audience out there?  [Brandon]Jaz, I appreciate you guys. I appreciate the love. I’m an energy guy. I felt the energy here was great. I’m looking forward to seeing everybody in London in February, 2026 and the world is yours and everything in it, brother. I hope that you guys are well and it’s been a pleasure having this conversation with you. Thanks so much for having me, and it means, it means a lot to us.  [Jaz] Thank you, buddy. Catch you soon. Jaz’s Outro:Well, there we have it guys. Thanks so much for listening all the way to the end. Yes, indeed. Dr. Brandon Mack is coming to London. I think it’s Feb, sixth and seventh, 2026. It’s in a central London location. Some of my friends such as Bal Sohal are flying Brandon into London to deliver a two day experience. They have given the Protruserati a discount code. As always, it’s protrusive and it’s gotta be with capital letters. I’ll just make it very clear that I do not have a financial interest in this at all. But having spoken to Brandon today, I’m sure you enjoyed his appeal and his energy. I think there’s a lot we can learn from him. So if you’re interested in this event in February, head over to protrusive.co.uk/returnofthemack. That’s protrusive.co.uk/returnofthemack. Mac we’re spelling MACK ’cause that’s his name. I’ll put that in the show notes of course. And this episode was eligible for CE or CPD. We are a PACE approved education provider. Answer the questions, get 80%. Look, you’ve done all the hard work. You’ve listened to an hour of dentistry, you deserve a CE credit and the only place to get that is on the Protrusive Guidance app. If you haven’t got an account yet, head over to your web browser. Go to protrusive app. And you get to choose a paid plan that suits you best. If all you ever do is listen to the podcast, you’re gonna rack up 40, 50 hours of CE every year just from listening to our weekly podcasts. And we have a plan for you. If you want a bit more than that, and actually watch all our clinical walkthroughs and premium clinical videos and masterclasses and the live monthly webinar that we do, that you get CPD for. Then we have a package for you as well. It’s all tax deductible, of course. And as far as education’s concerned, it’s one of the best value dental education subscriptions out there. So if you want the full fat experience, head over to protrusive.co.uk/ultimate and join the nicest and geekiest community of dentists in the world. As always, I wanna thank Team Protrusive for all their hard work behind the scenes. Some of the recent infographics we’ve been making are absolutely killer. We share them in our email list, we share them on Instagram, but the number one place to check them out are on the Protrusive Vault. And again, that’s on the app. And so with that, I’ll catch you same time, same place next week. Bye for now.

We use articulators to help ‘mimic’ our patient’s jaw movements, to ultimately do less adjustments/revisions in the future. But are digital articulators there yet? Or is analog king? Or is digital dentistry just flashy tech with no real-world benefits? Can a virtual articulator truly match the movements of your patient’s jaw? Is a CBCT really better than a facebow—and WHEN should you use which? In this cutting-edge episode with Dr. Seth Atkins, we dive into the world of digital articulation—exploring how tools like virtual articulators, CBCT alignment, and 3D-printed provisionals are transforming clinical workflows. You’ll learn how to combine analog wisdom with digital precision, improve lab communication, and make full-mouth rehabs more predictable and efficient than ever. From mounting accuracy to motion capture, this episode is your ultimate guide to articulating smarter in the digital age. https://www.youtube.com/watch?v=fT31Ecf_kDo Watch PDP230 on YouTube Protrusive Dental Pearl: Always send your lab the color version of your digital scan — the PLY file — not just the STL. STL shows shape, but PLY shows color — like markings and tissue detail. Ask your lab: “Are you seeing color, or do you need the PLY?” Better scans = better results Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: Digital methods can enhance accuracy and patient outcomes → but only when used intentionally. Understanding both analog and digital techniques is crucial → they complement each other, not compete. Mentorship plays a significant role in advancing dental education → experience accelerates clinical confidence. Digital workflows can significantly reduce chair time → and improve patient comfort in the process. The integration of CBCT with digital workflows enhances diagnostics → giving clearer insight into static and functional relationships. Digital provisionals offer a cost-effective and efficient solution → saving time, money, and frustration for both dentist and patient. Axiography is essential for capturing patient motion accurately → because real movement matters more than assumptions. Highlights of the Episode: 00:00 Introduction 04:00  Protrusive Dental Pearl 05:32 Interview with Dr. Seth Atkins and his Journey into Digital Dentistry 08:06 The Evolution of Digital Articulation 13:38 Digital Workflow and Mentorship 20:01 Accuracy and Efficiency in Digital Dentistry 22:32 Static and Dynamic Relations in Digital Dentistry 31:01 Interjection 1 36:05 Practical Guidelines on Integrating CBCT 37:15 Interjection 2  40:59 Clinical Observations in Dental Rehabilitation 42:29 Interjection 3  45:21 Introduction to Axiography 46:40 Advancements in Digital Dentistry 49:33 3D Printing in Dental Practice 53:31 Motion Tracking on Digital Articulators 57:30 Cost Efficiency of Digital Tools 01:01:10 Alternatives to CBCT 01:05:52 Involvement with AES and Future Plans Check out the study mentioned: “Comparison of the accuracy of a cone beam computed tomography-based virtual mounting technique with that of the conventional mounting technique using facebow” 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”  📍 February 18–19, 2026 · Chicago, Illinois Don’t miss Dr. Jaz Gulati and Dr. Mahmoud Ibrahim as featured speakers, presenting on “Occlusion Basics and Beyond.” If you loved this episode, be sure to watch Basics of 3D Printing, Milling and Digital Dentistry – PDP224 #PDPMainEpisodes #OcclusionTMDandSplints This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcome C – Maintenance and development of knowledge and skill within clinical practice. AGD Subject Code: 610 – Fixed Prosthodontics – Emerging techniques and technology Aim: To provide a comprehensive understanding of how digital articulators can enhance clinical workflows, improve occlusal precision, and minimize restorative complications through accurate static and dynamic articulation. Dentists will be able to: Differentiate between analog and digital articulation methods, including their benefits and limitations. Apply digital workflows to provisional restorations, improving efficiency, patient experience, and predictability. Recognize cost-saving and diagnostic advantages of digital design in restorative and full-arch treatment planning. Click below for full episode transcript: Teaser: I got into some of the digital things initially, more for selfish reasons. The key there is not necessarily digital for the sake of digital. It's how well can we do analog? Teaser:Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing? Yes, and the reason I say that is I think it’s the correct answer for both. Yes, bad and good. Are you at any point picking up your analog facebow and then working on analog articulators to wax up, or have you got to a point now whereby the trust and the faith you have in your digital workflow means that you can do it fully digitally? The biggest thing that a lot of people don’t understand is-  Jaz’s Introduction:Analog versus Digital. Are we there yet? How on earth does a digital articulator work and what’s the point? And are there any real advantages to the digital workflow other than it looking cool and pretty on the screen? Can it help you be more efficient, more accurate, more predictable? We’re gonna cover all those things with our guest today, Dr. Seth Atkins. I tell you, this guy is a wiz. He’s part of the organizing committee of the AES, that’s American Equilibration Society, and this is part of the AES takeover. We are promoting the AES 2026 conference, which has got some of the biggest names in occlusion, comprehensive dentistry and TMD over two days in Chicago. The date is 18th and 19th of February, 2026, and it’s called the Evolution of the Oral Physician. The lineup, I tell you, is absolutely phenomenal, and also it’s a privilege to be one of the speakers alongside Mahmoud Ibrahim. We have the 8:00 AM slot on Thursday 19th of February, so it’d be great to see as many of you there as possible. Hello, Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Let’s talk about digital articulators. Now, let’s go back to basics for our students and younger colleagues. The whole point of an articulator is that we can mimic the patient on the table because we can’t take the patient home with us and design the restoration in the mouth. And then fit it the next day. We have always needed a way to mimic the patient, mimic their head, mimic their movements, mimic their bite so that we can work on the benchtop. So the analog way was to use a face bow and then feed that face bow into something like a semi adjustable articulator. Now what you see on the articulator, this analog articulate in front of you, we’re hoping is somewhat representative of your actual real patient, so that when you design the cuspal inclines of the molar, let’s say that you are restoring that when you put it in the mouth. And the patient then moves left and right, it happens, so in the same way as it did on the articulator. The ultimate benefit of that is less adjustments, more accuracy, and ensuring that the design that you intended actually works in the patient’s mouth. Now, when you talk about comprehensive dentistry and doing more units, doing full mouth cases, you can appreciate how important it is to replicate the patient. And let me tell you, this episode is all about digital. We are moving away from analog facebow and analog articulators. Now you’ll see how Seth explains why we can never probably be fully a hundred percent digital in these big cases because the final stages still need to be analog because our patient, when we fit the crown in the mouth. That’s an analog process, so we still need some analog knowledge, but how can we harness the power of digital articulators? It’s a very exciting, very geeky episode, and I put a few interjections in there to help make it as tangible as possible so that our younger colleagues, our students, can also follow along. That’s always the mission of this podcast. I asked Seth how we are now transferring the patient to the digital articulator. So like I said, in the analog world, we use a face bow and we talk about the role of face bow, but then how do we actually now use a digital face bow, if you like, and then how do we ensure that the movements are as close as possible on the digital articulator? Dental PearlThe Protrusive Dental Pearl is one that was given to me by Dr. John Cranham. As you know, I attended his lecture recently in Copenhagen, all about occlusion, cosmetics and digital. And what he’s doing with digital is amazing. Just like Seth, the top tip that can help your lab technician is as well as when you send over the STL files to your lab, what they don’t get is the color. Very often the lab software, all they get is like the digital stone models. They don’t get to see the color models, they don’t get to see if there’s any ink on the teeth, i.e. articulating paper marks. And sometimes when it’s clear when you’re looking at a color scan. What’s gingiva and what’s tooth? Sometimes when you’re looking at it on stone, it’s difficult to tell. So the tip is to also ensure that they can see the color version of the model many times. This is with a .ply file. That’s a .ply file. So our scans are STL files. The color overlaying is a PLY file. So ask your lab, hey, are you seeing what I’m seeing? Are you seeing color? Or do I need to send you the PLY file? If anything, if it’s one thing that this tip allows you to do or encourage you to do is to have that conversation with your technician. Anytime we can have more of a conversation with our lab techs about our workflows, we are benefiting. We are growing because we depend so much on our lab techs. So my friends, get in touch with your lab. Ask about the PLY file. Do they have it already or do they need it? Because it can help them, it can give them additional data. Make sure you check out the link below to learn more from Dr. John Cranham and of course, how you can come to AES 2026. I’ll put all the links there. Let’s now join the main episode and I’ll catch you in the outro. Main Episode:Dr. Seth Atkins, welcome to the Protrusive Dental Podcast. Thanks for being up at this time in the US, whereabouts, since you’re in Texas, right?  [Seth]Yes, sir. That’s correct.  [Jaz]Well, it’s great to have you, my friend. I saw you, two years ago now at the AES. A wonderful presentation. You are a real whiz. You are a, I’m sure you get called all the time. You’re a real whiz with the whole digital stuff. And we’re excited to learn from you today. But Seth, I wanna start with more about you, my friend. Tell us about you as a dentist, a family man, a practice owner, your digital enthusiasm. [Seth]Absolutely. Yeah. I mean, honestly I got into some of the digital things initially more for selfish reasons. I practiced South of Dallas, Texas, about 30 minutes, and when I took over the practice, I guess 2013 or so, my kids were six and four. And we were blessed in the sense that the practice got busy. Things took off quickly, which was good. But the last thing I wanted to be doing was working up patients after hours. And during the day, you’re seeing patients, it’s hard to have time to do it. And yeah, I’d bring my wax at home, wax at the house. My wife would get mad so I’d make a mess. All these things. And it was tough to do, after the kids went to bed. And so originally I started looking at things really more just, how could I do this more efficiently? What can I do to streamline some of these things to make it easier to be more present with my family, hang out with the kids, and do all the things you wanna do as a father and a parent in those scenarios on it. And it kind of occurred to me that it’s a lot easier to do a lot of this on the computer. I can have a laptop at home, I can wax up on the screen, I can combine the photography, do all the things that we want to do digitally, and it’s a lot easier. You don’t have to carry the stuff back and forth, it expedites that quite a bit. And you kind of quickly learn, you gain a lot in efficiency in doing it. Not only cost-wise, but time-wise. And for me, that was huge, initially. Was lucky in the sense that I started scanning back in ’07, ’08, like as soon as I got out of dental school. And so I’ve had a long time learning the scans and the pitfalls and pros and cons, but it took me a good seven, eight years before I realized we’re not really doing anything with the scans. And we’ve reached this tipping point where I think the majority of clinicians are now scanning finally. But you really don’t get the return on the technology and the leverage you’ve got digitally until you start to do something with that data. And that was where- [Jaz]More than just printing the models. The next step, the next level like you did, but you did it so early. I mean, back then, were you a little bit like worried like, am am I doing the right thing? Am I sacrificing accuracy? Were you a little bit concerned at that point?  [Seth]Well, yeah, for sure. I mean, that’s always a concern, right? Even all the literature early on it was, digital is not as good. Analog has been the standard and over the last 10 to 15 years, we’ve seen that change dramatically. We’ve got a number of systematic reviews now showing digital is at least as accurate in some cases, especially on the articulation side, some other things. It’s the best representation of the patient by far. And that’s kind of been, I think the paradigm shift for many people is depending upon where you get your training, when you were trained, all those things. We’ve got some, maybe, I don’t wanna use the word bias, but legacy concepts that permeate. And we’ve always gotta be critical in reevaluating what is the current state, where are we at? And because the point of digital is not just to go digital. ‘Cause at the end of the day, everything digital ends up analog, right? ‘Cause we’ve gotta go back to the patient’s mouth. So the key there is not necessarily digital for the sake of digital, it’s how well can we do analog? And what’s kind of ironic with that is we’re reaching the point that digital, at least in certain arenas, does analog better than analog. And that’s kind of spot where your mind kinda goes, wait a minute, what’s going on? Like, where are we at with this? And I think that’s really the take home on all of it is, some of the things we looked at with the articulation, things were meant more to bridge the gap because you had this fear, right? If I went digital, how can I go back home? Am I stuck? How do I get out of the pool if I jump in the deep end? And the reality is, I think we’ve got the capability now to seamlessly go back and forth between analog and digital. And that gets rid of a lot of the hurdles for people. Because if you can go back home to what you’re used to at any point in the process, it makes it easier to try something. The nice thing with digital in a lot of ways is that once you’ve got the technology, it really doesn’t cost you much to try something. It’s kinda like a video game, right? I grew up as a kid playing games and if you’re gonna go fight the Bosch, you save the game right before you go fight them. So if you screw it up, you just turn it off, turn it back on, you’re right back where you were. And that’s the same thing with digital. If you wanna print something or design something and you’re at a spot where you’re kind of sketchy, if this is gonna work, save it and you try it. If it doesn’t work, you reevaluate. Go back and, you know, go back to the other methodologies on it.  [Jaz]So Seth, I was at a lecture by John Cranham in Copenhagen just last week, and it was about the cosmetic occlusion workflow and then how much of what he’s doing is digital like you, and he made an interesting point, which is very relevant to what you are saying about, okay, you can still go back to analog. But an interesting observation that John made is that nowadays with the new grads coming through, because they never got to or they don’t get to go and wax things up and mount an articulator. He was worried that when they go straight to digital, that they be missing out a huge chunk in education. They may be missing out in terms of the why or the foundations of it. But actually, he concluded that it’s not really a disadvantage at all because they get the concepts through digitally and for them they kind of bypass the whole analog and that’s not necessarily a weakness. What do you think about that? Do you think the new grad, the new generation coming through, all they’ll ever know is digital, is that a bad thing or is that a good thing? [Seth]Yes, and the reason I say that is I think it’s the correct answer for both. Yes. Bad and good. For a couple reasons with it. I think understanding where we came from is important because it lets us, from a chronology perspective see how things evolved. It also gives us the capability to evaluate is something new really better or is it just new? And I think if we don’t have that lens of being able to go back and reference that, that can be a problem. And then the other half of that I would answer is right now, except for a very, very small percentage of people, analog is how we do articulation. And if you don’t understand how we do things, the analog with the facebow, the articulator programming and it’s relative strengths and weaknesses, it doesn’t allow you to manage the miss and handle that instrument appropriately. And when I say that, ’cause we’ve always used the analog articulation and it was the best that we had, but it’s not a exact representation of the patient. And so if we don’t have the capability to be absolutely accurate, we need to understand and try to control our misses. And that was basically the strategy with how we program the articulator, how check bites work, even just all of those things with the analog instrument. And to understand that basis and where that came from, I think you’ve gotta have a little bit of the analog side of things. Now, fast forward 20 years when the technology is different, and we may have digital axiography and all these things being more ubiquitous, it may be a different ballgame because I think that’s the big debate that we look at now, is instead of resigning ourselves to a certain level of inaccuracy, can we shrink that error and make it where we’re really shooting to hit the bullseye as opposed to just being on one side of the dartboard or the other. And I think that’s really the next evolution and where things are going, but that’s also where things are developing currently. Maybe the state of the art is how do we handle that? How do we think differently? How do we design differently? How do we really try to build that in to be more efficient chairside doing it.  [Jaz]Well, you mentioned axiography and so from my younger colleagues. I’m gonna just get you to define that in a moment. But just one part of your journey, which I’d just love to know is two part actually. The role of mentors in you uptaking digital and really going for it. And also your source of education and comprehensive, because not every dentist is gonna think about going home and waxing up, right? It’s really you enter the stage of comprehensive dentistry. So tell us about your background in becoming a more comprehensive dentist and the role of mentorship that you may or may not have had when you were moving digital. [Seth]Absolutely. I mean, failure is a great motivator, right? And you get out and you see something and it doesn’t work, and you try to figure out why. And initially my goal for going more comprehensive was I didn’t like redoing things, and you don’t like disappointing patients, and you wanna try to give people the best that you can. And then, we realize when you graduate, the education’s kinda lacking in a sense. I don’t mean that to be despairing, but just they don’t have enough time in three or four years to cram in just even the basics, let alone trying to figure out bigger, comprehensive things. So I started going down the road initially of figuring out, there’s a lot I don’t know, and where do I start? So I went down, ideally a comprehensive pathway. I started with Spear kind of going through that continuum on it. In looking at it, going back, just the basic training, that’s where you started looking at the bigger picture. How do I need to understand joints? And I don’t know how the education is over there on the UK, but we spend maybe two hours talking about joints in dental school. It’s abysmal. And they just basically tell you if you suspect intracapsular issue refer, and when you start looking at patients, especially the ones that need restoration, the chances of having some issues at the joint level go up tremendously. Because in my experience, people with healthy joints structurally intact, joints, good anatomy, barring a couple of exceptions, really don’t thrash their teeth. And so we’ve got stability on the back end of the system, more on the posterior determinants that nobody talks about. And so, starting to understand failure, you look at, a Monday morning situation, you go to the office and patients fracture the distal lingual cusp of a lower second molar. You see the big wear facet, you see the cupping, your brain’s looking occlusally. Like, we have some issues here. We may not have vertical at the joint. Like we want all these things. And that’s the one that’s the frustration coming out, right? Your new grad clinician, you prepped the tooth, get everything ready. A team member comes back, I’ve got no room, I can’t make a temporary. And you know you did the reduction, you checked everything out, it’s like, what the heck? And you go back and reduce some more and you’re still outta room. You do some more and you’re still outta room. And now you’re thinking, do I need to talk to this patient about endo? What are we looking at? Because we’re running outta space to reduce. And these are all conversations that I would much rather have on the front end of the system or the front end than an excuse on the back. And so it was just the school of hard knocks a lot of ways trying to figure out, okay, why did I not catch this earlier? What can I do to try to make that better? And that’s what kind of got me started on it. And then the digital side was more initially from the scanning, just the practice builder. Just nobody likes impressions from the patient perspective. And so it was initially kind of a builder to say, all right, we can get you in and we can do the diagnostics and we can take the mold or whatever we need to do and not have to have that analog experience in doing it. And with that, that was probably my initial motivation to try to figure it out is if more patients are able to say, yes, we can help more people do more things, grow the office, all the good parts that come around that. But early on, scanning was tough. I mean, it really wasn’t accurate. At times, depending on when you did it, we didn’t understand the limitations of what the machines can and can’t do. And sometimes we’re trying to fit a round peg in a square hole in the sense that, that’s not the right modality to fix the problem that we’re going after. And I think even today, that’s where a lot of people run into issues, is we listen to the reps and who’s selling the scanners and oh yeah, you can do everything with it. There’s no limitations. And then you quickly find out it doesn’t always work like you want. And there wasn’t really a support system to help people troubleshoot that. You know, when I started doing a lot of the digital stuff, there was no manual in any of it. So we try something, I would go to lab groups and look at their forums and ask questions. And sometimes in Dentaltown may have it or just honestly Googling it, trying it, trying to figure out something that did it. And my background in college, I was initially electrical engineering and computer science. So I like technology, I like all these things.  [Jaz]It all makes sense now. Every podcast with a guest, I have a a click moment where they mention something in their journey and it’s just like, oh, that’s why he’s into this. That was your click moment for me.  [Seth]Okay. Yeah. And I got to third, fourth year university and I really liked interacting with people. I didn’t wanna write code behind a computer all day. And my younger brother who’s an oral surgeon, we were, nobody in our family was in healthcare. And my dad was like, well, what do you think you wanna do? He kind of thought dentistry or medicine, and he’s all right, well go volunteer in a bunch of offices during the summers, just sweep floors, pick up trash, just watch and see what you think you wanna gravitate to. So we went to all the different kinds of offices we could find, and dentistry kind of clicked for both of us. Just different specialties in doing it. But when you look at it, you see how things work and you see the workflows and you see the inefficiencies. And that’s when it kind of started putting together, at least in my head. Okay, some of these digital things offer an opportunity and if we can implement them correctly and kind of put together a framework that allows us to do that predictably, I think that’s when it really takes off. And I think that’s what you started to really see the last five to 10 years is a lot of the wrinkles that get worked out. People have beat their head against the wall, figuring out the initial hurdles, and then that makes life easier for everybody else. If you’re willing to share and say, here’s how we did it, this is what I would avoid. How do we move forward with something in a framework that’s much easier to implement on it? And that’s really kind of what got me into it, is I was willing to play with things and check it out initially, and that allowed me to have the experience to share it with other people. Okay. If I was starting today, here’s how we do this. Where would I implement, what would I pick, what order, kind of all those things to make that a much less of a headache, putting it in and actually a benefit for the practice. [Jaz]Well, as we evolve this discussion now, I think the first thing I wanna know from you is, are you fully digital now? Let’s say you have a wear case. Are you at any point picking up your analog facebow and then working on analog articulators to wax up? Or have you got to a point now whereby the trust and the faith you have in your digital workflow, it means that you can do it fully digitally? [Seth]Fully digitally for I’d say 99% of it. Now, we’ve got some capabilities now where we bring the mounted models based off the CBCT positioning on an analog instrument, but that’s mainly for the lab to finish the final restorations. And you know, because like I said, the whole point of digital is to go analog. So we’ve gotta go back at some point. And that was one of the main hiccups is you’ve got these unmounted models and you could check contacts and things, but when they wanna do the final finishing, if they stain and glaze and all the little hand touches that they put on, we really didn’t have a good way to evaluate all that. And that’s where, we came up with the jigs and the ability to basically add attachments to the printed models that precisely replicate the position on the analog instrument that we had on the digital instrument. And that gives us a number of options we didn’t have in the past. So now predominantly for the lab to check, but early on before we had the trust, it was more to give us the capability to go back and forth when we need to. And the biggest thing that a lot of people don’t understand is whether you’re taking an analog impression or sending a digital scan at a lab, you’re probably digital either way. And the reason I say that is what is the lab doing? They’re scanning your model, the models that they make, virtually designing and waxing everything and then bringing that to you at the end of the day. And so, that was kind of initially the knock on digital was, it’s not accurate, all these things. And then people didn’t realize you’re digital regardless. You just don’t know it yet because it’s such a small percentage of labs now that are hand waxing, hand investing, doing all those things. And they realize the efficiencies that we gain doing it a long time ago, and they’re doing it at scale because they’ve got more restorations, more clients, they see more things that we’re gonna see as individual clinicians on a daily basis. And then the next reason that we did that predominantly was, if you send your scan to the lab or you’re just sending impressions in a facebow with no check bites, ask the lab how they’re programming your articulator. And if you don’t know the answer to that question, I think it’s a worthwhile. Path to go down. Because the reality is we’re giving the labs many times, part of what they need. We can give them some information to help with the static relation. But when you do an articulation, there’s two types. So you have your static, which is your relation, the maxilla to the hinge axis, but you also have your dynamic relation. That’s your programming on it. And before we had the digital axiography, the patient motion, the mod jaws, that kind of thing, we didn’t really have any good ways to derive the programming values for the dynamic side with a digital scan. They had some programs.  [Jaz]So, to clarify, talking about the condylar guidance on the articulator and-  [Seth]Correct. Because you think with analog instrument, you take check bites, right? Take your protrusive bites or your lateral check bites. When we had our mounted model, you would put those check bytes on and that’s how you program the po, the back end of the articulator doing it digitally. And my argument is the most compelling reason to go digital, quite frankly, is the virtual articulator because it’s got many more or much more capability to replicate patient anatomy than the analog. But what was simultaneously, I think is potentially its biggest strength was also initially the biggest weakness. And that the virtual articulator was great, but you had no way to program it. And because of that, it wasn’t really useful. And for a long time, even with the design softwares, ExoCAD three shape, those kind of things, labs weren’t even buying the articulation module. They would just have it purely as a clap clap type scenario because they didn’t have a way to program. And the reality with that is, and when I started looking at the softwares kind of playing with all this stuff, I quickly realized we need to know what the inputs are and what it’s capable of as clinicians, because it’s really more designed for us in the lab. Once you realize that, and I said, oh, if I give you X, Y, and Z to my technician, they can execute at a much higher level because we’re giving them better input. And that was really what kind of started me thinking, okay, how do we drive these values? How do we give the lab what they need to execute at the highest level possible? And once that happens, you start to collaborate more. You realize some of the synergies and the software, your collaboration on design goes up to another level. Because we’re no longer like taking snapshots and emailing pictures. They can send me the entire scene file, I can go through the software, change the wax up, manipulate it, do all these things in real time, and it’s much more efficient and it gives me the capability to visualize the case much more efficiently on it. You know, because really with digital, the advantage lies in twofolds. Computers are very good at aligning things and they’re also give us the capability to combine different records that aren’t able to do that we can’t do in the analog world. So that’s why you can stitch like your CT to your intraoral scans, to your face scans, your photography, and it gives us the capability to layer the patient from a diagnostic perspective. And that’s something that analog, you can’t take a pano, combine it with your CT or your articulator. They’re all different media and because of that, we lack the ability to cross over.  [Jaz]That’s what excites me the most, Seth, I mean, just that stack is just phenomenal. I’m not there yet, but in my journey, that’s what excites me the most. The fact that the capability to layer, just like you said is phenomenal. What I wanna draw now is some, some ideas for those most dentists who may be listening right now are probably analog, right? For this part. They may be scanning, but when they have a comprehensive case and they wanna do kind of a wax up, they’ll then be getting their face bow out. And the ultimate goal is to try and get the movements that you see on the screen to be somewhat identical is a strong word, but similar to the real movements that you have in the mouth. We all know the TMJ is the best articulator, but when the mandible, the digital mandible moves to the left, it moves in the same way that the patient’s mandible moves. So now that you’re using a digital workflow, please explain, instead of using a analog facebow or an ear bow, what are we using to capture the relationship of the maxilla to the condyle? How are we doing that digitally so that we can actually, get represented cans and whatnot on the digital articulator? [Seth]Sure. Well, and there’s a couple different ways to accomplish that. When we talk about, you know, ’cause you’re asking about static relation there, which is gonna be the first part of the articulation, the mounting side. And when we talk about static relation, it comes in two flavors. We’ve got an anatomic relation, which is purely relating condyles to the hinge axis. Then many times we’ve got an aesthetic relation, which is relating things to the horizon, and those are both important because they allow us to do different things. The patient, if you’re trying to get the instrument to mimic the patient anatomy as best you can, you ideally want an anatomical relation, right? Because we want to get things as close as possible to the anatomy. But with their technicians, many times we send ’em a scan and that’s all they see. They don’t really know where the horizon is, they don’t know where the cant is. We’ve gotta give them more information to capture that and that’s where the aesthetic relation comes in. You know, Dr. Kois did a lot of work with the Kois boat and it’s not necessarily, it’s an average value relation anatomically, but what it does to do is correct the cants so that you can wax in a way that gives us aesthetic results that are coherent with facial anatomy and what we’re looking at from that perspective. Interjection:Hello again guys. Another interjection for this episode, Kois Bow. What is Kois Bow? It’s named after the legend, John Kois. And I try to like find some visuals or clips for those who are watching. Obviously for those who are listening, I’ll make sure you can follow along. But I have to tell you that the video I found is like it needs an update. Maybe I didn’t look properly, but the video is from John Kois and it’s like from a long time ago, and we know it was uploaded 12 years ago, but it looks like it’s from a lot longer. And it literally looks like someone is doing like a facebow transfer or a facebow recording on what someone who looks like John Travolta basically. And that’s what I’m seeing at the moment. And so essentially, you know that fox’s guide plane we used to use for like dentures, right? Complete dentures. You get that fox’s guide plane, make sure the cant is good. You look from the front and then you check the occlusal plane from the side. Well, it kind of is what a Kois Bow is like. It’s actually properly called the Kois’ Dento-Facial Analyzer. And you don’t need like a traditional face bow if you’re using this. But the real advantage of this is that how it prioritizes the aesthetics, because you’re looking from the front, you’re making sure it’s all level with the eyes and you’re looking from the back and you can use an aesthetic plane. So you truly are using the aesthetic relation rather than the anatomic relation. And now in combination with the Kois reference classes, the Kois group are really taking this to the next level. So this led the ideal of using the aesthetic reference back to the episode. [Seth]We did that with the ear bow for a long time. And we’ve got a lot of literature with the regular face bow that on a good day it’s gonna get us within five millimeters of the true hinge axis, which sounds like, okay, we’re pretty close in doing it. But now that we’ve got this digital data and more things at our disposal, many times now we’re using a CT initially to do that hinge access relation and it makes sense. ‘Cause you know, the facebow, the whole point’s to capture the maxilla relative to the condyles. If you have a CT of adequate volume, you’ve got the condyles, you’ve got the maxilla. If you take that scan in a seated position, all the anatomy is there that you need for the relation. So how I’m doing that today in the digital side, if we’re not doing axiography, and I’ll kind of get off on the nuance of that in a second. You’re aligning an intraoral scan to your CBCT, and then once you do that in the software, you can move them as one cohesive unit. So then I’m overlaying that on the virtual articulator and you just position the condyles of the patient over the articulator condyles, rotate it till you- intraoral planes parallel to the upper member. You’ve got all the information you need done with it related now that’s gonna give you.  [Jaz]That’s the ultimate then. Using the CBCT to use, essentially got the skull of the patient, the maxilla, and you are manipulating the articulator relative to that. And you can see the condyles. There’s no guesswork. That’s amazing. And so that is, would you say the most accurate, is that what the evidence is saying as well?  [Seth]So we’ve got literature now. There’s a paper that was just released that was interesting. They were comparing clinicians and they were given a multiple trials, I think it was 15 times for each clinician and they, versus an analog facebow positioning it. On a reference model and then translating that to the analog instrument and then doing the same thing with the CT and aligning the scans and transitioning. Once they did it, they scanned the final mountings on both and overlaid all of them to get an idea of how repeatable is each one, and also how close to the hinge axis of the analog of the reference instrument. The final results were. And what they found is they confirmed with the ear bow still five millimeters, it was like 5.2 millimeters plus or minus two. What was interesting is that you had better repeatability and closer to the actual anatomy doing it with the ct. So they found that the rare, there was only two and a half millimeters plus or tip minus a little. So they cut the variance from the hinge axis in half doing it on the digital side already. And I’ve got that article. I can’t remember if it’s pre-press or it was just published in JPD, but it’s interesting ’cause we’ve already cut our error in half. Just going through that method with it. It’s also something that’s easier to store because you don’t have to worry about, if you take your facebow records, some people don’t wanna mount it in office, they wanna send it to the lab. It gets beat up, distorted in the process, the wax melts. I mean, any of the things that go into potential sources of air and doing it. And that’s one of the other nice parts on the digital side is record storage becomes much easier. That record on the CT, if we align, it’s gonna be equally as accurate 10 years from now as it is right now. And not that you would need it that far down the road, but it gives us the capability to keep things on hand, replicate things with a higher level of accuracy. And it makes that aspect from the maintenance side much easier to do. And so CT, if I’m on that respect, I think already is cutting the air in half. Now I know sometimes you can’t get the CT and then there’s concerns on your radiographic exposure, things like that. And many times if I have a reason to get it, that’s where I’m using that as well as kind of an ancillary benefit. But the other part we talked about was the patient motion, and you’ve got ways that you can do the articulation now that don’t require-  [Jaz]Before we get to the articulation, ’cause I’m really enjoying this bit on the static relationship. You raise an interesting point there about the radiation, right? So I think where I’m getting from you is that if the sole reason for the CBCT is to help you align it on the digital articulator, then that’s probably unjustifiable or justifiable. But if you’re also applying some implants, you might as well just get a bigger field of, you get the condyles in and for that sake, a little bit more radiation. You’re getting a better programming. Can you just give us some clear guidelines on what you are practicing?  [Seth]Sure. Well, let me maybe backtrack just a little for reference. So, we talked about allowing the CT, the intraoral scan in overlaying that on the virtual instrument. And the virtual instrument is a carbon copy of the analog. Everything is identical. Same programming inputs, same dimensions. They move the same if you have models in the same positions with the same programming. So in a sense, interchangeable in that regard. And when I started overlaying scans of patients on the instruments, you very quickly realize they don’t match very well. And that was kind of a light bulb moment for me. If you look at the semi adjustable instrument, at most, every intercondylar distance is set at 110 millimeters and you start to unpack where did that number even come from?  Interjection:Hey guys, it’s Jaz with interjection number two. semi-adjustable articulators, okay. Briefly, right, that 110 millimeter value is from like one condyle on the articulator to the other, condyle on the articulator. And this is where some inaccuracy comes from. ‘Cause you know, if you look at the average person, fine, they might be close enough. But we have a huge variation, lots big heads, small heads. And so this is a source of error and just getting very primitive for the function of a semi adjustable articulator is that its purpose is to replicate the mouth. So when you’re doing a wax up on the articulator and they transfer it to the mouth, we hope that because you use an articulator to create the jaw movements, that it will be similar in the mouth, therefore, least adjustments as possible. But we all know the best articulator is the TMJ. And now obviously this episode’s all about digital articulators, which will eventually fully replace these physical articulators. But when you understand things like this fixed distance of 110 millimeters, or the fact that in a semi adjustment articulator you can change the condylar guidance angle to help improve your accuracy, these are some things that we should know about analog articulators. Back to the episode.  [Seth]It was kind of an artifact originally on the Lee panographs that were courting elements on those back when they were doing the old school fully adjustables were at 110 millimeters. So when they moved it over to try to make the analog instrument match the patient tracings, they put the condylar heads at the same width so that they could make sure the movements were one-to-one in doing it. What’s interesting is you start looking at actual patient anatomy. Nobody’s at 110, and I’m talking even at the lateral poles. Generally, if I’m doing my virtual articulations for splints and things, I’ll measure from the midpoint of each condyle ’cause I think that’s kind of probably the middle of the road. If you take in a heat map of activity with lateral and rotational movements, it’s probably somewhere in the middle. But even then, on a lot of patients that need restoration, the articulator at 110, they’re at 75, 80, 82. And you start thinking, okay, you got 30 millimeters of shift. When you start to model that digitally, it’s interesting. So you can take a model on an articulator. Have the 1/1oth intercondylar distance and if you’re measuring the distance from each condyle to like midpoint between the maxillary centrals, changing the intercondylar distance to correct it to let’s just say from 110 to 80 will shift that link to the central seven or eight millimeters on each side. And so what initially got me looking a lot of this is, yeah, I’ve got a practice that we’ve got a fairly heavy joint based diagnostic component to it. And so I see a lot of patients with compromised joint anatomy and invariably we make these patients appliances at times to see if we can change the load at the joint level to facilitate adaptation and healing as best as we can before ruling out surgical intervention, those kind of things. And I would go through the same process in every patient, take your ear bow, facebow, get everything done, have a splint made. And sometimes the splints were 20, 30 minutes easy for like a flat plane group function appliance. Other times it was an hour and a half and I’m like, what’s the difference why are some of these so much faster than others and you start trying to investigate that. ‘Cause initially you think, okay, the lab screwed it up. I’m gonna do it all myself. Started making ’em myself. Same thing, same variability. It wasn’t until I started overlaying these scans on the articulator and comparing the patient anatomy to our instrument that I realized some match better than others. Some are more average than others. And the patients that were a better match to the analog instrument, the adjustment times were lower. The ones that varied more, we were working with poor data on the input, which is makes perfect sense while the output doesn’t match. And we see the same thing clinically. There’s times, you’re doing a rehab and you insert it and you’ve got minimal adjustments, and then you’ve got the other, where it looks great on the analog instrument or the articulator, but you go to the mouth and the guidance isn’t right and you’ve gotta go in and grind a bunch of things. And we’re getting a more compelling body of literature that there’s not a single restorative material on the planet that benefits from adjustment. [Jaz]That’s very true.  [Seth]And with zirconia especially, if you sue on them, had some date, literature out that the minute you touch it with a bur, if we don’t refire it, we’re losing 50% of the strength. Then they probably, if we’re not firing it to heal ’em and maybe 1% of people are re firing everything after adjustment. It just doesn’t make sense from a practicality perspective. So all these benefits that we’re seeing with zirconia being the strongest material and all these things, you take half the strength away, we’re below Emax immediately. And you start wondering, okay, maybe that’s why we’re seeing some failures in certain places we didn’t expect. And there’s a number of factors that play into that. But the take home there was many patients don’t match our instrument. And especially the ones that I see that need more comprehensive restoration, when the joints aren’t structurally intact, the growth gets to be altered and you lack projection. They end up being class two. It’s the same difference in orthodontic practice. 80% of ortho patients are class two. And the reason is the back end’s not growing like it should, which leads to compromises on the tooth position, on the front end of the system.  Interjection:Hello, Protruserati. Jaz here with some injections, right? So this episode, because it’s about occlusion, because it’s about our articulators, we need some interjections just to make sure everything’s really tangible. So the point Seth is making here is that many class two patients, class two, meaning, large overjet classically in a class two div one. But if you think about the causes of a skeletal class two, well, it’s either that the maxilla is too big or it’s the mandible that’s too small. That will create you a class two skeletal pattern. And so what Seth is saying, and he is totally right, is that the main cause of class two is that the mandible is too small. Not necessarily that the maxim is too big, but the mandible is too small, it’s too set back. It is retrognathic in nature. It’s smaller and set back in nature. And, and the final distinction here is he said poor posterior growth. And what he is referring to is the condylar growth and the health of the TMJs. So someone who does a really good job of talking about this is Dr. Jim McKee. Jim’s a previous guest on the podcast, Jim McKee, came on the podcast before, talked about piper classification, but he’s brilliant at talking about this stuff. And essentially if you have a destruction in your TMJ, in your growth years, during childhood, during teenage years, then that condyle and that posterior mandible will not develop normally. If that doesn’t develop normally, then that will contribute to a class two because it’ll make your mandible deficient. So just making that important distinction. Once again, if you’re enjoying these and these are helpful, please comment, let me know. The last few times I’ve done this, everyone’s been saying good things generally, and so we’re kind of keeping it in the podcast, but there’s still time to say, no Jaz, this is not good, so you gotta let me know. Back to the ep.  [Seth]My wheel spinning on that was, okay, how do we make things better match the patient? Because at the end of the day, that’s the goal. Legacy concepts, if you look at how we did things, it was more about making our patient fit an analog instrument. It’s a fine point, but instead of making the instrument fit the patient, we are making the patient fit the instrument and trying to control where the screw up was. And I think that’s where I was kind of alluding earlier that I think is the biggest difference we’re going to see is we’re switching the order now. We’re actually truly trying to make what we’re doing digitally truly match the patient as opposed to forcing them into a box that they may or may not conform to. [Jaz]So with the digital articulator, then that intercondylar distance, can you just simply just plus, plus, plus minus, minus, minus, and change that seamlessly?  [Seth]So on some, yes. Some programs, yes. Some you can. Others you gotta be a little more adventurous and maybe go into the code and tweak it. Like ExoCAD does it let you do it off the rack. But there are ways to go about it, but the digital axiography side overcomes that limitation as well.  [Jaz]So tell us, what is axiography tell us the definition. What is axiography?  [Seth]Sure. Yeah. So initially in the analog world, it came from the fully adjustable articulators where they would go in and they had an apparatus that went on the face that attached to the lower jaw. And as it moved, it made physical tracings on paper, on recording elements. And that’s how they use that to program the analog instrument. They would use that to find a hinge axis and you could actually change all the parameters on the D5A Denar and some of the old, fully adjustable articulators. And it was a great way to match the patient as best we could, but it was cumbersome. It took a lot of time and it a lot of effort. And what they found was most people weren’t gonna do it. So we started going then to semi adjustable where you only have a few things to input, but you try to manage the miss so that the analog instrument is designed to, as a general rule, be flatter than the patient’s anatomy. And that’s a benefit, right? Because if the instrument’s flatter as we grind everything in the accessory, cus pipes are shorter. So when you go to the mouth, you have a steeper disclusion, you don’t have interferences. And that works great if we’re trying to execute canine guidance where you only need to have one plane steeper than the others and things come apart. But when we start having to do these progressive group functions and other things where patients may need more support at a joint level, it gets a lot harder to accomplish. So what we started looking at on the digital side is we’ve got ways now to capture all that data much more seamlessly. And these would be like Zebris or Mod Jaw or the different, you know, digital axiography or sometimes term patient motion that you see. And what it really is, honestly, it’s a high speed camera that sits in front of the patient. There’s reflectors that are fiducials that get attached to the lower arch. And as the patient moves, the camera’s just purely articulating and capturing those movements at very high resolution relative to a tiara they wear that gives you the reflectors for that upper arch. And once you have this data, it can be brought in seamlessly into your design software, like ExoCAD or 3Shape, and it comes in fully mounted. The articulator gives you programming, so you’ve got all your programming already done. And where it overcomes the analog, the virtual limitations is you actually have the movement on the screen. So I can take you through protrusive closest speaking space, left and right, para function. You can even have the patient chew and eat and masticate. And what you start to see is, articulators mainly on the bench work inside out. You start it static and you go into discursive this way. Where the form really meets function is when patients chew. They’re not starting in and going out. They’re coming out on return stroke in, and there’s a lot more variability and a different dynamic to that than we’re used to thinking about. And because of that, that’s just data we weren’t able to capture ’cause you can’t replicate on analog instrument, any of that. Where we now, when we start to see it digitally, one of my preferred workflows now in any case is we virtually wax the case up ahead of time. We go to prep. And when we’re doing our provisionals, I’m not relining provisionals or doing shells or doing full arches anymore, we’re virtually combining our definitive prep scans with the virtual wax up and 3D printing. The provisional is fully contoured. So everything is two year definitive margins. There’s no reline. It allows us to do like full arches of single units now, which is huge for hygiene staging. It makes life so much easier ’cause now you know, if you’ve got a full arch maxillary restoration or provisional. The worst call you get is Ms. Jones calls one of ’em chipped. Okay? Which, where? Where did it break? What do we gotta do? There’s nothing more inefficient to try to patch or take off a full arch provisional. Doing it as individual units is massive because now which one chipped number five. I can have number five reprinted before the patient gets the office. The characterization is done. We verify that the scan was accurate initially when we did it. So I mean, I hardly even have to see the patient. We can go in. Assistant can see the provisional, make sure everything’s good. I’ll come in, double check the bite, figure out what went wrong. And it’s just a huge time savings doing it. [Jaz]And these 3D printed provisionals are like a temp bond, placed in. Is that how you’re doing it, like temporary cement and then you are giving some time for adaptation and checking whether you are happy that the patient’s TMJ is articulating as you planned for everything in the design stage? [Seth]Yeah. Generally, I like Duralon for the 3D printed provisionals just because I think I’ve had better success with that, but just from a long-term maintenance perspective on it. But exactly that. And it gives you the capability to one, verify everything, right? Especially on the aesthetic side. Do we like the tooth form? Do we like the shape, do we, is function what we want it to be? And even though you can plan everything digitally, I feel very to very high level. The patient articulator is always the final judge. And because of that, I still always want to give them some time to evaluate and check and make sure we’re on a path that we like. I also like it from a phasing perspective because, I mean, that’s the biggest issue that we see a lot of times is, if a patient is of more modest means, affording a full arch at once can be very tough. And so it gives us the capability to phase cases differently. So as opposed to, let’s just say they’re in an insurance environment, they can do two crowns a year. We can initially get the case stable with the 3D printed provisionals, get everything where we wanted as individual units. Well you’ve already got a fully designed crown, you’ve already got your master scan, your margins are done, everything’s done. I don’t need to bring that patient back in to prep and press two crowns a year. I can send those to the lab, have them turn it to our definitive material, bring the patient in, pop those two off, put the provisional, their definitives on a ceramic. They’re not having to come back to the office to repress, they’re not having to do any of those things. So now my chairside efficiency goes dramatically in doing it. I also like it because it’s easier to maintain those patients ’cause if you wanted to maintain a phase a case over two or three years. If you’re doing it splinted, you worry about hygiene, you worry about can they get in there to clean all the different things. As well as, two years is a long time to trust any provision without something going wrong. And going in and remaking a full arch provisional could be three, four hours by the time you get it off, clean it up, have everything redone. Now it’s literal 20 minute visits ’cause you know, individual, which unit broke you can accommodate for all that. And the next objection or question that sometimes gets asked is, well what if they wear change over time? Well if that happens, you just bring the patient in and re-scan for the occlusal changes. The lab can combine that seamlessly without having to redo all the other parts. And you can adapt very quickly to anything that happens when you do it. And that’s probably, honestly my best part of doing this digital now is I really don’t, it’s taken a lot of the stress off full arch provisionals, bigger case temporization, and even the stress on my body doing it. ‘Cause now a lot of times we’ll do in demand design with my lab technician. So if I’m gonna prep the maxillary arch at eight, I may tell them to definitive scan by 10:30 or 11. I send the scan off, the wax ups done. I can go have a coffee, hang out, take a break. My designer will virtually combine the two 30, 40 minutes later, all the files go to my inbox, drop ’em on the printer. It’s a 15 minute print, 20 minutes to characterize, which I can have my team do that in the back and I’ll come back 30, 40 minutes later to see all of ’em when we do it. And so, huge difference. And you could go see another patient if you wanted to. I prefer to sit and take a break and I don’t, prepping is tough. And it, and to me, if you want an argument on why to go digital doing it, that’s it. I mean, it’s huge and not that you yet necessarily have to start at the full arch level. Take the scenario where a patient comes in, they chomp down number 19 and shattered existing crown. So you’ve got no crown, new patient, no matrix. And that’s always a time consuming deal, right? Because you’ve gotta figure out, okay, did I put a stainless steel crown on and take a matrix? How do I get something to make a provisional crown for this patient? Well do it digitally. Get everything prepped, get everything where you want it. Pack your core, take your definitive scan. You can virtually wax the tooth up in two minutes, put it on the printer like the Midas now from SprintRay, you know, seven minute print and then five minutes post-processing and you’re ready to go. I mean huge efficiency perspective.  [Jaz]I mean this concept of putting your cord in and scanning for the definitive has so many advantages. Like you said, I mean, I guess there was a phase where people might have been doing the rough prep, then putting temps on it and then going back and refining it. I mean, what a service to our patients, not only just time, but comfort. This whole digital workload you described really is fantastic. But one thing we touched on was yes, getting the static right, and then we touched on axiography, and you mentioned about motion collection. But in terms of actually the articulation, what are you currently using? You described all these, I mean, are you using a module at the moment? How can we make sure that when you put it on the digital articulator, yes, you’ve got your CBCT and the condyle and you’ve lined that all up to give you sort the best idea. You’ve got the cancel correct, but now the actual motion, what metrics are you using or what can we be recording chair side to make sure that the kind of checks that we have so that when you move the mandible on the screen, it’s like the patient moves.  [Seth]So two ways of looking at it, one is we try to match the patient precisely, and that’s where I think you’ve gotta have the digital ay side of it, just because there’s no way to capture those movements, mod jaw, debris, any of those that allow you to capture. The other is we get the better static relation using the CT. So we’ve got a better initial starting position, but we still have to use analog check bites. That’s the only other way to derive those values. And the way that we would do that is we’ve gotta get the model in the identical position on the analog and the virtual instrument. So if I’m not using Mod Jaw on these scenarios, what I would do is take my CT, align that to the analog instrument and my project, a few years ago I was working with AD two, which is an articulator company. It actually came out of AES. it was maybe four or five years ago at AES and I was taking a break walking through the vendors and Dave who owns AD 2, was at the booth. I saw he had a jig in the back. It was kind of, one of the jigs for putting a printed model on an analog instrument. It was kind of more akin to what Dr. Kois and them were doing with their analog jig, with their average value jigs that they had. And we started talking shop a little bit and I said, if you figured out how to position the jig coordinates, where it loads relative to the virtual instrument as opposed to the model. And that was what I was working with ’cause initially I like ExoCAD for doing a lot of this, but ExoCAD has a different global coordinate positioning system than 3Shape does. Where 3Shape positions, everything relative to your scan. ExoCAD has a global positioning relative just to that reference. And that sounds like we’re off in the weeds, but the significance of that is I was able to encode the positioning of a virtual attachment in ExoCAD. Not relative to the scan, but relative to the articulator. So when you add this virtual attachment, it loads in the same position relative to the virtual instrument, not the model. So the benefit of that is when you use the CT to position the model, the attachment loads relative to the articulator. So as long as they intersect, when we print those as one unit, it puts it in the identical position on the analog instrument with the same jig.  [Jaz]So you don’t need to get the mounting stone and that kind of stuff, right? [Seth]No, never that. Exactly. And what that allows you to do is, we talked earlier, we have the same programming, same dimensions, same instruments. If the models are the same in both, I can now take my check bites on the analog instrument. So take your protrusive bites, take your lateral bites program, the analog, and I can plug those values directly back into the digital. So now we’ve got the dynamic movement programmed without having to guess. The downside to that is we’re still resigned to the same miss, right? Because the analog instrument can’t precisely replicate the movements. So we’re gonna have accurate programming on the analog to give us the flatter movements, the things we’re desiring, but it’s not going to be the highest level of replication of the patient. And so, depending on where you’re at in the process and the adoption, and to be clear, yeah, if somebody was asking me today, what order do I get these things in? The motion side is the absolute last thing you need. You need to be scanning, you need to be comfortable with the software, you need to be 3D printing all those things. Because if you don’t have those tools in your tool belt. You can’t really take advantage of what the motion offers in that scenario audit. So from that perspective, that would be where I would tell you to start is if you’ve got a scanner, you’ve got one of the more expensive pieces of the puzzle, but you need to get comfortable with software because the software is what’s going to allow you to manipulate the data and actually do something with it that’s productive, both from an efficiency and an ROI perspective. Because when you send to the lab, you really don’t gain much. But when you’ve got the software in-house, if you wanna 3D print the provisional, that’s where you gain the time on. And the other deal I didn’t even talk about is 3D printing than the provisionals is less expensive than using bisacryl. [Jaz]Oh wow. I didn’t know that.  [Seth]Which is huge. Yeah. The average bisacryl in the US is about a 1.50, a provisional. I can print them, if you’re using, depending on the resin, it’s usually 60 to 75 cents per. So you’re already cutting your cost by more than half.  [Jaz]Something that’s stronger and better fit and all those advantages for something that’s way less that, I didn’t know that. That’s amazing. [Seth]And that’s where you start to actually pay for the digital stuff, right? ‘Cause when you buy a scanner, the rep’s always saying you’re gonna save $20,000 of poly vinyl. Well, yes, but over five years. And they don’t tell you the monthly fee on the scanners and the maintenance. And what if things break when you’re just scanning, you’re really neutral at best in terms of the financial side of things. But when you start doing provisionals, okay, now we’re saving 75 cents to a dollar every time we print one. You do a splint, a digital splint from a labs 150 to $200. It costs you $7 to print a model is $4 to print, which sounds okay. It’s cheaper on its own than doing mounting stone and all the others. But now when you’re doing a wax up. A wax up in the US is 50 to $75 a unit virtually, it costs me $4 just to print the model for the stent. And so a 10 unit wax up, 700 versus four. It doesn’t take you long to actually start to pay for all the technology you wanna bring into practice. And that’s something that many times isn’t talked about because as clinicians we’re always looking at what’s best for the patient. But the reality is we have to run a business because if we can’t be profitable, we can’t pay our team and pay our staff and do what we need to do to learn the things we need to learn to handle our and take care of patients. And that’s something that isn’t touched on very often. Or I guess it’s, I would say it’s more rare that usually when you bring in something new, you’re doing it at an expense for a clinical benefit, right? So I’m gonna be more accurate doing this, but it’s hard to make it truly cash flow and make a good business decision. And I think that’s where digital really has the potential to differentiate itself, is you can bring in all these technologies and all these synergies come in and you actually have a way to make it a good business decision. In addition to enhancing your clinical outcomes, and that’s where I think it’s special in that regard. [Jaz]And for many of us, Seth, think of how much fun you can have, right? Think it’s the intersection of technology and dentistry. I mean, you could stand, you can see from how you speak about it and your presentation at AES man, like. For, many people, right? This may not be their cup of tea ’cause they just hate it. They very much love the analog world. They hate anything digital, I get it. But for most of us, we actually embrace this. We went to scanning because of the problems it solves and patients love it. They love when they can move their models around. And then when you’re able to give them that level of service that you’re describing, and then the amount of fun you can have with it as well, it makes our job so much more satisfying, so much more rewarding. So I think that alone has a huge benefit and always, always gotta keep learning, right? If you keep it fresh, keep your mind stimulated, then that’s another wonderful reason to look into digital. Last question before we just talk about how we can learn more about the AES and the exciting things coming up with AES 2026 is for those of us who don’t, I mean, we’ve got a CBCT at our practice, but many clinicians around the world don’t have access to CBCT. I’ve seen whereby a good way to perhaps replicate the static detail, the cants and whatnot is aligning the digital articulator with the patient’s photos. So using that as a tool for the lab, can you describe that workflow, whether you think that is the second best or is there anything else that is perhaps inexpensive and something that we can use to get digitize the patient without using face scanning? Without using CBCT?  [Seth]I mean, photos give an opportunity right now, the problem with the photo side is it’s two dimensional. And so if you’re using a straight on and a side photo to try to do it, you can get some idea of it. But there’s some wobble in the system on it. In those scenarios I would tell you go with the analog facebow and used the traditional method to do it ’cause that’s inexpensive, easy to do. And we can then digitize that and work off that framework very easily doing it. And so that’s the other way to look at doing it is, you can take measurements off the analogs and plug those into the digital and use that for your positioning and you’re going to be probably as good as the photos, if not better doing it for sure.  [Jaz]So essentially just so I’ve got the workflow right, it’s as an alternative to the photos, it’s doing everything as we usually do, face bow mounted and articulator at your desired bite. And then how are we getting the articulated models? Is it by scanning the positions or just taking like ruler measurements and then plugging those into the software?  [Seth]You can do both. So, if your lab has a lab scanner, you can send that mount to model to the lab. They can easily digitize the articulator and that allows for the alignment of it. The other way to do it would be, and that’s actually how like one of my favorite splint programs is a program called D3 Tool or D3 Splint. It was written by a dentist who also was a coder, or he also did commercial software design. And I like it from that scenario because he understands what we’re doing as clinicians, but it’s also very intuitive and it’s dirt cheap. I think it’s 600 US one time fee and you own it. But in that program, there’s arrows that you can drag and draw, and it basically has three measurements ’cause to position something in space, you need an X, Y, and a Z coordinate. And it’s a measurement from each condyle to the central point between the centrals and an angular measurement from the infraorbital through the condyle down. So you’ve got right condyle to central point, left condyle to central point and an angle. Well, that gives you your three coordinates. So all I would do if I wanted to do that virtual articulation, you can use a ruler. So measure, just put that face bow record on the analog instrument. You don’t have to pour a model, you don’t have to do any of that. And just take a linear measurement condyle to there, condyle to there, and use a protractor. Between those that you can put in the digital splint program and immediately go in and do your virtually articulated splint. Now you have a little wobble for the can and there’s some finer points that you can do to tweak that, but you’re gonna be much closer than you otherwise would’ve been arbitrarily throwing that in. And so that’s kind of the very easy, low cost MacGyver way to get there doing it. But there’s other methods that you can do that obviously increase complexity going down, but that would give you a starting point. For sure. And I would tell you that’s a great place to learn to trust it is make two splints, have one done, starting it with better values at on the input and have one, do it done as average and start to see where’s the difference in doing it. And that was really kind of one of the nice things digitally is when it only costs me six or seven bucks to make a splint, I can do multiple proposals. Same thing with wax-ups. Usually having three or four aesthetic proposals is cost prohibitive ’cause it costs you too much to the lab. Well doing it now with virtual libraries and only costing $4 to print the difference, you can actually have so much more flexibility and it lets us see, have the patient see these proposals ahead of time. There’s less guesswork. More likely they’re gonna be happy with the initials which is less time remaking, less time starting over, just everything gets more efficient in that scenario.  [Jaz]I think the thing to emphasize here for those listening is what Seth has done is because of the fact that it doesn’t cost much more to change a few variables and print it, you’ve been able to test and test and test, what if you change this? What if you change that? And really your workflows now a representation of all those near misses and failures, which were inexpensive failures because you were able to make that adjustment, spend 10 minutes to print it again and get it corrected. And what a service to your patients. So that again, is a huge advantage of digital there. Tell us about your involvement with AES, Seth. How did you get involved with AES? You’re on the squad of AES in terms of organization. What role do you have with AES and how did you come into that and what have we got in store for AES 2026?  [Seth]Awesome. Yeah. I had a couple cocktails one evening and started talking up in one of the suites after the meeting. And the next thing I knew, I woke up the next morning and was gonna be involved in planning the 26 program, which sounds funny, but that’s kind of how thing it goes down occasionally. And it’s been a great opportunity. Jim McKee was the one who originally got me involved with the organization on it and had never planned a program before. So first time coming in as a program chair doing all that. Yeah, I would’ve been blessed. The fantastic co-chair Liz Turner, who is awesome. And she and I were kind of charged with executing the vision for the current president’s meeting, which is Bobby Supple. And Bobby is very much an occlusion nerd. He’s very much tech scan digital guy. So he was trying to put together a meeting that would bring a lot of these concepts together. And one of the nicest things about AES for those who aren’t familiar is they make it a point of trying to bring different vantage points into the same room and letting ’em talk it out. Which this panel discussions and things where the point is to let everybody see what’s out there and then try to figure out what you believe is the best truth going forward on. And so for 26, we’re looking at a lot of different things. There’s a very heavy digital component, but we have a lot of sympathetics and airway and all the different things coming together that are problems for us clinically today. So we have, example Jeff Rouse is coming in and looking at the etiology of wear patterns and maybe he is gonna look at, is it more of a global thing as opposed to a toothpaste level deal. We’ve got Tracey Nguyen, talking about airway on it as well. We’ve got Mark Piper, Nick Yiannios talking about the roles of Sympathetics, how they play a role, ’cause the sympathetic nervous system I’m finding in my practice is something that makes a huge difference in a lot of cases, but it’s something we were never taught to look at. Alter alterations and sympathetic tone. How do you diagnose it? How do you figure out if that is part of the problem? And I’ll use an example. We have these patients that maybe have an asymmetric response to procedure pain wise. So you go in, you think, man, the tooth popped right out. It shouldn’t be a problem, and I’m hurting the next day. And three days later, they’re hurting, and a week later they’re hurting. And then they don’t look like they have a dry socket. You can’t figure out what is going on. Well, you start looking at these patients and the apnea patients and the airway patients and people who have systemic inflammatory diseases, their sympathetics are cranked up all the time. And we start looking at substance P and pain response. And they’re just, they respond differently. And I had a patient where I was curious that they had increased sympathetic tone and we were taking out two teeth, 18 and lower second molars bilaterally. And there’s diagnostic nerve blocks you can do to kind of turn off the sympathetics to see if they play a role. We do that a lot for the joints. But so outta curiosity, I told the patient what we were doing and I was gonna do this block on one side and not do the block on the other. Taking out both teeth, same teeth, symmetric, same side, the two, the side where we block the sympathetics, uneventful, healing, no problem at all. The side that we didn’t had that asymmetric pain response, it hurts dry socket, I can’t get it to go away. All the things. And at that point, my mind was like, there’s a piece to the puzzle we’re missing here. And I think that’s what Mark and Nick are gonna really focus on is maybe a different way of seeing the same patient and using that to factor in our diagnostics, our discussion, our treatment planning, setting expectations for where we’re gonna go. We’ve got Lukasz Lassman coming in who I think was on the podcast last week?  [Jaz]Just yeah, just yesterday was published.  [Seth]Insanely smart guy. And he’s looking at vertical dimension and how we alter it. Maybe some of the conceptions and misconceptions we may have on the literature and what that supports. He’s even gonna look at the role of the sympathetics and how does that play in? There’s a lot of things that tie in. I think at the end of the day, it’s going to be a very interesting meeting and it’s a fantastic time to come check out the whole dental world in terms of the States is in Chicago at that time. There’s eight or nine other meetings going, you have lab day, all the things. It’s a cool way to come spend a few days when it’s cold in the middle of February. Not much else to do.  [Jaz]You know what, it wasn’t so bad that when I came two years ago, the weather was actually really good, but I know it can be very variable. But what a beautiful city. What a beautiful city. Chicago and honestly like, what you guys are, are bringing together all these top level clinicians is phenomenal. So I’m just wanna champion the event you guys are running. And so it’s been a great pleasure to host yourself, Jeff Rouse, Liz, Lukasz in terms, and Dania Tamimi. We recently published our episodes-  [Seth]Oh, I forgot Danny. Yeah.  [Jaz]And so, so many superstars and so many learning points. So I really encourage you all, if you’re able to come Feb 2026, make it the conference that you attend. Seth, thanks so much. Your hard work and organization so far. But the best is yet to come. The hard work is yet to come still. But for now, we want to just spread the good word and honestly keep up the amazing work you’re doing in the digital side. Like, my mind is blown in terms of the possibilities. And may you continue to be, this super nerd in a nice way possible. Like honestly, you are. You’re very clear, you’re very passionate and really intelligent. So, thanks so much for the good work you do. And I appreciate your time today on the podcast.  [Seth]Absolutely. I enjoyed the visit. Thank you very much.  Jaz’s Outro:Well, there we have it. Guys, thank you so much for listening all the way to the end. Hope you enjoyed the injections, but my goodness, Seth is some sort of wizard. I appreciate him very much for allowing us to use his slides during this presentation. But don’t worry for the audio listeners on Spotify and Apple, you didn’t miss out because the whole conversation happened without any visuals. It was just to enhance what we’re doing. Now if you’d like to get CE, this episode is very much eligible. There was plenty of juice in this one. Protrusive Education is indeed a PACE approved education provider. The episode is eligible for one hour of CPD or one CE credit. Head over to our app Protrusive Guidance. It’s also home to the nicest and geekiest community of dentists in the world. Click on this episode in the all episodes and CPD section, answer the quiz. And if you get 80% Mari from Team Protrusive, our CPD Queen will send you your certificate. You’ve done all the hard work, you’ve listened. You might as well get that certificate. We’ve crossed the threshold recently so that now if you tally up all the CPD and CE available and Protrusive Guidance, it’s less than a dollar. So imagine getting a CE certificate for this episode for less than a dollar. There is so much good stuff on there, and just the network and the community that’s on Protrusive is absolutely amazing. We’ve somehow attracted the nicest and geekiest people in the world. Head over to protrusive.co.uk/ultimate. That’s protrusive.co.uk/ultimate to get a free trial to make sure that you are happy with the education that’s on there. As always, thank you to Team Protrusive for their hard work in putting this together for the visuals of premium notes and to ensure that the mission of making dentistry tangible is totally accomplished. Thanks again, my dear friends, I’ll catch you same time, same place next week. Bye for now.

Are you considering the airway in your treatment planning? Could centric relation (CR) be compromising your patient’s breathing? When you open the vertical dimension, are you making the airway better—or worse? Welcome to another AES 2026 series episode, this time with LEGEND Dr. Jeff Rouse as he joins Jaz in this eye-opening episode to explore how airway, aesthetics, and function are deeply interconnected—especially in prosthodontics. They discuss key clinical scenarios like vertical dimension changes, examining how your choices may impact the airway—sometimes in ways you didn’t expect. With practical insights and examples, this episode will help you make smarter, airway-conscious decisions that elevate both your functional and aesthetic outcomes. https://youtu.be/-Ut-qme7Vcg Watch PDP229 on Youtube Protrusive Dental Pearl: Plan your breaks 12 months in advance to avoid burnout and ensure quality time with your loved ones. Prioritize rest and connection before reaching exhaustion—your body, mind, and heart will thank you. Need to Read it? Check out the Full Episode Transcript below! Key Takeaways Airway health is crucial in dentistry, impacting aesthetics and function. Understanding airway issues can lead to better treatment outcomes for patients. Breastfeeding plays a significant role in childhood development and airway health. Interdisciplinary approaches are essential for effective adult treatment. Aesthetics and function are key factors in airway prosthodontics. Most patients are unaware of their airway issues until they are addressed. Early intervention in childhood can prevent future airway problems. Combining orthodontics and prosthodontics can enhance patient care. Airway management is crucial for overall patient health. A great bite is not just about teeth alignment. Pathway wear can indicate deeper dental issues. Vertical dimension changes can negatively impact airway. Understanding joint positions is essential in treatment planning. Continuous education is vital for modern dental practices. Highlights of this patient: 02:22  Protrusive Dental Pearl 04:34 Interview with Dr. Jeff Rouse Begins 09:05 Understanding Airway Prosthodontics 15:58 The Role of Cone Beam CT Scans 17:58 Treating Children and Early Interventions 24:50 Addressing Adult Airway Issues 29:43 Multidisciplinary Approach in Dentistry 31:46 Patient Transformations and Airway Focus 34:42 Understanding Pathway Wear 41:32 Impact of Vertical Dimension on Airway 48:55 Exploring Different Occlusion Philosophies 51:34 A Sneak Peek at AES 2026: Dental Wear Patterns Of The Airway Patient 55:25 Upcoming Events and Resources Explore the world of sleep disordered breathing with Prof. Ama Johal in PDP033: “Airway – Dentistry’s Elephant in the Room.” 🎓 Join the world’s leading organization dedicated to occlusion, temporomandibular disorders (TMD), and restorative excellence — the American Equilibration Society (AES). 🗓️ AES Annual Meeting 2026 – “The Evolution of the Oral Physician”📍 February 18–19, 2026 · Chicago, IllinoisDon’t miss Dr. Jeff Rouse as featured speaker, presenting on “Dental Wear Patterns Of The Airway Patient” 🎓 Learn more with Dr. Jeff Rouse on The Spear Education Online #PDPMainEpisodes #CareerDevelopment #BreadandButterDentistry This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes A, B and C. AGD Subject Code: 730 ORAL MEDICINE, ORAL DIAGNOSIS, ORAL PATHOLOGY (Sleep medicine) Aim: To deepen clinicians’ understanding of airway prosthodontics and empower them to recognize airway-related dental issues across all age groups. Dentists will be able to – Differentiate between anatomical airway dysfunction and sleep-disordered breathing, and understand the unique role of dentistry in addressing each. 2. Explain the principles of Airway Prosthodontics, including the significance of tooth position in facial space and its impact on breathing. 3. Recognize signs of airway compromise in both pediatric and adult patients, including atypical wear patterns, bruxism, reflux, and chronic fatigue. Click below for full episode transcript: Teaser: They don't want us playing in that world either. They don't. Their world is completely different than ours. And you as a dentist, you don't want to be in that world. It's an ugly, ugly world and most physicians would love to be dentists nowadays, 'cause we have so much more freedom to change and to act and to care for our patients than they do. Most people don't know what they don't know. They just call it normal. Teaser:A woman I was visiting with earlier today had had orthognathic surgery and she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. People that are constricted in their bites like this, their maxillas are constricted. And if their maxillas are constricted and their nasal cavities constricted, they can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it. They can’t, so their chewing cycle will move forward and they’ll hit their front. For me, airway is just established the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close the mouth and breathe through their nose. That’s dentistry and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level? We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early, but at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with.  Jaz’s Introduction:How does the airway relate to aesthetics and function? Interesting concept ’cause we think about aesthetics, we think about function, but are we necessarily thinking about the airway when it comes to our treatment planning? Related to this is a scenario like, let’s think of complete dentures. When we deliver complete dentures, the joint position that we usually select is centric relation or seated condyle position. Now the question is, is this position adversely affecting their airway? i.e. by moving their condyles in into centric relation, which usually means they’re moving their jaw a little bit further back. Is that necessarily worsening their airway? Well, we answered that in this episode. And how about when we’re opening someone’s bite? Well, in prosthodontics, when we open someone’s bite, there are some scenarios where you are at risk of making the airway worse and other scenarios where you’re probably not gonna make the airway worse. And you’ll learn this episode exactly what those two distinctions are. I’m joined today by the Dr. Jeff Rouse absolute giant in our profession. What a lovely guy he is. Author of one of the best dentistry textbooks there are Global Diagnosis. He’s also a very prominent educator with spear education and the impact this man has made in airway and dentistry and prosthodontics is just absolutely amazing. So it’s real privilege to host him today as part of our AES takeover. See, Jeff Rouse is one of the speakers at the AES Conference, 2026 in February, and that will be held in Chicago. And we’re trying to shine a light on this conference because it’s based on occlusion, right? It’s related to occlusion, but it’s so much more than occlusion. In fact, the theme of the AES conference next year is the Evolution of the Oral Physician. Let me say that again. The Evolution of the Oral Physician. So it really looks more than just the occlusion. When I attended a few years back, they really are a comprehensive, holistic group that brings together all the occlusion camps and me and Mahmoud Ibrahim, have the privilege of being able to speak there. But we are a small piece of it. You know, some of these giants, like Dania Tamimi that we had on previously, Lukasz Lassman, Jeff Rouse, who you’ll hear from today, is gonna make a really great conference. We’re shining a light, so check out aes-tmj.org, that’s aes-tmj.org to learn more about this conference in Feb 2026. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode, I give you a Protrusive Dental Pearl, and quite often the pearl I give depends on my mood and my context and what I’ve been doing that day or the few days beforehand. And whilst this episode’s being published, probably six to eight weeks later, it’s actually Easter Monday today. And so Spank Hall in England, I’m just reflecting on this Easter break that I’ve had. And honestly, it was just very, very special. For those of you who’ve been listening to every single episode, you may remember I had pneumothorax, a spontaneous pneumothorax. My lung collapsed in February. It canceled our family holiday, like a first world problem. Yes, it was not nice. It was devastating actually. But there’s a reason for that. For me and my wife holidays are very, very special. It’s really quality time with our kids. It’s a time where I switch off and so we couldn’t go away in February. And so I was really nervous about flying in April and thank goodness, I survived and everything’s fine. And honestly, it had just the loveliest 10 days away in the sun with my wife and two kids, and I’m feeling really great. And I guess the pearl is, please make time to rest. If you have a young family. And if they’re at school age, then yes, school holidays are expensive time to go away. But even if you don’t get away, just having that time to reset and connect with your family and making time for that is so special in my opinion. And the reason I’m having to mention this is too many times I’m having conversations with dentists and they’re burnt out. And I always ask ’em, when was your last holiday? And they keep saying to me, ah, you know what? I’ve been meaning to book something, but I never get round to it. And I get to a point where I feel like I need a holiday right now, but I can’t actually book anything because of practice commitments, blah, blah. So something I’ve said over and over again on the podcast, and I make no apologies, do you plan your breaks 12 months in advance? So I do. It’s why I’m able to be so organized in my diary. I know exactly when I’m taking a break from teeth, paying attention to family or things that are important to you. And the next thing is really quite celebratory. Like for the first time in probably 20 years, I managed to get eight hour sleep for about 12 days straight. That was absolutely transformational for me. So Protruserati, please make time for your loved ones. Plan those breaks well in advance so you don’t have to wait until you’re burnt out to book a holiday. You always have something to look forward to. So I’ve said it before, I’ll say it again. Look after your body, look after your mind, and by spending more time with loved ones, look after your heart. Let’s join the main episode now and I’ll catch you in the outro. THE Dr. Jeff Rouse. Absolute pleasure to have you on the Protrusive Dental Podcast. How are you, sir?  [Jeff]I’m wonderful. Thank you. Thanks for having me here.  [Jaz]I’m so stoked. I told you this before we hit the record button. Your reputation, what you’ve done, your contribution and dentistry already just been phenomenal and I’m so excited that you’ll be speaking. You are such an established educator, your work with spirit education, your own stuff you do and you’ll be speaking AES as well. It’s gonna be amazing. And as part of the buildup and excitement of that, it’s so great to talk about some key themes today. But for those younger colleagues who perhaps haven’t heard about you, tell us about you, your journey and what inspired you to take the route that you did take? [Jeff]It’s strange you asked me that question, Jaz ’cause and by the way, thank you for having me on. I know the Protrusive podcast is worldwide and so it’s such a treat to actually get a chance to talk to you. It’s strange you asked me that question ’cause I was, today, I was sitting around thinking like, what a weird route I’ve taken to get to where I am. How some of the things that happened to me, if I had made a different decision, there’s no way I’d be in the position I’m in right now. So for all those people out there that were horrible and undergraduate and dental school, there’s hope you can actually make it to a podcast one day ’cause I was terrible in school. I had no passion for it. I didn’t really understand what dentistry was all about. I went into dentistry because a friend of mine wanted to be an orthodontist and I lost my desire to go to medicine. And I say lost desire. I would’ve probably never gotten into medical school. But I didn’t want to get into medical school, but I didn’t know what else to be. And so a buddy of mine said, you want to go to dental school? And I said, yeah, whatever. And I must have done well on the exam ’cause I got into dental school somehow ’cause my grades were horrible. Got to dental school, the guy there said, C equals DDS. And so I just said, well, that’s easy enough. I can make Cs. And so I did. And the last year in school I met a professor, Bill Robbins, who I later ended up working with and writing a textbook with. But I met him and he showed me the dentistry could be more than what my local dentist was doing. And that there was science to it and there was an art to it, and that allowed me to go to a residency. And so I did a two year GPR came back and went to general practice, practice as a general dentist for 14 years. And once again, Bill and I were working together. We were writing textbooks together, we were lecturing all over the world. And I knew there was something different or something more that still I was passionate about. And so I had an opportunity where I could work my practice and go to prosthodontic residency at the same time. So it took me four years to do it, but I did, and I became a prosthodontist. And after that, then I had opportunities that would’ve never happened had I not taken that, which is I got to work with Greg Kenzer and Frank Spear up in Seattle. And from there ended up teaching at Spear. So a handful of decisions of just saying yes to hard work and saying yes to the fear that was accompanying it and it paying off. So I think we get comfortable and I’ve always gotten anxious when I’m comfortable. And so for those of you that think there’s more, there is, you just have to be willing. Like I tell my kids, you have to be willing to take a deep breath and take that leap, even though it’s scary. And in many ways I got lucky, but in a lot of ways, it was just being able to say the word yes, I’m gonna do that. So that’s how I ended up getting here.  [Jaz]Wonderful way to start the podcast. Richard Branson says, if an opportunity comes along that just really, really good, say yes and then figure out how you’re gonna do it later. And so this is the same Bill Robbins that I think spoke at AES two years ago on global diagnosis.  [Jeff]Yeah. That’s what we wrote here.  [Jaz]And I met- and that was all work together. And what a charismatic chap he is. What a lovely human being. And just his charisma. It’s just oozing, it’s just pleasure to see him.  [Jeff]There are very few people in the world that you’re better, you as a person are better off having been around him. And he’s one of those people that just being around him and being in his presence creates such a benefit to you. Like the energy coming from him just feeds you. And yeah, I was lucky enough to work with him for four years and he’s my best friend in dentistry for, I don’t know, 30 years now. So it’s awesome. [Jaz]What a story. And yeah, that was definitely palpable when I met him a few years ago. Today’s topics we’re gonna take lots of little detours and stuff because to do a topic like this justice, you have to kind of like build the context into it. And I want to help dentists understand a few key things related to airway based prosthodontist. Some people may be thinking that’s a new term for others who maybe done your classes and stuff, they may be more familiar. But what I was thinking was when we do our restorative dentistry, let’s say. We can do something that may affect the phonetics, and we think about that. We think about the tooth length and thinking, oh, that might affect the phonetics. We plan our restoration. So we think about the cleansability. You know, we often opt for certain designs, so there’ll be cleansability, but sometimes perhaps we may be guilty in dentistry of not thinking about how our dentistry, obviously more and more with your good work, people are becoming more aware of this, but how might our dentistry affect the airway? So I guess I’m gonna let you really lead the direction on that. But when it comes to the decision making and the kind of dentistry that we deliver, what kind of situations where may we be impacting the airway without perhaps realizing?  [Jeff]Yeah, good question. Let me back up a step so that everyone is clear. The biggest confusion that I run into when I’m speaking today is when you used the word airway and you used it properly, in my opinion. The issue that I run into is people, at first when you would go to lectures would say, my patient has sleep apnea, or My patient has a sleep problem. And then myself and other people kind of following the same course started utilizing the word airway to differentiate it. And now if you go to a lecture, you’re gonna hear people say, my patient has an airway problem. But the next thing out of their mouth is they went in for a sleep study and their apnea level is 24. So they’re using the term incorrectly. Airway, the way that you were using it was about anatomy or changes to anatomy that could affect your ability to breathe. Tooth position, vertical dimension are some of the things that you were outlining. And that’s where we start. So back in the day, I came up with the term airway prosthodontics, just to differentiate it from sleep dentistry. So we were clear, but it still hasn’t become clear. So let me see if I can create some more clarity to it. [Jaz]Because what I’m thinking immediately is will not, the first part, will not, the airway based prosthodontics that will also impact our sleep. And so they are connected in a big way, right?  [Jeff]They are, but I would go to an easier step because if you connect it to sleep and say sleep apnea, let’s say, the moment you connect it to a medical problem, your markers for success change dramatically. The minute you say my patient has sleep apnea, in order for you to be successful, you have to make that go away. Right? It either has to, success is reducing the apnea level by half and being under 20, cure is under five and the apnea hypopnea index, right? So the minute you establish the standard for care or your metric for care as apnea, you’re playing in the medical world. I don’t wanna play in the medical world. I don’t want anything to do with that. And to be honest with you, I had a physician in my office, an ENT in my office for five years, and they don’t want us playing in that world either. They don’t. Their world is completely different than ours and you as a dentist, you don’t want to be in that world. It’s an ugly, ugly world. And most physicians would love to be dentists nowadays because we have so much more freedom to change and to act and to care for our patients than they do. So with that in mind, that was my original goal, was how can I use this to integrate medicine and dentistry for the first time, let’s work together as a team. And the more I did it, the more I figured out we don’t wanna do that because they’re gonna take over. And if we are treating to the apnea level, it’s medicine. And medicine then wins and every decision. And I don’t want to be there. So came up with the term airway prosthodontics, which actually could impact the apnea, but doesn’t focus on the apnea. That’s not our central theme. Our central theme is doing the two things that we’ve taught at either in global diagnosis or facially generated treatment planning in the spear world, which are where do the teeth belong in the face and how do you get ’em to function correctly? Those are one and two of every system that’s ever been developed that you’re using for treatment planning. So when we look at aesthetics, there are three main areas of aesthetic tooth positioning that happen on a wax rim before you ever set a tooth, which is you’re gonna get the transverse dimension correct. You’re gonna get the AP dimension correct. You’re gonna get the vertical dimension correct. So you get all those three things established, and then you start setting the teeth into ideal position. The vertical, the transverse, and the sagittal dimension and position of the upper arch are all key airway factors. And so if any of those anatomic factors are irregular, you will have more difficulty breathing during the day and at night when you go to sleep. So aesthetics in the maxilla is number one, not only the way we’ve always thought about treatment planning, but it’s number one for airway because it’s connected to the nasal cavity and changes in those dimensions. Orthodontically, orthopedically, orthognathically will make you breathe better. How much better? We don’t know. No one will ever be able to tell you in advance, but we know it makes you breathe better. The second is function. By the way, function used to lead back in the day when I learned it, function was the leader. It was all occlusion. It was a lower arch dictated treatment. And even in ortho, lower arch dictated treatment. Tweed orthodontics take teeth out, put the lower interiors over the ridge, move everything to it. Lower arch gnathology, Pankey-Mann-Skyler, everybody was lower arch. The upper arch just sort of sat there and you worked around it. Today, if we established a maxilla first, the aesthetics first, and then do the lower arch the same way we would do a denture when we get the lower arch in the proper location to inter interdigitate, the airway is also better at that point. So are there other factors beyond that? Yeah, sure there are. There are soft tissue issues or tongue ties, large tongues. Adenoids, tonsils, deviated septum, which actually come from constricted maxillas. There are lots of things that could be added onto that. But the two main factors that make you breathe better during the day and at night are aesthetics and function. They’re exactly what we need to do in treatment planning. So for me, airway is just establish the aesthetic position of the teeth first and the functional position of the teeth. If you get those things normalized, then we help the patient normalize what they do, which is close them mouth and breathe through their nose. That’s dentistry, and the success of that treatment is does the patient have a beautiful smile and a great bite? That’s success. Not did I reduce the apnea level. So that’s the big difference between the two. [Jaz]When you’re assessing that in a patient in the medicine world, they use the, yes, apnea hypopnea index as a marker. You said that aesthetics and function, are you also using cone beam CT scans and they look at the volume of the airway? Is that a metric that you use as well in terms of, okay, by doing our prosthodontic intervention, we’ve improved the airway by volumetric percentage?  [Jeff]Yes, but I don’t treat to a number that way. Do I look at it? Yes. You know the interesting thing about cone beams, the thing I look at most often is we now know that if you do a cone beam and do slices at the first premolars, so we’re doing AP slices first, premolars, then go back to the first molars and do the same thing. Measure from bone to bone on the palate. We know the widths that you need to be healthy so I can take a CT of you or any of your patients. And I can cut it and go, you’re too narrow. You’re gonna be sick. And you look at me and go, well, I don’t snore, I don’t have this, I don’t have that. I go give it 10 years or 10 pounds. And you’re gonna, so why would you wanna wait around the way medicine does until you’re sick? Why don’t you treat it in advance ’cause we know you’re gonna be sick. And the closer you are to that number, the more risk you’re gonna have. We also know, if we look from the side, sagitally, we know that distance. We know that from porion, which your ear hole, if you drew a vertical line off it, an a point which is up under your nose, if you drew a line measuring between those two points, 97 millimeters is a number, you have to be greater than if it’s not greater than 97 millimeters, your odds go up dramatically with or without obesity. Your odds go up because cranial facial is more important than weight. And we also know that vertical, people that grow vertically, VME patients. Those are airway patients. They’ve always been airway patients. We’ve called them adenoid faces forever. We called them that for a reason. So we know if your anatomy is off, you’re gonna be off. So yes, I do use cone beam and I use it that way. I like cone beam even in children because I can see the nasal cavity, I can see any deviations, any issues in the nose. I can see the adenoids. I can see the tonsils in 3D. So we get a nice view of those structures also. So if I can get even really, really little kids, they have those quick cone beams, the four second versions, if you can get one of those, then even like four year olds, it’s awesome ’cause you can see anatomy you wouldn’t otherwise be able to see. And in fact, we now know another, there are many reasons why you wanna treat kids very, very young. We’re treating 26 month old as the youngest I’ve ever heard, done Invisalign first to expand, start expansion early. But at four you can start to see if you’re leaving them in a constricted pediatric arch that the permanent teeth are gonna erupt outside of the housing of the bone. So, the orthodontist never moved the teeth outta the bone. They were never in the bone to begin with. So.  [Jaz]Well, that was actually gonna be my question. My next question is that, okay, based on what you’re describing, what percentage of your dentistry is for children, and then what percentage is for adults, let’s say someone in their forties who seems to have minimal dental issues, but you’ve made these diagnoses and you know these metrics and they’re gonna run trouble. At that point for an adult, it’s very much, I’m guessing, gonna be surgical orthodontic or a combination of both would be the mainstay of treatment, would you say?  [Jeff]All right. Let me answer the first part, which is children. Children are absolutely the key. I ran a family practice before I went back to pros. I don’t enjoy treating children anymore. I did ortho on kids. I did all that. It just wasn’t something that I enjoyed, and so I stopped. If I had to do it over again, I would continue. It was, the reason I stopped is I had one case that the patient went away for six months and the wire was active and I didn’t know how to recover from it. And so in my mind, I was like, I don’t know how to deal with that, so I don’t wanna do anymore. And so I gave it up. I just gave it all the orthodontists. In hindsight, I should have just said, I don’t know enough. I need to learn some more. And instead of thinking, I knew it all, you know, right up front, and if I did, I would still be treating kids and I would have a bigger impact on my community because I would be treating young. That’s where the problem needs to be dealt with. The problem needs to be dealt with in newborns. Newborns that are tongue tied. And having difficulty breastfeeding if you can’t breastfeed as a child, if growth discrepancies are huge. So breastfeeding is absolutely the best thing you can start. And if the mother doesn’t want to do it, that’s fine. But what I find and just hate to see is when the parents come in and I look at the kid a little older and their tongue tied and lip tied, and I ask ’em about breastfeeding, they go, yeah, they weren’t good. They didn’t latch well or it hurt, or whatever it happened to be, well, they wanted to do it, but there was this anatomic restriction, which now we’re having to play ketchup because they didn’t get to grow normally as a kid. So breastfeeding, what they eat, how they eat, lots of things that we can do to make kids grow and we start intervening way earlier. We getting ENTs involved to look at tonsils and adenoids in an earlier level. We don’t require apnea before those things are removed. We require symptoms, attention deficit, grinding their teeth, reflux, wetting the bed, thumb sucking beyond early years, moving around in the bed, sleep, talking, sleepwalk, any of those things. Start promoting the idea of getting tonsils and adenoids out, and then also expanding arches. And so, yes.  [Jaz]This is very relevant to me, Jeff. So I’m sorry to intervene, but just to let you know that my son’s gonna be two tomorrow. He’s gonna be age two tomorrow. But since he’s never been a good sleeper, since he was born and I knew something wasn’t right ’cause I hear snorting and sometimes he would stop breathing and I knew something wasn’t right. And we have so many healthcare challenges around the world and getting diagnoses and stuff in the UK in particular. So I managed to see the right person that got this sleep test and lo and behold, he was diagnosed with moderate sleep apnea at age 18 months. And he’s on the list for eventual when he’s like healthy enough for adenoidectomy, which actually my elder had as well. So I’ve seen firsthand why my interest grew in this ’cause I wanted to help my own son and he was breastfed. And he was breastfed fine. In fact, my wife made it to one year. And interesting stat is that in the UK, and I dunno what the US or rest of world stats are, but in the UK only 1% of mothers are breastfeeding at month six, only 1%. So my follow up question will be, do you think this has been a huge player in terms of the why we are seeing so many more of these issues?  [Jeff]Yes, there was a perfect storm of problems that happened in the late fifties, early sixties. Antibiotics started being used instead of surgery for tonsils and adenoids. Part of it was, it used to be if, like, if your brother got his out, you got yours out, which is wrong. So they were overdoing the surgeries. Then they went completely the other way. Women went back into the workforce at really high numbers. And so breastfeeding went way down. Gerber introduced soft foods and mushy baby foods instead of the natural course was six months minimum breastfeeding, and then introduction of solid foods after that. Gnawing on solid foods grows your face. There’s crap in the air, crap in the water. I mean, there’s all kinds of different stuff in our food, right? Everything plays a little bit of a role in what we call epigenetics. And so it’s environmental factors that are altering natural growth and development. In addition, and this is totally a guess, there is some science to this, but not enough to be causative at all, but somewhat correlational, folic acid in prenatal vitamins, decreases neural tube defects, but the tongue ties are neural tube issues, so they close earlier than they should have. And so we get a lot more tongue ties than we used to in the past. So yeah, it was a perfect storm of bad things that happen. Interestingly, I think it will be interesting to watch that percentage because at least in the states, people are starting to take an approach of what can I do to be healthier? Can I have clean foods? Can I do supplements? And in the space of taking care of children, there’s a refocus on breastfeeding I think. So we’ll see if that number grows, but that would be a good thing if it does.  [Jaz]Absolutely. I mean, it’s much high in some of the Scandinavian countries, like 33% and whatnot. But yeah. Interesting. Six months. It was 1% in the UK so well done to my wife. But yeah, sometimes not possible and stuff, so I wanna make this about, make anyone feel guilty and whatnot. But no, I think as a fact we know that if you can, you are able to breastfeed your child. Yeah, it’s the best thing. I mean, a stat I had at the time was something like 20 times less likely to have some sort of orthodontic issue properly to do with your palate dimension, I imagine.  [Jeff]Absolutely decreases sleep disturbed breathing issues and it reduces malocclusions prematurely born children are absolutely gonna have sleep disturbed breathing issues ’cause they’re so far behind in growth and development and breastfeeding is the best way to catch them up. ‘Cause you can almost get them caught up to normal kids growth and development through breastfeeding. The nice part for, to sort of file away for people is whatever time you do it is good. If you breastfed for a month, the numbers are significantly better at eight years for your kid. So whatever you do is good. Your question then was about getting the older patient, the 40-year-old- [Jaz]So that scenario described where you take a CBCT and then you notice that the dimension from first molar to first molar and the palatal bone and it’s not meeting a minimum number. And they say to you they don’t have any issues because they’re now an adult, they’re fully grown. What kind of treatment interventions are available to these patients?  [Jeff]Part of your question that’s interesting is they say, I don’t have issues. But most people don’t know what they don’t know. They just call it normal. Woman I was visiting with earlier today had had orthognathic surgery. And she said, I didn’t really realize that I never was able to breathe and I never slept until I had the surgery done. And she said, you told me that about all this stuff, but I did it ’cause I didn’t like my profile and so aesthetically I thought it was gonna be a nice change. And she said, I just didn’t realize it. And now like it’s a different world. So part of our job as dentist is to, well, airway, like I said, airway’s just putting the teeth where they’re supposed to be is for aesthetics and function. So if a person says, I don’t have a problem, I don’t necessarily have to argue with them about it. If we can come to some agreement, your teeth are in the wrong place and your bite is off, and that’s all I’m doing, then I know I’m gonna make your airway better and I don’t have to focus on it ’cause in the end, what success you have a pretty smile and you have a good bite, so, I don’t need you to believe you’ve got an airway problem. The time it becomes important to get you to believe you have an airway problem is if you have ugly teeth and a bad bite and you’re not really wanting to do a whole lot about it, but you know that there’s an airway problem and a bad smile and a bad bite, the airway problem is the one that you can have a conversation about easier than any of the other ones. I find it extremely difficult to have a conversation with people to say, oh my God, you’re ugly. Right? I mean. You don’t walk into a room and go, oh man, look at that. That’s hard. Even when it is like they got a crown on a central and you go, wow. Like, whoa, we can make those look like teeth nowadays. I don’t know if you knew that. So you see that, or you look at their bite and it’s just totally messed up and they’re chipping teeth, breaking teeth. Oh no, I do fine. I eat right. Those two things for me are really hard to talk about, but if I can talk about health and link all of those things together, now I give them something they’re interested in, which is being healthier for a lifetime than they are right now, or would be in the future without any care. But I get, what I get from it is I get to do all the cool dentistry I always wanna do, which is put the teeth where they’re supposed to be, rather than camouflage it with ceramics and stuff, put ’em where they’re supposed to be and then make ’em beautiful. And then, you know, put the bite together. And a lot of times I do less dentistry. I mean, huge advantages from a dental perspective, great smiles, great bites, maybe less dentistry. Maybe if I have to do the same amount of dentistry. At least it’s the right shapes of teeth. I mean, they’re anatomically correct rather than warping teeth around and stuff. So what do you have to do? And you’re right, typically orthodontics plays a big role in this, but it doesn’t necessarily have to jump all the way to to orthognatic. There’s a middle piece nowadays that is surgical based orthodontic therapy. And the surgical base, orthodontic therapy is not orthognatic in nature. The two main ones are, well, I’m gonna lump into surgery for a second, but it’s really not surgical. The two main ways of expanding arches are surgically facilitated orthodontic therapy where we make corticotomy and cuts in the bone and add bone. That’s like adding base plate wax, so you get a little change in the anatomy, right? The other one is MARPE, so, so mini implant assisted rapid palatal expansion. Now, I said you have to do a surgical intervention. That’s a non-surgical intervention, but it is an intervention, right? You have to put Tads in the palate and expand off the tads. Today, I’ve kind of gone the whole route on this. The original MARPE that we used was MSE, so four Tads, small, little tiny screws and such. Today we’re using custom MARPE, so we’re using 6, 8, 10 long Tads, big solid MARPEs. And so we can split anyone open up to the age of 70. So you walk in my office and you need expansion and some AP, we can do all that non- Interjection:Hey guys, it’s Jaz with an interjection. So we’ve got two interjections for this episode. Let’s talk about dual bite. Okay, so dual bite is basically a scenario whereby you have a patient who when they bite together, their teeth fit together well. Right. So they have their dental home, their maximum intercuspal position. The relationship between the teeth. Now this patient, right when you seat their condyles, their jaw drops right back like distalises, and they also have a bite in that position. So this patient is said to have a dual bite, okay? They have a bite where they have like a dental home, and then they have the bite where they have a skeletal home, i.e. the condyles are in the Fosse, or I like say the balls are in the cups and in this position, their teeth also have a bite. So they have a bite that’s further forward and a bite that’s further back. And this is a dual bite patient. If you routinely start to check your patients for where their centric relation contact point is, or where their stable condylar position is, whether you deprogram your patient or use a leaf gauge or whatever, then you’ll start to identify these dual bite patients who have this very large slide. So that’s what we mean by a dual bite patient. [Jeff]Surgically, and then orthognathic comes into play only in my office when non-surgical expansion with MARPE and SFOT on the lower ’cause the lower dictates how wide I can make the upper go. That doesn’t resolve whatever the problem is. My smile doesn’t look good, my bite doesn’t look good. But the main one is I’m still don’t feel good. I’m still grinding my teeth. I still have reflux, I still have TMD issues, I still whatever. And in that case, we’ve gotta move forward and any big protrusive movement in particular mandible has to occur surgically. So orthognathic comes into play at that point in time. [Jaz]So what you do is very, a lot much multidisciplinary, right. Orthodontics, oral surgeons, what you do is very much a team-based approach.  [Jeff]Yep. I’ve got a practice where the first visit I ought to have like a rotating front door ’cause they come in, they see me and they go right back out to see other people. It’s just in and out from other consults. So I have most of my new patients that are interdisciplinary in nature.  [Jaz]That’s really the whole-  [Jeff]But you know, if I was, like I said, if I was smarter back in the day, I would’ve stayed doing ortho and I could have done a bunch of this ’cause I would’ve, the skills at this point in time to do for sure 50% of it, if not 75% of the stuff I’m talking about. I don’t think I would’ve ever taken on an  orthognathic surgery case. I think that would’ve always scared me to deal with those cases. But I actually personally did the SFOT surgery and I put MARPEs in so that I can expand. So I’m expanding people.  [Jaz]So you’ve had all this done to yourself? [Jeff]No, I had the SFOT done to myself, but I do it to other patients now.  [Jaz]Okay.  [Jeff]So I just, the other day, I always get this question in the classes, which is, where do you find somebody that’ll do that? Like, I don’t have any in my community. And the answer always was, well, if the guy that’s doing it right now doesn’t do it, go find someone. Go find a younger guy, that’s hungry and has some new knowledge and such, and would like to establish his practice based on this and get a chance to work with you. I bet they would love to do it, but a lot of the people I teach, the orthodontist comes in once a month and does ortho in the town. Right? So if that orthodontist says no, who are they supposed to go to? And so I got to thinking about that, like I’m spoiled by working in San Antonio and I am spoiled by having so many great teammates. And so I’m speaking from this position of well just go down the street and find another one, right? And so it hit me one day and I was like, well do it yourself. And then I thought, well, if I’m gonna tell somebody to do it themselves, then I better be able to do it myself. So, I started doing a few and it’s not that hard. So.  [Jaz]What kind of changes have your patients experienced that you look back? A lot of my colleagues that I look up to that have been practicing for years, they say, the full mouth rehabs they did when they come back, 15, 20 years later and everything’s working well and it makes ’em really happy and dentistry and their smile looks great and whatnot. That’s the kind of stories I’ve heard. With your focus on the airway, what kind of changes have you experienced in your patients?  [Jeff]All right, so first thing is your colleagues are lying to you. Nothing looks good at 15 years. It’s still in the mouth and it’s not broken in 15 years.  [Jaz]Yes.  [Jeff]Ceramic ages. It always, you look at it go, ugh. So yeah, I don’t get much of a thrill at seeing rehabs. I always tell the story. Back when I was in dental school, people were so grateful. They’d like, you’d put these ugly crowns that you made and residency or in dental school, you’d put ’em in and, and in hindsight you go, man, those were ugly. People were crying, they were bringing you presents. They’re like, oh my god, my whole life I’ve always wanted white teeth and you gave me, there is just like the greatest day ever in dental school, right? And then you get out and you charge a fair fee for it and they start like, wow, what about that edge right there? I don’t really like that. So they complain a lot. The nice part about the airway is if you do it the way I am suggesting is you are transforming their lives in multiple ways. You’re giving them a great looking smile. You may be giving ’em a great looking face, right? You send ’em out for orthognathic. By the way, if you do that, custom MARPE, their face will look better as well ’cause they’re midface will fill in because you’re actually expanding the whole maxilla up under the eyes, the zygoma everywhere. So you give ’em a great smile, a great face, you give ’em a great bite, they can function wonderfully and they feel good. And then you give ’em this great airway. And the way they know great airway is whatever the thing that triggered you to say, you probably have a bad airway like bruxing, reflux, TMD headaches. Those are gone. And because it takes a while to get ’em through the whole treatment, a lot of times they forget. And so in the end I have to remind them, hey, you still get those headaches? And they’re like, no, those have been gone for a while. Oh, that’s so good. So yeah, it’s very cool.  [Jaz]I manage TMD patients there, Jeff. And what I also realize is they kind of forget where they were. And so at the very first few appointments I get them to mention all their issues and give it a score out of 10 about how much it affects their life. And then oh, as we go through, they’ll score it. And then when they’re down to like a two or three as like, oh, that’s interesting. You were a seven. No, like eight months ago, whatever. So it’s very, very true to that point you raised. It’s amazing what the impact you’ve had on these patients through thinking in this way, but this level of knowledge that we need to upskill and we need to open our eyes to this and you’ve done great contribution education. I’ll ask you and again at the end, where can we learn more from you and whatnot. So it’s our duty to upskill. But two things I want to just talk about for our younger colleagues. One thing is you mentioned a great bite, so what are some features that you look for? You look at a bite and say, that is a great bite. What constitutes a great bite?  [Jeff]Well, are you talking about a restored bite or because a restored bite for me is gonna be in a seated condylar position ’cause that’s what I work to. A great bite doesn’t have to be the teeth all in the right location either. It can be a bite that the patient is so adapted to that there’s no damage to the teeth. I had an 85-year-old lady in not too long ago, and there were nowhere on her teeth at all, and they weren’t what you would call a dentoform perfect teeth. But yeah, that’s a great bite. It functions without damage. That’s perfect. now, that actually leads me to talk a little bit about one of the topics I’ll have at the AES meeting and its pathway wear or envelope of function would probably like, or envelope of dysfunction. People call it all kinds of different names. You have posselt’s diagram.  [Jaz]Well spotted.  [Jeff]So once again, just for younger people, I don’t know what term they use or where they’re in the world or where they’re in their education, but I’ll describe what we at Spear Education would be a person that actually comes in and we call it pathway wear. Pathway wear. So pathway wear is that as you chew your lower teeth, nick the lingual surfaces of your upper teeth. So the lower anterior teeth will wear at an angle, so they’ll be higher in the back, lower in the front. They typically will create a shiny wear facet there. So if you took a photograph, you’d see the light reflecting off of this shiny area, and then the upper lingual surfaces will be hollowed out and they can be hollowed out in different paths. They can kind of come in a lot from the side, or they can be tighter paths, but they can’t kind of just eat out the lingual without really taking away the length of a tooth. So the tooth still remains long. You just eat the backside out and as the backside goes away, tooth erupts. Not only does it erupt straight down, but it also erupts in. So it keeps getting tighter and tighter over time. And with that tooth loss, sometimes at the very end, it’ll chip at the edges and you can almost see through the enamel ’cause they’ve hollowed it out so much. Very difficult case to take care of because we want to do everything restoratively. That’s a huge flaw in how we’ve been taught as restorative dentists to work when teeth wear they move and if they move you need to move them back. And so we should always think in terms of orthodontics first. So a wear case walks in your office, you figure out am I gonna move them back or is the orthodontist gonna move ’em back? But somebody’s moving these teeth back where they used to be before I fix ’em ’cause you can fix ’em so much more conservatively that way. The only other option you have is open vertical dimension, in which case you’re doing all the teeth upper arch or lower arch or both arches, right? So huge amount of dentistry and most of our patients don’t need it and or can’t afford it. So we need to learn to integrate orthodontics in that regard as well. Alright, back to the topic, which is this pathway wear, where the teeth are getting worn out. So we have for years said, that’s what happens. And people just nodded and said, yeah, that’s what happens. They hit the backs of the teeth and they can’t be restored there. And so then we talk about orthodontically moving the teeth and here’s you have to put ’em back in the right. But we just made the assumption that happens, and I have this weird thing that I do, which is if I ever have a question, I go to the literature and if I go to the literature and can’t find an answer, I do experiments on my patients. Now, I don’t tell ’em really. I just ask. I got this new toy you wanna play with it. And I got a lot of patients that are really fun, been around forever, so they love being involved in that stuff. So here’s what happened to me. I heard it from a lot of people. I heard those patients being called, like they chewed like rats. So they just keep chewing. And I just wasn’t convinced that people would run into their teeth ’cause I never honestly banged into my teeth when I chewed. So I wasn’t convinced. So I went to the literature and then, you know what the literature says? The literature says that if you give people that have tight bites like that, so class two div two type patients. You give them food and they chew, they never touch their front teeth. They’ll do anything in their power including mess up their joint to stay away from their front teeth. And I’m like, well those two things don’t work together ’cause I’m being told by really famous people that they do bang their teeth. But I’m also being told by the research that watches ’em chew that they don’t touch their front teeth. So I went in and did the experiment on my patients to mimic what they did in the laboratory and I found that no one touched their front teeth. So started looking for different answers like. You know, what could it be? What could it be? Well, now airway has entered my world, so I’m now in this airway world and I kind of lose focus on this chewing pattern thing. And one night, about three in the morning, I wake up and I’m like, I wonder if those two things are related to one another. And I got on the internet and I’m searching through the literature on PubMed, and I found a group that actually did a study where they did exactly the chewing study I was talking about, and found that no one hit their front teeth. And then they said, what kind of sandwich do you want to have? Because if you think about it, all the people that break stuff in your practice, they break when they’re eating a sandwich. It always has bread involved in it somehow.  [Jaz]Always a soft one.  [Jeff]Yeah. So occasionally it’s hard foods, but almost all the time it’s like tuna fish salad sandwich, right? Something soft. And it has bread in there. And so this study did exactly that. What they found is that during a chewing cycle, you have to be able to manage your airway. You have to be able to breathe through your nose. People that are constricted in their bites like this. If their maxillas are constricted, and if their maxillas are constricted, then their nasal cavities constricted. They can’t breathe well through their nose. And so if you go from giving a small piece of cheese or beef jerky or a peanut to chew, they can manage their airway, have ’em bite into a sandwich with a bunch of bread and a bunch of stuff in it, they can’t. So their chewing cycle will move forward and they’ll hit their front teeth. In addition, apnea patients make their soft palate numb to holding a food bolus, and so the food wants to slip early on them and so they actually get out of normal chewing cycles a lot. So airway explains a lot of the reasons for tooth damage that we never had an explanation for in the past. We always just called it, this is what they do. They just do that. And we never knew why, and now we know.  [Jaz]That was brilliantly explained. Absolutely love that. And it makes so much sense. You also talked about, when I asked about the great bite, you mentioned a seated condyle position and you also said that, okay, well, in that hypothetical scenario where you have someone who has a restricted envelope function or constricted or basically a lack of overjet, deep bite, and if you open the vertical dimension, then again, perhaps overkill, where ortho is needed and just bringing all those themes together. Do we have a concern in dentistry that when we are doing a rehab type case or when we are choosing to use a repeatable joint position, i.e. stable condyle position, seated condylar position, centric relation, call it what you will, that we are making the airway worse. But from the bulk of this discussion so far, I like how you’ve been addressing it from the maxilla and you’ve been talking about the maxilla predominantly. Whereas quite often in my learning as well, I made a mistake of perhaps being a bit too focused on the mandible. And so what do you think about, if someone’s got a huge slide or they’ve got a long way to go back and that could be making the airway worse, what advice would you give to dentists? When we look at the joint position, when it comes to the airway?  [Jeff]Two things. One is you’re talking about a dual bite patient. A dual bite patient will have greater than three millimeters between their maximum cuspal position and their seated condylar position.  Interjection:Okay guys, interjection number two. What are TADS? So TADS are Temporary Anchorage Devices. They’re also called mini screws. And I’m gonna explain it very briefly like this. Imagine you are extruding a broken down premolar and the way you’re going to extrude this premolar, and actually this topic is on my mind at the moment ’cause I’m going on a course next month exactly about how to do more of these kind of cases where you take like a broken down premolar and you extrude it orthodontically. Anyway, imagine you are extruding this and you are relying on the two teeth next door to extrude. Now imagine that as an unwanted consequence. Yes, the premolar extrudes but the two adjacent teeth, let’s say the canine and the other premolar, they end up intruding. So the premolar that’s broken down, we extruded orthodontically and the other two teeth, they intruded. You could say that you lost anchorage or you didn’t have enough anchorage. Now imagine if the two teeth next door to that broken down premolar were implants. If they’re implants, they’re kind of like fused to the bone. And what then happens is the premolar extrudes. But nothing happens to the implants because the implants give you lots of anchorage. And this is how clever ortho folk, they use these mini screws and temporary anchorage devices to do all sorts of crazy movements because it gives them skeletal anchorage. It reduces those unwanted movements. Back to the episode.  [Jaz]I’m happy to talk about that, but also just generally, like, we know that for most patients, their seated condyle position will be further backwards, further distal. So how do we know which patients can be making worse?  [Jeff]But not much. So my take on this and to my knowledge, there hasn’t ever been a study, so I don’t know of a study. So I’m gonna base this on my opinion ’cause I don’t know of literature. My opinion is that the patients that you and I deal with routinely, that all we’re doing is seeding and equilibrating to and keeping the vertical essentially the same. Those patients that has no impact on their airway at all, the patient would do a dual bite. Absolutely is gonna have an impact ’cause you’re gonna drop ’em back significantly. But the one that people forget is, you were talking about doing a rehab, I would assume you were describing doing a rehabilitation in a seated position at an open vertical dimension. [Jaz]Usually yes, we need the space. Teeth are worn right.  [Jeff] So when you open the vertical dimension, it will absolutely have an impact. And it’s usually negative. [Jaz]So I guess what you’re trying to say also then is, sorry if I’m putting words in your mouth, but you know, correct me if I’m wrong here, is it’s the opening of the vertical dimension that is the sinner rather than the seating to a seated condyle position. [Jeff]Yes, unless you’re talking about a dual bite patient. Okay, so if we take that case out of play, then yes. It’s the opening of the vertical dimension that is the problematic part of it. And unfortunately it hasn’t been studied a lot, but there have been three studies and every one of them shows when you take patients with mild to moderate apnea. And you make ’em night guards and we’re talking just a classic one to two millimeter opening posteriorly, five millimeter open anterior, the one everybody makes that at least 50% of those patients are gonna get worse. And it’s usually somewhere between 60 and one study at a hundred percent of the patients. Now the a hundred percent didn’t get much worse, but they got worse. So if you have a class two patient and you open their vertical for whatever the reason happens to be, there are airways already constricted anatomically, and now you, doubling up on, ’cause they’re actually down the arc already and you’re even like really gets bad fast. Class two even worse than class one patients. So the vertical is the killer. Bill McCor taught me resolution before reconstruction. So McCor is a big gnathologist, lectured at AES and his idea was you need to get the joint healthy before you actually reconstruct. And so he would make orthotics before he would do reconstruction. And his logic was that if opening the vertical dimension was a bad thing, then the patient would react badly. Well, that logic has gone away a hundred years ago. I mean, it just, no one believes that anymore. ’cause that if a person comes in in pain, you make ’em an orthotic and you open the vertical and so you’re making the thing to make ’em better that he thinks might have made it worse, but now that we have this airway data, you go, well, maybe there is something to it. ‘Cause maybe we go old school on this and make an orthotic at a proposed vertical dimension and see how they react to it. If they’re grinding really aggressively on the orthotic, you just made their airway worse. If they get headaches, if they, whatever. I haven’t gotten there. I actually now watch my provisionals more than I used to in the past. I don’t trust my provisionals up front. I tend to stay with them longer if I’m opening the vertical a fair amount, so significant opening of the vertical dimension or more class two type of patient that I’m opening. I stay in provisionals longer just to see how they react ’cause I know I’m gonna probably be messing with their airway.  [Jaz]One school of thought that’s been shared to me is in those patients potentially with a dual bite or those who are, you are opening up significantly. So your vertical dimension increases quite significant due to the level of wear and compensation that’s happened. And because you are opening up so much, there is a concern about the airway. And then therefore you may then not be choosing to use a repeatable condyle position, a seated condyle position. You’re using what they say, an arbitrary position, which could be further protruded or the mandible be set further forward. Do you have any concerns about using such a joint position, which many people with a dual bite may function on? In terms of stability? Mostly in terms of stability ’cause I always think, okay, you build them there, but what’s gonna keep ’em there long term? Is that a way that you’ve managed your patients? What would you recommend to people who who’ve heard that advice?  [Jeff]Okay, so you had a lot of things in there. The first is people that had a lot of wear, they can either lose vertical or they don’t lose vertical, they just lose tooth structure, right? So if a person doesn’t lose vertical, just lose tooth structure, and then you open the vertical, now you’re impinging on the airway. If the person loses vertical and you open vertical, you’re actually just making ’em normal again. [Jaz]You’re reestablishing what they had.  [Jeff]Potentially. You’ve normalized anatomy rather than altered anatomy. The dual bite patient, I tend to work to the bite, to the MIP position, and I remember having this epiphany and I had two denture patients in a row that had an old denture in like a class one setup that were all worn out, and I was making ’em a new one, and I put ’em in centric relation and they fell way back. I was like, holy crap. And so I started trying to make their denture in that position and they go, I don’t like it back there. I don’t go back there. And I’m like, well, I mean, I was cocky.  [Jaz]I’ve been to this exact same thing, one year outta dental school. I remember this exact patient and how much he hated it and it was a huge slide. So yeah, definitely been there.  [Jeff]I’m the dentist. I know it was fast. I can’t control your occlusion unless I worked at this position. It was horrible. And finally, I remember in the end there were two patients in a row. It was weird ’cause it was like God was smacking me twice. You didn’t learn. Here there’s another one, there’s another, all these, keep sending ’em. And I finally learned, right? The second one, I remember one day going, just bite wherever you want. And so she bit down and I made her denture there. It was fine. So I then like went, okay, I don’t need to work to a seated position. I can work to their maximum intercuspal position. What disadvantages are there when they chew hard foods? The chewing data. Remember I said I kind of got into this looking at chewing data. The chewing data on hard foods says they seat their condyles, and so that’s where you damage second molars a lot is they put a piece of beef Turkey in their mouth. They have to load through the food, they will seat their condyles, they’ll hit posteriorly. And so I try to mount them in the seated position and see if I can adjust that on the articulator. But I worked in the MIP position, so I just see if I can provide myself a little bit of a lack of interference in the seated position. But everything else is focused up front. The other one that’s interesting is since I got into the airway part that kind of feeds into this as well, is I went and took some courses in neuromuscular dentistry. And so I started using. A TENS unit on patients that were those rat chewers, the pathway wear people that needed freedom-  [Jaz]Class 2 Div 2 type.  [Jeff]Yep. And then I married that information with MRIs on them, and what I’m finding is that the cases that work really well for neuromuscular dentistry are actually disc displacement cases where the condyle is back and down and the disc is slipped forward and is crowding the condyle out. And if I either tenses them or I can just relax ’em on an orthotic, either way they tend to get to the same spot. But we’re not working down and forward on the eminence. We’re actually centering the condyle by giving ’em the freedom to go there. So, I don’t know, the airway stuff’s kind of opened up a lot of really cool different avenues to look at for like why things work. Because you know, there are too many people that I think are smart people that do things differently than me that I just can’t understand why you would do that. And like, that’s not how I was taught. That can’t possibly work, but they’re smart people and they’re running good practices and I can’t believe they would just like do it wrong. There’s gotta be something to it and airway really feeds a lot of answers or at least can. And so little things like that, like the neuromuscular people got such a bad wrap over here and were just berated every time they did anything. And I was like, those guys, they just can’t be wrong on everything. I do think they overuse it, but I think in the right cases it’s great. It works out perfectly. So I’ve done a few cases like that as a proof of concept.  [Jaz]What you said is very validating for me personally as someone who’s always wanting to learn from the different occlusion camps. And it ties in very nicely what AES is about nowadays in terms of bringing everyone together, sharing knowledge, different camps coming together, if you like. And I always say that listen to everyone, but do what feels right to you. One of my listeners actually sent me that advice and I always like to share it. And so I always find that certain cases, some of the principles I’ve learned from the course of philosophy, they work really well here. Some things that work in this philosophy really well. Just like you notice that okay, certain patients, what you’ve learned from neuromuscular dentistry can be applied well on those patients and I really admire that we can learn from everyone and then pick the right time to use that skill where it makes sense to you the most. Jeff, we’re coming to the end of the time, I just wanna say, wow, that was just absolutely packed full of stories and interesting anatomical explorations. We focus a lot on the maxilla, which was very good for me. This is all learning for me as well, which is fantastic. Can you give us a flavor of what you’ll be talking about at AES in Feb 2026? I’ll put the links and everything below obviously.  [Jeff]Yeah, I’m gonna build on the idea almost exactly what we ended up with, which is questions you’ve always had in your practice that airway might explain and sort of a medical dental connection that the airway could be the component that we’ve been missing all along. At least in my dental school, we didn’t study how people chew. We studied how an articulator moved around, right? So we forgot the biologic part of it. And we talked about my patient, bruxist, but we forgot there’s might be like, why? Why would they do that? And we really didn’t spend a ton of time, we talked about how to make a splint, right? My patient bruxist is let’s make ’em a splint like we always are jumping to how do we fix something rather than asking why. Because if I can figure out why I might have all kinds of cool ways of dealing with the situation. So we’re gonna ask a lot of why questions. Why did this patient do this? Why did this patient do that? And obviously because of the topic and the title, the answer’s gonna be airway. So if at any point I ask the audience like, well, what do you think? Just answer airway, you’re gonna probably be right.  [Jaz]That sounds amazing. And over the years, what does the AES mean to you and why should some of our younger colleagues around the world visit this conference in Chicago? [Jeff]I have to get ’em to add it up. I’ve at least lectured five times, maybe way more than that. I probably have lectured there more than anywhere else in any big conference. And so I’ve gotten to watch it evolve over time. If I was to kind of give you an idea, actually you summarized it really well, it’s because it looks at the broader scope. It’s not exclusionary to any different perspective, even some that you would consider sort of out there. Neuromuscular has been at this conference a lot. Like the best people in neuromuscular have spoken a bunch at this conference. And the other beautiful thing about is they’ll put ’em on panels with people like you were talking about today. We talked a lot about the maxilla. Well I was on a panel with Jim McKee and Mark Piper, they’re the mandible. And so I just kept saying, you gotta get the maxilla in the right place. You know, the mandible follows the maxilla. And so we have this debate and then the audience gets to be involved in that debate. So I don’t know of any other conference that allows that unique of a format and breadth of information. Like AES. So if I was, coming to Chicago, absolutely, the AES starts the week. So it’s a Wednesday, Thursday conference, and there’s no better way to start the week than at the Equilibration Society. [Jaz]And most importantly, Jeff, where is the place to eat when they’re in Chicago?  [Jeff]So this one’s one that it’s, you need to save for a long time. Alinea is the best restaurant in Chicago, and it’s gonna cost you so much money. It’s crazy.  [Jaz]But it’s all tax deductible. It’s fine.  [Jeff]Alinea is phenomenal. It’s a, actually everyone needs to have one of those kinds of experiences and then go back to your practice and try to make your practice like Alinea, because it’s just service at a higher level and thinking about every detail instead of, you know, like I walk into my practice and every day I enter from the back, but I try to go to the front and walk through my practice as if I’m walking through as a patient. And I’m looking at everything. I’m looking at it as a trashcan full. We need to get rid of that. Is anything dirty? Is there a book out of place? Is there I looking, is there anything that a patient might see? And then I listen constantly to how do my staff talks to people and Alinea does a beautiful job. So that would be-  [Jaz]There we are another learning experience through that. Thanks for that share. I’ll make my reservation well in advance before people listen to this podcast and it’s oversubscribed on that Wednesday night. Jeff, for those who are hungry to learn more from you, I know you’ve got so much, you’ve contributed in terms of, in the form of education, so many programs that you deliver. Where’s the best place to book some of your courses and learn more from you?  [Jeff]So it’s my main place to lecture about this is at Spear Education. Spear education’s in Scottsdale, Arizona. It’s a beautiful teaching institute, and the seminars are two days long. The workshops are three days long. But for a lot of your listeners, that’s gonna be quite a bit of traveling to do. And me personally, I’m cheap. And so, although I just told you about expensive dinner, but I’m really cheap if I’m trying to make a decision about continuing education or whatever I want to know, I’m gonna have value when I get there. One of the things you can do is go to Spear Education and get in the online platform, in which case you’ll see all the videos, we produce all the courses, and you can actually watch some of the stuff in advance of coming to Spear and you’ll see the value behind the education that we give you at Spear. So that’d be the introduction I would have if I was living somewhere else. If I was in England, I would watch the online platform and go, okay, that’s something I want to do. Or, I mean, we’ve got courses and everything, so if you happen to be working tomorrow and you’ve got a horizontal root fracture and you want to know what to do about it, we’ve got courses that you just pop on, like a YouTube video and you’ll find out in five minutes what to do with that particular case. So we’ve got all kinds of things, but airway is part of it.  [Jaz]Amazing. I can definitely vouch for the quality of educational videos on Spear Education website as well. So I’ll put the links on there, especially to your stuff on there as well.  [Jeff]Oh, you know what else I got coming? Oh Jaz, I forgot about this, that global diagnosis textbook I wrote with Bill? We got a second edition coming. It’ll have airway in it.  [Jaz]When’s it coming out?  [Jeff]Oh, I don’t know. Whenever I finish writing my chapters, he just yelled at me last night about it. I’m thinking probably the end of the year. So Quintessence and handles it and so they’ll Bill announce it. [Jaz]Amazing. I can’t wait to get a copy and I’ll get signed by you personally when I see you in Feb. Awesome. I’m very excited to meet you in person, but thanks for giving up the time to speak about something that’s so dear to your heart. And I think we can all just learn more about this because the impact, like you said, will have on our patients will be so great. And anyone out there in a position of which way to pivot their career, the early in the career, which way to pivot, then what a wonderful direction to go in, with a health focus and the ability to help children in all ages actually. But such a positive influence you can have. And I think that’s something definitely I’ve picked up today. So thanks so much, Jeff.  [Jeff]Oh, you’re welcome. Thanks for having me.  Jaz’s Outro:Well, there we have it my friends, thank you so much for sticking all the way to the end. Some really great points that Jeff raised there, how the airway is there to explain so many things that are almost unexplained or unanswered. So I’m really looking forward to his talk next year. Also, highly recommend his textbook Global Diagnosis. I know the second edition will be coming out probably, I think at the end of the year. But I’ll put a link to his excellent textbook. If you have access to it, please do check it out. If you’re like a student and you have this book in a library, then please get it. If not, then tell your librarian, you need to get this book. It is phenomenal. Once again, this was an AES takeover episode, so please do consider coming to join us in Chicago in February, 2026. It’s on the Wednesday and Thursday. That’s the AES conference, 18th and 19th of Feb. And it’d be great to to see you there. Come and say hello. If this podcast is the reason you ended up at the AES, please do come and say hello. Now, just to wrap up for those Protruserati who are subscribers to Protrusive Guidance. Thank you so much. This episode is very much eligible for CE Credits or CPD. We are a PACE approved education provider. As you’re watching in the app, just scroll down, answer the quiz, get 80%, and our CPD Queen Mari will email you a certificate. In fact, what we do is every quarter we’d email you your personal dry folder with all the certificates that you’ve collected from the podcast episodes and our mini courses on the Protrusive Guidance platform. More than the education, it’s about the people. Now we’ve really attracted the nicest and geekiest dentist in the world. The reason I specify that is I’m trying to attract people who listen to the podcast, but who identify themselves as nice and geeky. And for those who don’t, they stay away. And that’s amazing ’cause I’m trying to build a special group of people, people who can share failures with each other, be a little bit vulnerable, and it is very much a protected space. We have to manually verify each person who applies to come on Protrusive Guidance. So if this sounds like your bag, then check out Protrusive app that’s www.protrusive.app sign up, and it’d be great to see you there. Whether you want to get the CPD or just join the community, it’d be nice to have you. Thanks for listening, watching, or wherever you’re tuning in from today. Don’t forget to leave a review. I read every single one, whether that’s on Spotify or Apple Podcasts, wherever you are checking this out today and a thumbs up button on YouTube. Thank you. Once again, Protruserati. Catch you, same time, same place next week. Bye for now.

Have you actually looked back at your long-term cases to see how layering compares to injection moulding? Is traditional freehand layering still your go-to for anterior composite aesthetics? Are you using it because it gives the best result — or just because that’s how you were trained? In this episode, Dr. Marco Maiolino joins Jaz Gulati for a meaty discussion about injection moulding—a technique that’s changing the game in anterior composites (and posterior!) This isn’t about trends. It’s about clinical outcomes. We’ve all admired the beauty of layered composites—translucency, halo, the “natural” look. But after 5, 7, or even 10 years… do they hold up? Dr. Maiolino brings over a decade of follow-up data—and the results might surprise you. https://youtu.be/wHs8QQkgPhU Watch PDP228 on Youtube Protrusive Dental Pearl When in doubt between two shades (e.g., A1 vs. A2), always choose the lighter shade. Higher-value shades blend better and result in higher patient satisfaction. Techniques: Use the composite button method and black-and-white photography to objectively evaluate shade blending. Outcome: Lighter shades minimize the risk of patient dissatisfaction and rework. 🎁 Download the full Premium Notes for this episode—including clinical comparison of injection moulding and layering technique, long-term before/after documentation, and Marco’s complete injection moulding protocol: 👉 protrusive.co.uk/im Need to Read it? Check out the Full Episode Transcript below! Key Clinical Takeaways Injected composites often outperform layered ones in long-term follow-up. Color stability is as much about technique as it is about material selection. Edge bonding requires careful occlusal planning and respect for functional dynamics. The biologic cost of veneers is frequently underestimated—additive approaches can be more conservative. Composite thickness and occlusal harmony are critical for restoration longevity. Rigorous documentation and honest case review matter more than dramatic presentations. Failures are not setbacks—they are opportunities for professional growth and better patient care. Episode Highlights: 0:00 Introduction 02:45 Protrusive Dental Pearl: Practical shade selection hacks 08:54 Dr. Marco’s journey into injection moulding 15:44 Why Marco transitioned away from layering 18:00 Edge Bonding and Occlusion Considerations 25:20 Layering vs. Injection Moulding 29:15 Variations of Injection Moulding Techniques 32:32 Injection Moulding for Edge Bonding 39:29 Edge Bonding Protocol and Materials 49:18 Understanding Failures and Diagnostics 53:23 Managing Tooth Wear with Injection Moulding 55:47 DAHL Approach Complexity and Cost 56:41 Swallowing Patterns Affecting Treatment Success 01:00:07 Importance of Case Selection 01:01:08 Rubber Dam Use 01:03:17 Flexible Use of Techniques 01:17:24 Outro 📅Upcoming Talks & Courses Dr. Marco Maiolino will be one of the notable speakers at the Injectable Restorations European Summit 2025, taking place on November 7–8, 2025. This highly anticipated event gathers leading experts in the field and will be held in Europe. For more information and registration details, visit the official website: injectionsummit.eu. If you loved this episode, be sure to watch Stop Being a Perfectionist – it’s OK to Fail – PDP184 #PDPMainEpisodes #OrthoRestorative This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.  This episode meets GDC Outcomes C and D AGD Subject Code: 250 Operative (Restorative) Dentistry (Direct restorations) As clinicians, we’re constantly challenged to balance esthetics, function, and longevity in our restorative work. In this episode, Dr. Marco Maiolino joins Jaz Gulati for a candid, evidence-driven exploration of injection moulding—a technique that’s rapidly shifting the paradigm in anterior composite restorations. This isn’t about chasing trends; it’s about critically evaluating what truly works for our patients over the long haul. Dentists will be able to: 1. Understand the indications, benefits, and limitations of edge bonding and injection moulding. 2. Recognize how minimally invasive dentistry can provide reversible, conservative treatment options.  3. Appreciate the importance of proper planning and case selection when using techniques like injection moulding. Click below for full episode transcript: Teaser: More layers you do, in my experience, more aging, you will get on that restoration. So if you see in my office, I have just three comp, I have a A1, A2, A3. So injection moulding is a way to apply composite that for me is the best. Teaser:I’m glad you mentioned it, that you are so convinced and dedicated to the injection moulding way to deliver a restoration that you’ve pretty much now found ways. As long as you can make your scaffold.  On the mesial distal, you have some composite with just one shade. Now this brown area is much more evident than before. So the patient completed the appointment. Saying, I am very happy. I have no more black triangles. I am very happy. But when you’re doing a study patient with the worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while. But honestly, when I see with air drying the restorations with magnification, and I see the interproximal surfaces in comparison to the surface that I have with injection moulding with matrices. This surface-  Is there a composite that you found to have superior longevity in terms of color stability, polishability? Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays?  Okay. What I use every single day in my life is I use-  Jaz’s Introduction:Protruserati, there’s been a big shift over the years towards injection molding. Now, some of this has been driven by the industry, of course, right? So we always have to be careful about biases. Biases are everywhere. Now, use this technique, use that technique because there’s a lot of money involved for these companies. But what I look for is clinicians that change, that pivot from a technique that’s perhaps established and we know of, and they pivot and change to a different technique. And if they can justify why they’ve made that change and share the science or the rationale, I like when something is justified. There is a clear science behind a decision that’s made by a clinician that’s fantastic. Rather than, oh, this company’s paying me. So I’m talking more about this product. This is why I really respect today’s guest, Dr. Marco Maiolino. We’ve had him on as a guest before on the imperfect dentist. He is such an authentic character. He talks about his failures very openly, and it’s his failures in layering over time, right? He shares the long-term data of seeing his composites and he is a very good practitioner. High quality isolation, high quality materials microscope, everything. But what he noticed at the eight, 10 year mark is that his layered composites were not looking very aesthetic despite using the best materials and best techniques. They certainly did not look as lovely as they did at day one. So many years ago. He moved, I believe he said 2014, he moved towards injection molding. Now when I say injection molding, you guys probably think, oh, exaclear or memosil stent, and then you inject the genial injectable composite or any other composite that may be available. But actually, injection molding is just the name of the technique, the act of injecting into a space. So this could be bioclear or these transparent matrices. It could be just a humble mylar strip behind a tooth, and then you inject the composite into that space once you’ve made your scaffolding.  So really, this episode is about the process of injecting that material and why the injection of composite is superior according to Marco than layering bit by bit and some of the issues that you can face with that, and why in the long run, whilst your layered composite may look a little bit more beautiful, a little bit nicer on day one compared to your injected composite, when you look at them at eight, 10 years, the injected composite looks more consistent, more stable, both types of color. Luster, shape, all those things. So there is a science behind it. And to discuss that science we have Dr. Marco.  Dental PearlHello Protruserati. I’m Jaz Gulati, and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental pearl. Today’s pearl is something I shared a few weeks ago on our community Protrusive Guidance, the home of the nicest and geekiest dentist in the world. And it’s about my thoughts on shade selection on composite. Now, in previous pearls, I have discussed the button technique. Getting a small button of composite, curing it, and then having a look. Hmm, does it match the adjacent tooth? Is this gonna be the right shade to use for my patient? And in another episode we did with Dr. Jason Smithson, he talked about using a black and white photos.  So as you’re doing the shade test, you taking a black and white photo of your patient, you can use a phone for this and see, hmm, what’s the blend looking like in this black and white photo. But I’ll tell you one thing I’ve picked up through experience call it wisdom. Call it Learning from Failures, is that if I’m not sure, between, let’s say an A1 and A2, just to make it really easy to understand and clear if I’m unsure. Ah, it’s kind of A1. It’s kind of A2. They’re both matching. Please, for the love of God, use A1. Okay, use the lighter shade.  In my career so far, every time I’ve opted for this, slightly darker, ’cause this will match better, it’s been more risky and in some occasions it just wasn’t light enough. I’ve been disappointed at the end, and there’s more risk that the patient will say something that, ah, they’re not a hundred percent happy. But where I’ve used the whiter shade, then you know what, no one ever complains. Everyone’s happy. I’m happy. And I just made it a rule. Okay? My rule is if I’m undecided between two shades, whichever one has a higher value, that’s the one I will use. It’s a really stupid thing, really, but sometimes when you are stuck in that scenario thinking, Hmm, what do I do? Just remember this rule and make it easier for yourself. Pick the lighter one and you shall be much happier, or it’s gonna be just a more predictable decision. Now one more announcement, my friends is with Protrusive, we’ve grown so much over the years, and I’m constantly looking to strive for better. How can we serve you better? How can we serve our community better? How can we make learning more fun, more impactful, more actionable, easier to implement? And so some years ago, we introduced the Premium Notes. The revision PDF we have accompanying each episode as like a cheat sheet, a guide, an aid memoir, a quick reference to the main lessons that you picked up ’cause sometimes there’s so many lessons you might pick up in an episode and it’s difficult to implement. But when you have it also in writing that you can highlight, it can follow along. It makes it easier for things to stick. But I’m pleased to announce that we’ve taken this to the next level. Now we now have a section called PITC. This is called Patient in the Chair. The best example of this is when you have a patient who’s had trauma in the chair, like an avulsion or something, what do we all do? Even though we all kind of know what to do when there’s an avulsion, we still look at the guidelines ’cause we just want that quick reference and we wanna be sure that we’re doing the best thing. Now, anytime something is shared on the podcast, which is like really important, really worthy of a quick reference. We are gonna put it right at the top, and we call it PITC. These are the one to three things in this podcast that you just need to know, and it makes it like a lovely quick reference. Oh, what’s that thing that Marco and Jaz said in that podcast? Now you’ll see it right at the top. You’ll also see that our Premium Notes are more visual than ever before. And all the key takeaways summarize without any waffle. Think of that dental student that had the best notes at school, and everyone copied their notes is kind of like that. It’s like the revision notes of your favorite podcast episode. Now this is a paid feature, so if you’re on Protrusive Guidance, if you’re on a paid plan, you can access the Protrusive Vault, which has all of our infographics, all of our premium notes, all of our premium resources. Every episode takes a team hundreds of hours to put together, including the PDF transcript, including this extra premium note with references and visuals. Now to celebrate the launch of this new style of premium note. I’m gonna give away this episode’s premium note for free. It’s a wonderful summary of everything that me and Marco discussed in this episode. Complete with the visuals in case we’re listing on Spotify or Apple, and you want to see some of the visuals that before and after of how composites don’t look so good when you layer versus how good they can look when you injection mold. All the visuals stacked in there, any references that we think you might need, all the references that you should really read, all the key references, the key takeaways, the visuals that really add to the episode and enhance your learning. Everything is there so you can download it for free as a taster, as a gift from Uncle Jaz to celebrate this upgrade that we’re doing. If you wanna get your hands on it, check out protrusive.co.uk/im just the two letters, right? Injection molding. protrusive.co.uk/im. If you are already watching this on Protrusive Guidance, don’t worry. You don’t need to do that. You can just scroll down on the app and it is available under this episode as a download. But if you’re not on the app yet and you wanna check out this download really quickly, just head over to that site and you can download this news style premium notes for free. Let’s now catch Dr. Marco and I’ll catch you in the outro.  Main Episode:Dr. Marco Maiolino, my good friend, just every time I see your cases online, every time I see you come, I think of a wonderful time that we had at your course in Syracuse in Sicily. I still remember Granita, I still remember the culinary experience that you gave us. And if anyone wants to go on a hands-on course of Verti prep scene to check out Marco. But another one of your passions, Marco, is injection molding, bioclear. And I really wanted to speak to you about these topics. Now, I’m gonna tell everyone to listen to our previous episode we did, the Imperfect Dentist. A good lesson you passed on is that if we strive to your perfect every day, we’ll be miserable. And to aim for a consistent seven, eight out of 10 rather than three and 10 and three and 10, that kind of stuff. So just summarizing that episode. So I encourage everyone to listen to that. But Marco, just tell people who may be new dentists who haven’t seen your stuff. What do you stand for? Tell us about yourself, Marco. [Marco]Okay. It’s a pleasure to be here again, also because with just, we had the wonderful experience of being in the real life together because we did the vertical course, the real one, the three days course here in Sicily, and we’ve been enjoying a lot of time together. So this has been a huge pleasure to see Jaz in the real life and to see-  [Jaz]And even though Marco has no interest in football, he still took us by the seaside to see the match.  [Marco]Yeah.  [Jaz]I think it was Italy, Switzerland. I think Italy lost. It was sad. But you were in the sea, you were having fun. You were with your family and friends. It was nice actually. So.  [Marco]For me, the course is not just the course about speaking and doing something about dentists, something like about enjoying. The reason, because I do the course is a small course with just six, seven people is because I really want to do a real connection with each one, because sometimes I do bigger courses, not in my town, but abroad with 25, 35 person. But for me, and even for them, I think this is not absolutely the same thing. The connection that you have when you are in few people. You go outside for a dinner, you go outside for the lunch, and you spend time joking about everything. It’s the time that you cannot compare with other kind of situations. About me, just because of course. I just want to introduce a little bit. I am a general dentist, a real general dentist. I do almost everything in my office. Of course, I do also wisdom teeth. I do implantologists, I do implants, I do soft tissue, I do mucogingival surgery, I do everything. But of course, most of the people know me for two main things because I have something that it is a little bit more different to say, and it is about restorative dentistry, because in this field I have my own ideas. And about prosthetic dentistry because I started working now 15 years ago with vertical preparations. And so I have 15 years of experience and follow up. So on these two fields, I have something more to say. When just came in Sicily apart, the Granita Granola Pizza and all the other incredible things that we do in Italy, we spent three days talking about relations, Arancini. And also, I love reading. I am an obsessive reader. I read something like between 40 to 50 books every year and I love to read about psychology, management, all these kind of things.  [Jaz]So what are you reading right now, Marco? Tell us what you’re reading right now. What’s the flavor of the month?  [Marco]Okay. In this month I’m reading a book from [inaudible]. He is one of the most famous anti-aging doctors that we [have] in Italy, because I am very well into these kind of things. I know cold shower, sports, fitness, nutrition, and all these kind of things. I am very well to these kind of things because I have to work at least until my 85 years old. I have to see all the other doctors in the coffin and I will gain in that way with my handpiece working on the, this is the plan. After I am reading on another book that it is Martin Jan Stransky,. It’s about the collapse of our mind. It’s a book about how today, especially on children, the exposure that we have about social media, iPhones, these kind of things, it seems that our children are the first generation that are starting to have a sort of devolution in the last million of years. We always went through an evolution, but this is that from this point on in this century, now we are doing a sort of devolution. So it’s something that is interesting about, it explains how the brain is working, all the psychology behind the brain and about what happens when, since you are very young, you expose yourself to social connections or social media connections. These are two completely different things. And I think that this will be also a challenge-  [Jaz]A real connection and a junk connection.  [Marco]Yes. We are living in a strange period. Like for example, just to say about the first topic. It’s a strange period because there is a lot of discussion about, for example, nutrition, about fitness, about all these things. A lot of education of content. Yet the number of people with obesity is always rising. The number of people with diabetes is always rising. So there is a sort of mismatch between what we know and what we say and what really happens. And this is the same thing that happens in industry sometimes because we talk about that. And this is also the reason because I’ve been lobbying the other episode about perfectionist, because sometimes this is the missing link. Because when there is a huge gap between what we say and what we do, it means that there is something that it is wrong about that. And what I want to do in my dentistry, in my life, this is me, you wrote me. It is about closing the gap between these two things. This is reason because I’m not a perfectionist. I share my cases and I want to do perfect cases, but I am perfectly fine with doing good average cases because this is my real life. But when I am able to do an alignment between what I say and what I do, I think that this is the best example that you can give to people. Honestly, because you can teach what you are. When you are teaching something that it is not your real everyday life, there is a gap and the message is wrong, in my opinion. This is the reason, because I have not very good relation with several speakers because for them I’m doing slightly more than average dentistry. But for me, they’re doing something that’s different, that it is just a sort of cinema, because it’s easy to bring five cases in the near and to bring five perfect cases when you have the possibility to choose the patient, choose the case, choose the time. Because if you take five hours for doing two empty restoration, okay, of course you’ll be able to do to great restoration, but this is something that it is not real. Also, the obsession that we have about photography. Okay, I cannot talk, I mean, I have bouncer, I have here, I have everything. But there is a huge difference about the approach because something is to consider the documentation in the real value that it is to follow up cases. I did this 10 years ago. Let’s say what happens now, and this is what today, for example, we share, because sometimes I joke about I am a layering survivor. [Jaz]You’re layering what, sorry?  [Marco]Survivor.  [Jaz]Okay.  [Marco]To survive.  [Jaz]You survive layering.  [Marco]Survive. Perfect. Yes. Because my follow up on layering, for example, is not that great at seven, 18 years and it is something that I saw on a constant basis. It said my follow up injection molding that it is the main topic that we are going to discuss today, and this is also something that I’m going to organize something, you know in Milan at the end of the year is because I saw result that are less statistic. Of course we are talking about a more concrete dentistry, but the result is much more stable over years. And I’m much more interested in the long-term follow up than on doing the artist day zero. When you do just the fourth at the end of the work and nobody knows what happens after five years, seven or even 10 years. Most of our patients are much more connected with the long-term result and for the result that they are able to perceive. Because honestly, I have never a complain about the lack of opalescence about an intensive milky on one mamelon. Never. I have complain about the shape. I have complained about the triangle. I have a complain about the leg of in insiders. So there are things that are much more important if we want to talk about real dentistry. Real dentistry, I mean the dentistry that you need to be successful in the real life of your town. There is another dentistry that, it is the dentistry that we like to share instead of social media on congresses. But it’s like real life and cinema. I am much more for real life. I’m not the guy aiming for the cinema’s approach. It’s just me.  [Jaz]It’s what I love about you, Marco, is the word to describe. It would be authentic, authenticity is there and that’s so, so important in today’s world full of social media dentistry, and I love this fresh injection of authenticity. Now, you mentioned about following up these cases and how people don’t actually care about the tiny little details is the bigger picture, which makes sense. And it’s like the Pareto principle, right? 80% of the magic comes from the 20%, the overall shape really, and how you finish it to a seamless transition. And then with that you get 80% of the benefit and then you can follow that up long term with success. And that is the definition of success. Now, today’s episode I want to just cover ’cause there’s so many different ways we can approach the different ways that we can do an anterior composite buildup. So what I wanted to present with you, maybe I thought this structure may be better, is that if I give you three to five real world examples, and if you suggest, okay, in this example my preferred technique is A, B, C, or D, and then you say, why. Now obviously there’s so many ways to do it, but people may be inspired or maybe they have, ah, okay, this makes sense. So if we start with edge bonding, every time I post about edge bonding people in the US they say, I dunno what that means. What is edge bonding? Okay, so just to clarify guys, what we mean by edge bonding is the patient has finished aligners, the teeth are a little bit short, maybe they’ve had a bit of incisal wear and you are just lengthening the teeth without having to veneer the entire labial surface. It’s just composite on the edges. Yes, you will do a transition, but in your edge bonding cases, Marco, what kind of techniques and tools do you like to follow and use? Is it freehand? Is it led by a wax up always? Is it led bioclear, whatever it could be? How do you like to do your edge bonding, let’s say after aligners? [Marco]Okay. The problem about edge bonding is that most of my cases about edge bonding are cases after orthodontics because the problem that I see is that when you have patients with some wear, with some fractures, there is 99%, unless there was a trauma, there is a problem of occlusion because my worst failures have been when I’ve been dealing with patients with worn dentitions and have been working just from canine to canine, doing an increase of the length doing veneers in these cases without changing the vertical dimension of occlusion. So before, to talk about the technique about edge bonding, injection molding is about talking about little bit about occlusion and and I know that an occlusion you are one that it is very well into this kind of field. What I see is that because my experience is that you have never increase the overbite of a patient. Especially if there is a patient with some parafunction or with some wear. So the main problem is to say, I do edge bonding when I have this kind of patient, but after orthodontics. So if there was, for example, a deep bite, I’m opening the bite and I’m opening a bite a lot, at that point I can edge bonding about edge bonding. The same is about anterior restoration. The most important part, and I did this mistake despite of this just two days ago, is about the color of the tooth. Because we can do edge bonding, we can do parts restoration when we have easy shades. I mean, you take the Vita shade, A1, A2, A3, and you have the surface of the tooth that it is matching with that color. In this way, doing just a little bit of bevel is very easy to do a nice transition, even if we have to remember always that composite is material, especially when we are going to do addition on dentine that you need certain amount of thickness. And this is another point that people doing layering many times in order to get a little bit more of transparency, they’re doing very thin restorations. And when I was doing these thin restorations, the typical outcome after one or two years, that was a small chip of the incisal margin, the incisal margin, asked to be thick, big goes composite is not ceramic. David Clark, that many things, he has been a pioneer, says that composite has to be minimum two millimeters thick on incisal margin. Of course. When you have two millimeter with two millimeter, of course you are going to struggle if you want to do all these special effects in the incisal term. But if you’re going to discuss about the long term longevity of this restoration, you are not able to match the result of David does because you know the problem is the approach in your dentistry. You want to be the artist or you want to be the engineer. In this moment, I’m doing a new office. You remember when you were in Syracuse, in my office, every single week. I have a struggle between my architect that it is focused on the static of the office, and he said there is the engineer that it is focused on. For example, said on the stability at 10, 15, 20 years of the office, the same problem we have in dentist. The problem is that in a villa, in an office, in a house, the aesthetic is very important. Instead in the dental office, how much is important, the aesthetic for the patient, because aesthetic for the patient is completely different from the aesthetic for the dentist. There is a mismatch between these two things. So what I did in these years has been two find tune my aesthetic perception to the real one of the people that it is paying for the work. So most of the times monolithic restoration are more than enough for this patient and they reserve veneers for some of them, but just for some of these patient, fewer of our patients really needs the plus value of indirect ceramic veneers.  Also, because there is a different biologic price. When I’m working with direct restoration, most of the times I can work in a very minimal approach or no prep approach when you’re doing veneers, that with veneers, there is the problem of the axis of insertion, and there is a huge biological price sometimes. There is always this sort of legend about veneers that you can do. Always minimal veneers, no prep veneers. But in the reality, the cases that are ideal for no prep veneers or minimally invasive veneers are not so many. They are the exception. And when you are dealing with diastema or black triangles, the coverage for veneers in this cases is quite invasive because in order to manage the diastema or a black triangle, the preparation to arrive on the palatal side.  And you have also to go in the sulcus, subgingivally because in order to shape the emergency profile. So I think that sometimes we complicate our life to we as dentists and to our patients more than we need. And the layering is something that in the last years I realized that most of the layering in the restorative dentistry is much more complication than something that helps us. Especially because that I have some cases that I can show you. Okay, so for example, okay, in such cases when, for example, anterior restoration, this is restoration a case of with 10 years of follow up, what is interesting to see is what? I did the conventional restoration layering, in this case, after a conventional preparation with a small bevel, I did all the steps that we know and I did what? I placed two layers of dentine. One layer in the parallel shell of enamel, another layer of enamel in the top, and they put some special effects. The result at the beginning of the work in 2014 was quite good, but if you see what happens after 10 years, it’s something that is unbelievable because this is something that I realized very well with David Clark, is what composite is a material with a strange behavior.  If you see, now, I can show you, for example, if you see the surface that we have when we work with composite, just with the spot, just putting the composite in such a way, and you see instead the composite that we have with injection molding, it seems that you’re working with two very different materials. With injection molding, you always get a surface that it is like glass, it’s shiny. There are zero bubbles, zero void, and zero porosity. When you’re working, say with your puddle, you always, this is my experience several times, even outside of the mouth, you know there also to collect cases, to do some documentation, you have always bubble void proposities, and the initial layer that you do there is a sort of transition between the layers that exposes the composite over time to water absorption and to accelerated edging.  More layers you do, in my experience, more edging you will get on that restoration and I can show you several cases like the one we’ve been discussing now, several cases and up 10 years. The outcome is always poor. When I do the same instead of injection molding because I started injecting my cases in 2014, so now I am close to my 11 years follow up. I can show you some cases if you want. The follow up at 10 years of this case with injection molding. They are very similar to the first year of work, so injection molding.  [Jaz]I think the lesson here is the way that you choose to handle composite has a significant bearing. You could use the same composite handled in two different ways and then-  [Marco]Yes, the same composite. This is the case that I did for example, in similar case, it’s very similar to the other one. On this incisor, there is a restoration always with, but injection molding, one layer. And if you see the follow up at 10 years, this is the 10 years follow up on two to 1.1. You see that the edging of the incisal area is almost zero.  [Jaz]So for those listening on the podcast, he showed a layered case, and Marco’s a very skilled, gifted dentist. And no offense, Marco, but that 10 year case looked like maybe a student had done it right at 10 years. And that’s done by a skilled practitioner. The injected case you showed, it looked flawless at 10 years. And so the comparison there is very stuck.  [Marco]Yes. This is another case just to say, it says, with a broken incisor of such a way, look, the difference that we can get. This is at one month. You see, I did the layering with three dentine. I did the primary anatomy, secondary anatomy. You can see everything here. I did the opalescence in the incisal third, but the look after 10 years, again, this is short, very short. And the opacity that, the etching that you have in the composite is something that it is unbelievable. And if I do the same case with injection molding, instead the composite is able to preserve its optical and physical properties in completely different way. This is the reason because I said that I am a layering survival. And because I stopped layering my cases now since many years because when you start to collect your follow ups, and this is the real value that we have in using every single day, our photographic machine, our camera is this, not using the bouncer to improve our cases just with proper lighting and transform a dental office in a photo studio with the papers bouncers five, this is craziness.  Sometimes it seems that we lose what is the main point of our work. The main point of our work is not to the show. The show is just for the dentist. It’s something that, it’s very true. Sometimes I think, yes, sometimes we are the push from social media, from courses, congresses, where you raise the bar, but you raise the bar in a bit different direction. It’s like, for example, I am passionate about fitness. But if you go on social media about fitness, you see just people with six packs, arms like this. But we all know how you can get this kind of body, and it is not just with training and nutrition. It’s adding other things that I don’t want to discuss, but you know that when you do that, I do fitness in order to be able to work at 85 years old just to say they are doing, just in order to have an aesthetic boost. But after 10 years of that life, what is left me is fitness for longevity. Fitness for health. This is fitness just for aesthetic. It’s the same thing. And in dentist with social media. And also I am sad to say that the most of scientific association, the push is always in the bad direction. It’s always about the aesthetic.  This is my feeling is that if you look at injection molding, another case with injection molding, this is the follow up at 10 years. This is two restoration on the distal part of the lateral and on the medial of canine. This is a patient that it is not a very good patient with is plaque. You see that the edging of the restoration is almost zero. Another patient with a very complicated case with subgingival margin, with very tough cases. But at six years, this is the follow up that we can get with injection molding.  [Jaz]So this is with the bioclear technique though, right? That would be a posterior bioclear, I imagine. [Marco]Yes. This is a posterior bioclear, but it is not about bioclear. The point is a one there is injection molding is a way to apply composite in your restorative workflow. At the beginning in 2014, I was doing injection molding also with metal matrices with the TOR matrices with saddle matrices. So injection, of course, with the metal matrices, we have to change a little bit because the polymerization is different, but injection molding is a technique. How to apply composite? After is what is your restorative workflow, and here we can discuss about metal matrices, TOR VM Matrices, bioclear matrices. Of course, bioclear have been designed in order to take all the advantages of injection molding, but you can do injection molding also with other techniques, honestly. So injection molding is a way to apply composite that for me is the best. If you have to work with the composite, of course, after we can discuss about the restorative strategies, because what is interesting is that nowadays we have several strategies because you can do injection molding with bioclear matrices. And I am a Canadian leader about this technique, but there are several interesting techniques. There is the iVeneer technique of an Israeli guy  Itay Mishaeloff  did other kind of matrices that are very smart in the idea. I don’t know. Do you know  iVeneer ?  [Jaz]No.  [Marco]It’s another technique.  Itay Mishaeloff , This Israeli doctor did different veneers that are going to shape all the buccals of face. I have some video if you want. I don’t know if we lose something about people that will listen, but I have some video about this technique. However, it’s a matrix that it is covering the buccal wall and you are going to print with the ready premade matrix. All the buccals surface. So you have what? You have in your kit, you have matrices with whom.  You can shape the buccal surface in a very good way using always an injection molding technique because the matrix as a whole where you can put your material, or like for example, Marco, because it would be the spear in the summit that I’m going to organize about this topic in November. He is doing what he is doing an impression of the patient. They are also also [inaudible], you know, he is another speaker about this topic. They’re going to do what? They do an impression and you can do the impression digital or analog. You are doing the wax, again,  digital or analogic of the case. They are doing the silicone matrix with the transplant material and they’re using the silicone matrix with some holes in order to inject again the material. So you see injection for me is the way to go, but how to inject is very interesting because all these techniques have pro and cons. And this is what a lot, because in the recent years we had an evolution of all these techniques and there is always a growing, a growing interest. And what a lot is that all these techniques are something that you have, you can use in your daily work, not just for doing the case. Because nowadays in my dentistry, I hate to do the case. I mean, it’s nice. The case, but if your dentistry is focused on the case, there is something that it is wrong. My dentist is focused towards everyday dentistry. Sometimes I’m able to do the case, but it is not my main focus.  [Jaz]That one nice one. The unicorn one that comes along. That you get to have lots of fun, but you’re a real world dentist. Just so I can get the structure of this podcast, Marco, edge bonding. Okay, so you’ve discussed that injection molding as a way to deliver your composite has some advantages and I can see that compared to layering and what you’ve done is shown clear examples, follow ups whereby the injection molding looks superior. At day 10 years, maybe on day one the layers maybe looks a bit nicer, a bit sexier, but at 10 years the injection molding technique is superior. But do you, after aligners to get a better occlusion, let’s say, do you utilize injection molding for edge bonding or do you think this is such a simple, direct free hand that you still use your paste and you try and do edge bonding without the injection molding technique? [Marco]Okay. I think that injection molding is mandatory for me. So what I do is we do watch bonding. I always want scaffold. Of course, when the case is easy, you can do the scaffold also with transplants matrices or something like that. But the problem is one, for me, free-hand there is not the pressure that we need in order to put the composite in the best situation to perform. So I never take material with a spatula and they put some work. So if I have to do edge bonding, what I do, I want always to have some matrices. In easy cases, I put varistrip, for example. You know the blue transparent matrices, they are very easy. I put that by Garrison. So that I do what? I always want to have David Clark talks about adding an aquarium, a chamber, a place where you can inject with some pressure, heated material. So what we do in all my cases, small restoration, big restoration, I always want to add something like a chamber and aquarium where I can inject. Of course, in the simple cases, this, most of the design means to have maybe just a  varistrip matrix just wrapped around the tooth or in the rounded area, and maybe I just stabilize with some teflon, some liquid dam or with some flowable in order to have, but I always try to do a small chamber also, because when you start to be in this kind of rationality to put a matrix and build something that it is like a small chamber, it’s something that you need 20, 30 seconds. I do even class five in this way, for example. See, I have a technique about doing class five because doing class five, for example, is the same problem with class five. I was doing the action with Teflon and I was applying with my spot, but there was feeling that after seven years I was seeing that the follow ups on class five, it was not the same of restoration made with injection because when I was applying with my spatula, I was missing the pressure of the composite in order to put the composite in the best situation. Now instead, I have a technique, a very easy one, where I use an automatrix or unica matrices, but I always build a scaffold where to inject my composite. This is my way to go nowadays in all my restorative work. And it is something that you can do in your everyday cases because to put thematic in that way, one minute, one and a half, it’s something that I’m not discussing about two hours appointment, three hours appointment. If I see my scheduling nowadays here in the office and I’m working, most of my scheduling is based on one hour, 75 minutes appointment. I have not long appointments in order to show my artistry. I am a very basic dentist, but I do something when I say that this thing works every single day in very good way on the long term. And for me-  [Jaz]What I like about you, Marco, is when you talk about a technique and it’s a bit like, you know, at one stage you are enjoying your layering, you’re doing this, but what you do is you’re not afraid to look at your own work and say, hey, you know what? We can do better. I need to change something. And then you can put your hand up and say, I was wrong. I was wrong to do it that way. I think this is the best way. And maybe in 10 years you’ll refine that even more, and something new might come out. And it’s important to be open to change. And that’s something attractive to do is being keep your mind open that hey, you know, this is working, but I’m willing to change if something better comes along. And so far, I am injecting in some cases, like anterior wear, we’ll discuss that. But for class fives, sometimes I inject, sometimes I do freehand with like PTFE retraction. And I agree. Once you get that scaffolding, I love that the aquarium, the chamber, the scaffolding. It just makes so much sense. I’m surprised you actually said about edge bonding. I’m glad you mentioned it, that you are so convinced and dedicated to the injection molding way to deliver a restoration, that you’ve pretty much now found ways as long as you can make your scaffold, you can inject. So I’m imagining you now, when you’re doing edge bonding, you used a various strip, for example, you create your scaffold, you inject in now just tiny geeky details that dentist love. Do you like use a tiny drop of a flow and then you like a snowplow technique and then put your heated composite like that? And what’s your preferred composite of choice for let’s say edge bonding?  [Marco]Okay. During monolithic restoration, the other good part that my assistant, the assistant that it is working for the storage is very happy, is that I reduced the heavy way, the storage composite. Because if you see my office, I have just three comp, I have A1, A2, A3, and I have a bleach. And it’s easy in this way to manage because the problem is that if a tooth has a strange color for me, what I have to do is to cover all the surface. It’s much easier because too much your composite shades with the French colors, like you know when you have a sort of orange, a sort of brown, it’s MS, I saw on the book layers of the group that they start to combine a little bit of A2 shade with a little bit of brown, super thin, super core in order to create another. This is not everyday dentistry that you can practice also, because when you have to mix in a different way for every single case, it means that there is a question mark everywhere. Instead, I want my dentist to be fast, reliable, predictable. When you have strange colors for me, you have to go over the bucket surface. Most of the times it’s much easier to get a good result and all the patients also love the aesthetic result when you’re doing that. So you have something that patients love.  Doing injection molding, I have ecosystem result under long term and it’s very easy for you also to manage, so you have not to get crazy about matching the color, the composite to a strange substrate to a strange color. You do the opposite. You go over that and you close.  [Jaz]The shade system just makes so much sense in terms of simplifying, and this is why your team now loves you even more because of this simplification there. Is there a composite that you found to have superior longevity in terms of color stability, polishability?  Is it a 3M Filtek? Is it Estelite? I dunno, what are you preferring nowadays?  [Marco]Okay. What do I use every single day in my life is I use 3M materials that they are no more 3M, but because they did a change. Now 3M became Solventum and I’m also speaker for them. But between all the materials that 3M is doing, I use for all the cases, whether I want aesthetic, both anterior and posterior. I always use supreme material. I know that supreme is not the newest material that 3M did. Even if there is the technology, it’s always nanoparticles. This kind of technology, but supreme in both posterior and anterior cases in my hands, gave very stable results over time. So what I use is I use supreme flowable always after warming the material. I put a little bit of flowable. I don’t use the light lump at this stage. And after I inject again, warm composite, the heat that I have is bringing the composite to 70 degrees Celsius. I don’t know in Fahrenheit how many degrees these are, but I warm a lot of the material, especially because supreme is a little bit viscous material.  [Jaz]Is it stiff?  [Marco]Yes, it is deep. So I warm a lot, but I love the aesthetic result and the consistency and also the how you are able to polish this material. Instead, for example, there is for people with a heater that it is not so strong. There is, for example, the universal restorative is much more creamy. So it’s enough to do just a little bit of warming and the material is already flowing everywhere because injection molding is also, for me, the only way in which you can manage claustrophobic restorations. Interjection:Hey guys, it is Jaz with an interjection. So firstly, thank you so much for approving the interjections. I did it for the first time on the Lukasz Lassman episode. We did occlusion miss and red flags just a few weeks ago. And sometimes what happens that the guest is on a roll. But I’ve got so many questions in my mind and the guest is going for it. And so I kind of hold back, but I know that I want to talk about something ’cause I do feel to make something more tangible, it just deserves us to go slightly down this rabbit hole just to explain something or to put some more clarity on something. And I’d asked you to write in the comments what you thought about the interjections. And thank you, Joyaffif, Emily, Joseph, Barbara, so many of you said, and the interjections are good and approved, so they are here to stay. So the first interject one of two for this episode is just heated composite. I think it deserves just a few words. Many of us are already using heated composite, but if you’re not using heated composite, you might be thinking, what’s the point? Why would you use a heated composite? If you want it to flow more, why not just use a flowable? And I get that. But a flowable is different to a paste composite. A paste composite has a much higher percentage of filler particles. It is categorically a stronger and a mechanically superior composite to a flowable. And yes, the number one reason why I use heated composite is ’cause I don’t like working with stiff composites. I like them to go a little bit soft. It just makes handling better for me. And adaptation as you are dispensing that heated composite from the compule into the cavity, for example, it’s just smoother. And the way that that composite adapts to the cavity walls, it’s more seamless. It just flows better overall. So it’s the handling that I love the most about it. Typically speaking, composite is heated to 55, 60 and Marco is 70 degrees. I also do about 65 to 70 degrees Celsius. All that kind of range is totally fine and sometimes if you’re using something like Estelite, which is a softer composite, you probably wanna go for that 55 degree region. But if you have a stiffer composite, like I use a lot of Venus really enjoying Venus Pure at the moment for my aesthetic work, and that is a stiffer composite, so I like to go to 70 for that. Again, for me, a big part of it is improving the way the composite handles in my hands. When you look at the literature resoundingly, it’s mostly good stuff when it comes to heating composite. It does not negatively affect the strength. In fact, it actually improves the flexural strength in some studies and you get a higher degree of monomer conversion. So is there any bad stuff out there? Well, some studies say that repeated preheating cycles have a detrimental effect on color stability of composite resin. So basically the takeaway here and what the manufacturers are saying as well, is to use the small compules when you’re heating. ‘Cause when you use it, it’s done. You throw it first to those large composite tubes, then the manufacturers are saying, look, it’s probably not a great idea to heat. And allow that to cool. And then heat again and allow that to cool. And listen, if you’ve been doing this, don’t worry. I’m just saying it’s one of those things that we just don’t have enough data for. Like definitely a bad thing, I don’t think. But it’s just much safer to be heating the small compules than to heat the entire slab, the entire tube of composite that might be going for several months constantly heating, cooling, heating, cooling. And in my mind, yeah, that could potentially have an issue, but I at the moment use compules have doing so for years and I’ll continue to, because I love using heated composite and from the literature that I’m reading, it’s totally okay to do. Just one more little nugget is that yes, you heat the composite, but it cools really fast, so don’t worry about you thinking that you’re gonna cause the tooth to burn and the pulp to burn. Usually we have enough remaining dentine thickness. It’s really not gonna be an issue. And also as soon as you take that composite out of the heater, it’s gonna rapidly cool. This is why I sometimes will actually heat my metal instrument as well to just prevent it cooling so quickly. So heated composite. Big thumbs up. Crack on guys, let’s get back to Marco.  [Marco]Like for example, do you see this case just to say?  [Jaz]Yes.  [Marco]Okay. For example, when you have a claustrophobic restoration, like for example when you have, let’s say less than one milimeter diastema, that you put your matrices and you have two restoration of three 0.4 millimeters. How you can be reliable about being able to layer and bring composite to go around the tooth and behind the shoulder of the tooth when the space is just 0.3, 0.4? Or when you are doing, for example, a small black triangles and you are dealing with 0.5 millimeters restoration, very close to the gingival margin. Injection molding also is the only way in which you can be reliable about getting this kind of restoration in a very smooth way. And this is the follow up of the cases that you can get. You see when you are starting, like in a case that I’m showing with a normal color of the teeth, you can do just the restoration of the diastema or of the black triangle without any kind of problem. Honestly, composite here is supreme. Composite is very biomimetic material. It is very mimetic, but when you are dealing a study with the fit with strange colors, I did a mistake last day. There was a patient, and I’m going to post this case in the next days. I have the appointment Monday. And after I will fix my mistake because the main mistake was on my side. I will post the case. There was a patient coming in my office for black triangle after orthodontics, but there was in the third medium of the center incisors. This was a sort of brownish area, not so much. I told to the patient about this area and you told me, okay, I never realized this, but this is not, has never been a problem. I’m coming from black triangles. The problem must be that when I did black triangles, and so you have on the mesial and distal, you have some composite with just one shade. Now, this brown area is much more evident than before. So the patient completed the appointment saying, I am very happy. I have no more black triangles. I am very happy. But we called back again saying that the brown area that he never noticed before, now it was more evident. It was much more important. So he asking me to solve again this issue. So Monday I will go back in this case. So the diagnosis of the case, for example, about all the edge bonding, what is the reason behind the chipping and the fracture? It’s the occlusion. And what do you have to do many times orthodontics or when you’re going, for example, with patient with worn dentition. It’s about because of abrasion or it’s about erosion. These are two complete different situations with a complete different solutions because on patients with erosion, as long as they have enamel, a sufficient amount of enamel, I am always successful regardless. We can say with the occlusion, okay, not, but it’s less important occlusion. But when you’re doing a steady patient with the  worn dentition because of occlusal problem, if you are going to do, for example, an important canine guidance, an important incisal guidance, they’re going to break everything after a while. So there is much more that we have to discuss about why the patient is in that situation before doing the treatment. And this is something that honestly we can understand, just sharing our failures, because many times the failure is not in the technical part, but the failure is something in the diagnostic part. But the failure is coming after three failures. For example, I have not a great outcome with very compromised teeth with fiber posts. Okay? But most of my failures are after six years. Most of my failures with fiber posts in compromised case, we scarce failure are between six and nine years. So the problem is that how many times do you follow up your patients for six, nine years and you start to collect all the first that you have? Few are doing this because if you see on social media, on congresses, you always see short term follow up most of the times. Like for example, with shoulder, we know and there is something that you find out some papers that soft tissues on shoulders are easier to get recessions. Easier to get recession. Instead with vertical, it marked more easier to avoid the recession, but in the past you were never able to discuss this because people was not going to show 10 years cases with horizontal, with recession of courses and congresses. They were showing all the artists of the technician at the 10 0 6 months and after they were going to the next case. We have a disease about showing our best. Instead, what would be interesting would be showing what is not going to work. I understand that people, that it is starting to introduce themself in this world. They want to show their best because I did the same, honest when I started 12 years ago, to be a speaker, to speak to lecture, I was doing the same. I have to be honest. But after a while, I think that it is the responsibility of those that already showed that they are good dentists to show what is not working. I think that I can forgive easily people that is starting now. If you’re starting now lecturing, you have to show your best because you have to show the people that you’re good dentists. But after 10 years, I think that it is your responsibility to show your best, but even what is not working, because I’ve been learning much more from my failures than from my best cases.  [Jaz]One of the best lectures that you do, Marco, as you know, is in your course in Sicily the last few hours dedicated to all the failures and lessons, and that’s always very special. Shout out to Costas Koleonidis, who currently I believe is a Greek dentist in Switzerland, who’s one of your alumni as well. That’s right. Before I went to Sicily, he told me, watch out for this one lecture. Watch out for this one lecture. And I can say it’s so lovely. When people share their failures and mistakes. And open like an open book to everyone. So appreciation for that for sure. Now we discussed edge bonding and you’ve convinced me that yes, the way to deliver the composite to not get so much air is perhaps not with the spatula to make the scaffold. I love the scaffold. The chamber, the aquarium. That makes sense. You mentioned composite veneers with that technology. Now, just for the interest of time, black triangle closure is kind of like that claustrophobic area and you use an injection molding just makes so much sense and something like Bioclear is amazing for that. Some colleagues are using metal matrices and they burnish them out and then they create their scaffold. So there are many ways that you can create your scaffold, not just the bioclear, but the thing is, as long as you then create the scaffold and then you’re able to inject into it and place into it, it makes a lot of sense.  When we think of injection molding, Marco, most colleagues are thinking of using the genial injectable gold one into a clear stent like Exaclear that, usually we think of that as the injection molding, but you are right. All the other applications we discussed are the method or the technique of injection molding. How often are you using this technique as your favorite technique for managing tooth wear? Either erosive attritive, or usually combined erosion and attrition. What are your thoughts on the exaclear technique with the GC composite?  [Marco]Okay. The problem, I use this technique, but in my practice I work something like 80% to 90%. I work with the Bioclear and 10% to 15%. I work with this technique with Exaclear, the main point is what? The problem is, the inter proximal control. When you do this kind of technique, there is a huge problem about the interproximal areas. So if I have a patient with no black triangles or very small black triangles that I’m going to keep putting little bit of Teflon, and so the biggest problem is on erosion of the buccal wall or abrasion of the palatal wall. I’m doing what I am doing the waxing with my technician being zero point something short under the proximal wall so that I’m printing my composite on the buccal or on the palatal and incisal. But I’m going to do zero invasion on the proximal wall because when you are trying to do, in my opinion, when you are trying to close something like a diastema or even worse like triangle with this technique, the problem is that after you have to spend a lot of time about finishing inter proximal areas, the problem is what that in the photos, I have to be honest in the photos. It seems that you’re able to get a decent result, but honestly when I see with air drying the restorations with magnification and I see the interproximal surfaces in comparison to the surface that I have with injection molding with matrices is surface is — honestly. So the problem is when you are doing with these cases, what is the critical part of the restoration? The buccal wall, you can do the exaclear. Palatal wall, you can do the same, but when there is a huge interest in shaping the interproximal wall and especially the inter proximately the subgingival wall, at this point I’m starting to maybe start on other techniques. So it’s about the involvement of the interproximal area. The most important part that is driving me towards the decision between the Dahl technique, maybe with bioclear matrices or the injection technique. This is the most important part, the control that you have. There is also the problem that we are discussing about occlusion, because again, I never increased the bite. So most of my cases are cases with the increase of the vertical dimension. And there is, I think also something that in UK I think that you’re doing a lot. But in the rest of Europe studies less used is the DAHL approach. DAHL approach is a very smart technique because most of the times we have rise the vertical dimension. But economically speaking and technically speaking, it’s completely different. The work, if you have just work from canine to canine and after, wait for the extrusion of the posterior teeth and instead if you have to place also overlay on premolar, premolar, molar and molar, the cost is almost doubled because from six tip you are moving to 12 tip. So there is also this, even on this topic, there are other interesting considerations that I never heard about because I had what doing DAHL approach you have to be careful about. One thing, there are people with atypical swallowing. Most of the times when we talk about atypical swallowing, we always talk about the anterior open bite. There is these people pushing the, what is the name?  [Jaz]Tongue thrust.  [Marco]Okay. They do that. And you have open bite. And so it’s easy for most of the practitioner to understand that with the tongue thrust, you have open bite that you’re able to close. But there are other people that have another kind of atypical swallowing. They put the tongue or the posterior tip doing something. They are in the age of development. They develop a sort of deep bite because the tongue is keeping the molar in the position and you have the extrusion of the lower incisors. But if you’re going to do the DAHL approach on this patient and you’re opening a little bit more that the tongue is able to come, right, that position. Interjection:Hey guys, it’s Jaz again with the second and last interjection for this episode. So Marco just mentioned something really interesting, right? Typical versus atypical swallowing. It’s actually a really interesting thing and a really important thing that often gets overlooked. Normal or typical swallowing. What we do with our tongue is we rest it behind the upper incisor, so in the incisive papilla region and the teeth are able to come together usually in your normal bite, AKA maximum intercuspal position. So teeth come together, usually lightly, and then we can continue with the swallowing reflex. The fact that the teeth are now together, it kind of stabilizes the jaw to allow you to swallow. And it’s important to stabilize the mandible because if you try and swallow with your mouth open, just try it for a second, right? Keep your teeth apart and just try and swallow. See, it’s much more difficult. You need your mandible to be stabilized. Hence why one of the functions of teeth is to help with swallowing anyway. So that’s a normal swallow in atypical swallowing, which usually happens in kids, and they grow out of it by age nine onwards. And what the tongue can do can actually do many things, right? The classic one is like the anterior tongue thrust. And so now instead of the teeth biting together, there’s your tongue in the way. You’re kind of biting on your tongue and then swallowing. So your tongue is being used to stabilize your jaw. And what Marco’s saying is that there’s a variant of this tongue swallow whereby tongue is like spreading laterally and it makes sense ’cause I think we might have all seen patients with these like posterior open bites and you’re thinking, why are these teeth not settling back into occlusion? Well, how can they? If every time the patient swallows the tongue comes in the way and stops the teeth from meeting together. And so it makes sense that if you open the vertical dimension on these patients and you do a DAHL type treatment, if they do have an atypical swallowing, that this will interfere with the dental alveolar compensation eruption. Call it what you want. And actually the tongue, we know the tongue is the strongest muscle in the body. And I see some patients in my career so far who have destroyed fixed retainers, i.e. These metal fixed retainers typically bonded to the palatals of their upper incisors, right? So it’s upper fixed retainer. They just snap, snap right in half and their teeth start to splay because of this all mighty tongue and this atypical tongue swallowing. So if you see something strange going on, have a look at their swallowing again. Once again, let me know, guys, are you enjoying these interjections? I’m happy to continue them. I love doing them. I learn a lot and I love to share it. Thanks for listening to far. Let’s continue your almost to the end.  [Marco]These are the cases where I had huge failures about doing a DAHL approach and keeping the posterior open bite without end, we can say. So but again, talking about failures, this is the main point because it’s easy to say, do DAHL approach and it’ll extrude. Yes. But what if they don’t? Because this happens. And why? Because if you’re able to understand, sometimes it happens, but there is a reason you can select the cases. Cases selection is the most important part of our work. The patient has parafunction. The patient has erosion, the patient has abrasion. The patient has strong thrust the patient that there is enamel or not. Because even on adhesion, I get aggressive. I’m doing mainly adhesive dentistry, but adhesion is not the religion. For some people it seems that addition is a religion. They do adhesion everywhere. You see teeth with zero enamel and chronic sclerotic, dentine, and they are doing adhesion. Adhesion is not the answer to all the problems that we have. Sometimes we replace things that work, like for example, a cuspal that sometimes is the best solution with things that seems more modern is the difference between science and scientist. Science is science and we know. But scientist means just because something is more technological, we think that it is better. There are a lot of wrong messages that you are exposed every single day. Like for example, rubber dam, I use rubber dam, you see my cases, and there is always the rubber dam, but sometimes rubber dam became a sort of indicator of quality of dentist. You are not accepted in a scientific society unless you put the burden in a graphically perfect way.  So there is something that was born for a news and we have to say when the dentist that started using the rubber dam started, you know what the reason they were working with amalgam, there was no suction available. That was the reason because there was suction available. When suction was available, they immediately discarded rubber dam immediately. So when they say they were smart because they started working with rubber dam 150 years ago, they were not smart. They had no suction because when suction arrived at the beginning, it was much easier to work with suction after of course with composite hydrophobic materials adhesive that are not friendly with saliva is rubber dam again became useful. But again, from something that is useful to something that became mark of excellence, there is something that it is missing between these two things because you can do excellent dentist, for example, without rubber dam. I do most of my class five, for example, in class five, placing the rubber dam sometimes is a mess. It’s much easier and reliable and predictable to do a class five sometimes without the rubber dam.  [Jaz]But I agree. Rubber dam is helping you and then use it if there’s a tongue in the way, if there’s a tricky scenario. But if rubber dam is hindering you and making your access more difficult, then why bother? [Marco]Yes. The problem is that when you are exposed to courses in congresses, all the speakers say that they play rubber dam in 100% of cases. They say that the rubber dam is mandatory for the success. I know that we humans don’t like uncertainties, so we like strong messages. The point is that sometimes these strong messages are leading in a very wrong direction. So if we were able to share more our failures and problems, this would be a very good way to improve our life. The life also of most of the majority of dentists, because they are exposed to very different messages.  [Jaz]We can’t be dogmatic about anything. Yeah, it’s a key lesson there. Marco, as we wrap up, we’ve got a few questions in that scenario with generalized wear. I’m just trying to visualize it makes sense about the interproximal success you get by using something like a bioclear, right? Because I agree when you use the Exaclear stent and how messy, even if you use the every other tooth there is finishing to do. And I agree that under magnification and when you dry it, it’s a surface that leaves much more to be desired. I agree with you. But when we have to add material to the palatal surface and we want to be guided and directed by a wax up, by a planning, how do you do that with bioclear? Do you make a scaffold palatally first and then do the bioclear? Or how can you do that part?  [Marco]Yes, because the nice part is what, because if you start to be much more horizontal, I say about our techniques, you see that the indication, like for example, if I have a patient with a lot of palatal wear, let’s say, and then black triangles, why not to do just let’s say an index for the palatal wall without the embedding interproximal space? And so you do the injection of the palatal wall so that you have right vertical dimension, you have the right anatomy of the syndrome because this is extremely challenging you to do the right anatomy of the palatal part, the free end, and after you can work instead on the black triangles and the buccal surface, maybe with a direct approach or sometimes you have, for example, in the posterior you can work with injection for example. I have a case that I have to do by two weeks and I will do injection with the Exaclear in the posterior teeth because there is a problem of loss of vertical dimension plus erosion. This is a patient with erosion. So I’m going to increase the vertical dimension, injecting like table top, the posterior with composite, and after I will do just bioclear instead on the anterior, this is the case of a lower arch, and I will do from canine two canine, I will do just Bioclear. If we are a little bit more flexible, we can combine and take the best of this approach. Even the other approach, I have to start with the technique of Itay, but I think that also the technique of Itay, iVeneer, there is something that it is very interesting and smart about this technique. So the best is to master different things so that you can mix all of them in order to fit the case. Because if you want for a man, if you give to a man and a hammer, everything will be something that has to crash, you know? Instead, if we have several horrors in our work. We can use the best for each case. Also, because again, now we are discussing about composite, but you know that I am also a speaker about [inaudbile], so prosthetic dentistry, so the decision is even before when ceramic and when composite. So the topic is even, there are even more nuances about this topic. But again, the decade is well show your case with ceramic and the failures that you have show the case with composite and the failures that you have. There are problems about the technique or there are problem about the choice of the material. Again, we have to discuss failures, but this is something that I find extremely challenging. Now for example, with the summit that I’m organizing in November, I am quite picky about all this speakers about, show some problems, show some problems. I don’t want. Sure you have.  [Jaz]It can’t just all be fairies and rainbows. You gotta show your struggle. You gotta show. I am asking, I knew when you were organizing a conference that you would bring this ethos and make sure that people have this on board.  [Marco]The conference that I’m organizing is because it’s not for economical reasons, because I’m mainly recollecting expenses, but it’s because I want to give a message. The message is what I’m discussing in this podcast with you. But the point is that I have to make that all the speakers more or less because of course they are not like me. But more or less, each one of them has to deliver some problems why these things happened and now they have been solving this. Otherwise it would be just again, another show. So it’s about-  [Jaz]Tell us more, my friend. Remind us of the date. And it’s in Milan, right? So tell us, because this sounds amazing. I mean, I had a look at the date personally due to family reasons I can’t attend, but it looks amazing. You got some brilliant speakers. I mean, you mentioned Veneziani, Sakowski, our good friend, Johan Hagman, what a great dentist he is. Yeah, lovely guy as well. You got a great list.  [Marco]Okay, this is the summit about, because there has been an expansion and the growth of all these techniques about injecting composite, I start to think about doing a different event, doing a sort of point of the situation, collecting all the different techniques we will get David Clark, of course, is the founder of Bioclear and he is a man with several interesting insights.  So is a math that David is coming. After we have José Roberto Moura. José Roberto Moura is a Brazilian. He is an excellent dentistry and he’s combining in his practice injection molding plus layering and is combined these two techniques. Also, it’s nice because José Roberto Moura is working always with microscopes, so we will see a lot of videos and so we have a very good perception of his work. Ronaldo Hirata is a very famous Brazilian dentist. I don’t know if you know Ronaldo.  [Jaz]Yes, yes, I’ve seen him. He was very well known. International speaker. Absolutely.  [Marco]Yes. Ronaldo is a very famous speaker and he will come in Milan and showing, even in his case, because is working both with injection molding and is working also with layering. So it could be nice to see how to manage all the indications for different things. It that it is the speaker next to me is instead the inventor of I veer matrices. So he will show this other approach if you want to have a small video about this technique. But the problem is that for people just listening this episode, however, these are matrices that are covered.  [Jaz]I’ll put it at the end of the video. For those who are watching, they can stick around and watch that actually, yeah. [Marco]Okay. After we have Marco, Marco is one of the most renowned I speakers. Marco is doing excellence in the dentistry. He is working with the index technique, the Exaclear, but he has his own protocol because he did some modifications in order to improve all the workflow. And this is something that he will be able to show in our summit. Albar is doing something that they love. Alvaro will show just cases with minimum five years of follow up composite restorations made with different techniques. What happens after five years? So love it. Alvar. We will sue the truth about composite, and this is something that I will really love after we have another speaker that it is Abdurahman. Abdurahman is a Egyptian speaker. He very close friend of mine.  [Jaz]The Prince of Egypt, I call him.  [Marco]Yes, yes, he is. He is. He’s the prince of Egypt and we will talk about his, that treat situations that we never discussed and it is how to manage composite restoration close to implants. And this is some, because there are several complications because when we have decay or other problems close to implants, usually decay is more cervical than usual. There is the problem of the separation. So we will discuss about all the restorative strategies that he has been looking for in these years about how to manage these tricky situations. With John, we’ll discuss a evergreen topic, especially in real world dentistry that it is subgingival margins because this is an evergreen topic.  With Matt. You want know is that this is the French print. We can say, Matthew is interesting because he started working with the printed composite because the printer in his office and he will discuss the difference between working with printed composite and direct approach about time efficiency. So I am not the printer in my office, but when you start discussing about being efficient and being productive, it is something that for me is very an actual topic. And after we will get workshop so people will be able in classes of 20 persons to touch together with upper and tadi, she’s a Biore speaker from the south of US and Claire Vargas that it is the Biore speaker for UK.  [Jaz]UK. Woo.  [Marco]Yes. UK. Yes, Vargas is the bio center in UK. People will be able and together with also Marco Ani for their technique. So we have three tutors. We’ll be able to organize workshops so that people at a very low price because we are discussing something like 100 euro for two hours.  [Jaz]Oh wow.  [Marco]Two and a half hours workshop. We’ll be able to touch with their hands, the material, and so to feel what is injection molding, what is to inject on Exaclear. They will be able to touch with their hand. Everything in the wonderful place of Milan that the problem in Milan is just the amount of mind that you’re able to spend going outside and will do also gala dinner will do also some social activity because again, it’s something that-  [Jaz]Wish me luck. I know I have some family commitments, but I’m gonna do it. I’m looking these speakers again and just how excited you got me about injection molding and why I realized, okay, I need to be doing more of this. I’m gonna ask my wife today to see if I can get her blessing level one permission. So wish me luck. But you missed the most important speaker, Marco, as well as yourself. You missed the loveliest person, honestly. Just absolute sweetheart of Aara Aara.  [Marco]Yes. AP is the tutor and she will be the tutor of the Biore approach. We’ll do anterior restoration.  [Jaz]She doesn’t drink alcohol. But she came to your course in Sicily and she brought everyone a bottle of rum, right? And she’s just the loveliest person you’ll ever meet. And I’m always a big fan of not only going to the educators that inspire and show excellence, but their human side. They are beautiful inside as well. Right. And so I’m just very, you, it’d be nice to connect with Aara. So wish me luck. I’m gonna ask my wife if I can get a day off seventh and 8th of November, 2025. [Marco]Two things, just because this point I have to say something more aara together with me, the one that will manage all the speakers will be the, I don’t know, master of ceremonies is something that you say.  [Jaz]Okay, MCs nice.  [Marco]Okay. She will help me on the stage, introduce the speakers. Because what we want to do is something that it is new. Nobody will come on the stage talking about their curriculum. I will never say, here is doctor Jaz Gulati, got his degree. Nothing. Everything would be about the person, the approach, the philosophy. We want to do something. It is fresh. And also, there is a dentist coming from US, Joshua Sullivan. He is a very, a famous pediatric dentist. And he was nice because he told me, I went home like you say, and I said to my wife, look, I would like to go to another congress. And she said, no, another Congress, no. But where is in Milan? Whatcha waiting for tickets? So this is another reason that it is. Yes, yes, yes. It was-  [Jaz]Maybe a weekend away I might arrange some childcare for the boys and I’ll whisk my wife away for a romantic weekend in Milana. And she’s a dentist, she’s a pediatric based dentist. But you know, I can tell her, you can learn something for your patients. In fact, I think it’ll be good for her.  [Marco]Yeah, also, because Milan is a very nice place. Also, the venue is called Grand is five minutes using the subway from the center. So we are in a strategic place also for a holiday. So I think that it is.  [Jaz]This is gonna help a lot.  [Marco]Yes, a good situation in order to connect a little bit of education and a little bit of fun because we spend a lot of time together. And also the possibility to visit Italy because Italy is Italy.  [Jaz]It was my first time at your course in Italy actually insisted my first time in Italy. I’m just, the food was just, everything was good and for those of you listening on Spotify and Apple and stuff, one thing you missed is the hands gestures that Marco like, it is true. Italians speak with their hands. It was very evident for those who are watching the video. Now I’m gonna put the links and everything in the show notes so people can check out injectionsummit.eu is the website. And fingers crossed me and my wife will be able to come. If not me and my wife, then hopefully just me. Either way, I just really wanna come. So pray for me guys. Now one thing, unrelated a little bit, I just want your opinion, Marco, right, you must have seen on social media, right? Marshall Hanson in US is doing incredible work. Have you seen his work online?  [Marco]No. What is the name?  [Jaz]Marshall Hansen, he created the home of the 48 hour Smile makeover. So essentially what he does is, and I hope I’m not perversing this right, but essentially what he does is he brings one patient and he keeps him in his office for two days, basically. Okay. And in two days they will leave with composite makeover, which is just phenomenal, I believe the way he does it, he’s the first day he just builds the shells, builds the base, okay? And maybe he’s doing some injection molding type technique. He’s using the Garrison Strip and whatnot and using these special matrices and he’s building the base all in monolithic, I believe. Okay. If I haven’t got this wrong. And then the next day he will cut back and then well, from the cutback, he will layer and get everything looking great. So not only patients all over the world, but many dentists from the world are going, flying to him, staying for two days to have their makeover. But okay, if you haven’t seen his stuff, then maybe you cannot comment. [Marco]But this is the same that Marco, just because you are talking about this, Marco is doing the same, Marco is doing two things. He started doing what? Using Xgl to doing the injection to the final shape. So it was injected with DC after he was doing a cutback and he was layering 300. Now instead he is doing what he do two different indexes. One for injecting the dentine and the al shell after he is doing alce mammals, all these kind of things, and that he has a second stent for injecting the enamel. So he has also the texture, the anatomy.  [Jaz]So you get the both benefits. You get the polychromatic result. with the method of injection molding.  [Marco]This will be the election of Mark Marconi. I show you a case. This is Ani, this is the case that he is doing and this is the result that is able to obtain. You see, you can get both things of the world. Of course you need more time. You need two indexes, two Exaclear standard one. There are more steps, but for people that wanna go in the direction, we will discuss also about this. Of course the workshop with Marconi will be about the single xgl, the workshop, because it’s a beginner workshop, but during the lecture you will see Marco’s technique. You see the innovative customize, the ebr, the hind index and updated clinical procedure. So this will be the lecture from Marco. It will show about also this technique. So it will be the summit will see all, everything that it is around injection molding concept plus some modification about layering for people that it is into these kind of things.  [Jaz]And of course I know we talk about Injection Summit, but you know, you also do the Bioclear course in English and in Italian, so maybe I’ll put some links for that, for those who want to learn that. Definitely. Again, I wanna take a group of dentists back. The same group actually there, our WhatsApp group, we want to actually learn from you, so maybe one day we’ll arrange that as well. So I’ll put all the links. Marco, thanks so much for your time, for your passion, for your authenticity, for your philosophy, for your kindness. And fingers crossed we meet again in November and I can convince my wife.  [Marco]You know, the film in Padrino. The Godfather.  [Jaz]The Godfather film. Yes.  [Marco]I am sending a gift to your wife. She will not be able not to accept.  [Jaz]An offer she can’t refuse. Let’s see.  Jaz’s Outro:Well, there we have it guys. Pray for me for, I shall ask my wife today if she’ll let me go. And I mean that in a nice way, right? I mean, it’s one of those things, right? That marriage is a partnership. So it’s a joint decision. Whenever I go away or she goes away and it’s work related, it needs to have some sort of synergy. It needs to be planned. I’m gonna get a little bit philosophical here, right? ‘Cause you know, one of my highest values is family. And to give you some context, right? As a father, like you get woken up by your children early morning, 5:00 AM sometimes, or in the middle of the night. You’ve all heard me on the podcast talk about how my second born son in my firstborn, terrible sleepers, I’m up a lot at nighttime. Either getting a milk feed or calming my children down. And it’s a common thing amongst us parents and those of us committed to a partner. We have to have that dialogue. We have to kind of get what we call level one permission. And so let me read out this quote to you. When nobody wakes you up in the morning and when nobody waits for you at night and when you can do whatever you want, what do you call it? Freedom or loneliness? Right. So to be able to be in a position where I’m gonna be able to check, hey, can I go through this event or not, is what family is all about. So I’ll keep you posted if I will be going to Milan, but for those of you going super jealous, for those of you interested, again, I’ve put the link below, check it out. It does sound brilliant. And hey, if due to family reasons or whatever, you can’t go. Don’t worry, there’ll be plenty of more opportunities always. But whenever you can, I’ve just learned that whenever you can go somewhere and feel energized by the people and that magic of in-person events is just, you can’t beat it, right? It’s one of the times that, like me personally, when I go to like a music concert, I’m excited, but I’m actually so much more excited when I’m going to a conference. I feel energized. It is always a highlight for me. So for me, call it sad, call it geeky, whatever. I am far more energized when I’m going to a dental conference than I am for when I’m going to Wembley to see a singer I love. So let’s keep the magic of in-person learning alive, my friends. Go and support these conferences that are out there and always keep learning. Thanks so much again for listening to the end. You can claim CE or CPD for this episode. You’ve just done all the hard work. You’ve listened, answer the questions, get 80% and Mari from Team Protrusive will send you your certificate. You need to be on the app to be able to do it. You can make an account on www.protrusive.app and unlock 380 plus hours of CE or CPD. Don’t forget that you can download the premium notes for free. The new and improved the elevated premium notes for this episode by visiting protrusive.co.uk/im. I’ll put that link in the show notes as well. I hope you absolutely love it. Please do comment if you did download it and what you thought about it, and of course, join us on the app. As always, thank you to all of team Protrusive, without whom this podcast would’ve died many years ago. But thanks to their support and your support Protruserati, we’re going from strength to strength. We’re making learning fun. We’re making you fall in love in dentistry all over again. In fact, this reminds me of an email I literally just got yesterday. I won’t say his name ’cause I didn’t get his permission to read this out loud, but he’s a board certified prosthodontist. I won’t say from which country. And we had a little email exchange about occlusion and stuff and he said, by the way, I love what you stand for. For a long time, I hated being a dentist. It caused me so much stress. This is a prosthodontist, by the way, guys. I recently found my passion for it. And your attitude and passion towards dentistry is what I am striving for.  My friends, this is what it’s all about, right? There’s no point being in this stressful profession if you resent being in it. You need to change something to change your environment. You need to change who you hang out with, you change what you listen to. If you are not happy, something needs to change.  This could be your practice. This could be your working hours, your working days, the techniques you’re using, the education you’re receiving. There’s so much to do and that’s why Protrusive is dedicated to your success. I’ll end with that, my friends. I’ll catch you same time, same place next week. Bye for now. Do not forget to hit the subscribe and the like button.

Should we really restore primary molars without local anaesthetic or injections? When should we start taking radiographs for child patients? Is it time to say goodbye to traditional anterior strip crowns and embrace preformed zirconia crowns? And seriously – how do you get a wiggly, fidgety child to sit still long enough for a solid restoration?! The secret lies in choosing a technique that’s both quick and effective! In this episode, Dr. Tim Keys unpacks the real challenges of restoring primary teeth, breaking down the pros and cons of popular approaches like the Hall Crown technique, Pediatric Zirconia crowns, and conventional stainless steel crowns (SSCs). Tune in for practical insights to make pediatric crown work less stressful and more successful – helping you find the best fit for your little patients. https://youtu.be/VJm4TFKLXEA Dr. Keys is also involved in dental education and offers courses through his platform, Kids Dental Tips. One of his upcoming courses is titled “Restorative Paediatric Dentistry,” a two-day event scheduled to be held in Brisbane. Protrusive Dental Pearl: One of our best ever Protrusive Infographics! This week’s Pearl is a handy downloadable PDF infographic summarising the key points from this episode on Children’s Crowns Techniques. Grab your copy here! Need to Read it? Check out the Full Episode Transcript below! Key Takeaways: The Hall crown technique is a non-invasive approach to treating pediatric teeth. Radiographs are essential for accurate diagnosis and treatment planning in children. Case selection is crucial for the success of pediatric dental treatments. Zirconia crowns have superior aesthetics over stainless steel crowns. The success rate of intra-coronal fillings in primary molars is lower compared to crowns. Zirconia crowns rarely fracture compared to strip crowns. Mild supra-occlusion is acceptable in pediatric dentistry. Hands-on experience is crucial for mastering crown techniques. Highlights of this episode: 00:00 Introduction 01:32 The Protrusive Dental Pearl 04:19 Dr. Tim Keys 06:26 Work-life balance & parenting 12:05 Hall crowns Vs Zirconia crowns 13:12 Pediatric crowns and caries management 15:40 Failure rates and clinical implications 17:51 Stainless steel crowns: conventional vs Hall technique 21:03 Case selection and radiographs 25:31 Radiographic criteria 27:04 The Hall Technique 29:59 Technique tips 38:00 Zirconia crowns vs strip crowns 46:55 Education, resources, and further learning 51:02 Outro Key Article mentioned in this episode: Effectiveness, Costs and Patient Acceptance of a Conventional and a Biological Treatment Approach for Carious Primary Teeth in Children | Caries Research | Karger Publishers #PDPMainEpisodes #BreadandButterDentistry If you enjoyed this episode, you should check out PDP159 – How to Manage Children in Dental Pain. This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance. This episode meets GDC Outcomes A and C. AGD Subject Code: 430 Pediatric Dentistry. In this episode, Jaz and Dr. Tim Keys explore practical approaches to restoring pediatric teeth, focusing on the selection, preparation, and placement of direct restorations. They discuss material choices, clinical tips, and how to tailor techniques to improve outcomes and cooperation in young patients. Dentists will be able to: Understand the clinical indications and benefits of various crown techniques used in the restoration of pediatric teeth Recognise the importance of selecting appropriate cementation materials and techniques for different types of direct restorations in children Appreciate the key clinical considerations involved in the preparation and placement of a range of direct restorative techniques in pediatric dentistry https://media.blubrry.com/protrusive/content.blubrry.com/protrusive/PDP227.mp3 Click below for full episode transcript: Teaser: The success rate at 10 years sits between 97% and 99%. Teaser:This is the traditional conventional approach. Yeah.  Conventional crowd. Yeah. And I would argue that is more successful than what you would be doing in an adult tooth. A name of restorative material in adult tooth that you know is got a 97% to 99% success rate at 10 years. It’s incredible. So there’s nothing like this. So if you’ve got a patient who’s got a clinical issue, I would encourage all your listeners, please do not do anything without x-rays. And if you can’t get x-rays on that patient because of compliance issues, you really need to reconsider your ability. The strongest way to get that crown to sit down as the kid ’cause their jaws a lot stronger than my thumb. And so I put a cotton roll in it. I get the kid to bite down really hard and you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assist to put their thumb over the top of the crown. You floss down and then pull it out and then go to the other side. Floss down, pull it out. I haven’t done a strip crown on a primary interior tooth in five years. And I’m so bloody happy I don’t do them anymore. Keep in mind, each x-ray is the equivalent of around six bananas. Six bananas got radiation in right? So the radiation test is insignificant, really. And I think I need your listeners to really understand that we don’t treat children differently because they’re children. You know, we wouldn’t treat an adult and extract a tooth on an adult without an x-ray. You wouldn’t do a filling on an adult without an x-ray. You wouldn’t do a nerve based treatment on an adult without an x-ray. So please stop doing it on children because there is no defense for it. It’s completely wrong. Jaz’s Introduction:This episode is such a wonderful resource and refresher on the whole crown technique. If you listen to the end of this episode with the wonderful Tim Keys. He’s like the Aussie, you know, Aussie man reviews those hilarious videos with a funny Australian accent comedy like Tim has that voice where he should just do dental videos and a funny commentary. He’d be like, Aussie man dental reviews. And Tim spoke so well, so passionately and so clearly about this topic so that by the end of this episode, you will know the difference between the conventional stainless steel crown technique versus the more contemporary hall crown technique. When should you use? Which one and all about this newcomer, the zirconia children’s crowns, and how the technique actually is really different and how to prepare the tooth accordingly for a zirconia crown, which is relevant both for anterior and posterior teeth, from knowing which cements to use and whether or not you should use local anesthetic on a child. And something that Tim’s very passionate about. Should we be taking radiographs on children and at what age? What are the clinical and radiographic science look for, to make sure that a tooth is suitable for this type of treatment, i.e. the whole crown treatment. Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. Like I said, Tim, honestly just absolutely smashed this episode, and I’m so excited for you to learn from him. As you know Protrusive, we have guests from all around the world, but I have to say there’s something. I have a soft spot for my Aussie guests. I dunno what it is. They just come on and they put on a show every time. So sending love to all the Aussie Protruserati. You guys have been supporting me for over the years, but we’re gonna win the ashes. I just had to put that in there. Dental PearlEvery PDP episode I give you a Protrusive Dental Pearl, and today’s pearl is just the most wonderful summary of this entire episode. It is one of our famous Protrusive Infographics. There are two ways to get this for free. One is if you’re viewing this episode on the Protrusive Guidance app, then thank you for being a member of the nicest and geekiest community of dentists in the world. Just scroll down and you’ll see the PDF there, and please comment if you’d like it. Number two is, if you’re not on our community, then head over to protrusive.co.uk/kidsteeth. That’s kids teeth. And when you enter your first name and your email address, I’ll email it to you personally with the PDF in your inbox. Our infographics are pretty famous, the ones that we have on deep margin elevation to which ceramic to use, which type of zirconia to use. We work really hard, especially the oral medicines one. Again, that was actually another Aussie guest we had on as well. So once again, hat tip to all the Aussie guests I’ve had on the show. But yeah, you’re gonna love this infographic, so please do download it. And if you’re not on the Protrusive Guidance community, what are you waiting for? Honestly, it’s so, so nice to learn from everyone and to share my special snippets. And actually, there’s a part of this episode that is gonna be only on Protrusive Guidance, and this might actually sway me in a different direction, but. You know at the point of recording this in February, I know it’s gonna come out much later in the year, but I’m recording this in February, 2025 and we’ve got 30,000 YouTube followers and I’m so grateful, honestly, like thank you so much. But there is a percentage of these subscribers that are members of the public. They are non-dental. They are patients of dentists, they’re the public. And I feel a little bit uneasy about that because we need our little safe space. This is dentist talk like you’re a patient. I understand that you are seeking information and it’s good to be informed, but this is dentist speak like this is not the best place for you to get information. And so what I worry about is some pieces of information that is like just dentist talk, getting through the wrong is. And so what I’m gonna suggest is, if you want the full experience of this episode, please check it on Protrusive Guidance, even the free subscription on Protrusive Guidance. It’ll be there, the full video without any interruptions on YouTube, you’re gonna get a little bit of an interruption where I probably censor about five minutes, and the reason for the sensor is a really appropriate and a really good recommendation that Tim makes and is totally appropriate, and I love him for what he says. But if patients hear this, then I worry about them taking it to their dentist and it’s just not the right environment. So this is very much secret dentist talk that patients shouldn’t hear. It’s a fact of life. And what we do on Protrusive Guidance is that we have a systems in place that we will email you for proof. So I know that Protrusive Guidance is a safe space because it’s not easy to get accepted. We ask you for proof that you are a dental professional. So if you’re watching on YouTube and you have access to our app, just switch over now so you don’t miss any of it. If you’re watching YouTube, still love you. Thanks so much. You’re just gonna miss out a few important minutes, which make a very clear clinical recommendation that you should be doing, and me and Tim feel very passionately about that. But yeah, we’ll not go into it anymore. Enjoy the episode and I’ll catch you in the outro. Main Episode:Dr. Tim Keys so nice to meet you on here. Welcome to the Protrusive Dental Podcast. Your kids are asleep. It’s a great time. It’s morning here. It’s evening where you are in Australia. So tell me, my friend, whereabouts in Australia are you and are you a general dentist? Are you a pediatric dentist? I wanna learn more about you sir.  [Tim]Mate, I live in a state called Queensland, which is a very sunny place, one of the more sunny places in the world. And I live on a location called the Sunshine Coast, which is a nice, a beach area, very well known and it’s a beautiful, beautiful place. Absolutely. I’m a pediatric dentist, have been now for several years and obviously prior to that was a general dentist. And I love my pediatric dental job. I enjoy it and I love teaching too.  [Jaz]Would you call yourself a big kid? Would you refer yourself like you’re a big kid yourself?  [Tim]The best part of the job of working with kids is that you can have a lot of fun. You’ve got an important job to do, but you get to do fun things and you get to talk about all sorts of crap that you can’t talk about to adults, so you can have a joking time. They converse the worst part of our jobs, dealing with parents, which sucks.  [Jaz]And you live in the Sunshine Coast. There’s a book by the “The Almanack of Naval Ravikant” and great book. And then this really clever guy, he says that in life, we don’t spend enough time thinking about where we want to spend our lives, where we want to live. So what I wanna know from you is, were you just born into there and then you just stayed in your Sunshine Coast? Or did you make a conscious decision to design your life so that you live in a beautiful place?  [Tim]Conscious decision, Jaz. Conscious decision. I live 800 meters from the beach, very close to little canal system. It’s beautiful here. Good surf. Good weather. And I’ve got my commute one kilometer to work. I go through two sets of traffic lights. So if it’s a bad day, it might take me five minutes to get to work.  [Jaz]That’s amazing. I’ve experienced that joy before. That has its downside as well. Like, you know, I know you’ve got kids and we’ll talk about that, but I’ve got two young boys and so when I used to work literally right next to the clinic and I’d be like home in like four minutes. I never had time to read because I was always serving my children or whatever. And so therefore now I’ve gotta commute back. I’ve got like a 45 to maybe an hour commute now. And so now my audible credits are getting used up, which is great. So, you gotta take the ups of the downs. How old are your kids? [Tim]I got a 4-year-old, a 3-year-old, and a 1-year-old.  [Jaz]How would you do it, man?  [Tim]Alcohol helps few bees, mate. Absolutely.  [Jaz]Lovely. Why paeds why did you go into paeds?  [Tim]I feel like it’s the last real remaining specialty where you can actually do a lot and try to still refine your skills within that. So by that I mean, it’s not just doing fissure sealants and crowns and fillings and extractions on kids. You can do surgical extractions, exposures, and bonds of canines and teeth. You can do some pretty gnarly sort of auto transplants. You can do endodontic treatment as well. So there’s a whole scope of things where you can still focus on certain stuff. I quite enjoy dealing with children. I thoroughly enjoy the job. It does get fatiguing, like I think three to four days of clinical peds, like in the clinic dealing with kids and anxious kids can get quite emotionally draining. So therefore it’s really nice to have that one day a week or a fortnight, under general anesthetic where I could just somebody else’s behavior managing ketamine and profile. [Jaz]Really fascinating. It reminds me of people I speak to whose spouse happens to be a chef. And so, when they’re cooking all day long. They don’t cook at home ’cause they’re just done with it. So how do you, right, this must be the toughest gig. Like that week we got like anxious children all day long and then you come after, you have to come home to your own kids. How do you make sure that the dad mode is on?  [Tim]Mate, it’s hard. Like I leave home and I have screaming children from 6:00 AM. I go to work and I’ve generally got screaming children for eight hours, and then I go home at nighttime and I’ve got screaming kids until seven. So I have 13 consistent hours of screaming children. And you’re right. Look, it does get a bit sad sometimes that I can use up all this patience on other people’s kids. And you go home and you think, ah. But yeah, what do you do? Right? But I’ve gotta say, everybody that’s got older kids and Jaz, I don’t know how old your kids are-  [Jaz]Five and two.  [Tim]Five and two. So you would hear the same advice. Anyone that tells you, they say, you’re a bit in the trenches now, but these are actually such magical years. You got these little humans who all they wanna do is spend time with you. And sometimes you get a bit over that, but that’s all they wanna do. They just wanna spend time with you and I really do. I don’t work weekends. I don’t work late nights other than doing podcasts after the kids are asleep. I think for all of us with kids, it’s just that really valuable special time, which you just, that’s that 20% you gotta think about while you get through the 80% grind of just screaming battles, right? [Jaz]It’s an absolute joy ever. I totally agree on the book I’m listening to the moment is “Hold On to Your Kids” by Gabor Maté and Gordon Neufeld. Have you heard of this book?  [Tim]I haven’t, no.  [Jaz]Okay. So I’m early into it, but I love it because it’s talking about the culture we have brewed as a society, we have created this culture of sending our children, encouraging them to have attachment with their peers. And then children, it is like you can’t serve two masters. And so what happens is that because now they are attached more to their peers than to their parents, then this is why they don’t wanna hang out with their parents anymore. This is why they’re sort of moody at home. And we think this is a phase, but what the book argues is that actually this is a new phenomenon and we need to make sure that we hold onto our kids. Their primary attachment and guidance in life should come from their parents, not from their peers, because otherwise the blind leading the blind. So that’s a really fascinating book. I thought it’d be nice to mention it in the pediatric. There’s lots of parents listening. The other one I’m listening to, thanks for a recommendation from someone in the community is the anxious generation. How the newer generation and screen time is really messing up our kids’ brains. We know this already, but like it goes deep into the science. Any guidelines you follow at home just as parent to parent on screen use.  [Tim]Mate, we are very limited, but I’m fortunate that our kids are young. So we’ve got the point now where we can, to some degree, control them. Yes, there’ll be a big screaming fight and argument, but we’re pretty rare. Like we might do, there’ll be multiple days in the week where they get no tv, and then if so, they might get short periods, 15 minutes, like after they’ve cleaned up the playroom and things like that. So it’s used just as a reward basis. Don’t get me wrong. Occasionally when it’s like five o’clock and you’re late for dinner. And you’ve got three screaming kids and it’s chaos. You’re like, we’ve gotta crack this. But we actually found about a year or two ago, we were finding that we were resorting to it too much. And I’m the same as you. I just feel like, particularly where I live, like our winters at worst are like 12 degrees to 25 degrees. That’s how cold winter. So that’s excuse.  [Jaz]Excuse for those Americans out there. It is pretty good.  [Tim]Yeah, absolutely. So we’ve got no excuse where I leave not to be outside and playing. And we’ve got a fenced house so they can have a good time. But yeah, I agree. Absolutely. I think there’s a few things, there’s a lot of ultra processed foods and that sort of stuff. A lot of sugar, a lot of tv, and I’m so happy that Jaz, you look similar sort of age to me that we grew up prior to social media.  [Jaz]Big time. And so the book argues, and I’m glad you mentioned this because I remember growing up and I would be away from the home. Like I’d be like nine, 10, and I’d be like, in a distance park, maybe 500 meters, maybe in a kilometer away from the home, and I’d be in the park, no phones, no contact, and I would just come home six hours later or something. Okay. And parents were accepting of that. Nowadays we can’t bear to not know where our children are at such a young age and for them to just go and walk off. And so this is what the book argues is a real one. The biggest tragedies of our time. So it’s interesting to talk about this.  [Tim]Absolutely. I agree. Yeah. I mean, to be honest with you, but I think I would struggle to let my kid, I did the same. I used to go for a bike ride, 15 K away, but I’ve still got young kids, but I struggle to feel like I would let them do that. It’d be emotionally tough for me, but I don’t know. We’ll see what happens when we get there. [Jaz]Yes, exactly. So it’s society, but I enjoyed that pre-check. Thank you so much, Tim. I’d like to learn about why someone goes into this particular specialty and learn a little bit more about the individual. And I know it’s nice to learn about you and your family and just parenting advice is nice to talk about as well as books. But the main crux of today is hall crowns or rather formally, we used to call them stainless steel crown technique versus hall crowns. But now the new player zirconia. And I was saying to you before we hit record, actually my wife, she did a MSC at Eastman in pediatric dentist. And her thesis, a master’s thesis was on zirconia hall crowns versus stainless steel hall crowns, basically. So, very interesting. I believe the only supply, and you correct me wrong, is it new view or new smile that zirconia-  [Tim]New smile. So there is another company called Sprig, which came later to the game, but the predominant market in the world is a company called New Smile. So they’ve made the zirconia crowns, which I think those particular crowns are not suitable for a hall crown, and we can go and discussing that why. But they’ve created another crown, which is like a resin base, is acrylic crown called BioFlex, which they’re trying to say is a bit more like a hall crown. But I think what we should do Jaz is let’s go through the pros and cons and things of stainless crowns and zirconia, and we’ll talk about the pros, cons, limitations in how we can do it. But I’d be very fascinated to read this. This thesis.  [Jaz]Yeah, I’ll send it to you. I thought I just mentioned that as a little background, but yeah. Where I want to start this podcast is for our younger colleagues, and actually, you know what, for our older colleagues, because they probably qualified at a time where the technique wasn’t being used so much, or not in the way that the whole crown suggests they were still prepping perhaps. And so let’s talk a little bit about the history of using stainless steel crowns from pediatric molar teeth and how that’s evolved and where, when, and why the whole technique and what it is.  [Tim]Yeah, so Jaz, essentially the way we have managed decay, as many of us are aware, has changed, right? And the reason is we are moving away from this infected and affected dentine and things. So dental caries, the outcome is a cavity. Okay? Once you’ve got a cavity, you can’t tend to remineralize it without plaque control it will continue to progress. And that’s our justification for putting fillings in, right? Restoring form, function, and aesthetic. So for pediatric teeth, there’s significant limitations to putting intracoronal restorations in teeth. So my thesis was a part of a series of surveys of dental protection is nation, so nations wide, so internationally, and so for us practitioners in Australia, what do they use to treat kids’ teeth? And the dominant material used for primary teeth was GIC followed by composite resin and then some RM GICs and some stainless steel crowns. And you’d find the variability was significant. You’d have 25, 30% of people using this, 30% using this, 20% using this. Well, if you asked for permanent teeth, it was 85% composite resin, right? So why is there so much variability for primary teeth? And I think the reason comes is that there’s not a great deal of research on this. And essentially everyone’s just having a crack at it. My supervisor’s using fuji and, but a fewer GICs, and that works really well. The issue that we’ve got primary teeth takes six months to form, not three years. The enamel that’s present is much thinner. It has a much lower mineral content. Now we use predominantly resin based or a chemical adhesion. Yes, GIC has that ion bond, but the vast majority of our resin restorations. They’re just glued in and we don’t have, even, despite trying to go for that, still, our best bond we can form is with enamel. And so you can imagine if a primary tooth begins its life with less enamel. And the enamel that says, got less mineral content, it’s much more difficult to glue a intracoronal restoration into the tooth. Our main drawback with GIC based materials is that they’re structurally weak and children, because they’ve got their flat occlusal plane, can actually have higher bite forces on their marginal ridge than weak can as adults. So, but why therefore do we use a inferior strength material to restore primary teeth? And so the failure rate for tooth surface intracoronal restoration at three years sits at about 35 to 40%. That’s what our evidence shows us. So that means if you’ve got a child in your clinic-  [Jaz]And that’s any restoration that’s GIC or comp, any direct restoration? Yeah?  [Tim]Much higher failure rates of GIC. Like if you look at the American Academy of Pediatric Dentistry and other guidelines, a lot of them are recommending, once you get past a single surface for GIC. It’s really not indicated. It’s contraindicated, it’s a temporary restoration-  [Jaz]But while RMGICs does that make a big difference? ‘Cause you know they are two different materials. RMGICs, you know, far mechanically superior.  [Tim]Yeah. But it still can’t put up with the years. If you’ve got a 5-year-old and you’re putting a DO in there first primary molar, you got six years of occlusal forces on that. I guess the question Jaz to you is would you expect six years to survive in an adult tooth with an R-M-G-I-C as a tooth surface restoration?  [Jaz]Put it this, say it’s not predictable treatment. You wouldn’t say to a patient, ah, it should be fine for many, many years to come. Whereas with a composite, you definitely could say that, yes, I expect this to last long, whereas your reducing the predictability for sure.  [Tim]Correct. And so the same thing applies to kids and so therefore, composite resin has a higher success rate when it’s small. The moment you move past the contact point, so it gets wider and extends onto the buccal or lingual surfaces, you’re actually now moving into a three surface intracoronal restoration and it is a contraindication of placing in intracoronal restoration and that for longevity. Why else? If you wanna put an R-M-G-I-C in what’s in it, what makes it stronger?  [Jaz]So it’s the silica.  [Tim]Well resin, right? It’s a resin modified glass, ominous cement. Is resin moisture resistant?  [Jaz]No, it’s not. But there’s the same issue with the composite.  [Tim]Correct. So if you want to do an intracoronal restoration that you want to survive, you need local ’cause you’ve gotta drill. And you need rubber dam on ’cause without rubber dam your failure rate increases by 200%. And then even then, even if you’ve got a tooth surface resin put in those areas, your composite failure rate can still approach about one in five. So if you’ve got a kid, you put four fillings in, you would expect at three years at, to be getting close to one of them failing at least. Keep in mind that’s an average place under rubber dam with local anesthetic. Can’t be hard to do, so therefore we move to stainless steel crowns. So a stainless steel crown on a primary tooth was traditionally, as you said, the conventional technique, and it was reserved for those teeth that were heavily compromised. Large multi-service areas, decay or pulpotomy based teeth where people were scared to put a filling. The success rate at 10 years sits between 97 and 99%. I would add-  [Jaz]The traditional conventional approach, yeah?  [Tim]Conventional crown. And I would argue that is more successful than what you would be doing in an adult tooth. A name of restorative material in adult tooth that you know is got a 97 to 99% success rate at 10 years. It’s incredible. So there’s nothing like this. So in the UK there was a particular dentist who was audited because she was claiming a lot of NHS think it is, a lot of the rebates but she was doing so many stainless steel crowns. It was just like this can’t be right. This girl’s lady’s doing too many and they went and ordered her records and found out she was putting them on non-invasively. So this goes back to that decay scenario. If we can deprive the bacteria of a food source, they’ll die. But it has to be well sealed and that’s where standards of chronic overcomes that. As long as you have sealed the decay. So they ordered her and actually found out her success rates were brilliant, and this is what became the hall technique. Now, pediatric dentists were actually one of the more resistant groups to adopting this technique. So they said, this can’t be right. We’ve gotta sit down and drill it and put a conventional crown on. Otherwise it’s gonna be too uncomfortable. It’s not gonna work. They were two, there’s actually a studies done, and there was two comparison postgraduate pediatric groups in the UK that did this. They treated 836 teeth and had a 77 month follow up. One group did conventional crowns and one group did hall crowns. [Jaz]Before we talk about the success rates there, because I just wanna just clarify to our audience, what actually does a conventional technique entail and what makes a difference to a hall technique?  [Tim]So a hall technique is no preparation. So you put two separators between the tooth. So you’re leave there for a couple days, then you come back and take the rubber bands out, and so now you’ve got a little bit of room to fitch ground. Then you just size up. The best size you can and the more you do, the more comfortable you get it. Doing the size, you still gotta crimp and adjust the crown. So crimps like bending the crown to make it tight. Then you fill it full of glue and this is probably the best place to use. GIC in kits is within a stainless steel C crown and you squish it on over the top. Okay, now it’s heavily reliant on your diagnosis. And investigations prior, which I think we’ll cover, but in comparison to a conventional crown. And a conventional crown is where we used to just, you’d numb a kid up and you’d take about a mill and a half off the top. Then you get a bur, like a stiletto, or what’s called a flame bur sometimes, and you just sort of open the contacts up and round it all around a little bit. Then you get a crown, try it on several times, bend it, adjust it, fill it full of glue, and stick it on. Okay? So they’re your differences. Now, you still need to do conventional crowns in circumstances where hall crowns are contraindicated or following a pulpotomy. Okay? So you still need to know that skill set. But going back to this study, the hall crowns are non-invasive, filling full of glue, squishing on when it met the guidelines, which we’ll go through in a second. The success rate for that was 95. 0.8% for the hall success rate. Hall crown success rate for conventional crowns was 95.3% statistically insignificant. So that converted us. So you got, yeah, that’s a lot of kids. That’s 400 kids. And that’s like, okay, this technique works. So in my clinic alone, I think we probably pace about 1200 hall crowns per annum. So a reasonable number. And your failure rates are not significant if you place ’em in the appropriate situation. And just to be honest with that, we’re beginning to see a much larger number of failures is where they’re probably placed on teeth that weren’t suitable for this technique.  [Jaz]So like in everything in dentistry, right? Case selection is so, so important to actually doing the technique well and correctly and to get the success rates.  [Tim]Yeah, spot on. So, to know how to treat kids, you’ve gotta have done a comprehensive clinical examination. And arguably, even more importantly, you’re gonna have x-rays. So it is medic legally indefensible to do a restorative procedure on a child without an x-ray. I mean, we wouldn’t do it on an adult. We see a lot of people doing it on kids ’cause it’s hard to take x-rays on kids.  [Jaz]But have you seen a big friction here, Tim? On social media perhaps with dentists where I’ve seen dentists openly say that, listen, I don’t radiograph children until they’re 12. Like, and they’re very adamant about that, right? And so whereas I was taught by Professor Helen Rodd in Sheffield, and so when I saw children, I would take radiographs at the soonest opportunity. Maybe age four if they’re looking like they’re gonna be high risk if I can do it. But definitely age five and beyond. What guidelines do you suggest in terms of, okay, when should you start? Basically, I just want you to encourage the listener to remember that actually it’s okay. We should be taking graphs for children.  [Tim]Absolutely. But these people that are saying they don’t take x-rays on kids to 12 should probably cease practicing on children. To be realistically, ’cause they’re causing more harm than good. When you should take radiographs on children, let’s say you’ve got a child who’s got no clinical issues, you’ve done a clean exam, it looks good, but you’ve got closed contacts. It should be taken 18 months after closed contacts. So Jaz, well done. Four years of age, that’s about when we should start taking them. It’s hard. There’s lots of variations you can do to the technique to still achieve it. Keep in mind, each x-ray is the equivalent of around six bananas. ‘Cause six bananas got radiation in right? So the radiation test is insignificant, really. Now, if you’ve got a patient who’s got clinical issue, I would encourage all your listeners. Please do not do anything without x-rays. And if you can’t get x-rays on that patient because of compliance issues, you really need to reconsider your ability to treat them. ‘Cause if you can’t get an x-ray on them, how do you expect them to sit through an extraction or a restoration or even a bit of putting a bit of Fuji2 over the top of it, right over RMGIC. So you need to get x-rays and sometimes you gotta vary the technique. So you might do like instead of getting a set of bite wings, you might get, like, you might capture like a quadrant with a little crocodile. So you get your little sensory, your plate in the crocodile, get the parent to hold it, just angle it up, try and get the contact points. And the benefit of doing that early is that you can also do prevention such as silver diamine fluoride and things like that to prevent lesions from developing. But then you’ve got a firm diagnosis, and I think I need your listeners to really understand that we don’t treat children differently because they’re children. We wouldn’t treat an adult and extract a tooth on an adult without an x-ray. You wouldn’t do a filling on an adult without an x-ray. You wouldn’t do a nerve based treatment on an adult without an x-ray. So please stop doing it on children because there is no defense for it. It, it’s completely wrong. [Jaz]I mean, what got me from memory, and I appreciate you saying that. And I think we need people just sometimes to say how it is. And I wholly agree with you, except, what I see on social media is reluctance of dentists. So I’m glad you’ve really been very clear about that and I appreciate that. It can be challenging, but we must do it. And the piece of research that always stuck with me in final year dental school and now, I dunno, it’s been like many, many years since then, but it was like, you are likely to diagnose eight times more caries when you have radiographs. So if you think you’ve got two lesions or two areas of caries, it’s probably a lot, lot more than that basically. And so you’re missing a lot of diagnosis.  [Tim]Correct. So, Jaz, if you can see a cavity in a primary tooth, let’s say the five, the upper right. First primary model, what we would call five four. What environment is the six four sitting in? Same environment. Where’s the seven, four, and eight, four sitting? Same environment. Maybe they’ve got a tongue, a bit more saliva, so maybe less, less effective. What’s happening to the five five? By the time you can clinically see a cavity in the mouth, it’s been there for a long 12 months. How close is it to the pulp? I can guarantee you if you just go put a food, just bog up that little five full, A) it’s not gonna last. B) the kid’s gonna come back for probably an extraction of that tooth. And C, you’ve probably missed the three or four other holes that are there.  [Jaz]Totally. I’m glad that’s nice and clear. So the message here is, let’s start taking radiographs in children. And then it’s imperative, I mean, to any treatment modality you do, but in terms of how could this sway you in terms of, okay, is this now suitable for the stainless steel or hall crown approach? Or actually we should be considering another way of treatment.  [Tim]Let’s say you’ve done a beautiful clinical and radiographic examination and you picked up a couple of holes in the mouth. With the hall crown, the main key is at this point, according to the guideline for this, which is once again published UK, you need to be able to have a clear, radiographic band of dentine between the cavity and the pulp. So you’re looking for about a mil. It shouldn’t be something where you like, ooh, I think I can see it. It should be, yeah, I can see hole and I can see decay. And what we’re thinking there is that you’ve got like a bit of insulation, okay? At that point, hall crown is eminently suitable. You can treat a single surface. Two surface, three surface doesn’t matter as long as you’ve got a radiographic band to-  [Jaz]And if it’s cavitated or non cavitated, does that inform the prognosis? The broken marginal ridge. Okay, good. Good.  [Tim]No, doesn’t change it. So we’ve moved away from that thinking that a marginal ridge involves pulpal involvement, therefore you require pulpotomy. You only need a pulpotomy if radiographically the decay is into the pulp. Or if the symptoms are guiding you to question the health of the pulpal status. But if you’ve just got a standard hole, whether you can see it clinically or not, with on your x-rays and you’ve got that radiographic barrier, and the kids just say, oh, it hurts when I eat. Happy days hook in. Now, where would you do a hall crown over an intracoronal restoration? I would probably encourage you to do a haw crown in most circumstances. Why? Because you don’t need local, you don’t have to drill it. Your success rate’s higher. And so it’s cheaper, quicker, and easier to place happy days. What’s your big drawback? Aesthetics. And what is becoming increasingly more important for people these days is aesthetics. And that’s obviously why we’ll talk about the zirconia crans shortly. Now with the hall crowns, you need a vital tooth with decay not involving the pulp. Two other things I want your listeners to look out for because you are not adjusting the occlusal surface. The ability for the crown to sit down towards the gum level, it can only sit down as much as the crown will go down, right? And when it hits the top of the tooth, it’ll stop. So if you’ve got a really deep hole, not towards the pulp, but down like under the gum, I need you to think. If I put the silver crown, the Staines stainless steel on this without taking anything off the top, will the crown actually seal the cavity? Because what happens if it doesn’t? Well, the decay continues to tick away, and then you end up getting sent to me. I pulled the tooth out. Okay, so that’s tip number one. If you can see decay, that is about the gum level, I would start thinking my crown is gonna struggle to seal that. Okay? If it’s above gum level, you’re probably gonna be sweet if it’s well below gum level. You’re gonna struggle.  [Jaz]So well below gum level is obviously okay, as long as A is vital and B, it still has that band of dentine, it’s still okay to treat with the whole pan approach. Except what you’re suggesting here is perhaps consider some occlusal reduction?  [Tim]Yeah. The problem is, I don’t know why Jaz, but if I pick a little flame will still let the bur up and go in proximally without local, the kids don’t tend to feel it. ‘Cause there’s reasonable enamel there. The moment you seem to pick a footy up and touch the top, the kids do seem to feel it. So when I’m looking at my x-rays and clinically I’m looking at how deep down towards the gum the decay goes, and if it gets below gum level, despite meeting the other criteria. So plenty of space to the pulp. Symptoms are sweet. I might say to them, hey, we need to do a conventional crown here because I need to numb ’em up. Take some off the top to get the crown to sit down far enough to seal decay. The second thing I need people to look out for is when you’ve got a clinical cavity that’s present usually on the D, the D blows before the E or for the other people that know that the first primary molar goes before the E. The second primary molar reason is it’s been there longer and it’s got much thinner enamel on, so it tends to blow first. What can happen is you get a clinical cavity on the first primary molar and then the tooth behind it tips into the hole.  [Jaz]Hate that scenario. ‘Cause it just makes everything so awkward and tight. [Tim]Correct. And then how do you get a crown? You need to do like an S bend, it’s gotta get like a dog lick to get around the second primary molar to seal it. And that’s once again where you might look at the scenario and say, actually I need to numb the kid up into a conventional crowd. But they’re your two main ones. They’re the two things. Just for tips for young players, you’re getting started. I would say don’t pick a D, pick an E. So second primary model, they’re easier teeth to manage. Pick obviously a very compliant child. And if you’re a bit concerned and you’re worried, like you’d think, oh, I dunno if I actually sealed that decay. Take an immediate x-ray. So before the cement sets. So if it has, and you haven’t sealed it, get the crown back off and reassess your plan and maybe you need to numb ’em up and take a bit off the top.  [Jaz]Okay, that’s wonderful. And so the questions I have clinically on the back of that is just some common questions I actually see on forums on this technique is, let’s imagine a scenario where you have a, let’s say 5, 6, 7, 8, and eight. So lower right D for some of our listeners, it’s clinically cavitated, but it’s equigingival caries, and you have, or, it’s vital. You have that band of dentine, so it’s suitable for a whole crown and you don’t have any space issues per se in that scenario where, because it has got an an obvious cavity, the guideline says, obviously if you can get a seal, you don’t need to remove the caries. But in that scenario, it’s so tempting to just pick up an excavator and just scoop out some of that the most superficial decay. Is that something that you do because it’s just so easily accessible, just scoop it out in case there’s some bread or cookies stuck in there or something?  [Tim]Oh, absolutely. You gotta get the food out. Yes, please. So definitely give it a clean, but you don’t need to scoop out tooth structure, because once again, that boils back down to the understanding of decay. Decay is not an infection, it is a biofilm related disease. So if we can, so plaque bacteria related, right? So if you can kill all the germs there because they’re deprived of a food source, don’t worry about it. Don’t pick anything up. Just make your life easier, quicker. Don’t pick a drill up. Just squish it on.  [Jaz]And then just the point there to make is if you see an obvious bit of food there, just get rid of that, cleanse it in that way basically, and get rid of it. And then the other scenario is when you are a bit more experienced, and then I’ve done a fair few hall crowns in my time, don’t see children anymore, but I used to love doing them. And when I did them, sometimes when it’s a bit tight. We need to then, yeah, zip the contacts just to allow it to seat a bit better. And in that scenario, like you said, I also experienced that, okay, children were okay with that. They didn’t need any LA for that. That was okay. In that scenario, you are able to then seat it, which is great. Now going back to the stainless steel crown, the conventional technique is there sort of like a hybrid technique whereby you are doing the conventional technique, you are zipping off the contacts. But you are not adjusting the occlusal for whatever reason. And then essentially what you have is kind of like a modified approach because with the whole crown, they’re gonna have super occlusion, their mouth be propped open. And so is there a place to utilize that approach, either to make your treatment quicker, more efficient? So given the patient LA, you are zipping the contacts, but you’re not then doing the occlusal reduction because it will dahl in or it will settle occlusally anyway. Is that any need to do the occlusal adjustment?  [Tim]No, the short answer is no. I agree with you. There is certain circumstances where I’ve just got a zip between, and I won’t numb them up for that because they really don’t tend to feel it. I would still, for in my hands, I still sort of call that the hall crown. For me, conventional crown is when I’m picking a needle up and I’m giving LA which is pretty rare on its own. Usually it’s when I’m doing a pulpotomy or I’m doing like back to back things, I’m extracting a tooth and then I’m like, oh, I’ll just put this on at the same time. But, yeah, vast majority of time. Yeah, absolutely. You can just sort of zip between if you need to. But I’d say to most people, the vast majority of times, 80% of cases, you’re not gonna need to pick a single driller. You’re just gonna need to clean the gunk out. You’ll have seps (separators) in, leave ’em for a couple days, pull ’em out. You’ll have room and on your go.  [Jaz]And at the point of placing just a little technique here, but at the point of placing I placed, and then what’s the most efficient and best way to remove that GIC cement without then removing the crown or pausing discomfort to your child?  [Tim]Yeah. So my usual discussion with the parent or child before we’ve even got to that point is, I describe how we’re gonna do this technique. And I usually describe it in such a way, like you asking before about what, how does it work? My analogy I give to most parents is, imagine if I had a water tank and I put you in it, Jaz, and then I filled it full of concrete. How would you go? Not very well, you’d be dead. Right? And that’s what’s gonna happen to all the germs in here. Okay. Now I need to put rubber bands between the teeth. Your child’s gonna be most upset by this bit out of the whole procedure. Why? ‘Cause it hurts. It’s like having a big chunk of corn stuck between your teeth. Usually at this point, I say to the kids, hey, you ever eaten corn before you eat meat? You know, we get stuck between your teeth. It’s really annoying. So what we’re gonna do, I’m just gonna floss this in. It’s gonna be a little bit annoying. Always do the harder contact first. So usually on a D, do between the D and the E first, and then do the D and the C, right? If you’re doing the six, do the most, whichever one looks, the dodgiest do the hardest one first, and then the kids usually get a bit upset because it’s hurting and they wanna pull ’em out. I always just reassure the kid and the parent that every minute it sits there, it’s gonna get less uncomfortable ’cause we’re making space and that’s the worst part of this whole procedure. So usually when they come back for the hall crown, they’ve got the space. Now there’s a particular set of pliers called Howe Pliers, H-O-W-E. So there’s two pieces of equipment you need to place the stainless steel Crown. Well, there’s Crimpers, which sort of tighten the the gingival margin and make it sort of click, click on and retain better. And Howe Pliers, they’ve got like flat ends. They’re like little pliers with just flat ends. And what you do is you actually put them on interproximally on the crown and you can squish it a bit meso distally. So they’re brilliant for those cases where you’re lacking a bit of space. Okay. And then it makes it a bit wide buccolingually, so you gotta crimp that in. That will help with you get those two things with good set of separates, you’re pretty good. Then I clean out the gunk, I’ve sized it up pretty well. I’ve eyeballed it. Sometimes I sort of nearly put it on, can be a bit uncomfortable. I don’t tend to put topical anesthetic on the gum anymore. I tend to find the kids just got the taste of it half the time and I hated it. So I just pretty much now just load the crown up. With a, like a runny glass ionomer cement such as, like in Australia we call them Fuji 7, would be the type and then-  [Jaz]Or like a Ketac™ Cem or-  [Tim]Ketac™ Cem, perfect GI cement. Yep.  [Jaz]So you shouldn’t use the Fuji 9, for example. It’s too thick.  [Tim]Too thick. Can you get a struggle to seat it down very well. So you wanna runny. Not an RMGIC. Absolutely not. You wanna run GIC bit more like a looting cement? Okay. Yeah, yeah. And then load the crown up and definitely load it up. Good halfway. Keep in mind ’cause you haven’t taken a whole heap off, you don’t need a huge amount. And then just push it on. Okay. And then to clean it up, I usually just get some gauze and just wipe around all the excess initially. Then the strongest way to get that crown to sit down is the kid, ’cause their jaws a lot stronger than my thumb. And so I put a cotton roll in it. I get the kid to bite down really hard. Okay. And then I get my triplex and I just wash all the cement off and off you go. Then you get a floss with a knot in it, and then you put it on and then you get your DA to put dental assistant to put their thumb over the top of the crown. You floss down, and then pull it out. And then go to the other side, floss down, pull it out.  [Jaz]That can be tricky, right? That can be a little bit tight and annoying. In my experience it has been. Have you found the same as well?  [Tim]Absolutely. But you gotta do it. Yeah. Otherwise you’ll glue the contact. [Jaz]It’s a stressful part of the procedure where you’re like, okay, quick, quick, quick.  [Tim]Yeah, spot on. But keep in mind, if you get a slower setting one, you’ve got about two to three minutes. And that’s where if you put it on and you look at it, you’re like, it looks like the one surface is sitting in the air. That’s when you’re thinking that’s not on, like it should be like a mill and a half high. Right? If you’re looking and it’s like, it’s low on the mesial, really high on the distal and that’s where my cavity is. And that’s your time to get it off.  [Jaz]Can be quite fiddly to begin with. But like you said, it’s such an incredible success rate you get, and it’s great to be able to intervene in this way just so I can make sure that for the show notes, everything is correct and my understanding has been correct as well. So I’ll summarize. You’ve done a wonderful summary here of the hall crown technique, why we do it, why it’s beneficial compared to the conventional technique, but just there are still some scenarios whereby you may use the conventional technique with LA, occlusal reduction, zipping the contacts, and that is. A, when you’re doing pulpotomy B, when the caries is very subgingival, is there any other times where you would veer away from the hall crown technique?  [Tim]When you’ve got that significant space loss? Okay. And then potentially, like if I’m doing a quadrant of dentistry, like the second primary molar is gonna hole in it. The first primary mole’s got a big hole in it and the canines got a hole in it. You can’t hall crown a canine, so I’ve gotta numb ’em up. And then I might just say, I’m just gonna knock out all three in one go. I’m not gonna get ’em, do all these hall crowns come in and numb ’em up. So I might do, potentially a composite on the second primary mole. If it’s small, if it’s big, I might do back to back crowns, for one needs an extraction, whatever. I’ll probably just move ahead and just, ’cause I can get a, it doesn’t take me long. I just get a quite nicer fit. Yeah. But you nailed it mate. That’s pretty much it. Brilliant.  [Jaz]Thank you so much. And that was all down to your wonderful summaries. So let’s now the last bit. Okay. Zirconia is a newer product in the market for children. It has been around for a little while now, but I haven’t seen it in the UK, been used very widely, but perhaps because the bias of me not looking at what the children’s clinics are doing in the UK at the moment. So tell me, my friend, how far are we in the zirconia being potentially replacing metal? And what have been your experiences with it?  [Tim]So we place quite a lot of them. They probably make up about 40% of the crowns that we place in comparison to hall crowns and conventional crowns. The main reason is obviously aesthetics. Okay. Success rates are pretty similar between a stainless steel crown and a zirconia crown. If placed well, okay, so why would we put ’em on? It’s just purely aesthetics. That’s it on posterior teeth. So I would usually discuss with the parents and say, hey, look, your kid’s got, let’s just say they got all back eight molars in decay. I’ll say, hey, look, all back eight molars with decay, whenever I’ve got a cavity in the first primary molar, the success rate of fillings is pretty low. So I usually will say, you got your choice is, are stainless steel crown or zirconia crown for a first primary molar. For a second primary molar, i’m a little bit more comfortable doing restorations on them, intracoronal restorations. Okay, so let’s say they’ve got that, I’ll be discussing with them and say, hypothetically, let’s say they need eight crowns based on what I’m seeing. They’re all really big holes. I will say to them, oh, we can do eight stainless steel crowns. Your success rate sits in eight, that 95 to 97, your main drawback is you’re not gonna love the way it looks. They’re gonna look a bit like jaws. So you’re gonna have all these visible eight teeth. So the other option you got is that we can do zirconia crowns. Now the more visible teeth are the first primary moles. So you can do them all in white. All in silver. Or you can do a mix. You can do maybe the front baby teeth in white and the back baby teeth in silver. And so then when the kids smile for school photos, you’re not really seeing all that metal work. You’re predominantly just seeing a nice aesthetic looking tooth and Jaz that would be our most dominant use. We don’t commonly get that many parents who wanna do like all eight teeth in white because it costs more to do, they do take more time as well. That can take fair whack a bit more time if you’re doing eight of them. And the reason is it’s a non flexible material. So if we talk about zirconia for a minute, most general practitioners are familiar with zirconia crowns or zirconia is a product for adult. We know it’s not flexible. We know it’s very strong and durable and compressive strengths, excellent once it’s cemented, but it’s not flexible. So if you sat there with your fingers or got a little interest. Banged on it, it’ll fracture which means that you can’t squish it on like a stainless steel crown for kids where you’re like, oh, my prep’s not perfect, but I’ll just push it and the crown will bend on. And that’s why hall crowns work. ‘Cause it’s a flexible material. So for zirconia, you have to prep the tooth and it’s a bit like an adult crown prep with like no edge, no, no ledge, no feather edge, no shoulder, nothing. So what you do is you take about a mill and a half to two mil off the top, and then you take roughly about a mill everywhere else. And then, so pretty much you create like a ledge all the way. So usually the way on which I would do it is I’ll take it off the top first ’cause it makes you crown shorter. So you then having to remove less. Then I stay on the same bur, which is usually like a football bur. Then I take some off the buccal and the palatal. ‘Cause you try to remove bur changes. That’s what makes things quick. Then I get a stiletto bur, or flame bur you gotta go below the gum. You’re about a mill below the gum, and then you buzz all the way around, get all your edges away, clear in proximals. And then for the new smile, you get a try in crown, which is excellent compared to that other brand called Sprig. The reason is you use the try in Crown, which will get contaminated by blood products and things, and you try to fit it on, and there’s a classic size and there’s a narrow, the narrow is obviously designed for where you got space loss and you try it on so it passively fits, so you’re not forcing it. If you force it, you break it so you don’t want it rocking. You want it passively fitting on with still contact points established. Once you go onto that, you then go and get your white crown, the one you’re gonna cement. You get good hemostasis of the gingiva. So sometimes they’re, I’ll use local ’cause it’s got adrenaline, so I’ve already had the patient numb, so whenever I numb a patient up for any procedure, I always numb through the interproximal gingival to the palatal lingual. Every case I do more so for zirconia. And then otherwise you can use like hemostatic pace like 3M makes a hemostatic pace. ‘Cause you would need much better hemostasis than you do for stainless steel crowns. And then fill it full of the same you want. Now you want a runny R-M-G-I-C potentially. Okay, so you take too long for you if you just go use just a thin, like Ketac™ Cem, you want something you can cure with a light. Okay? But you still want it thin. You don’t want like a food. You can cement with Fuji too. But for posterior teeth it’s a bit thin. Thick and sometimes you can’t get the crown out ’cause the cement can’t escape. So we use a 3M based product, which comes into syringe called RelyX. It’s really nice material and then you load your crown up, you put it on, and then I don’t touch anything. I just set it. And so there’s excess cement everywhere, but it’s sets really quite tacky. So it’s a bit like a tack cure, but you’ll set for 40 or 60 seconds and then I just clean all the extra cement up. If you use Fujii2, it sets like bloody, like sets like rock, and it’s really difficult to get out in approximately, and then you’re done. That’s it. Nice and easy. How long would it take? Look, I can probably do a stainless steel crown, conventional stainless crowned tooth in about three to four minutes. Okay. While zirconia might take me closer to 10-  [Jaz]This is because the zirconia involves that buccal and lingual additional prep, and essentially you are removing the belly of the tooth, right? You’re just removing the undercuts.  [Tim]Spot on. You just sort of, I mean the listeners, they can’t see. But for those who are watching on YouTube, I am going to describe something. So Jaz, I’m sorry for your listeners, they won’t be able to see this, but I’m going to describe it. For those watching on YouTube, you’d be able to see this. So this is an anterior case, but I’ll show you posterior. So with it, you’ve gotta make them quite sort of peg, like see, there’s nice hemostasis there. I’ve got stainless steel crowns on the first primary molars, and on the anteriors I’ve reduced the anterior is down to look a bit like a conventional crown preparation, and then I’ve cemented four zirconia crowns there. The gums look a bit like minced meat. They get a bit traumatized here, but they always heal up really quite nicely. Now I’m gonna show a photo of a posterior.  [Jaz]Yeah. I’m gonna say it looks a bit like a vertiprep in a way that you just went round. You got rid of all the undercuts and it is not much of a margin. [Tim]No. No, you don’t want a margin. You don’t want a ledge. So on the posterior tooth, I’m now showing, you can see that I’ve actually created a ledge. That’s what I was talking about before. So you create a ledge, it just gives you an indication of where to reduce. Then you cut that entire ledge away, which you can see there goes under the gum. Then you try the crown.  [Jaz]This is the shoulder that Verti prep. Lovely.  [Tim]And then that’s your crown cemented. So the crown’s cemented on sits quite nicely. You want it roughly the same occlusal height as everything else, and you want it sitting under that gum quite nicely. As I said, the gum will be a bit traumatized, but it will be okay.  [Jaz]Now here’s an interesting question then, because you’ve just raised a really good point that you want it the same occlusal level in this scenario whereby you are off a bit, then you’re kind of like in the whole crown scenario, you are leaving it in supraocclusion. Are you okay with that because you’re used to doing it anyway in children and they adapt really well? Or are you a little bit more fastidious that you’re gonna start adjusting to equilibrate the bite?  [Tim]No, I’m okay with it. I do try to get it a bit more even, but just for comfort and particularly, let’s say if I’m under anesthetic and I’m doing a whole quadrant. I don’t want, just like I’m only chewing on a couple of teeth, it’s just a bit uncomfortable. So if I can, I’ll try to get it as close as I can. It won’t be perfect. But we do know for the whole crown, it can sit proud and it’ll settle in quite well. So they’re really good. The other place where they are so much better, which I actually personally feel they should replace entirely, is strip crowns so anteriorly, right? So for a strip crown, it’s the same sort of principle you gotta do like that vertiprep, get rid of the decay. The issue is strip crowns. Success rate’s not great ’cause it’s resonant just chips. Kids go put bloody carrots in there and they bite grizzly bars and all sorts of things. And you just, in any pediatric dental program, when you’re a a first year, you spend all your time dealing with fractured strip crowns from the third years of the guys who graduated. And so you benefit of your zirconia crowns is they very rarely fracture. You need a really solid trauma to break it, which would’ve broken the tooth anyway. So your main drawback is they might to bond. There’s not much retention on ’em. So that’s where we do cement them with Fuji 2. So we are at thicker R-M-G-I-C in the anteriors, but they are such a better aesthetic result. You don’t get discoloration . They work very well for pulpotomies. You can successfully pulpotomy and anterior tooth, they can mask. If you’ve put silver diamine fluoride on and it’s black, they so they look a lot better. They last a lot better, so they’re much more superior material. Your main drawback is if you’ve got a kid with heaps of crowding, it can be a bit difficult to try to get ’em to fit all together. So just tip for young players on that one. That’s where strip counts can help. But mate, well I haven’t done a strip crown on a primary interior tooth in five years and I’m so bloody happy I don’t do them anymore. [Jaz]And for those you know who are listening, I would encourage you just reference back to this video, make a little handout ’cause this is Tim, this has been absolutely amazing. We make a little handout. Do you have permission to use those images in that handout for our Protruserati?  [Tim]Yep.  [Jaz]Okay, amazing. So I’ll put those images so you can easily download because they were wonderful. It really shines. The benefits of this approach. And it’s nice to know that, a very significant percentage of time actually you are using this. And also to learn about how you’ve no longer pretty much using strip counts anymore. That was amazing. You’ve answered pretty much all my questions in terms of the technique itself. Now I know you do some teaching in Australia and maybe more as well. Before we get to that, I wanna say, give you, pay you a compliment, Tim, if I had your accent right, which I love, by the way, if I had your accent, I would do the dental version of Aussie Man reviews. Right. I would just think it’d be so funny and good to see these dental procedures happening, and then you just like, honestly, I really enjoyed listening to you today. The hour went by really quickly. The audience would’ve loved you as well, the Protruserati. Please tell us how can we learn more from you? I know you are active in the education circuit, and I think for everyone. Like it’s nice for them to be inspired by what we discussed today, but I think it’s very fiddly and to just secure the protocols and so much more to it to get hands on experience. How can they learn that from you?  [Tim]Yeah, absolutely. So we have a like free dental website could kidsdentaltips.com and you can describe, there’s a whole heap of articles on there. How to manage permanent traumas, do pulpotomies, how to extract primary teeth prevention techniques, fluoride, toothpaste, or anything you can think of for peds. That’s pretty much on there. It’s free access. There’s not a great deal of videos yet. Jaz, I haven’t quite got to that point yet. There’s some free lectures on there as well that you can view. Otherwise, we do do hands-on programs in Australia with which I’m actually doing one, I’m doing a four day one coming up on Thursday, the next few days, we haven’t done any internationally, but Jaz if you think there’s a place for it in the UK, I’d be very happy to come across for a nice trip to the sunny UK. Do some courses there, but, otherwise, if you are interested in doing something like a zirconia crown. You can find in videos of like how to on the Nu Smile. So N-U-S-M-I-L-E, the Nu Smile website will have like how to videos and they do tend to run international events as well. I just dunno if they’ve gone into the UK ’cause I know that you market is quite different in regards to nHS and private. So for example, in Australia, there’s really no very limited public funding dentistry where it’s all private, which has got its own problems. If you don’t have money, you can’t pay for it. It’s bit like America. Conversely, in the NHS, I know you’ve got a lot of restrictions on time and how much you really encouraged to get through things quickly. So, and perhaps that’s why that they haven’t targeted that market previously. Look, if you listen this, there’s good demand out there. So I’m very happy to come across and run a course on hall crowns, zirconia crowns, restorative materials, local anesthetics and stuff.  [Jaz]Yeah, I think that’d be wonderful. So I think if there’s enough comments below, we’ll reach out and see. But I think what you’ve talked about today was absolutely fantastic. In one hour we actually managed to to cover a lot. So I would encourage you, I’m gonna put the website, just say the URL again for my benefit.  [Tim]It’s kidsdentaltips.com.  [Jaz]Lovely. I’ve seen the website, that’s how I managed to reach out to you guys. If you wanna learn more about Pediatric Dentistry, check out Tim’s website and check the articles out there as well. And if you are in Australia, there’s a good whack of Protruserati in Australia. Please check out Tim’s courses and maybe coming soon to a nation near you. And Tim, I wish you all the best. ‘Cause I really love your education style. I just love people that you are so direct and honest and just full of little nuggets and tips. And I know for a fact that Protruserati would’ve loved today’s episode, so we’re gonna make a little handout for them as well. So, Tim, thank you so much my friend. I put all the links in the show notes. Are you active on social media?  [Tim]Not too much. I am in Facebook and I do a few posts and things like that as well. But not, I just time poor Jaz, with three young kids.  [Jaz]Oh, I can relate. I can totally relate my friend, but no, it was so nice to connect you on Facebook and thanks for applying to me and being so wonderful on here. I really appreciate it, Tim. Thank you.  [Tim]My pleasure. Thanks for having me. I think you do a great job as an interviewer mate. You’re very engaging as well, so thanks very much for having me.  [Jaz]Amazing. Thank you. Jaz’s Outro:Well, there we have it, guys. Thanks you so much for listening all the way to the end. If you’d like CPD or CE credit, scroll down, answer the quiz and get your CPD. You’ve done the hard work, like how many times do you have to sit through boring webinars to get your CPD? Well, you’ve just enjoyed Tim’s fantastic commentary and explanation of this awesome technique. And now to validate your learning to be able to reflect and get a certificate, you can just answer the quiz on Protrusive Guidance if you are on one of our paid plans, which I think is the best value educational resource on the planet, but of course I’m biased. It’s fully tax deductible as you know, and it helps team Protrusive to grow and to make better content. So if you’re not already on there, head over to protrusive.co.uk/ultimate and that unlocks Verti Preps for Plonkers or Sectioning School, all the various other master classes we have on there. Especially, and of course, the community of the nicest and geekiest dentists in the world. The infographic is also there. We also have a secret space called Protrusive Vault, which has got all the downloads from over the years. And lastly, like Tim is such a cool guy to learn from. I know he does his courses on Australia, so next one is in November. So if you scroll down, I’ll put a link to his course in Australia in November. Predominantly for the Aussie and Kiwi audience. But you know, if you’re in Asia or sometimes you wanna make a tax deductible trip to Australia, then this is a great reason to go. Tim is absolutely brilliant, and of course I’ll put a link to his website. And with that, I will say thank you so much guys, honestly, for listening to the end. If you enjoy this episode, please send it to a colleague. This is how we grow. All the best. I’ll catch you same time, same place next week. Bye for now.