Protrusive Dental Podcast

TIME SENSITIVE – 50% off Maciek’s Online Contact Point Ambassador Course! Click here Let’s face it, Class IIs may be our bread and butter Restorative Dentistry but they are ANYTHING but simple. In some scenarios, achieving a perfect contact on a class II restoration seems impossible.You have likely been in a scenario where everything is going to plan and your matrix is looking like it will achieve a lovely contact area – however, as soon as you insert the wedge or tighten the band (circumferential matrices) the matrix leans away from the adjacent tooth, revealing a ghastly looking open contact. How can we overcome this? Is soft tissue removal an option? In this Group Function, I’m again joined by my boy Dr Maciek Czerwinski who answers this emphatically! https://www.youtube.com/watch?v=V6pu7FLb9Kw The full episode! Minor video issues with Maciek https://www.youtube.com/watch?v=cvX-oaEaqUI How to do Teflon Floss Technique – the Main Interview Podcast Video has some syncing issues, please bare with us! Need to Read it? Check out the Full Episode Transcript below! “If you use the stiff wedge, if the wedge is too big it will just move the matrix (and you lose your contact), but if you’ve got something soft, it will go under the curvature of the matrix, and then it will just self adapt.” – Dr Maciek Czerwinski In this group function we also discuss: Is it necessary to remove soft tissue? – Why? How? What to use?  How to improve the contact area Why and when to place an orthodontic separator to help your future restoration Tired of spending hours just to customise your stiff wedges and matrices? Check this gem shared by Dr Maciek – FINALLy the video on how to do the Teflon Floss technique (as promised in the episode): Also, Dr Maciek is giving 50% off to all Protruserati up until June 30. Click here to check it out! I have done his online course and it was very comprehensive and is guaranteed to improve your contact points no matter how tricky the situation. It is an all-encompassing direct restorations online course – with play by play explanation of matricing, wedging, ring selection and isolation! Click on the image to check out Maciek’s course! If you have any other questions that would make a good group function, please do message me on @protrusivedental Instagram page or the Facebook Page If you enjoyed this, you might also like my other episode with Dr Maciek Czerwinski on Which is the Best Matrix System for Class II Restorations  Click here for Full Episode Transcription: Opening Snippet: When I first saw this I was disgusted when I first saw this I was like you're removing healthy papilla, you're gonna destroy the biological width. The patient will die, the patient will get necrosis you know all these things. Jaz’s Introduction: Have you ever had that scenario where you’ve got your matrix band in and you’ve got this lovely looking contact area and thinking great there’s gonna be a home run restoration but then you put in your wedge and okay the whole contact is now open right? The matrix that was beautifully contacting the adjacent tooth before is no longer contacting that tooth. What’s happened there and how can we overcome this really simple basic but daily bread and butter issue? I’ve got none other than Maciek Czerwiński obviously came on to do an amazing episode all about Matrix Selection which is the best Matrix and I hope you enjoyed that episode. So today we’re gonna be talking about this class two woes. Do you make these class two mistakes? We’re gonna be talking about the importance of recognizing how to overcome this issue that as soon as you put wedge in the contact area opens or the second scenario is the importance of soft tissue removal. Like I couldn’t believe that when I spoke to Maciek, He revealed that in 70% of his Class II cases he’s having to remove some soft tissue. Now if you’ve seen some of his work on Facebook you’ll see why he’s dealing with some pretty deep lesions the whole time. So that makes perfect sense. And he gives you one more pearl as well. So welcome Protruserati. I’m Jaz Gulati to this group function all about how can you IMPROVE your Class II contacts and how to OVERCOME common scenarios. We’ll catch the main episode and I’ll catch you in the outro. If you catch the outro you will see a massive discount on Maciek’s Class II course. It’s called Contact Point Ambassador, it’s way more than a Class II course. It’s like getting solid contacts consistently. So if you want to kind of cases he does on social media in terms of like really solid dentistry, restorative dentistry without never having open contacts again from all different types of rings, Teflon floss, matrices, the whole dissection of it for the cost of one restoration. You can do his course with this 50% off. So catch that in the outro and I’ll see you there. Main EpisodeMaciek A.K.A. Magic welcome back to protrusive dental podcast. Had to bring you back one more time, my friend. Because you absolutely blew everyone’s mind when we talked about, which is the best matrix system. How are you, my friend? [Maciek]Thank you. I’m fine, thank you for invitation. It’s a big pleasure for me to be with you second time. Nothing really big change except I did something for the very first time. I launched my first online course and I was very happy about it also a little bit nervous because it’s a little bit nervous when you do something for the very first time also like in dentistry. But yeah, it’s everything is really great. Thank you. [Jaz]I’m so glad you did that because Maciek is someone who creates online education myself. I was waiting for you to do that because the matter value that you give on your social media posts. I was waiting for something a bit more structured and you finally did that. And I was happy to say I was one of the first students and thank you for giving the opportunity to work through it. And oh my God, like from the Teflon floss, to matrix selection to wedge modification, you covered everything beautifully. But today, what I wanna do is extrapolate maybe just pinch squeeze out of you some gems that can help everyone. Right? So this is today. It’s like it’s the Protrusive Dental Podcast episode. But it’s also like a group function. Okay. Group function is what I do when we have a problem in our community, the listeners and they have a problem and they need the answer to that one specific problem. And that problem at the moment is a contact points. Right? So the reason I got you on is because who better to get you on Maciek because your course is called Contact Point Ambassador So great. Great name. And I think the times as a dentist where I felt the lowest after a clinical day is when I in my mind I cannot get rid of that stupid, silly open contact. Right? And you try your best, you do everything and you still left an open contact, right? It’s not nice. It’s not nice feeling. And sometimes you think I could have done something better or was that impossible? Now I know in your vocabulary there is no such thing as impossible. I’ve seen any contact. I’ve seen you closed it. But I also appreciate, by the way for those who don’t know is that you share your failures, your past failures and how you learned and adapted. Which is why it sets up perfectly to the first question Maciek, which is that annoying scenario whereby you put your matrix in. So this could be a circumferential matrix or a sectional matrix. Right? You put the matrix in, okay? You’re sealing the cervical area of the cavity. So remember we’re on video but also for the audio listeners. Need to be very descriptive what we’re describing. Okay, so the matrix has a good seal and the matrix looks like it’s got a nice contact to the opposed adjacent tooth, which is good. But as soon as you put the wedge in, the contact is gone and now you have like a one millimeter open contact. What are we doing wrong when this happens? And what tip can you give to the dentist who are having this problem now and again? [Maciek]Probably this is one of the most common problem. And that was also my problem for many, many years. And so I know this frustrating moment when you see it, especially that very often we don’t have enough time to correct it. And it would be superb if we have some solution for that. And that was the beginning of the idea of the Teflon floss. So the biggest problem is the fact that the wedge is a stiff material. So if you use the plastic wedge or the wooden wedge, very often those wedges are just too big or they’re moving just too close to the occlusal surface. And this is the biggest reason for losing the contact point. So my advice would be to try to use the Teflon floss because Teflon floss is a game changer because this is something that we’re going to adapt to the space that is the Interdentally and it’s pretty soft at the beginning. So if you’ve got the matrix with some kind of the curvature, if use the stiff wedge suddenly if the wedge is too big, it will just move the matrix. But if you’ve got something soft, Teflon floss will go under the curvature of the matrix and then it will just self-adapt. So if you’re using the stiff wedges, you always have to customize it. So you have to cut it, so you have to reduce it from the [cape] or you have to cut the plastic wedges. That is pretty time consuming as well, because as you know, we also have to customize often our matrices, so there is so many things to customize that suddenly turned out that there is no enough time for finishing the whole THING. So Teflon floss make everything much much easier. However, you have to learn how to use it, like with everything. [Jaz]Well those people listening right now who maybe didn’t catch our first episode, we discussed Teflon floss, great depth, essentially, this floss is – you’ll describe much more intricately than what I’m describing, but wrapped in Teflon and essentially you get like a softer wedge, but I can get a really nice seal that is adaptable and I’m definitely sold on the Teflon floss and I believe you released a video recently as a preview for your course and I’ll add that on my website, so people can check it out how to do the Teflon floss and then they can start seeing the advantages of switching to a Teflon floss rather than a stiff wedge. Now, the issue that I described, you stick your wooden wedge in and the contact opens. Do you think that also happens? Not just because it’s a stiff wedge, but maybe because the wedge is too coronal i.e. it’s not deep enough, it’s not gingival, or cervical enough. Could that be a cause of this issue as well? [Maciek]SURE, that’s the another reason. So this is why it’s very easy when we’ve got pretty shallow cavities because then the wet will go always under the curvature of the tooth. But if you are pretty deep then it will always move. One of the solution is definitely to remove the gum. So to create more space for the wedge. Because it’s impossible if you’ve got a lot of the gum interdentally it’s impossible to squeeze all that tissue with a wedge. Or you have to use very big force. That will be not very pleasant for the patient, especially if you work without anesthesia but probably not. But sometimes it’s really necessary to remove the gums. So probably in my case is like the second class cases. Almost 70% of the cases I will going to remove the gum. So this is like the really essential element of the restorative treatment. When we talk about the Class II, to remove the gum because then it’s much easier not only with the wedging but also with the matrix placing with the rubber dam placement. So a lot of the advantages of doing that. [Jaz]There are so many advantages of removing soft tissue and I believe it was you and Pasquale Venuti who I first saw on social media many years ago removing soft tissue. And you know what, Maciek? When I first saw this I was disgusted. When I first saw this I was like you’re removing healthy papilla. You’re gonna destroy the biological width the patient will die, the patient will get necrosis, all these things you think. But man when I started to do it, wow the rubber dam started to see more apically, my matrix was able to sit and get a better cervical seal. My wedge finally had the correct position to go to. Right? So there are so many advantages of soft tissue removal. It did surprise me that 70% of the cases you removing soft tissue. But then again, if you look at Maciek’s population base and you look at the kind of carries bombs that you get, like they’re always so deep. And then I think that’s why because you’re having to remove the gum because you’re dealing with really deep lesions. So it makes perfect sense. Now, the most common question people are thinking now while we’re talking about this is okay, what do you got to use a laser or what I mean? I know what I use. But I want to hear about what kind of things do you use to remove the soft tissue in an efficient way, in an idiot proof way? [Maciek]I was trying almost everything because for me it was also like the complete switch of my approach in the restorative treatment. So even that I want it in the past to be a surgeon. I really don’t like to use a blade during the restorative treatment because you have to tell your patient why you are taking the blade, why you want to cut him. And it’s not so not so easy. Also, the whole management and all the manual connected with using the blade. It’s not so easy especially when we talk about the interdental space. So for me when Pasquale Venuti shot for the very first time, this magic bur that is not covered with the diamond, this very smooth bur that you can really easily remove the gum. That was the completely switch for me. And it’s really probably the best possible option to do that. I was trying also the laser however to be honest, I am not a fan of laser, especially in this area because you never know how deep you’re gonna burn the tissue with the laser. So the friend of mine sent me a message that he made the bony crosses because he was cutting the gum but it was just too deep. So he also cut the bone. So I also like to have like very simple protocol and using the bur is just the easiest solution for us because you can just put the bur into the hand piece into the turbine and you can remove it. So this is also a very important factor to use something that is very very quick because also I was using the [cauter] electro surgery in such situations however it’s not always ready. So I had to ask my dental assistant to prepare it. And then, and if if something [class more land than three] or four minutes, you will probably resign using that. So the bur is the easiest, the quickest and probably the best possible option to do that. [Jaz]Well, I’ve used Electrocautery firstly out of dental school. I start using Electrocautery. I wish I knew at that stage about matricing and getting the best seal and stuff. And I suffered a lot at that time, as you do when you were learning right? And then I would use Electrocautery when it’s like really deep and I had no choice. But then I also used a laser, but I agree with you, you don’t know exactly the depth that you’re penetrating the soft tissue. But when I switched to the thermal cut bur, this bur without any diamonds and they come in. The one I recommend to buy if anyone’s gonna buy it is you have an assorted set of like five different sizes, six different sizes. That’s the best one because you got a tiny one for really tight spaces and the fat one for really fatspaces for really meaty papillas and just put that on high rev no water. And I just love just all the papilla comes away so precisely and very minimal bleeding. Painless. And obviously as part of this, you’re doing anesthesia anyway for your Class II restoration. And I’m giving a little bit in the papilla buccally going all the way and it’s just a great way to do it. So it’s a thermal cut bur that really made a huge difference. And yeah, you’re right. you’re completely right, like if you’re gonna be using Electrocautery and if you already have this expensive system or laser and stuff then to actually tell your nurse ‘oh can you please get it, wait for it set up.’ When you can just stick this bur in. It’s so so good. And what do you say to patients like we’re having this papillectomy for afterwards and after care? That’s the most common question I get as well. [Maciek]Yeah, that’s a very good question to be honest definitely, in the past I was telling to my patient before that probably we’re going to have to cut the gum. Right now, when I’m doing it with a bur I even don’t mention it before because sometimes we’ll make patients more stressful and we know that it’s nothing really big. So very often they will not even have been after the visit but it’s very important to say it after the visit. So I always said that they should take some painkiller that they can feel some pain afterwards. However, in 90% of cases they feel just nothing. So on the next visit, when I asked do you have any pain after the previous visit, they said no it wasn’t painful at all. So but there should be always the information also what was pretty important for me and this. Let’s treat it as a like a hint. And I always had a problem with making my price is a little bit higher. So if we are using the Gingivectomy at the beginning I was telling to my patient that will have to make some extra surgery because of the filling and they will have to pay extra for this. So for me it was much easier to rise my prices because I just added the price for the gingivectomy. So that is the best possible business because you know how is it can be and how quick it can be. But this is also one of the options how if you don’t know how you can increase your prices. This is also one of the solution to just divide the whole restoration to the restoration and the gingivectomy. Right now, I don’t have this this problem. But in the past it was a problem for me. So it was really useful trick. Let’s call it. [Jaz]And that’s important to discuss because when we’re less experience where a bit more trying to charge and we have that whole dilemma about charging. So you’re right, you can say to the patient to add value to treatment saying, you know what? This is a tricky one. The hole is under your gum. I need to perform a very small surgery. Don’t worry. Mrs smith. It won’t hurt very much. You will be numb, you won’t feel anything and then you’re right. Afterwards, I find that patients hardly feel a thing. Now some things that I do as a precaution and there’s zero evidence of this, Maciek, in terms of what I say. But I do follow like as if someone’s had a crown lengthening surgery, the similar advice that you might give like, don’t do too much aggressive flossing there. let it heal. do some warm water, salt rinse. And then one more thing I say actually, which is like a funny thing, right? Is that just before I do it because I’m using no water, using it dry. I will say to the patient, it will smell like a barbecue, don’t worry. And we just laugh about it, right? It’s a little thing to say as well just before you do it and stuff. So yeah, absolutely ise a thermal cut bur. Use to remove soft tissue where it’s appropriate. And you will find so many benefits of doing that and you can get the thermal cut bur pretty much worldwide. I believe it’s made from dentsply. There might be some fake ones out there as well, whatever. it’s just steal, right? It’s just diamond, no diamond on it. It’s very simple thing. So, Maciek, I’m gonna end this group function now. But can I just ask you can you just give us one more because you mentor people and you teach on this all the time, what is a common dilemma that you find dentists are doing as well as the ones I told you already like the lack of soft tissue removal, the wedge getting in the way, and moving removing your contact. One more issue that you think that we could have a little trick. A little gem you can give us to help improve our contact areas or contact points. [Maciek]I think that one of the most important part also that I didn’t know for many many years is to prepare our visit to make the restoration. So in the past I thought that we need some preparation always when we are doing this digital smile design and so on. We have to plan everything. But to be honest it’s also very important to check how much space do we have for our filling. Because very often when we deal with the very old fillings sometimes the one tooth overlap the another one. And then it’s very important if you see on the dental checkup that you’ll have to make the restoration on the next visit. And there is a really small amount of space or there is a very flat filling that is almost connected to the neighbor tooth. It’s sometimes it’s much better to place the ortho ligature in between the teeth just to create more space because when we talk about- [Jaz]Like an ortho separator, right? [Maciek]An the separator or the there is something like wedged, to make the rubber and more stable. So this is just a piece of the rubber. So like with the Gingivectomy, we’ve got the some surgery here. We’ve got even some orthodontic connected with the restoration. Because the most difficult, at least for me is the situation when we’ve got a very small amount of space in between because then any matrix will be good. So then we’ll have to use like the stripe and it will just make our contact point very, very bad. So it’s much easier if you’ve got more space than if we’ve got just a little bit. So it’s much easier when we create additional space, we put just the wedged for two weeks and then we’ve got extra one millimeter. That makes everything much much easier during the visit. [Jaz]That’s amazing. And to make it even more tangible- [Maciek]and it looks so cool on the photo. [Jaz]That’s another reason to if you’re not gonna do it already, but to make it tangible to listeners like something, I do quite a lot of his whole crown. So these like stainless steel crowns for children without any preparation. and sometimes not always, but sometimes we need to plan ahead and create some space because you’re not doing any prep, you want this metal crown to seat? It’s like preformed metal crown. Right. And that’s when commonly we’ll be using these ortho separators or ligatures. So just like you said, we’ve all seen that restoration of that premolar commonly it’s a premolar. It’s almost like impacted into next pre molar and you don’t have any room. It can be difficult to floss. It can be difficult to give you a very nice contour. So your gem there is brilliant. Use an orthodontic ligature or a separator and put it in a few weeks before your appointment opens up that space and now it will give you better control, a better curvature on your contact and therefore more chance of getting a contact area than a contact point with less deformation of your matrix. So amazing. Maciek, thank you so much. Please tell us which is the website. We need to go on to check out your new course contact point ambassador. And do you have any closing enrollment or any dates we need to know. So I know when to get this podcast down as well. [Maciek]So I think we’ll link the address to the website under this talk. But yeah, there is this special promotion that will last only this month. So till the end of the June this is the 50% off from the original price of the course. So I believe that it’s a very good moment to watch all the course. [Jaz]Amazing. That’s fantastic. And like I said, I’ve done it and there are so many gems in there and I’m not gonna give away too many secrets. But one thing I know is where do I buy and Elliot separated from? [Maciek]There are many distributors right now, I bought a couple of them. So right now, I like to check different brands, different instruments. So right now I’ve got one like the Chinese version, one from the Japan. So there are many, many places that where you can buy in important, when you type the Elliot separator, you will definitely find one. where to buy it. [Jaz]Amazing. Cause I haven’t looked, I just was wondering basically because I don’t know many UK dentist who have one. But I think it’s time because I’m not gonna give away the secret because you have to do the course. I mean there’s such a beautiful way to use these in a really clever way. I mean, I’m not gonna get away with the Teflon floss as well. Like you will never have an open contact ever again. And it’s just, that’s our bread and butter and for the cost of one, I mean privately for the cost of one restoration. You’re putting on the whole masterclass on contact points. That’s amazing value. So, okay. That’s putting it very tight for me. So now as we’re recording, this is June 24th by the time this episode comes on will be Monday. Okay, so that will okay, you’ll have around about four or five days to get this discount. But honestly, even if the price rises, it doesn’t matter. It’s a fantastic course. You should do it. But definitely check it out. I’ll link the website in the outro if I can or if not it will definitely in the website as well. So it’s protrusive.co.uk/contact points I’m gonna make it contact points. There we are. Thank you so much, Maciek for your time. I really appreciate you coming on again and giving so much value. [Maciek]Thank you, Jaz. Jaz’s Outro: Well there we have it guys, that was Maciek Czerwiński on this group function. All about how to improve your contact areas and contact points and have to overcome these common challenges. So take away points were make sure you modify or select an appropriate wedge, something like a Teflon floss, which he covers really well. Now, as promised, if you’re watching the video version on the website or on YouTube, I’ve got a link to how to do the top Teflon floss so you can do it in full and it’s really, you know, a little bit [50] at first. But once you do it and you see that beautiful contact, maintained its awesome the importance of soft tissue removal. So again, I will link you to the thermal cut burs they are brilliant. Every practitioner should have a pack, a multi assorted pack of thermal cut burs and of course the ortho ligature tip was absolutely fantastic. Now, if you wanna take advantage of this discount, that Maciek is offering 50% off before the end of June, please go to protrusive.co.uk/contactpoint or one word. That’s contact point. And I’ll take you to exactly where you need to go to take advantage of this offer to do his amazing class twos and contact point. Course, I’ll catch you in the next episode. Protruserati. Thanks so much for listening all the way to the end.

A fun little comparison episode discussing the differences between Dentistry in the States and in the UK – in this episode I am joined by the host of Dentistry Rising podcast, Dr Bette Robin! https://youtu.be/N_u8LkD8EnY Need to Read it? Check out the Full Episode Transcript below! Dr. Bette Robin, who desired to make a massive change in her life and left clinical Dentistry some years ago and went in to Law and practice sales – she never looked back!  Join us in this light hearted discussion where we chat about: Cultural differences in USA vs UK Dentistry – dental school, earnings, biggest barriers, treatment plans How the national health systems compare Finding different paths out of Dentistry How to become a better communicator  SplintCourse update: Enrolment ends on Monday 21st June! Enroll now by clicking here to join a community of Dentists around the world who want to End Splint Confusion!  If you enjoyed this episode, then do check out Dr. Bette Robin on her Dental Rising Podcast You might also enjoy The American Dental Dream – PDP002 with Dr. Kristina Gauchan! Click below for full episode transcript:  Opening Snippet: Is another cultural difference I mean dental cultural difference is that we have this perception in American dentist that you guys are, no offense. You guys are really aggressive like treatment plans is that you guys are like you know you got like two hand pieces of his big fat burs and rages crowns everything. Jaz’s Introduction: Hello, Protruserati. I am Jaz Gulati and welcome to this interference cast all about the differences between UK and US dentistry. It’s quite a light hearted interference cast view today with someone very special. Her name is Dr. Bette Robin, and she’s the host of Dentistry Rising podcast. And it’s from podcasting. And her being a dentist actually doesn’t practice dentistry anymore, which is actually interesting. So we’ll discuss that in a moment. But her also being a podcaster in the dental niche, we sort of connected on this software podcasting platform. We joined this weekly mastermind all about communities and online courses. And we’re both part of that. And what are the odds that two dentists, who podcast who re also interested in running successful online courses were eeting together. So that’s what he story of how I got to meet Dr. Bette Robin. And then I got o listen to her podcast and t’s really great. I really like er voice actually. So we had a ery light hearted discussion bout the differences, the ultural differences in USA ersus UK as a dentist, what are he earnings like? What are the iggest barriers like? One hocking thing for me was the evel of debt that US graduates an land themselves in. But also he understandably was quite hocked to learn about how the ational Health System works ere in the UK. So it makes a ery interesting sort of fly on he wall sort of listening istenership you guys, let’s oll to the main interview, and I’d catch you in the outro. Main Interview: [Bette]Well, I’m here on the Dentistry Rising Podcast today with Jaz Gulati, who’s a dentist in England. And Jaz and I met on an online study club on how to do online classes. And I was just absolutely thrilled that in the small little study group that another dentist joined. So what part of England are you from Jaz? [Jaz]Hey, Bette, thanks so much for being on. I’m enjoying doing this sort of joint thing with you. And like you said, you mentioned, what are the odds of two dentists in this very small, little micro niche, finding each other. So that’s been fun in the last, I guess, three or four months connecting with you on that I’m based in London and Reading. So it’s a place called Reading, but I guess most of your listeners will obviously know, London in England. And that’s where I practice as an associate. I also have my own podcast, the Protrusive Dental Podcast, obviously this is going on both of our podcasts. So both listeners will hear a little bit of an interesting story between us and also how things are in the US and how things on the UK in terms of dentistry, because I think there’s very contrasting working patterns, I think. [Bette]Well, thank you so much for doing this. Because yeah, I think it’s gonna be really interesting. I don’t know a whole lot about how dentists practice in England. So I’m really excited to hear what you have to say. So can we start with, I think, in England, that you go right from high school and to dental school, basically, where you do your basic sciences, where we do them in college and you go right in dentistry. So how do you become a dentist in England? [Jaz]You know, what do you need to think about where to start? And I think you’re so right, let’s start there. Because there is already a big difference there. Because, as far as I know, in US, it’s like dentistry is a post graduate degree, right? Like you already saying, or you have like, they’ve done one thing already. So here is like, you’re 18. And then you’re pretty much in dental school. And then at 23, you qualify, which for you guys probably sounds like that is way too young. Right? [Bette]Well, not really, if you’re focusing on, you know, because like my Dental School was three and a half years. So you’ve got five whole years to get your basic sciences and which I did in college. Before I did go to the graduate school, which is dental school. [Jaz]Okay, that makes sense. I see. I didn’t know that. [Bette]Still a little young for us. Let’s see. So you graduate from college? 22 here in general, and then 25-26 out of dental school. [Jaz]Yeah. So we’re about four on average, three to four years younger when we qualify. So I guess that’s the first big difference [Bette]And what does qualify mean? [Jaz]Qualify means you get your bachelor in dental surgery or BDS, you guys call it DDS or DMD, that kind of stuff. Right? So that right essentially, I mean, [Bette]Interesting. And then from there you go, mostly intent dependent practice, or mostly into groups or what your career path from there. [Bette]Most people or 99% of the dentist will do a training so it’s called like, Dental Foundation year. So it’s like a year which bridges the gap from being a student into being an independent practitioner, and it’s pretty much publicly funded. So we have the NHS a which is a National Health System, and we can go into that but I don’t want to go too into that because quite a controversial area. Of course, I also want to learn about you guys and the insurance system because we have some perceptions of the insurance system being maybe quite similar to what we have with the National Health System. So basically, we have the National Health System here. And we do this one training year treating patients under this sort of public health dentistry. And just to give you the most shocking example of one of the issues with dentistry in the UK and the National Health System is like. The NHS is great for like the other week I dislocated my shoulder right half an hour I turned out the hostile accent emergencies we call we call it a&e you guys call it er, fixed up my shoulder I was never presented a bill there was no insurance to contact like there’s we don’t pay for health care, right so it’s just taxes pay for that. So everyone can get free access to health care. So that’s that’s the medical side. But on the NHS dental side, you pay a little bit but a complete fraction compared to private dental care. But here’s the downside Betty, right? If you if I’m a patient, okay, if you’re a patient, Betty, and you come to me, and I’m performing NHS dentistry, and if you need one restoration, or you need 10 restorations, you pay the same fee, and the dentist gets the same fee. So sometimes that and that fee is pretty much let’s say 40 I’m making us dollars 42 US dollars. Okay, so whether you I do one restoration, or I do three root canals, five restorations, I get 42 US dollars. So sometimes my hourly rate is is like I might as well just work in McDonald’s. [Bette]Yeah, it sounds like you have no incentive to diagnose then [Jaz]that’s the thing. So the way we’re going out so used to be fee per item, right? And to make money, dentists would be on the other side of that. So be like over diagnosing maybe right, the trends. And now everyone’s like, Well, I think you know, it will remineralize and it’s okay. So but but the perception I have Betty of insurance based system you have is kind of similar. Like apparently, insurances are a very particular and they peanuts. Is that is that the way it is? [Bette]Well, not not really, I think you’re kind of comparing it to like an HMO plan, a health maintenance organization plan, where it’s kind of the same thing. There’s no incentive to diagnose but the dentist gets a certain amount per month per head, plan, whether or not the patient comes in. So it’s really not necessarily in the dentist’s best interest to have a patient come in and utilize their resources. So that would be comparable, I think, to an HMO, what you’re describing, but not comparable to preferred provider organizations, PPO and private practice where you definitely get paid for what you do, [Jaz]what percentage of practices are fully private? [Bette]Well, I’m not an insurance expert, but I would guess and fully private I’m going to call PPO and cash because the fully private just cash probably less than 5%. I mean, very small, but PPO, I guess, 60 to 70%, are ppl. So they are getting paid for what they do. And then we have, as you say, the other incentive was to diagnose too much. And to do too much work, as compared to the HMO which has, you know, a disincentive for doing too much work like what you’re describing. So but that’s not that’s not the norm is, you know, HMO is not the norm, even though it’s certainly growing [Jaz]without it without a doubt. Well, in the UK, believe it or not, a lot of practices are fully private, because it’s either your NHS, and then you do some private on the side. And the way you decide what you offer, the patient is, if it’s something they need, you give it on the National Health System, if it’s something they want, then you can do privately. But here’s where the lines get little bit blurred, right? Is whereby, like crowns, right? Like you say to the patient, oh, I can only do a metal crown. And they’re like, oh, but I want a white one. Or you want a white one. Oh, in which case you have to pay privately. So we call this mixed practice. So this is not how we are taught to be dentists. Right? We don’t this is the conversations we don’t want to have as dentists. So this is the biggest downfall as a nation we have, and because the prices are so low, like you know, I’m talking like I said, rock bottom low for National Health System dentistry. This is acts as an anchor for the private sector, and brings everything down. So you know, it’s difficult to justify true high fees, because everyone’s you know, the Joe public thinks, oh, but I can get five fillings for, you know, 80 bucks, and you’re saying one link privately is, you know, $700 or whatever. So it’s just a massive contrast. [Bette]And we get into that a little bit with dental collar dental care, as it’s called in other states where it’s, it’s funded based on income. So if you have a low income, you would qualify for dental or medical or, and we get into that kind of thing. What do you want with Danica, you get a silver crown, if you want to pay 500 700, whatever extra you can have a white crown. So we get into that as well with denti Cal as well as with HMOs. So what would you What do you think the average crown fee is in England? What do you what would you say? Okay, that’s [Jaz]a great question. And I would say so, if you’re doing a crown for a patient who’s getting National Health Service dentistry, so Just practice the patient would pay around about an hour I’ll commit to the US dollars the patient would pay around about 400 US dollars now really no extra extra get good, good. So extremely low. [Bette]Whereas more in the terms of our medical or dental [Jaz]Yeah, but but that’s like you know, you know, you could be earning very well in the UK and you can see NHS dentist and they will charge you $4. But what makes it worse Betty is remember, like, that includes everything that includes the crown that includes the core that includes a root canal, believe it or not, okay. And if they need three more restorations, technically, if you can do it like properly and play ball, you have to do it under that fee that $400 covers everything, which is the problem now I’m private dentist. So my crown fee is 950 pounds, which is around about 1600 1700 maybe less 1500 US dollars. That’s is that more comparable to? [Bette]For sure. Yes, I think most dentists here are probably a definitely over 1000. And that really, really good ones would be even over 2000 or 20 503,000. I mean, but I think most people in the 15 $100 range is Yeah, really comparable. So this NHS is that required is that like an internship, you have to do this one year out of school, [Jaz]you kind of do like you could go private, but who’s gonna hire you, right? Like, you know, who’s gonna take a risk on, you know, a brand new grad. So that’s why I said the 1% it might happen, but 9% you do it, but you know what, that’s the good thing is that this is like your training ground, right? You know, you actually get so much experience because like, he Now navigate to my appointment times because the average checkup time for NHS dentists or dentist forums or NHS contract will be like 10 minutes, or 15 minutes. Whereas I’m privately in our new patient, I would see 14 minutes to an hour, I just can’t operate like a hamster wheel like you’re constantly just in and out in and out patients. But all we can talk about this big difference now, I guess is where whereas we are seeing one patient at a time, right? So one patient gets, you know, 15 minutes in a diary. So we see four patients an hour, let’s say for checkups. And maybe that’s how the average NHSN says sometimes it seemed like kids 5555 minutes and just, you know, just burning through the mall. So in a day dentist might see like 6070 patients, which I think is crazy. And that’s why I couldn’t do it. I left the National Health Service. I’m fully private. So but we you guys from from my understanding, as most of you guys are just hopping from surgery surgery kind of doing the same thing. I mean, explain that to me. [Bette]No, not really, I think the high you know, the higher end dentist do see one patient at a time, the higher fee, the one you know, operate just the way you’re operating. I wouldn’t say that’s the norm I do I have people do jump from operatory to operatory. But usually only two operatories where they’re getting somebody numb and then they’re going back and maybe finishing a prop, that kind of thing. And then coming in and watch, you know working with the next patient. But at the lower levels, the HMO in the den a cow that kind of level. Absolutely. And like you say burning through the kids, where you have a whole line of them. And since we can delegate so much of it to you know, accelerate, so yeah, burning through the kids and even the adults at the very lower end, same thing, the better. You see, it [Jaz]seems so strange to me, the thought of the patients just sat there, you know, with the prep done, and they’re waiting for the next agent. I guess they’re all used to it. I’m guessing you’re used to this way of practice because, you know, how do you feel that awkward sort of silence awkward pause awkward gap, I just can’t understand it? [Bette]Well, I think at the lowest level, they expect it, they’re paying nothing and they know that’s what they’re going to get. And they’re going to sit there and be on their phone or that kind of thing. But at the higher level where you are jumping a little bit most doctors leave and assistant in the room with the person to chit chat the whole time or do impressions or you know, kind of waste time and a lot of ways. But you know a lot of people a lot of patients come self entertained with their phones now. And there’s the TV and all kinds of other entertainment options. But I would say the norm is to work with to ops. On most practices a dentist is working in two operatories all the time sometimes three. [Jaz]Okay. Well, most of us is 90 I’m saying we’re just working in one operatory and that’s it. One One question I have thought of his average income levels because here in the UK, we think like we all want to go to the US and practice because we feel like you guys earn a huge much bigger earning power. And I sometimes think the reason why our BDS our dental qualification is not valid in the US is because the US like dental boards kind of know that if you open the doors to UK dentists will all go there in a heartbeat. So that’s my sort of rationale. [Bette]Interesting. So how much do you guys make a year on average, okay, on average now [Jaz]this is according to Yeah, accountant figures. So I’ve actually looked at the National dental accountants figures and the latest figures suggest 68,000 pounds a year, okay. Now obviously these averages are based on a means and not medians and It probably involves lots of part time dentist, maybe mother of two who works two or three days a week. So the figures are a little bit skewed. But let’s go with it. So it’s 68,000 pounds. I think that’s around about, you know, 100,000 US dollars, I’d say. But that’s obviously gross before tax. And what’s that comparable to other jobs? Pretty good. Like the average income in the UK is 27,000 pounds. So 27,000 pounds, the average full time income, and then the dentist will get 68. So tell me, what’s it like in the USA, [Bette]I’m not really involved in organized dentistry to say so much. So I don’t know if I can give you exact figures. But I think it’s about 140 to 150,000 average for a general dentist specialist, probably double that on most specialties that are, you know, over 300,000. And certainly a lot of private dentists doing 300 400 Plus, you know, that really have it dialed in and, you know, high fees and art sitting with the patient and selling treatment and that kind of thing. So your lower, you know, but I don’t know how that’s comparable to cost of living. I mean, obviously, there’s a lot of other factors in there. But it sounds like we’re quite a bit higher. [Jaz]Yes. Which is why I think you guys have closed the door to us, you see, because we don’t want to leave this sort of contractual system that we have with public funds, dentry, and Republic all want to go to America. Now. I know some people who have left the UK for the US and done the additional, you know, three or four years or whatever, and, you know, spend a significant amount of investment to retrain and practice there. And they’ve all been pretty happy from it. You know, they’re happy happily practicing us now. And it’s a big jump to make, you know, five years in dental school UK, then you go to us and do it all over again. It’s a big, it’s a big step. Yeah. It’s [Bette]a huge jump. I don’t know if it’s worth that. But who knows? Maybe it is. But yeah, sounds like we’re making more money per se. What’s the ratio of women to men? [Jaz]Okay, so traditionally, it was very much a male oriented. So when I look at the photos from my dental school, like, you know, 6070s kind of thing. Male, but nowadays, let’s talk about today. It’s about 60 62%. intake females, and then about, you know, 38 40% male. [Bette]Oh, wow, we have very similar we have probably 5050 going into Donald school right now. But I think nationwide, it’s probably 20% or even less female still, you know, when you when you factor in all the 67 year old dentist and all that, you know, it’s still overwhelmingly male, which is gonna change. And here in a few years. Yeah. So very interesting. Well, I’d like to talk a little bit about I don’t you know, you and how you and I met I mean, we know how we met, but and then your course because you’ve just been so impressive in the group. [Jaz]Well, you know, you’ve done the the beach testing for me as well. And I was glad for that. But yeah, the course idea and the reason I joined the community that we’re part of now is sort of like podcasting, and then wanting to share knowledge. So I’ve been podcasting like yourself, I mean, how many years we’ve been podcasting at [Bette]about two, two and a half. But I’m been slacking lately for sure. No question. [Jaz]Well, yeah, same, same. Same here two years. [Bette]Yeah, I’ve had a little bit of issue with direction, I want to go. But what I, where I’m going now is to follow people’s journey, who just bought or sold a practice, I was focusing, we talked about this a little bit before, I think we turn on the recorder is like I was focused a little bit more on money, which I still think is really, really important to hop it. But I was getting hit up and having speaker having people record that we’re just what should I say? charlatans, you know, just trying to have data, most of whom were financial planners, and just do anything to talk to groups of professional, and I didn’t, I ended up not liking that direction. So I went back into, you know, what I do for a living, which is sell practices and try to follow people’s journeys and help other people that way? What were the pitfalls and that kind of thing. So yeah, I veered a little more into money, because that is a passion of mine. But I’ve kind of gone back to the practice self kind [Jaz]of thing, good for you. And well done for sort of, you know, taking that step and moving away from what you weren’t enjoying, and going into more of, you know, what you like and what you produce and what your listeners will value more, I guess [Bette]I just didn’t feel good about having talking to people and putting them on my podcast that I was not comfortable with them philosophically at all. And some of the podcasts that came across when I would question them on, you know, oh, yeah, borrow money off your from your house and put it in your retirement plan. So you make more money, you know, the financial planner, I was, I was just not on the same page with a lot of people. And that did come across. So that’s not the direction I want to go, to use my platform to do that kind of thing. But you on the other hand, did an online class for dentist. So tell me a little bit about that journey, how you got interested in, you know, the splint topic and what you did? [Jaz]Sure. So I mean, like I said, two years ago, I started the podcast almost by accident because So what I was doing at that point was, I’d moved back from Singapore, which I where I was practicing and really loving life. Singapore is a beautiful place. Have you ever been better now, just like Asia, like just the most beautiful weather all around great food, great culture. And we had a great time we my wife, but my wife got homesick. So we came back to England. And now word got out. Because morale in the UK dentistry scene is not very high. Okay, it’s low. So word got out there. Hey, there’s this dentist who went to Singapore. And he came back, and maybe we should start moving on to Singapore. So like, every day on my commute home, I was on the phone to a brand new dentists now they will ask me questions. Oh, what’s it like in Singapore? How much do you earn? Do I need to do any additional degrees? Are there any exams, the whole notion, the whole spiel, and everyday I was speaking to a new dentist. So eventually I was okay. Let me record an episode on a pod. Let me start on the podcast. And then the first episode was about you know, being a dentist in Singapore. And my experience is just so that I could free up more time for I want to help everyone. But I wanted to free up my time, because I was doing one to one I just couldn’t handle it. Right. So I didn’t want too many. And that was my first foray into podcasting. And then I started to come out my shell, because I’m quite a geeky dentist, I do. really shy, you’re so shy. Exactly. So that allow me to pray to practice my excess energy and, and place my excess energy somewhere. The podcast became my channel for my energy. And I started to bring on like, for selfish reasons, I start to bring on guests who I want to learn for. And at the same time, I was learning but then people were learning as grown and grown and grown, like, you know, recently about 150,000 listeners plus, and something that you know, 120 countries in the world, and it’s just amazing. But one thing I found around the middle of podcasting was, I was just doing some solo episodes about one topic I’m very passionate about, which is occlusal, appliances, and splints. And that absolutely blew up like there was one episode called Michigan splints are overrated. And people really, really took an interest in that. And then I just started to share like people, dentists, were now calling me up and asked me for advice about which occlusal clients to make for their patient. And this is something that I’ve been attending courses like for so long, to learn from different people and to develop and fine tune my own occlusal philosophy. And then I thought, Okay, that’s it, I have to share this content, I have to share this knowledge. So put together like 11 plus our modular learning. And by the way, along the years, I’ve done like, you know, a certificate in dental education because I love sharing what I know, and trying to become the best educator I can be. So that was the birth of that and part of learning about how to become a better online educator. That’s how I met you, because it was part of that community that we that we joined. And that’s how I guess it it led to this moment. Now we’ll be discussing all these interesting things and to podcasters have connected. [Bette]Yeah, very cool. So what what made you interested in splints? Where did it Where did that come from? [Jaz]confusion, like, I find like I’m such a geeky dentist that if something confuses me, like the two things that confused me the most at dental school was orthodontics. Like what the hell’s going on? Right? Like, what how is this working? This is voodoo magic. And then the other one was, I mean, occlusion, always right. Like most Auntie’s come out, thinking, you know what the hell occlusion is very complex field. There’s too many schools of thoughts. So fast forward now eight years and the two things which I ended up doing extra qualifications and extra learning on is lots of occlusion courses like I mean, a lot flying all over the world. And orthodontics I’ve got a deployment orthodontic, so I probably my personality couldn’t stand being confused. So I ended up just pursuing more and more than that, and and so that really piqued my interest, learning from different educators, Michael milkers, Barry Glassman, I did the Dawson Academy. My principal is panky trained. So all these different schools of thoughts and just trying to figure out why and how, and what are these different schools of thought, so that’s what I really got into and I also, I have a massive bruxism myself. So helping my own self and making my muscles relaxed, also, sort of sparked me on to help other patients and then dentists. [Bette]So what’s your philosophy was splints? Where did you I watch party your class? Obviously, I can’t, I could, but I’m not so interested in watching all those hours of dental anymore, but I watched I mean, the class was fabulous. You were dynamic. It was fabulous. But what what would you say your philosophy is? Is it more like Dawson? Is it more like spear or is it more like [Jaz]That’s it? That’s a great question, Betsy. I think my philosophy is an amalgamation of all those. But but very much it is diagnosis LED, and this I mean, there’s a whole app, there’s another episode of my podcast, which is like the which is the best splint and the whole episode I was leading my listeners on I was like, yeah, there’s something called the G splint, the Pilates plan, right. And this is like the best plan ever. And I was just like, building it up, building up building up, but really, the moral the story was, Every patient’s g splint is different, right? Because it’s like depends on how bad orthodontics before. Are they having pain or are they just is it just protection? What’s the goal? So the philosophy is very much getting a good History, getting a good diagnosis and also looking at the patient’s like features, what are they likely to comply with? What are they likely not comply with? Because Betty one, one thing we can’t rely on when it comes to occlusal appliances and splints is the evidence base, like the literature is absolutely poor and unreliable. So therefore, we have to use the other two arms of evidence based dentistry which is the patient’s values and condition experience. So I’ve been taught by such, you know, great people in occlusion, and I’ve adapted it and sort of taken a leaf from panky taken big leaf from Dawson, the whole beast splint stuff, learn a lot from the nti. Guys, Barry Glassman, and I’ve made my own school where which is very much lead by diagnosis, but that no one’s right or no one’s wrong. But what what does this come say? What can we learn from that? What does this come say? And sometimes it’s arts and crafts, right? No, every patient is different. Every patient is unique. And you have to find that magic potion that will work with your patient. [Bette]I think that’s a really good philosophy, because there are so many different camps. And I agree with you when I was practicing. I did not I did panky and spear and kois. And I was just confused. I mean, totally, completely confused, like, what’s the right way to go? And I never put it together, I just quit. So [Jaz]why did you always go? I never got to ask you want Why? What made you make that big life decision and leave Coco dentistry? [Bette]Oh, that’s a long story. And it’s multifaceted. I mean, I think that one of the main reasons is, well, let’s see. First of all, I got divorced, and I have two little kids. And I thought, I don’t like anything about my life. So I’m going to redo everything. And also, I think I wasn’t truly a dentist, where you are, you’re excited about it all that I love talking to people. I love diagnosing I love doing the treatment plan and selling a treatment plan that’s like, Oh, my God, I have to do the work now. So I I didn’t like being chained down, where I can say, okay, February 2022. This is what I’m doing on who and then the Rancho Cucamonga belta courthouse right behind my office. And I started getting a lot of attorneys and judges had lots of attorneys and judges as patients. And I just thought they had a lot more fun in [Jaz]life than I did. Wow, the grass is always greener on the other side is [Bette]always greener on the other side. But I just really feel like I wasn’t a dentist at heart. And I think I was a mediocre dentist. And I was doing all these great classes. But I thought I don’t think I can really perform. And you know, do it at the level that is needed. I wonder how many hundreds of dentists based on this last two minutes of this episode will now reconsider their careers. Probably none. But they shed I was in I don’t know if you’ve heard of, I’ll shoot what’s new. It’s called readers group. And that went on for many, many years. 40 years in Newport Beach, Newport and ultimate I’m kind of steady club. And they probably had it had several 100 members and I was a member. And you know, everyone knew I was doing this. I had 50 people pull me aside and say I wish I could do what you’re doing. And then I had probably another 50 say you’re making the biggest mistake of your life. And one person I said if I have to flip hamburgers at McDonald’s, I’m going to be happier than what I’m doing now. So I’m doing it regard and I didn’t have a lot of things tying me down like, you know, a spouse and debt and this kind of thing. So you know, it was the risk was all mine. And how do you feel now? And [Jaz]how’d you feel? Man? Like are you glad so glad I get it? Yeah, good for you. [Bette]I just wasn’t you know, I went into dentistry I was on the cattle train with all my friends going into medicine, dentistry, etc. But I really never made the choice that that’s like what I wanted to. And now that I sell practices, I would say 80% of the dentists are kind of mentally in my camp. Whereas 20% are like you they’re like love dentistry. Every little bit of it. But a lot of people do not. I mean, it’s it’s not unusual, even when even if they’re good dentists, they don’t like it. [Jaz]I agree and I think that 8020 I agree with it disfigure I agree with I think 20% are overly passionate. And then 80% I was just like, you know what, it pays the bills, it’s okay, I can tolerate it. And then some of those 80% are like, you know what, I’m living my life is fake. Like, I’m hating this. And you you made that decision that you know what this is not for me. And and kudos to you for for doing that. That takes that takes a lot of guts. So So while then look what Look, look what you made of it. You know, I love what you’re doing and what you’ve done and help so many people in a different way. [Bette]Yeah, I mean, totally different path, but I loved it. I made the decision early on after I graduated from law school to stay in dentistry, because all my friends were dentists to everything I knew and my whole world was, you know, was related to dentistry. So I made the decision to stay in that space. So, yeah, it’s been absolutely great and I’m very happy. I don’t think I’d be happy. If If I’d stayed a dentist so, but I think you’re doing the right thing. When if you’re not happy in dentistry, I think you need to look around for things that could make you happy by doing different procedures and staying engaged and interested and figure out what parts you do like and focusing your practice on that. Because I think, you know, there, there’s a whole bunch of middle ground between doing what you’re doing and me quitting. And most people are in that middle ground. [Jaz]You’re so right. And I think that one of one advice I can give to anyone listening now and then never heard you say that how you how grateful you are that you made that decision to leave dentistry. And here I am on the opposite end of the spectrum, saying, Oh, my God, I love dentistry, I guess, if you’re in a if you’re stuck, if you’re unsure, then I think totally do what you’re used to. Yes, there’s that dentistry is such a flexible field, like you can literally limit your practice to a couple of procedures, you can find your niche. Well, a lot of other professions, you can’t do that. So it’s about finding your niche in a way. And sometimes it means that you have to get out of your comfort zone to experience a new course or a new philosophy. And there are many, you know, as much as people hate it, there are lots of different schools of thoughts. And sometimes you see, to hear another school of thought it’s like a religion almost. So it’s like a call, you have to almost join the call, and then they might rekindle your passion for dentistry. And that’s the reason why I love the podcast I do because obviously, your podcast NC rising is has a different angle. Mine is very much trying to attract all these dental geeks. And so I love getting messages from all over the world saying, you know, I actually lost my love for dentistry. And now from listening to your energy, I’ve regained my love for dentistry. And that’s the biggest praise about had my life. So I think that’s what it’s all about for me. [Bette]Yeah, that’s, that’s really, really a gift. That if you can find that. And one thing, just to talk about my money passion a little bit, one thing that holds dentists back from being able to do that is having too much debt, you know, and not continuing to have the freedom to do what they want to do is this debt from dental school, like I would say, not dental school. I mean, dental school is useful debt in most cases. But when they go out, and they have to have the new Mercedes, the new, you know, the new BMW, the multimillion dollar house, and you know, we’re payment by payment. And then you have a hiccup and, you know, you’re in trouble and you can’t make other decisions. You can’t say, Okay, I think I’m gonna just chuck it all and move to Michigan, or wherever, you know, I think you really limit your life choices when you get in so much debt. And here where I live in Orange County. I mean, it’s very prevalent where you have to keep up with the Joneses, by having the new whatever Tesla, the new whatever. And that’s a huge mistake dentists make, I think, and it really limits their life. [Jaz]Yeah, I mean, maybe it’s because I’m an associate, and I haven’t taken on huge debt, because I haven’t even looked at buying a practice. So maybe I’m not speaking for the rest of our profession. But in the UK, it’s not something we discuss a lot about, you know, debt. And I feel so us grads, they do talk a lot about that. And that is like, quite a significant thing there. So that’s another difference between UK and US that you guys are always or, you know, I had lots of dentist friends in Singapore, who trained from the US and they moved to Singapore. And then they were talking about Yeah, huge debt and stuff. And it’s, it’s not something that you have here. And I think maybe it’s because one of the good things, I guess is that you wouldn’t believe how much I paid for my dental degree. Right? My tuition fee at the time, at the time. I mean, now it’s a bit more but at the time was 3000 pounds, let’s call it 5000 US dollars per year. And that’s the that’s the tuition. [Bette]So yes, I pay for my like rent and stuff separately, but that’s nothing compared to what you guys pay. Oh, it’s it’s very common for people to come out with four to $500,000 worth of debt. Very common. So that’s why I thought you [Jaz]guys, you know, predominantly the debt was that but I guess, I guess you guys are just accumulating that debt more. Yeah. [Bette]I mean, I think, yeah, you come out with a half a million dollars worth of debt. And then lenders will give you more money. And because you’re a doctor and you pile on top of that you’re your Tesla payment, your Mercedes payment, your boat payment, your this your that. And I think that dentists feel they have so much debt that it doesn’t matter. I’ve told this story before, but it’s still made one of the biggest impressions that, you know, on a money scale that I’ve ever had, I was speaking for the CDA at some California Dental Association with some new graduate kind of thing. And right in front of me, this girl sitting have this beautiful Louis Vuitton purse, and I just looked at that purse at the mall, you know, like a few days ago, and it was like 11 $12,000, and I thought I would never pay that much for a purse. But I’m thinking in my head while I’m talking. I wonder if it’s a fake? You know, I have all this internal dialogue going about her purse, and which is ridiculous. And I’m talking, you know, on and on. And then she gets in line to talk to me afterwards. And I had asked her, I said, Is that a real Louis Vuitton? She goes, Oh, yes. I like how much student loans do you have? She goes 500,000. I’m like, What are you thinking? And she got she said keywords to me. It’s like Monopoly money. She goes, I can never pay it off. It’s not even real. I don’t know. I buy what I want. That’s it. I mean, that’s a very, very common feeling or response that you Dennis tab because they don’t, they don’t understand what it takes to pay off half a million dollars of loans. I mean, they kind of get it, but it’s like a forever jail sentence, and they’re just not going to live that way. [Jaz]I can’t even imagine that level of debt. And that’s it. That’s one that another major difference between UK and US is that Yeah, maybe that’s why you guys borrow more money because you already have such a huge level of this. What’s another extra couple 100,000 here and there, right? [Bette]They just don’t feel it. They just don’t understand it. They don’t feel it. And they think, you know, I’m gonna be in the grave before I can pay it off. So I might as well enjoy life. [Jaz]Do you do know if most dentists actually do eventually pay it off? [Bette]Some people do. I mean, some people really focus on getting a paid off, but that’s a minority. And then you’re really trapped. I mean, you are trapped in that practice, and you better produce whatever it takes. Because then you take on a wife and kids and they all have expectations, too. So yeah, we get ourselves in a lot of many situations with dentist and dentistry here, which it sounds like you don’t have. That’s a good thing. [Jaz]No, we don’t. And you reminded me of something actually very interesting is another cultural difference. I mean, dental cultural difference is that we have this perception in American dentist that you guys are no offense, you guys are really aggressive, like three implants that you guys are like, you know, you got like 200 pieces of this big fat birds and rages crowns everything. Yeah, something that we think needs efficiency. And you guys like right, this crown it, you know, and I actually experienced this firsthand, like, you know, n equals one, like, there’s one dentist who qualified us who will work the same price to meet in Singapore. And we’re always doing all these come concerts and stuff being minimal. Every patient got a crown with her. So I know that this perception that we have that you guys are very aggressive treat implants. [Bette]I think that can be true. With a lot of people that can be true. And of course, then it comes down to an individual’s own ethics and morals and beliefs and that kind of thing. For myself. When I first got out of dental school, I had a job, it was really hard to find a job. So I finally got a job. And probably my first couple weeks or so they made me do to a pickle retro. Phil’s on six and 11. And I did it. I mean to this day, I’m embarrassed and ashamed. Except I did it. I have no idea how to do it. I’ve never done it. Yeah, I knew in theory, what should be done. And I swear to God, that person lost six and 11 because of me, you know, but it’s not. I mean, people, I people do stuff like that I did it. And so I didn’t lose my job. And so I wasn’t embarrassed that I couldn’t do it. But I’m way more embarrassed that I did do it. I’m just horrified that I did it. But it’s not you know, it’s just not uncommon. For whatever reason, you got to make the payment, you can’t lose the job, whatever people are compromising. So I think it does come down to your individual ethics, who you are as a person, how you diagnose [Jaz]Well said. So that’s one thing I haven’t told you about is that in one of my in every episode that I do, I have a protrusive Dental pal, it’s like one tip I give like, you know, clinical dentistry or communication or whatever. And one of them I just stole from your podcast. Okay, so I need to now credit you because you You did such a good job of reminding me of this, this is a great little poll, I’m gonna let you say cuz you’ll do a much better job. It’s basically the one about the power of a silence after you present a fee can just just give my listeners again a flavor, the only Betty can have them. [Bette]Well, I do think being quiet. And you know, after your present a fee being quiet is hugely important. I think it’s really important to present the fee in a confident and clear manner and not too confusing. And then be quiet and let a patient respond. It’s kind of the old philosophy of he who speaks first loses. But when you know that you’re doing whatever it is that you’re doing six anterior veneers, the fee will be $12,000. That’s it, be quiet, keep eye contact, and they’re either going to say something that lets you go the next direction. Sure, could you do it next week and time for my daughter’s wedding. Or you know, that’s nothing I can afford. But I’ll save for it. Maybe we can do it in a couple of years. Whatever it is, I think the doctor is always best positioned to handle that objection or the next comment compared to an office person. I don’t like doctors to delegate, you know, treatment presentations, at least of any magnitude to an office person because they can’t, you know, they’ll start talking about payments, they’ll start talking and payments may not be the issue. So I think the less you say when you’re presenting the treatment, the better. You don’t want to confuse people. You just want to be really clear, then be quiet and listen to what they say and go from there. So I don’t even remember what I said on that podcast. [Jaz]But no, you covered it well, but but it’s an important lesson. I shared it with my listeners as a poll and a redo thing that a lot of young dentists it can be a challenge right or any dentist it can be a challenge like when you’re not used to presenting fees and you’re doing more complex. Working to maintain eye contact and say confidently for the first few times, and then you have that silent and that and those three seconds seem like three minutes. And then what’s the most common thing? We’d say like, Well, why don’t you think about it? Well, once you go home, and that’s the worst thing you could say, like, get out of here. I’m uncomfortable. Yes, exactly. So I sort of highlight that, [Bette]I did use a lot of consultants in my dental practice, you know, and like you say, I took little bits from each of them. And even when I present listing agreements, now I do that, like, this is how much it is, this is what I’ll do won’t do whatever, you know, they do it, they don’t do it. You know, the same thing with with presenting treatment, I think you need to be eye level with the patient need a knee, I think you need to be looking at them not have not have the chart not have a lot of extraneous hand movements, just say whatever it is, you have the veneers cost. You don’t have to talk about everything else in the world, you can talk about that later. Like after they’ve accepted we’re going to need to take models we’re going to need to data die. But to present the treatment, confidence clarity and keep it short and be quiet. [Jaz]Perfect. And I love it. I just want to highlight again in case you missed it the first time on my show. One important tip that was any other tips. So you have and I’ll put you on the spot here. But any other like one more tip you can give maybe to to the dentist listening from the producer podcast side to help become better communicators when it comes to money or tree implant presentation. Any other tips that you picked up in your when you’re getting these consult consultations? [Bette]Let’s see what can I say is another tip I would. There’s a lot of dentists whose practice I go into and have no idea about their overhead. And you know, of course, that’s a lot more important when you own your practice. Or it’s very important when you own your practice compared to being an associate. But I think you need to stay plugged into your practice as to what the front desk is doing, what your numbers are, how much you’re diagnosing how much sometimes people say well, I you know, there’s no crowns on my schedule. Well, that’s because you didn’t diagnose anything. One of the consultants I had first I had, right, I had like a two and a four year old, I had arrived late, you know, I’m paying this consultant through the nose. And here I come in 20 minutes late. And she just kind of totally slowed me down. She said, Do you know that the energy that you bring into the practice today has a huge effect on how you’re going to diagnose how the patients are going to feel about you? Everything, so you need to calm it down, get their hair half an hour early and have your head in the game. If you only want to work four hours, that’s fine, but you for four hours, you have your head in the game. And I think that’s a huge mistake dentists make as they come in, very scrambled, not ready to work and not ready to be totally present in their practice. While they’re there. I’d like people to cut hours and be totally present and probably do double the production, [Jaz]well said about presence. And to add on to that, like forget about any arguments you have with your spouse. Forget about you know what you had for dinner last night, forget about all the unread emails, you have to forget about absolutely everything and give your patient every single ounce of your energy. [Bette]Yeah, and and then you will diagnose what you want to do patients will like you and come back and do the rest of their treatment because they feel that you’re totally present. I mean, that’s what we all want from our relationships we have, you know, with healthcare providers, with friends with everybody, like be totally present, be with me. And then when you’re not with me Do what you want [Jaz]100%. And that’s when you get to be yourself and show your true self and practice with your values at display, and then you obviously in time will attract the patients who have the same value as you so it goes full circle basically, [Bette]right? I think it does, too. It really does. And the people that do the huge numbers. That’s what they’re doing. They have their life together, or organize it in a way that they can be calm, they can be clear. They’re confident and focused. And it comes out into all aspects of their life. [Jaz]How many days is average dentist clinically work in the US? For four? Okay, thank you for hanging out there. Yeah, I mean, maybe four, maybe even four and a half five? It really varies. I think they’re a practice owner, you can have to maybe work three. It varies. But there’s a whole saying that if you drop back to three and a half days clinical, I think maybe panky sort of said this, but if you drop back to three and a half days clinical, you find that your income really doesn’t drop that much, but your productivity, your energy levels remain high. So the reason why just put that in there is because we can burn out if you do too many cocoa hours and to be able to show up in the way that we described the last few minutes. You have to almost do less and go in less than work less hours so you can have the energy to be the best entity you can be. [Bette]Yeah, I’m totally a fan of that three days, I think. I mean dentistry is hard work in every way not only physically but mentally, emotionally. Three, three and a half days I think is really powerful. effect, and you know, do a lot of see and interact with your colleagues and you know, and enjoy a long career not trying to burn out in five days, I mean, five days will burn you out really quick. [Jaz]Obviously, if you’re the new grad, then there’s the whole beauty because, you know, to to balance out with accumulating your 10,000 hours, right, getting those failures in. So there’s something to be said about actually going quite quite hard initially, but not at the sake of your mental health. So there’s got there’s a fine balance we struck initially, but as you gain more experience, definitely, you know, make time for the finer things in life and, and then drop back your clinical hours so you can have more energy and vitality. I agree. Amazing or better. It’s been great to have you on for the producer it listen to and I hope this has been valuable for your guests as well. [Bette]I’m sure it will be and I think everybody will be really interested in hearing it and hearing what dentistry is like in England and checking out your course. [Jaz]Thank you so much. [Bette]Thank you. Jaz’s Outro: So thank you so much for listening all the way to the end guys. That was Dr. Betty Robin from the density rising podcast, please do check it out. If you’d like Betty’s dial, she is very much like a her episodes are non clinical. So I think there’s something beautiful about that as well. And you have to respect her her journey and her sort of desire to make massive change in life and leave dentistry. So that has to be respected. And I think it’s great what she’s achieved as an attorney, and also now looking at practice acquisitions. So I’ll catch you in the next episode, same time, same place.

How to do Deep Margin Elevation? What are the most important factors in achieving high bond strengths for our restorations? I sometimes look at modern onlay preps and think, ‘God MUST exist’, because I think it’s a miracle how these flat, table-top onlays stay on! I am joined by a world-famous educator in Biomimetic and Adhesive Dentistry: Dr David Gerdolle David Gerdolle, based in Switzerland, introduced me to contemporary ceramic onlays 8 years ago. It took me 3 years to convince myself the techniques would work in my hands! In this episode I want to fast-forward your progress so you can gain more perspective on adhesive restorations and DME (Deep Margin Elevation). https://youtu.be/cOkEAaawgdI Super pragmatic and scientific bonding principles! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: How can you show patients what shorter anterior teeth might look like to them discing them down? Use a black Sharpie marker, colour in the part of the edge (maybe 0.5-1mm) that you’re considering removing. Take photograph and show it to them! It helps if their mouth is open for the photo so we see the dark backdrop of the oral cavity. With the knowledge of Dr. David Gerdolle and biomimetic dentistry, we discussed how it is possible to bond a material to the tooth structure in those ‘table-top’ style, flat onlays.  It doesn’t happen magically. It’s about the nitty gritty detail, the micro steps and respecting certain criterias. “If you don’t remember anything of your bonding protocol, just remember that, it has to be clean and rough” – Dr. David Gerdolle Clean and Rough, that’s it right there! In this episode, we also talked about: Failures in using biomimetic dentistry and what we can learn from that How these restorations have resistance form Bonding protocol step-by-step for adhesive dentistry Deep Margin Elevation – how to do it As promised, DM me on Instagram @protrusivedental for the PDF copy of the steps of deep margin elevation.  If you enjoyed this episode, then do check out Dr. David Gerdolle for more courses. You might also enjoy Ceramic Onlays from Preps, Temporisation and Bonding Protocols by Nik Sethi! Click below for full episode transcript: Opening Snippet: We have to compensate with the thickness of the inlay so that when we see fancy inlays, 0.3, 0.5 thickness of ceramic on Instagram, it can work if it's bonded on enamel. So if it's Niroshan case, bonded on enamel, which is very stiff, it's okay we don't need two millimeters that most of the time, which is that on dentine. Jaz’s Introduction: I know I’ve covered the theme of onlays before, it’s not new for us. But do you remember the first time you saw one of those onlays, the lithium disilicate onlays, which are like bonded on essentially what looks like a quite a flat tooth. And the first time I saw it, I was like, no way, this is not going to stick. I don’t believe it, I don’t buy it. I’m going to stick to my conventional crown preparations. But you know what, seeing these more and more now is great. And in my hands, they do work. And it needs a proper discipline and protocol, which we’re going to discuss today with someone who’s absolutely awesome. It’s David Gerdolle. And it was David Gerdolle around about eight years ago, I attended one of his Dentinal Tubules lectures live in London. And I just couldn’t believe it. That’s the first time I thought, whoa, this is crazy. This is insane. How could this ceramic stick to the tooth, it just didn’t make sense to me, right? But what I learned from that day has stuck with me for such a long time forever as part of my clinical protocols. And that is the following A) you just need a clean substrate and B) you need to have enamel. If you’ve got enamel circumferentially, these onlays can be extremely successful. And to take that a few steps further. I’ve got David on today to share some steps, just generally in just composite bonding and Emax bonding and the whole principles of adhesive bonding in general. And you leave with some real gems that you can improve your bonding protocols on Monday morning. We also discuss something that’s very topical and that’s deep margin elevation. So for those of you that don’t know, we’re going to cover it in the episode. But deep margin elevation, essentially, is when you have a tooth and you want to give it an ADHESIVE onlay therefore you want enamel everywhere. But maybe in one area, maybe at the depth of the mesial area it’s quite deep, and it’s quite subgingival. The problem with it being subgingival is that when you come to fit the onlay, it’s going to be difficult to isolate that rubber dam. So the way that we can turn something that’s subgingival into supragingival is by adding some composite in that very, very deep area mesially, which as you know has many challenges. But this whole concept of deep margin elevation, i.e., you are lifting that deep margin and you’re making it supragingival. David Gerdolle will do a much better job, I promise you of explaining it than I just did. But before we join David in this absolute brilliant episode. I hope you like the title. I Can’t Believe This Sticks – EXTREME BONDING EXPOSED because honestly, the first time I saw this, I just was absolutely. Honestly, the first time I saw this, I was absolutely amazed. And sometimes I still have it the first time I saw this, I was so amazing. Even nowadays on placing these onlays. I see them year after year after year. And I sometimes think to myself, is this really possible? How is this working? Right? But of course, it’s the science of bonding, which David Gerdolle covers beautifully. Protrusive Dental Pearl:Before we join David, I’m gonna give you my Protrusive Dental Pearl for today. It was inspired by a recent patient encounter I had whereby she felt as though that her lateral incisors were too short, and she requested for them to be lengthened. But in her so onload function, I knew that this will just lead to chipping, there was just a real lack of space, and it wouldn’t be favorable. So therefore, we delve deeper into the problem. And it wasn’t that the laterals were too small, it was up ahead her centrals which were bonded with edge bonding were too long. So before I took a soflex disc to the centrals to make them shorter, how can we show patients what shorter teeth might look like before we actually start hacking them down? Well, this trick I learned many years ago as to use a black sharpie marker for once, yes, I’m not using on splints I’m using on teeth. So you just color in the part of the edge, maybe half a millimeter to a millimeter that you’re going to be removing. And then you take a photograph, and you show the patient the mirror and against the dark backdrop of the oral cavity. It almost gives a patient and understanding an idea of what they might look like with shorter incisors. So in this case, we used a black sharpie marker to show this patient, okay, you know what, I think I want to remove half a millimeter of composite here. And then this might just improve the harmony between your laterals and your centrals and that’s what we did and she was happy. So I didn’t have to bond her laterals, which was going to be unpredictable without having orthodontics or increasing the vertical dimension. So this is a cool little trick when you want to communicate your patients what shorter teeth might look like. Protruserati, I’m not gonna keep you any longer. Let’s join David Gerdolle on I can’t believe this sticks: Extreme bonding exposed. Main Episode:David Gerdolle, it is fantastic and absolute honor to have you on this podcast. How are you my friend? [David]I’m very good. And thank you for having me. I have to thank you really. [Jaz]No, not at all. I think you’re going to give so much value to those listening. With a little bit of background about how I got to learn about you several years ago, maybe was eight, nine years ago, maybe it was your first encounter with Dentinal Tubules you came and you absolutely blew my mind with a presentation showing these onlays which I could not believe. I just couldn’t believe at the time that was sticking. So that’s why I named this episode, “I can’t believe this sticks”. Because even recently, I had a guest recently, Nik Sethi you might know him. He talked about the full protocol of ceramic onlays and we had a good discussion about that. And then he convinced me even though you told me many years ago, he finally also encouraged me. So to Jason Smith and all these great clinicians convinced me to start using heated composite instead of Panavia. So I did this recently, I posted a case on Instagram. And still people were asking questions like I can’t believe this sticks. There is not enough resistance, retention form on these. So even today, 2021 compared to eight years ago, people still have this objection. And so that’s what we’re going to talk about today. How can this stick, how’s it work, we’ll talk a little about the science of the bonding, and just what we can learn from you. But before I babble on too much, I want to do an introduction for you. So you have been so influential in my sort of career in terms of appreciating how powerful bonding could be, and you really opened my eyes many years ago. But tell us about yourself about the bio emulation group and about your definition of biomimetic dentistry? [David]Well, actually, the funny thing is that my first dental education with very traditional work, I was belonging to a Prostho department. So I’ve indicated drilling for crowns and bridges and a very conventional dentistry. And I am still thinking that could be for some cases, a very good dentistry and very good indication. So I don’t think that we have any war between biomedical and with conventional dentistry, it all can work together, depending on the patient and conditions. But the fact is that something like, 15, 17 years ago, I had for research, purpose to get more interest with the composite and stuff, and did some courses, especially with Didier Dietschi, in Switzerland in Geneva. And it was really like a revelation that we can just do something else. At the same time, we’ve got patient that are getting older and older. And we know that our treatment will not last forever. So if it makes the patient will die maybe in 100 years old, we still have to find solution when the patient will come back and do the 80 years old with a crown that has failed. So this is why I think biomimetic dentistry is just the best way to buy some time for the patient, meaning this is not a better dentistry. This is a very nice dentistry. But this is less invasive. So we just have all the cards to play for the future, maybe crowns, maybe implants. The problem is that if we jump right away for implants to a 40 years old patient, it’s a disaster, because still will live for 50 years. And we’ve got nothing left to propose to that patient. So I think this was the philosophy I was really seduced by. And then I met some guys, especially from the bio emulation group. And those guy are very, very interesting. First, they are brilliant, are amazing dentists. Well in England, Jason Smith, for instance, that is a very, very brilliant guy, very pragmatic guy, also very funny guy, so full of knowledge, and that this is the first quality of that group. This is just a good dentist. And at the same time, they are dreamers because they always trying to improve the thing and to find the best way to do the things but on the other hand, most of them are just private dentist, very normal dentist, so they have to earn money they have to live in the real life with their real patients. If you put all this together, this is very nice combination, of friendship, stimulation, with a nice experience and a nice proposal that we can do to our patients. Let’s drill a little bit less your tooth. Let’s try it and you know what, if it’s not working, we can still do something else, which actually you cannot do with the crown. Once the tooth is drilled off, it’s done, it’s nothing else. If the biomimetic solution fails, no problem, we can still move to something else. And the thing is that it doesn’t fail that much. So even better. [Jaz]You definitely infected me with that way of thinking all those years ago. And recently, I had the honor and privilege of reviewing one of your videos that you submitted to the series you submitted to Dentinal Tubules. And it was an absolute pleasure to see all your steps and you talked about veneers and how the detail you’re going into in bonding these veneers and rubberdam. And how much that can improve your results in certain ways and how you have to get around the common challenges of doing that. So that was mind blowing as well. So what I wanted to do was take some lessons from that and share it with the Protruserati, so the people who listen to this podcast are called the Protruserati. And I definitely wanted them to know about you if they don’t already they need to learn about because I think I’ve told you before we started recording, guys, if you haven’t heard David Gerdolle and stuff. He’s such a wonderful educator. His style of educating really appeals to me. And when I’m educating, I tried to model myself like David. So I just want to put that in there that I love it. I keep doing what you’re doing, because you’re really helping people understand this stuff. So I guess the first we can dive right in if that’s okay, David is the first question is, how can it stick? How does it work? Okay, but I don’t want to just answer about the science, I want you to teach me in a different way. Can you tell me about some failures that maybe you had early on, in using biomimetic dentistry, and then what we can learn from that, because if some dentists, young dentists are starting to use, maybe they’re trained more traditional way. And now they start to use and the first venture into extreme bonding or biomimetic dentistry, and what common mistakes they might make, and maybe some things mistakes that you have made in the past? [David]Well, I think the most common mistake is when you belong to wanting one type of education like your I don’t know, you are designing an inlay with some kind of geometrical retention form. And then you would like to drill a little bit less to why not bonding my inlays, I was just cementing my gold in these. Now I want to do composite inlays, ceramic inlays. And I would like to bond them and maybe I don’t need that kind of geometry. And the problem could be to abandon and to quit brutally, all the principle that we’ve learned from the past, meaning occlusion still exists, biomechanic of the tooth still exists. So it’s like, we cannot just trust the bonding system. And the composite in the composite is like something magical. And it will resolve all the problems. So I could just, I don’t know, don’t drill anything. It’s something like flat, no geometry, no retention, maybe no space, because I don’t want to drill so I have a very thin thickness of ceramic material. And then by magic, the bonding will just save my life. It doesn’t happen. So it means that we just have to do everything that we were doing before with all the precaution, with all the knowledge, with all the study of the patient, and especially the functional behavior of that patient. But then it’s true that respecting kind of certain criterias like, do I have 1.5 millimeters of thickness for my material? Can I work in a very clean conditions? Because we know that those hydrophobic product, they don’t behave good if we have moisture, ambient moisture or direct contamination? If the answer is yes, simple questions in criteria like those, I can just maybe switch to something that is bonded. And it can save one [course], maybe one millimeter  preparation, maybe one kind of drilling that is more invasive, that it’s not like, okay, I will change my mind now and do something completely differently. Because it’s still a patient, it’s still the same function. There are still teeth, and it’s the same, so I think this is the most common mistake and say it this is bonding, this is magic. It’s nothing magic and bonding. [Jaz]So as to follow this still not to forget the fact that the material still needs a desired thickness to respect the occlusion as you say. And just because we can bond so well. You don’t just purposely make your preps flat, you still build some resistance form into it. So what advice can you give to someone who’s starting out with onlays posteriorly, maybe out of ceramic, maybe lithium disilicate, leucite, whatever. How can you impart some natural resistance form without drilling too much and then making it look like a traditional prep? Any sort of tangible advice you can give on that? [David]I would say two simple things. Make sure that you have at least 1.5 millimeter, because most of the thickness, because most of the restoration, the posterior level, we have existing cavities, we have amalgams we have stuff like that. So it means that 90% of the cavity is represented by dentine. Dentine is something soft, it’s kind of trampoline, meaning that for this kind of lack of stiffness, of the support, of the dentine, of the dental tissue, we have to compensate with the thickness of the inlay so that when we see fancy inlays, 0.3, 0.5 thickness of ceramic on Instagram, it can work if it’s bonded on enamel. So if it’s Niroshan case, bonded on enamel, which is very stiff, it’s okay we don’t need two millimeters that most of the time, which is that on dentin. Dentin is soft, so meaning 1.5 at least, you can easily achieve that using like the penetration control technique or something like that, using specific burs or a bur, you know exactly the working part is two millimeters. So I put my bur entirely in the cavity so that I can make sure that I have those 1.5 to two millimeters. This is the first thing I would say make sure that you have definitely some thickness for the common cases for the daily cases. And the second thing to make sure each will definitely bond, I don’t think there is a proper geometry or way of let’s say a chamfer is better than a bevel or we don’t really know the people, they do really different things, it looks like everything is working. But at the end, it’s the way we will bond them. So it means if those substrates composite, ceramic, dentine, or clean and rough, you can put whatever you want any kind of composite, it will be good. So it means that the material has to be thick. And if it’s bonded properly, it will be resistant and it will not fade because one of the most common way to see that the bonding was not good is a fracture of the material. Because actually, doesn’t the bond is almost never the bond. So the kind of failure is a “Oh Doc, I just lost my inlay.” No, it doesn’t happen. [Jaz]Cohesively, do you mean like a material cohesive failure? [David]Exactly. This is a material failure that we have like a fissure fracture of the material. The translation of that isn’t or I didn’t do the right choice with the material is my inlay would maybe too thin for the kind of substrate I had in the cavity dentin, or it was badly bonded, bad bonding, bad resistance of the material. So this is like the demonstration that my bonding was not good and then the material did fracture. A proof, a very easy proof of that we’ve used for years feldspathic ceramic, can you imagine feldspathic ceramic? So brittle. It’s a fragile, you’re looking at feldspathic ceramic is breaking already. So it’s no resistance at all. But if you bond it, it’s unbreakable. So it’s not really about the resistance of the material. Of course, it helps. Disilicate is much more resistant, so it will forgive many mistakes very good. But we don’t really need the more and more and more resistance we need to have a minimum of a thickness and to make sure that we are bonding okay, in a very efficient way. [Jaz]And that’s it. Protruserati, it’s Jaz Gulati interfering with this very important message. Splint course is open for enrollment again. This is the course that I released earlier this year, we’ve had phenomenal feedback. I’ve been just absolutely blown away by the feedback from all over the world. This is my course to teach you how to prescribe, diagnose and deliver splints that will help your patients with headaches, myofacial pain. For patients to stop breaking your restorations, and for patients to help them to get their muscles relaxed prior to complex restorative work. So if TMD confuses you, if during the whole muscle examination and deciding which splint to use, when and how, then this course covers it all. From the theory to clinical videos, but don’t just hear it from me, don’t just take my word for it. Here are some of my students for the next couple of minutes just talking about their experiences with the online course. And then we’ll join David Gerdolle again who’s just already blowing our mind with bonding. [Protruserati telling about the SplintCourse]I absolutely loved it because it’s modular. And it’s broken down into little segments that are not too long, really easily digestible. So you can stop and start whenever you like, and you don’t feel trapped into learning all in one go. And I don’t think people learn very well that way anyway. So some people who do like doing that, can sit there and just be stared over a couple of days. But you allow me as a new dad and busy guy working and stuff, just to do it gradually over the course of sort of five weeks. So yeah, it’s really good being modular, and Jaz explains it very, very well. [Jaz]So if you want to start implementing splints and occlusal appliances into your practice to help your patients with pain and help them to stop breaking your restorations, and come and join us on Splint course, and I’ll see you in our secret Facebook group where we can support you and go for monthly live coaching. Brilliant, all that leads very nicely just a side question, sidetrack you is, which do you believe in more? Do you like to? Is it case dependent? Or do you always like to once you remove your amalgam? Once you do your cusp reduction? Do you like to build up a core and then prep back? So you have an even thickness of the material everywhere? Like some can they believe this? Or do you not mind that in one area your lithium disilicate will be three millimeters and another area might be 1.5 millimeters by not building up core, which do you do and why? [David]This is an excellent question and a crucial question because much more than the intrinsic resistance of the material or its thickness, if the uniform thickness that is that will create the resistance of the material mostly, we have many papers on that. So it means that by definition, in a cavity, you don’t have a uniform thickness because for some part you have five millimeters on the other part you’ve got one millimeter. So it means that sometimes we have to drill if the cavity is only one millimeter deep, well, this is not enough. So we might drill a little bit and compensate on the other side with a core building with some composite doing the immediate dentin sealing, just to try to make it a little bit more uniform. So we don’t have to trim, it’s impossible to do like something that is two to three millimeters super uniform, it doesn’t mean that we have to put three millimeters of composite at the margin because it will ruin completely the emergence profile, and we will discuss that point a little bit later. So it’s not a good idea either, what we just have to do is to try sealing the dentine to compensate a little bit though thickness to reduce the huge difference of thickness and to also raise completely angles. Because this is what will make the material fragile, difference of thickness not uniform, and also variation of angulation. Think about a vinyl with the occlusal part and the buccal part. If you got something quite thick at the occlusal part and super thin on the buccal part with a very nice 90 degrees angle between those two parts, it will break just in between. It just like automatic, so brutal change of angulation and brutal change of thickness is not good for the material. If we can compensate this a little bit with the form the morphology of the prep and with refilling the cavity with some composite doing the immediate dentine sealing. Perfect. [Jaz]Amazing. That’s a very comprehensive and direct answer. I love that, micro step. So dentistry is all about the nitty gritty detail the micro steps. So if you wanted to give the dentist a message in the most important of micro steps that that will get you the best bond. So like the Pareto principle, right, like 20% of your efforts give you 80% of the results. So what do you think is the 20% of the bonding, that will give you all the steps in bonding that will give you the 80% results even if you mess up the other steps? [David]Very simple. If you don’t remember anything of your bonding protocol, just remember that it has to be clean and rough, clean and rough, any substrate, anything you are facing could be ceramic, metal, composite, dentine, enamel, whatever you want any kind of substrate, if it’s clean, meaning no organic chemical species on the surface and rough meaning micro rugosities, this is just perfect. So there are many ways in different ways depending on the material that we have, to this clean and rough that it’s clean and rough, you just put composites in between those two substrates it will bond. So usually we are sandblasting depending on the material can be a different kind of sandblasting. But sandblasting and etching, acid etching, we have different kinds of acids, depending on the material to different kind of acid period. It could be 20 seconds, one minute, one minute and a half. That basically it’s always the same. So I think this is the 20% that represent the 80% of result for sure. It’s also very good news, because it means because always the question of the dentist is that “Oh maybe I don’t have the good composite, maybe I have to buy a new one, a new box with something new or I don’t know any company came in my office yesterday with a brand new one and showing great numbers of adhesion.” Well, one of my mentors always said, you know what, you just have to calm down a little bit because even the worst adhesive system is enough. It’s okay. And nobody will die. So I think I can work with the products I like because I like the viscosity, because I like the color, the opacity or I like it. It will be okay if it’s clean and rough. If it’s not clean and rough, you can just purchase the best of the best material of the market. The success is not guaranteed. [Jaz]Guys, can you see why I like David’s education style so much. He’s so direct and I just love the way he says things is amazing. I love that answer. Fantastic. So clean and rough, guys. Keep it clean and rough. The next question I want to ask you because we’re doing really well here is something that no matter you know, I had Jason Smith on the podcast we talked a little about DME, deep margin elevation. We started the podcast, yet still the number one question I get from the Protruserati is always surrounding elements of deep marginal elevation. So for those who don’t know I will let you explain because you do a much better job than I will. But what is deep margin elevation so if you don’t mind just describing to the dentist in the way that only David Gerdolle can. How would you describe to the dentist what is this deep margin elevation? [David]Well, deep margin elevation is a very simple idea, you have a deep decay. A decay that it extending beyond the gum level. So we are subgingival, we noticed that it’s very difficult to clean it, to get an access, to do the impression, to do the provisional or to eliminate the access. So, we have two solution, conventional solution, I will do a crown lengthening I will get something, get some gain, get some bone just get an access and facilitate my life. So, this is a very good technique, the only problem is that most for the if we are talking about posterior teeth, for instance, the deep caries are proximal. If I get proximal, some gum and some bone, I will lose the papilla forever. So whatever the emergence profile I will have, the patient will have food stick stuck in this area, and it will never be at it was before. So, we in that sense, we thought “Oh, this is not me inventing the deep margin elevation, the Swiss guys like Didier Dietschi, Pascal Magne, they thought like 25 years ago, let’s do something else. So, if the problem is the deepness of that margin, so cervical, so close to the bone level, could we maybe raise up the margin with some material, this is the margin elevation to change the level something that is like equigingival level, something like that. And with some kind of material, when the day we are prepping the tooth, can we do that and then it will facilitate the impression, the provisional, the fitting, the elimination of the excess when we will cement the inlay next week. [Jaz]So the isolation so much easier as well. [David]Exactly. The first isolation is really a pain in the ass. And the second one is easy peasy. So this was the idea. And they started to do that. So I remember very well, when I came in Switzerland, it was 2005. I didn’t know anything about margin elevation, didn’t even know the name of that. And doing one course with Didier Dietschi, he was telling me, he was teaching about it. And I say “wow, you know it’s something strange for me this double margin, what is that?” Is it you know what the problem is not the double margin. Because the double- the problem is, do you trust bonding on dentin on a proximal area? Yes or no? If you don’t trust, do the crown, do a gold inlay cemented with phosphate. If you trust, can you tell me the difference between a composite luting cement here, two millimeters subgingival and a direct composite here, two millimeters, subgingival. This is composite bonding in the proximal box. So, if you believe that this is possible, why shouldn’t you do margin elevation? And I say, oh, yeah, this is true. And then I started to practice this technique. The problem is that when Didier is doing that, this is very easy, it looks like it’s okay, but he’s a genius, but not everybody is the Didier Dietschi. So in my hands, it turned out to be a different kind of outcomes. And so this is the magic either, but this is how it works. This is what is margin elevation. The idea is to avoid surgery, change the level of the margin, adding by adding some material. [Jaz]Brilliant, you explain that fantastically. Now, in my own experiences of DME, deep margin elevation. I do believe in dentine bonding. So I’m happy to do DME and it makes my isolation so much easier, as well as all the benefits you said. So I believe in it. However, my one concern and my one element of case selection, when I emailed you is that if some, I know we shouldn’t be doing anything indirect and someone who has poor oral hygiene. So I don’t mean poor oral hygiene, but someone who’s just never 100% at getting the plaque at the gingival margin. They’re doing okay, they don’t have periodontal disease, they’re almost resistant to perio. But they’re just not fantastic. Over the years of getting their gingival inflammation low enough. And this is the real world. We all have patients like this. In that patient, I am less likely to case select for DME and go onlay. And I’ll probably just do the traditional method. Nowadays, I might do something that’s trendy or verti prep or something like that. I don’t wanna get into that too much but what do you think is my case, am I right to be case selecting these group of patients who are not amazing at the gingival inflammation and their general to oral hygiene, or should I be a bit more brave and do it on those patients as well? [David]I would say Yes and No, it’s a very smart approach. And I did this mistake myself not being that smart. When I switched to margin elevation and to bond industry, I did it because this is kind of my character, it’s I am a black and white guy. So it’s like, okay, I quit with the crowns. And I will do 100% of adhesive dentistry for everybody. Because everybody is deserving and this was obviously completely stupid. And for some patients with poor oral hygiene, or maybe they have a very good hygiene at 60 years old, what is happening at 80 years old, not anymore. So the patient can change, the bacteria can change, the tissue can change, the elf can change, the patient resist, and one day he doesn’t resist. So it means that we had numbers of failures about that not really, with the technique itself. But with the indication, bad indication for bad patients. So I think you’re right. There are two levels of question. The first one is, what about the patient? What is this patient looking like? If it’s, let’s say a good candidate for bonding dentistry, because I know that is coming regularly to the recall with the hygienist with the depth recall program and is really performant with the oral it is motivated. So why not doing adhesive dentistry? If, this is the second point, I am just able in that case, as a dentist today, Monday morning to do a proper adhesive technique. And this is an I have to answer. Yes, this is a good patient. And yes, I am a good dentist today for that patient for that tooth. So this is not like a general answer. Some kind of patient they don’t deserve. I don’t know above 70 years old, no margin elevation. No, you can have very good elderly patient no problem and very bad young patient. And it’s not like it’s for you the super good dentist or the super bad dentist because the same dentist the same day can be a Monday a very good one. And on Tuesday, the worst dentist on the planet. So it’s like I am able to do properly my work. This is a good indication a good tooth for that and the patient is able to just clean it properly. If it’s a yes, yes, it’s okay. I go for it. If it’s a no, yes, yes. No, I don’t go for it. And I move for some conventional technique. As you mentioned, vertical preparation crowns. Perfect. That simple. [Jaz]Brilliant and I think I’m hoping that question and the answer you gave will start getting dentist to think a little bit more about case selection and not just always just seeing, deep caries, dentine and always automatically going towards deep marginalization. Just take a step back, look at the patient as a whole, just like all the things you said. So that was a very great answer. I appreciate that. The next thing I want to talk about is the now that just defined to wrap up the episode, the nitty gritty details of how to successfully carry out deep margin elevation because anything subgingival is more difficult. We know that and a of dentists mess up saying you know what, I tried it, it was a disaster, it was a mess. I‘m never gonna do it again. So one thing that I have found David, and we haven’t rehearsed so we haven’t talked about this so I like to use a thermal cut bur, which is diamond, I like to just get rid of the papilla. So I’ll do papillactomy, that will allow me to get my rubber dam down and then able to get a more predictable seal with my matrix band. Is there a way I could do it without having to destroy the papilla? Are there any different ways that you can a tip that you can give us for a dentist who are doing deep margin elevation? And if you don’t mind this one last one more on that, and I’m happy to repeat these questions is, which is the best composite in term of viscosity to use in these scenarios? Is one of those, like g-aenial flow good enough in that region? Or is it to flowable? [David]So first of all about the protocol, people coming into some details or tricks. I just would like to mention maybe what are the goals? We should reach at the end for a good margin elevation because I told you, if today I’m able to do that I’m the good dentist. What is a good dentist in that case? Well, I think that the good dentist is the dentist able to isolate properly. So it’s something that can be really hard because it’s really down the gum level. So isolating good, meaning I do my isolation and during the procedure I can see that it’s not sealed. I will not do margin elevation using your composite or stuff like that because I know this will be a filler by definition, then I am able to place the matrix yes or no. This is also very difficult to get the matrix down to the margin and seal at that level. This is also a problem because we cannot use for most of the situation. No, it’s-wedges. Sorry. So the thing is that for most of those cases, we are not able to use wedges, because which is more or less, they go always are horizontal, maybe a little bit curved like that, but it’s horizontal, and the decay is never horizontal is always concave. So most of the time, I need something to push my matrix in to see my matrix towards the teeth. How can I do that, and this is why I don’t personally cut the papilla because the papilla can save my life, the papilla can push on the other side of the matrix. Of course, the papilla is complicating my life when I want to push my matrix in. But then once the matrix is in the papilla can help, the papilla is my wedge. And I can reinforce maybe the papilla effects with some Teflon tape packed on the external part of the matrix. So isolating, putting the matrix making it seal and then matrix with the good emergence profile. This is also very difficult because naturally, the matrix has a tendency to go vertical, and the emergence profile at the surgical aspect is always a bit divergent. So I am able to achieve that. And finally, when I will refill that space, that box, that property, that proximal box with some composite, am I able yes or no, to refill it like one shot, it means afterwards, I would not have to finish with strips and burs. And I don’t know what because the problem is, once we start to finish, I’m thinking about polishing and final polishing just finishing, I got an excess, I have to go to get these access with the strip, we will roughen the surface. If we roughen the surface of the material that bacteria adore, it’s a problem. Because it makes it creates automatically bacterial retention. So it means that the good dentist is able to isolate, put the matrix, seal the matrix and diversion profile, a good emergence profile, and just like more or less the one shot refill of the cavity. If it’s the case, it’s completely okay. And you can use whatever you want. I think that the best material is the best composite that we have the best composite meaning in terms of properties is the restorative composite. Restorative composite, viscous composite is always better than flowable composites. Flowable composites are more convenient to use, restorative composite a little bit more tricky to use. So this is why we can maybe heat them up a little bit to make them less viscous and facilitated the handling. But or maybe mixed both of them a tiny bit tiny to flow so that we don’t have too much polymerization shrinkage and then go with the restorative composite. But I think that if you want to refill two, three millimeters in a box in the proximal box, doing everything with a single increment of flowable is a bad idea. Because unfortunately, flowable is not the best composite ever. [Jaz]So how about HRI composite? It’s very stiff. I had one dentist always prefer– t message me saying that she sed HRI and she really struggled. And she asked me, “Jazz, do you think I should have used a slightly softer composite?” And I said I don’t know. But I know someone who knows the answer. So David, do you think a super stiff composite sometime the Venus maybe it’s quite stiff? Sometimes the HRI very stiff? Do you think something even when you heat it, it ca be quite stiff? Do you think I’m slightly softer? restorative composite might be the way to go? [David]If you can really heat them up. Usually I heat them up. It’s like 65 degrees for at least 10 minutes before you’re using them. Most of them they really became softer. And you don’t have 10 minutes to enter them and to enter with them. It’s like 20 seconds or something like that because it gets hard again, and viscous again very, very quick. So it’s like I take it out of the compule, and I try to put it into cavity and I have maybe 10 seconds of comfort to apply the composite, the best way I can. So, it facilitates a little bit my life. But again, I think that the priority is not really the kind of composite This is the way I can use it, I will give you an example, the injection molding technique of David Clark, very famous technique, and I say you put flowable and then restorative composite all at once and perfect polymerization, two minutes, no bubbles, no voids. And you say the first time I saw that is this is crazy in terms of shrinkage and everything, it would be a disaster. The problem is that if I am trying to do the alternative technique with very, very small increments and pushing my increments and polymerizing it at the end, I have bubbles everywhere. So, bubbles is a bigger problem that may be a little bit of retraction. So it means that if the only thing I can do, the only way I can achieve a proper refill of a proper filling of the cavity is by injection molding, injection molding is the best technique. If I can do it with small increments of composite without introducing any voids, this is the best technique. So, again, this is about the operator not really the technique. And I can tell you that some days, I’m not a big fan of the injection molding technique. I never do it in like at once for all the cavity. But for some tricky cavities with a very difficult access, I’m using it. Because I know that even if I’m losing a little bit in terms of contraction, I will gain on the other side by refilling some very tiny, very sharp zones that I cannot reach with the conventional technique. So we just have to adapt and to adapt to the dentist of the day, the ability of the day. [Jaz]And that’s brilliant. I love that fantastic. I think what we can do now is maybe just share one example of a deep margin elevation. And for those who are listening to podcasts, I probably have to direct you to the YouTube version to see this bit. And then we’ll come back and do our goodbye and how we can learn more from David. So maybe if you start sharing the screen and show a case. In the meanwhile, I want to ask you a question while you are loading that up. So when you have that deep margin elevation, maybe you will show in the photos. Now, when you apply the rubber dam, where you are very deep initially, the rubber dam is not fully seated in that area. So you can see the gingiva in that area. But only when you apply the matrix, can you now get that deep margin acquisition, you can acquire that deep margin? Is that generally the way you do it? And maybe you’ll show me now in the photos, I think. [David]Yes, because I think on that example with gut, I will jump directly to the clinical example. And it will be maybe easier to explain. So this is actually the moment, that moment, you put the matrix in its position. And you want to see the matrix that is sealing quite nicely the margin of the preparation and with a nice profile. And let’s check that everything looks okay. It’s never okay, because this is, even if you’re working with a microscope, and something like 15 times magnification, we know that this is not perfect, but it’s looking sufficient. And okay. So look at that case, which is kind of difficult one from the initial X ray, you can immediately see that you will sweat a little bit redoing that one because it’s almost bone level. Some tips and tricks here that can be very useful is that just put the rubber dam from scratch. If you take because the natural tendency is to remove first the filling, the existing filling, and then it looks easier to put the rubber dam in its position because we don’t have any proximal contracts anymore. But the fact is that the existing walls of the cavity, the existing proximal walls, even very bad walls done by the existing amalgam will guide the rubber much deeper. So put the rubber dam before removing the old restoration. And don’t remove the old restoration before putting the matrix in because again, that part of the distal amalgam on the six can guide a little bit the matrix band. So at that time, because this is a quite an old case, we didn’t have a specific matrix band to do the margin elevation. So we’re cutting some conventional bands and trying to customize them, I will show you the anatomy of those bands in a minute. But some help of the existing wall, which are supragingival, we can try to put the matrix down. But this is a problem because we never know what happenedwe are pushing with the finger as deep as we can, but nobody can tell us at that moment, okay, your matrix has reached the top of the cavity, and the margin of the cavity. So and this is actually the problem, the kind of bands that we are using mostly, and we will see them also in a moment as those Slickbands of Garrison like banana bands with a great curve. And this is helping to get a better seal and a better profile. But what happened is that you put your matrix before removing the definer part of the existing restoration. And this is what happened. Maybe we were just kind of gum or latex or something in between. Yeah, it happens every day, and you just want to die at that moment. So if we can keep calm for a moment, and hold on, what we can just do at that time is trying to push out the rubber of the cavity. So the usual tip to do that is not to go with the instrument, from the inside to the outside of the cavity pushing it out, is to come from the outside, we have to pull it out from the cavity and it works much better. And at the end, we have something like that. So for that case, as we previously said, it’s impossible to place at that level, at that deepness, any kind of wedge it doesn’t work. So it means that this is the tension of the matrix that is doing the sealing. And it’s also maybe something that I can place outside of the matrix here, we can see some Teflon tape that is pushing a little bit, meaning that the sealing anyway, when it’s very, very, very deep, it’s not very powerful. If I push very hard right away with the restorative viscous composite, I will open my matrix, and we lose the sealing. So for that reason, maybe it could be prudent to start with the flowable composite that will not push away the matrix and then refill the rest of the cavity with the viscous one. So we do the adhesive that time with the octave on the fel. So this is the layer of gone defended a tiny bit of flowable at the cervical margin, just to ensure that the sealing will not be disrupted. And then we will fill the rest of the cavity with the composite, but we can see very good on the underside that the profile is not good, the profile is super vertical, it will not work. So we are trying to do something to push the matrix away and to make it more divergent, with kind of instrument polymerizing at the same time. So it’s really a fight something that you’ve got your you’ve done your gym, you know that day, you don’t need to go to the gym, it’s already done, because it’s something that were difficult. And at the end, well, you’ve got something that should be divergent. So again, the matrix that are those banana matrix are the best. So the one I’m using the most is the SlickBands of Garrison. And you’ve got also another brand, I think it’s an American brand called Grater Curve, that is also very good. And what happens is that you put the concave part of the matrix towards the cervical margin and the convex part of the margin of the matrix towards the occlusal part and automatically here you can see on the right, with the tofflemire retainer, the matrix will just put itself divergently. So it’s very interesting to get that profiling to improve the marginal sealing because again, we cannot really use wedges to do that. So it takes time, I cannot tell you that is something easy to do. And at the end, we always wanted was really difficult to control with some x rays because it’s impossible to see what we’ve done down there. It looks quite okay. We don’t have any idea of the efficiency of the sealing and bonding down there, but we can just pray and hope that it will be okay. The profile looks like not a natural profile. But let’s say that it’s okay. And of course, during the second session, it’s really really easy. Super easy to isolate, it’s super easy to put your inlay. It’s preheated composite, which makes also the elimination of the access pretty easy. And you can see everything and you can check everything. And this is really nice. So this is the big advantage of the margin elevation, avoiding surgery, and maybe we can keep the papilla in its initial position, which is very interesting for the comfort of the patient, less invasive, less money, also less expensive. So it’s very good for the patient anyway. And it facilitates the life of the dentist during the second appointment, especially when it’s time to eliminate the excesses. So this is what we have on that one. This is a pretty old case, but the X ray is very recent, because I just saw that patient with a seven years follow up. So it looks like it’s quite okay. But the question is always, we don’t see any recurrent decay, we don’t see any bone loss. So we can imagine this is a success. Well, this is a success. Yes, you can see it, the papilla is still there. But I think that that is leading. Okay. We have some other let’s say questions, raising up like, what about the distal fissure? In the six, in the seven, in the second molar? What about the choice of the material, this is lithium disilicate. And we can see as always, that the lithium disilicate doesn’t wear at all, and the natural tooth is wearing down. So what can we do with that? So it’s, let’s say a compromise. It’s not a full success, in my opinion. But in terms of margin elevation, this is not so bad. And this case, it’s just interesting for that reason, because when I started with this technique, my two biggest fears were, the patient will never brush, will never eliminate the black down there. So it means that we will have plaque retention. So automatically after a couple of years, as we know that this is not the best dentin to bond on, we will have a recurrent decay. This, we didn’t see that. So I don’t know why, honestly, maybe because we don’t have the proper bacterias to make carriers down there in the sulcus. I have no idea. [Jaz]Maybe the gingival crevicular fluid helping us, we don’t know. But you know, this is one theory I’ve read as well. [David]Exactly, exactly. Could be. And my second problem with, this is a clear violation of the biological width. Because we don’t have those two millimeters of collagen and connective tissue and etc. It disappears completely. So what about putting a material almost bone level, we will lose bone, and we don’t lose bone. So I’m not a Perio guys, so I don’t have clear scientific explanation neither I can just tell bout experience that those problems we don’t have. But all the other problems struggling with the emergence profile with everything we have. So this is maybe one of the most difficult technique I know, actually. So again I think that it should be done. Only when you feel that the patient can ensure a proper cleaning and that the dentist is in a good day. If we have those both things is a very nice technique. But it looks great. It looks easy it but it’s not. It’s not. And it’s not I’ve done five hundreds of those that it becomes easy. I can tell you that most probably the one I will have to do tomorrow morning will be super tough. And I will sweat like crazy doing it. [Jaz]It’s just yhis is why I get so many questions sent in to bring on a difficult guest like yourself, even though we’ve covered DME a little bit not in much as much detail as we went through today. But this is a big pain for dentists because there’s so many nuances struggles, like sometimes if I remove the papilla and I and you taught me something today, I might not remove the papilla next time because I see what you mean about the papilla supporting your matrix band. I agree with you. And I will try that because usually what I’m doing is one thumb I’m keeping really tightly on that matrix as I’m trying to hold that seal. So you’re right there’s the gym workout for the day is done and David you’ve done this episode so much justice. I knew you’d bring so much value. And you certainly have you’ve covered all my questions, and you are a phenomenal guest. I know that this episode will explode on YouTube and counting views on the listeners who listened on in a while they chop onions, while I gardening, while they’re driving that kind of stuff. David, here can we learn more from you? Where if someone wants to follow you on social media or earn more from you, and they like I do enjoy your teaching tyle? Where can we find out ore from you, my friend? [David]Well, I used to have a website that was up to date before COVID with the list of courses and everything, so I hope that a couple of months I can set up everything because I had to change it almost every day because everything is canceled and postponed. So you can go on the www.davidgerdolle.com and you’ve got all the details about the courses. But let’s say that we are praying on Instagram and Facebook to publish regularly news about the courses that we can do. And I’m working also with some universities, especially in France and Spain. So we’ve got some educational program in French and in Spanish in Paris, in Madrid especially some of the people and unfortunately, not in the UK But I would like to come in the UK to start some educational programs too, you have no problem. Traditionally, the Brits are the forever enemy of French, but I’m out of them, I’ve got no problem with the Brits. So please welcome me as I would welcome you, no problem. [Jaz]Absolutely. You’re very welcome to UK every time you come to UK, and I’ve been you know, so great that I caught you all those years ago, eight years ago, and you really opened my eyes to bonding. So thank you so much for having that influence in my career. And I know you’ve really touched a lot of dentists in this episode. I’ll put all your links and stuff on my website when I launch this episode. David, thank you so much for adding so much value. Appreciate it. Thank you. [David]Thank you very, very much. [Jaz]So that’s it. That’s the episode everyone. I hope you enjoyed that with David Gerdolle. So if anything, just remember, clean and rough. If you want to do some good bonding, make sure it’s clean, make sure it’s rough. So I hope you enjoyed that as much as I enjoyed talking to him. Honestly, David is just inspirational. I love seeing his work. And there’s a really cool handout I’ve made for you, showing you all the steps of deep margin elevation. I’ve put it on Instagram. So if you just direct messaged me on @protrusivedental, we’ll send you the PDF file. I’ll also add it on our telegram group, which you can find on the website. I’ve also.. I’ve got, I can’t be forgot to tell you this. Every single Protrusive Dental Pearl up to Episode 75 is now on the website. So there’ll be like a banner at the top saying Protrusive pearls click on that you can download every single Protrusive Dental pearl beforehand. So I hope you enjoyed that jam packed episode and I’ll catch you in the next one guys.

‘The Riches are in the Niches’, apparently. In the last episode we already touched on the topic of finding your niche but this time we were able to dive deep in to this. Will your career sky rocket when you find your niche? Or are you better off being the jack of all trades?  What are the benefits of finding a niche, how to go about it? And what does it ACTUALLY mean? https://youtu.be/aGniihvrNpg Need to Read it? Check out the Full Episode Transcript below!  Protrusive Dental Pearl: a Challenge for you – grab a pen and paper and write down ALL the clinical procedures that you LIKE to do, and then also what procedures you would like to do MORE OF. Figure out where your niche could lie. And don’t forget, it’s not a race! It helps helps to make a list of procedures that don’t excite you (for me, I have no affinity to facial aesthetics!) My guest, Dr Pav Khaira is a MASSIVE geek and I loved that he quite openly admitted to failure in the past and helped us learn some lessons. I also enjoyed hearing that it is TOTALLY FINE to change your niche as you mature as a clinician. In this episode, we talked about: Being a super GDP vs niching down? Young dentists rushing to find their niche Is it okay to niche too soon or is too late to find your niche? The opportunities of learning Becoming a ‘go to dentist’ The downside of niching  If you enjoyed this episode, then do check out the Dental Implant Podcast by Dr. Pav Khaira. You might also enjoy 6 Signs You are a Comprehensive Dentist! Click here for Full Episode Transcription:  Opening Snippet: So I think the issue with trying to niche down too soon is have I jumped into implants right from the start. Well, actually, I'm actually a better implant surgeon now, because I understand chronic pain, I understand well, actually, I understand the forces going through my implants, forces going through my implant prosthodontics. I know how to deal with them... Jaz’s Introduction: Find your niche. Now, that’s a saying that’s probably been bonded around a lot, in all the sort of circles of career advice is something that I heard a lot in early on my career. And it never fully made sense to me. I’m hoping it’s gonna be this episode that’s gonna make the whole concept of finding your niche tangible. What are the benefits of finding a niche, how to go about it? And what does it actually mean? Now, I’m joined by someone who is quite inspirational for this episode, because he is someone who’s quite openly admitted to failure in some ways. And I do believe failure makes you stronger. And we talk about some struggles and failures early on in his career. And I’m very honored that Dr. Pav Khaira shared those failures with us because that’s how we can learn about others experiences. It’s not all rosy out there. And with that failure, or with the struggles, he was forced into trying different procedures, try and boost revenue for the practice. And through all that, eventually, he found his niche. And then he changed his niche. So he is a living example of no matter how qualified how many years of experience you have, that if you still are looking for that right niche for you within dentistry, then opportunity is still there. And if you’re at the very early start of your career, just use this episode, use the lessons from Dr. Pav Khaira as an inspiration to helping you finding your next steps and your niche. Protruserati,I’m joined by Dr. Pav Khaira from the dental implant podcast to talk about his niching down into implants, my fears about dabbling into implants and my challenges in terms of getting started with implants and the recipe to finding your own niche, whatever that may be for you. So the very relevant Protrusive Dental Pearl I have for you today is to sit down. And maybe at the end this episode, just take five minutes to get a pen and paper and write down all the procedures that you like to do, all the procedures that you’d like to do more of and get known for. Now, I don’t mean like an Instagram celebrity or anything like that. What I mean by that is someone who your colleagues, your peers respect, because you are the go to person for that procedure, and doesn’t even have to be in Europe, in the UK, in the world, whatever it can be in your town, if you can be known in your town for a certain procedure, then that itself can carry so much success. So there’s so many benefits as we discuss about finding your niche. And I want you to make a list of all the things that you like doing or that you’d like to do more of, and you won’t be known for. And also make a list of the procedures that you just fell out of love with or you don’t enjoy doing, or you’re not very good at for a reason. And either decide that you’re not gonna do those anymore, or decide to upskill in that because part of finding your niche, as we discussed in your episode is becoming comfortable in your skill that you’re not gonna be doing all the procedures and you don’t have to provide all procedures. So it’s an interesting topic. I hope you find it very useful. Let’s join Dr. PaV now, let’s not wasting time and I catch you in the outro. Main Interview: [Jaz]Pav, how you doing? [Pav]I’m good. I’m good. It’s Yeah, I’m about to start work at Evo so that I’m not doing surgery today, which is really strange. To do surgery like for me four days a week I normally do surgery, at least three if not four days a week. So coming in on a Monday not having surgery. I’m just like, wow, okay, that’s weird. [Jaz]What have you got planned today? What was the kind of agenda for treatments today? [Pav]It’s just a review appointments and and consults basically. So it’s one of my other colleagues. He’s he’s doing the surgery today. And then I’ve got some pretty interesting cases lined up for the rest of the week. So yeah, it’s good. [Jaz]Yeah, amazing. Well, for those who who don’t know Pav, I’m going to give my little introduction before you can do your official one. But Pav is the host of the dental implant podcast. And he is a friend that goes back, I’d say, a large proportion of why I started to really get involved with occlusion and splint therapy and APMSAs was because of you. We invite you to our study club back, about seven years ago now. And he came in London and you just inspired me so much. I think you remember that night, right? [Pav]I do remember it. Yes. [Jaz]So you said something off at that time, my friend. So it’s great to have you on the show today because you know, you’re so important, important cog in my journey and really important mentor if you like. So it’s been great to see how you have niched into implants since then. And you know, what a great way to introduce the theme of today’s episode, which is a niching down or if you’re in the US or somewhere else niching down, which just sounds wrong. But Pav, tell us who you are for those listening around the world. And you’re about your new journey as a podcaster as well before we dive into the nitty gritty [Pav]Yeah, so it’s for those listening to my podcast. This is a Welcome to the next episode of the dental implant podcast. And Jaz, I just want to say, apologies for sucking you into the black hole of chronic pain. You know, it’s a weird journey. But yeah, I do actually remember that evening. A lot of you were asking all the right questions, and I remember thinking to myself at the time or like he gets it or like he’s like, on, fire with this. And similarly, it’s, you know, I think we spoke a few months ago. And you basically turn around and said, We have we’ve got a lot of information, why don’t you set up a podcast. So in that context, you’re my mentor, you know, you give me advice on how to set things up. So a little bit of background, about myself, it’s I graduated in 2002. From Guy’s hospital, I purchased my own private practice in I think it was 2004 2005, I struggled along with it for the best part of nine years, ended up having to close the business I as well as closing the business, because I’ve given a personal guarantee on it, I ended up going bankrupt as a result as well. And after that, it was just like, because I’ve received bad business advice from a lot of people as well. [Jaz]Can you give an example, I mean, generic bad, what is an example of bad business advice, if you don’t mind. [Pav]So a generic example of bad business advice. And this has happened to me where people are turning around and saying to you “you can turn your business around, just do this, this and this, keep paying me I’ll keep telling you what to do” was what they should have done, or what the law says they should have done is looked at my box and turn around and says, I’m sorry, Your business is insolvent, you should pull the plug. And it was actually an external person who came, who ended up, she was actually a patient of mine and I can’t remember how we got onto this subject. But I told her that the business was struggling. And she goes, Well, you know, I’m in finance, do you want me to look at the books and I looked at her and she just came back to me, she turned around and said, You know what?You need to pull the plug. What do you want to hear it or not? She said, you’re going to lose this business at some point. You’re going to be better off doing it sooner rather than later. But I said to her, you know, my business coaches were telling me it’s okay, they will be able to turn the business around. And she goes, I don’t know who’s told you that but that’s not appropriate. So it’s, that’s when I realized that I was much more comfortable as a clinician, as opposed to a business owner. Some people thrive as business owners, and I’ve got great friends were they own practices, and they’re exceptionally busy, exceptionally successful. It just wasn’t for me, in terms of clinical work, I was far far far more comfortable in that, [Jaz]I would definitely say on the same path. I get asked all the time, Jaz when you open your practice? And I guess, it’s something that I’ve really thought hard about, but I feel exactly the same as you, I feel like I love my clinical dentistry and other pursuits and passions. So, to devote my time to all the stressful yet rewarding activities of a thriving business owner, multiple practices, that kind of stuff is just not for me and sometimes self realization is such a huge proponent in your success in the future knowing what you actually like. [Pav]I think the flip side to that coin is there’s a silver lining in every card Jaz is because I had a business which was struggling, I was constantly not, I need to bring more income into the business, I need to reward incomes, I was learning a lot so I had a lot of training in fixed removable prosthodontics I did a lot of training in the US with Frank Sphere. I was one of the first to implement Six Month Smiles in the UK. And in fact the guy who said he was the first to implement Six Month Smiles on the UK, he was on the same course that I was and I went down the Ortho route as you know, I went down the Chronic Pain route for quite a few years for as. I could do format reconstructions, IV sedation but what I found is a whole host getting bored clinically quite a lot, as I’ve started. [Jaz]But why you had so many different variations. I used to mentioned all the things and it ties in so perfectly well my main questions which I think you can just ask now because it’s perfect timing is being the jack of all trades, which sounds like you were you’re doing your sedation, ortho, complex reconstructions, fixed removal, that is for me, the super GP, right, super GP territory. So why not have that and why then eventually decided to niche down? [Pav]Well, for example, when I was doing full mouth reconstructive work, either arch or full mouth, when we first start doing it, there’s this rush, there’s this whole, I need to learn this, I need to do it this way. And then it gets to a point where you’re proficient at it. Now, I’m not saying all cases are easy, but you end up almost going through the motions a little bit. And you’re like, okay, as long as I follow these steps I’m not going to have a predictable result. And the only thing that really started to capture my interest and this is ironic actually where I am now is when I first started is I was like I’m not doing surgery, I hate surgery. I’m not doing your implants, I was told that about I’m not placing them because I was afraid of surgery because I didn’t have the clinical knowledge and the experience. And after a while when I got bored with the rest of it, I was like, Okay, let me do an implant course. And well, it just took off from there, you know, I started to realize quite quickly, well, the reason why I like implants is you do actually have to think of the restorative you’ve got to think of aperio is there’s a lot of times you’ve got to think of ortho. So for me implant dentistry is is actually all encompassing, it encompasses everything that that I’ve learned so far. And for me, it was just a natural progression to start to niche down in implant because I found more than anything else. That is what I loved. And I think we we hear this a lot. And we don’t take it on board, in that a lot of people here, you can’t be a master of all trades, you can be relatively proficient at a number of different things. But it takes a long time to become extremely proficient even in one thing. So to multiply that out becomes very, very difficult. I’m not saying that there aren’t people out there who are supremely proficient at a lot of different things, because obviously, that there are people out there. But what happened for myself is I just got to the point where I enjoyed him quite so much I started to progress more down that route, I was doing more courses, I ended up doing my master’s degree. And this is like a natural progression in anything. So what ended up happening is slightly as I was only doing implants in my practice, then I was branching out and doing implants in other practices. And quite recently, about 10 months ago, I got very lucky and very landed on my feet. Because I joined the team at Evo dental. Now, if you think placing just implants his niche, well, at Evo dental, all we do is treat full arches and full mounts. So My typical day is a do arch 10 implants. And you know, we do that we do that five days a week. So for me, it was almost like a natural progression, moving from boredom and necessity to bring more income into the practice to all of a sudden finding something that I love. And starting to expand those skills and the niche travel I developed itself. I did, as I said, I was lucky. You know, I’ve ended up at Evo, but it was just a natural progression that was doing more and more implants. [Jaz]Thanks so much that very honest reflection on how it started in terms of the necessity to keep your business running afloat and having to dabble in different skills and upskill yourself and eventually, almost by accident landing into implants because you thought okay, let me try a course. And it just took off from there. I guess to use analogy, you had to kiss many frogs before you found your prince, then what would you give? What advice would you give to young dentists? A couple years qualified which which they hear this advice, right? And then I’m hoping In this episode, we’re gonna make it really tangible because you hear this all the time. The the Guru is always saying find your niche, find your niche. But if there’s no predictable formula to find your niche that you might just accidentally fall upon it, you might have a mentor that inspires you. So I do feel as though how can you find your niche? If you haven’t given a chance I my niche might be endo. And I haven’t discovered it yet. Because I haven’t given endo a chance. So what would you give to someone first five years qualified or even 10 students or in that sort of young dentist category to help them find their niche. [Pav]Some people will never actually develop a niche. They’ll be quite comfortable in general dentistry. But the other thing I would say is don’t rush into trying to find a niche too soon. Let’s go back as that this is actually what happened to me. I was like, Okay, my niche is going to be cosmetic dentistry. It’s going to be veneers, it’s going to be format reconstruction, then it’s like okay, well that didn’t work. Now my niche is going to be orthodontics, and then after orthodontics, that’s when splint therapy came out. And I’m actually just progressing to into implants. Now, there are some people where they’re just like, you know, I want to become a specialist. That’s great. Go for it, okay. But if you’re in general practice, it’s important to extend your skills and learn more, and you’ll just get a natural affinity to one thing above anything else is what I think happens. So I think the issue with trying to niche down too soon is Hello, I jumped into implants right from the start. Well, actually, I’m actually a better implant surgeon. Now, because I understand chronic pain, I understand well, actually, I understand the forces going for my implants forces going forward from back in time prosthodontics. I know how to deal with them. I also understand the orthodontically. Even though I don’t do the author, I understand orthodontically what can and cannot be achieved and how it can improve my income outcomes. And because of the restorative work that I’ve done, and the training that I’ve had, I understand occlusion as well. Now you and I, we both sat with we as ER and he understands occlusion to a much higher level than what either of us do by professionals. And so this is the benefit of not meeting Too soon is that it gives you much better rounded ability, when you do actually start to niche down, you know, for examples, some of the better endodontists that I know, they also like placing implants and they can make that judgment call Wow. As to whether a tooth can be restored or whether it should be doing implants. Now, even within implant dentistry, it’s really important to understand those different niches with implant dentistry. Okay? When you first start, we always recommend placing implants out of the aesthetic zone towards the back end of your bridges, okay, then you can start to build up your proficiency in immediate implants, then you can start to build up the proficiency in grafting and grafting is not easy. No, people think, oh, you slap on a little bit of bone membrane, you’re great to go. It really isn’t easy. There’s different ways of doing it. There’s different indications for different methods. And it’s not always predictable. So you need to understand how that is. So I know some people where they will build a niche within implant dentistry and within the subtopic, of grafting, and then obviously, my niche at the moment is not even just within implants, is it within full arch reconstruction, because that’s what we do here all day, every day. And it’s just been a natural progression for me. So the advice that I would give to the younger dentist is a Don’t be in a rush. But I understand why you feel you want to be in a rush. I was in the same situation as you as well. I was like, I want to do this, I want to do it now. Okay. I see a lot of people, as soon as they as soon as they’re coming out of university, they’re like, I want to be a celebrity cosmetic dentist. There are people out there, I’ve been graduated since 2002. So that’s coming up to 20 years, I’m very good at my aesthetic work, there are people out there who will just walk circles around me because they have niched down to this. So highly professional. So what I was expressing is to the younger colleagues is I understand why you want to niche early. Sometimes it’ll work out sometimes it won’t, but have that flexibility that if you start to do something, you’re finding that you’re not enjoying it, you can shift into something else. You know, that’s what’s happened to me sounds like, that’s what’s happened to you on a couple of occasions as well, it is really satisfying when you find that thing that you really love. Yeah. So the benefits to outpatient because we’ve focused only on full arch implant is we end up being very proficient at it. And we can intercept problems before they actually, before they actually cause problems. Because you just exposed to it all the time. You know, if you’re doing one or two arches, or one to four miles idea, you’re not going to build up that muscle memory. In order to be able to really help these patients when you do it day in and day out, you’re immersed in it. And this is what happened when I started at Evo dental is I started right at the beginning of the training pathway. And I was just immersed in it with my mental. And I’ve progressed progress really quite quickly because I had the background and implants already. But you find that that muscle memory builds up really quickly when you’re doing it all day every day. So you need those 10,000 hours, you need that you need a good amount of time and exposure to it. To be able to build up that muscle memory. [Jaz]I think the two takeaway points and reflections from what you just said there was a not to rush and be be open to the opportunities for learning. They’re out there. And eventually you will automatically be attracted. Like for example, Rena guardia once told me when we had this guy having the same similar discussion about seven years ago, she was saying that automatically when you get their dental update in the post will be DJ will automatically start flicking through the pages that interest you just subconsciously. And you will slowly just through the forces of nature start to find the affinity towards that micro speciality. And I guess this was echoed to me by periodontist, saying that try and become the best person in competence for the best person in Perrier be the go to guy for sedation. And I think there is a lot of power on that, like you are becoming the go to you were you were definitely the go to guy for splints. And now you’re definitely the go to guy I think you’re emerging in a full arch implant case. I love your passion. I know you’ve studied so hard extra qualification stuff. So it was great to see you blossom. And I think it’s great that you have that story. Because it’s inspiring to young dentists who, who maybe feel as though they can’t change that needs to fall down that rabbit hole. It’s not the case, you’re living example of that, that, you know, you’re 20 years qualified, but you’re not slowing down anytime soon, right. You’re You’re still exploring this niche that you found, and it wasn’t something that you had from day one. So that’s epic. And one more thing that I’ve thought of is the riches are in the niches. So obviously it’s niches but you know, to make it all work, the riches are in the niches and I truly believe that once you can be the go to person for that one field, you’ll be rewarded for it. [Pav]I think there’s two sides to that sword, but you’re at Right, my training, my passion hasn’t slowed down at all. So the next stage of training for me is psychometrics. So we’re already in the process of being trained, because dogmatics, I’ve done some courses. And at UVA dental, we’ve got one of the most experienced zygomatic surgeons on the planet, joining the team next month. So my mentoring is going to be done directly under his supervision. So even within the niche of full arches, there is another subset niche, you know, you can just keep going and going with this. So I think the the upside to it is, when you start to lose down, there are people who can, from a business point of view, we can start to compete. Okay, who but what I was saying about that do leg short. And the other issue is, is a lot of people don’t understand it. So if you won’t get the referrals, but the patients don’t understand, I mean, let me give you an example, jazz is, you know, as well as what I do is that, you know, we can turn around and say to patients, we don’t care, if you’ve had migraine for 20 years, there’s a solid chance we’ll be able to get rid of them, they don’t believe you. And so generating that marketing to push the patient so that they understand that we can help them, because they’ve never heard of it. And quite often these patients have tried everything under the moon, they just think it’s another way to scam them basically. So the upside to the issue is you have a very strong skill set, which very few people can can compete with. But the downside solution is fewer people have heard of what you do. So it’s harder to generate that business. But once the once the momentum of that locomotive starts, then it’s hard to stop. It takes time, it takes effort. So anybody who’s listening needs to understand that it may take you 510 1520 years, but you know, don’t expect it to happen overnight. You know, it’s there was an old saying I can’t remember who he was. And I think it was a singer or all of a sudden within the space of four or six months became extremely like world famous. And people said, I remember reading in an interview somebody turn around, etc. How does it feel to deal with this overnight success. And he said this overnight success I’ve been working on for 20 years. It takes time to build. And people are in a rush nowadays, the world doesn’t work like that. Keep working hard, keep studying, we’ll eventually get there. And if you don’t want to be sure you’re quite happy doing general dentistry, great. [Jaz]That’s a niche in itself, I really was waiting for that message. Because it’s so important because lot of people don’t want to niche down to a specific area. And they love the variety. They look at their day list. They have children, they have some perio, they maybe have an implant in a premolar region, they have a root canal. And they love that and they’re great. And that’s good. So that itself should be respected. It’s great to have that. And you can market yourself more widely, which is a great point you made about the downside of niching down, I think the two themes that we need to explore in the next 1520 minutes or so is a if you start niching down the fact that you have to become comfortable to not doing model render anymore. For example, like let’s say I’m niching down into implants, as you have, I need to build that muscle memory and therefore I’ll be doing less of endo, I’ll be doing less of some other procedures basically. And then it doesn’t make you any less of a dentist because you won’t be able to do that stuff anymore. You have to be comfortable with that. And I want to hear your take on that. And then B let’s talk specifically then about niching down into implants for for the young dentist because I can share some experiences. And some reasons why I am hesitant to start dabbling in implants. Because I feel as though I need to go all in if I do implants. So we’ll discuss that theme as well. But let’s start with that. First one is about being comfortable in your skin that you now can limit the procedures that you do, it’s very hard to start [Pav]with, because it’s going to the first place it’s going to hit you as your wallet when you are trying to increase your skin and something but you’re not very professional to start with it takes a lot of time to be able to do even the simple stuff. And to dedicate that time, you’ve got to drop down other stuff, which is bringing you in income. So the first place is going to hit you as your wallet, but you just have to be comfortable with it. So when I own my practice, I did actually I did actually under microscope, I was actually pretty damn good at endo. But then I ended up having to sell my microscope to try to keep the business afloat. And I found out very quickly, I can’t see I can’t do endo anymore. And then I ended up referring all of my molar endo out. And then very shortly I was referring all my mother and pre molar endo out. And not too long after that. It was just like, No, I don’t want to do anything there whatsoever. And that’s that then starts to free up your time. So it’s important to realize that because it takes time, it has to start with that passion. Because if it doesn’t start with that passion, you’re just gonna turn around and say I’m sorry, I’m not prepared to drop this income and it will impact your income to start with it just naturally does. But then what happens like for example, because I’ve been doing implants for a long time now, if I get a very straightforward implant case, and they’re not, they’re not all like this, if I get a very straightforward implant, let’s say single implant, when I first started placing implants is it may have taken me three hours to do that case, I can now do it in 12 minutes. And I think the fastest I’ve placed an implant from the patient coming in to the patient leaves me with about eight minutes, including anesthetic. But that didn’t, I didn’t get to that position overnight. When I first started at neuvo, my average length of time that he took me to do a jewel arch is about five hours, five and a half hours. Now my average length of time is just under three hours. And that’s good, more complex cases that can take a little bit longer, you know, straightforward cases, to two and a half hours. But again, that didn’t happen overnight. That happened because I was immersed to it every single day, I had a mentor sat on my shoulder saying, don’t do it this way, do it this way, we’re going to get a more predictable result, it takes time. And you have to, you have to be able to let go of what doesn’t interest you to grab a hold of what does interest you know, you can’t you can’t hold on to two things with this thing pulling this way. And this thing pulling in this way, it doesn’t work. At some point, you have to let go of this vine to swing further on this fine. [Jaz]Well said, great analogy. And I think a lot of people need needed to hear that actually something is really important to hear that message. As you know you otherwise you completely oblivious or like you said, if you don’t have that passion, that only then does the decrease in income really start eating at you. But when you know there’s a purpose and an endpoint and you’re trying to upskill other areas which will hopefully reap rewards in the future, then you can you can be comfortable with that drop in income. [Pav]Sorry, I was just gonna say, one of the rewards that’s come from me from moving into implants and not even just dabbling in it a little bit. But really studying and grappling harder is I’m now in a in a position where my skills and my knowledge are indispensable to the practice that I work at Evo. So he’s actually jumped security for me, you know, so it’s, when you have that niche, it actually improves your job security as well. [Jaz]Absolutely. With implants. Now, I have dabbled placed a few with under some mentorship and guidance. And I just felt as though there was so many complications, surgical complications, technical complications, restorative complications, things like cold welding, which I never knew existed, and it happens to things like a screw being over tighten. Now you can’t unscrew it, things like someone comes in and you see on Facebook all the time, which implant is this or have a patient in Ealing, and they have this type of implant. And there’s so many different brands, that I just feel there are so many challenges, and I know you’re the best person to advise me. But the learning curve for implants is steeper than I’ve seen in any others and this from actually placing and going through that sort of procedure. So he but what people told me is that to place an implant is easy just to do actual procedure is easy. But it’s nothing simple about the overall overarching concept when it comes to healing as well and patient selection. But restoratively, the more complex you get, and the more challenges you are faced, it’s very, very difficult to perfect it. So what do you say to someone who may be because I hear this from young dentists all the time that you know what, I don’t want to get into implants, because it just seems like way too crazy for me. [Pav]So what I would say to that is, there’s two things that I want to address. Don’t be afraid of implants. You know, I’m living testimony that, you know, it can be learned, you know, I didn’t, I wasn’t born with this knowledge, I wasn’t born with this skillset, it’s taken me time to develop it. That means that it’s cost me a lot of money in terms of education is helpful cost me a lot of money in terms of equipment, and it’s cost me even more money in terms of mistakes. This is why I keep harping on about mentors, because when you start doing this type of work, and particularly more complex that that starts to become is you’re either gonna pay to fix your own mistakes, are you going to pay to a mentor to avoid those mistakes, but one ends up with a happy outcome that you’re still going to pay one way or another. I think the other side of the coin as well is and I see this a lot, where people are like, Okay, I’m going to do a one year course on implants, I’m going to do one day, a month, over 12 months, and I’ll be able to do full arches, I will be able to do absolutely everything I will be able to do that. It doesn’t work like that. It’s significantly more complicated than that. Okay. Like you said, he’s, you know, choosing your implant system, then you need to learn how to use that implant system, then you need to understand the biology of patients. You know, we’re talking about things like gut bacteria, which can affect healing, psychological stress that can affect healing. Vitamin D, we are talking antidepressant use, we’re talking proton pump inhibitors, you know, all of this stuff adds up. And so a straightforward implant case isn’t actually a straightforward implant case. So what I would say is, don’t be overly daunted about starting but understand that what’s not going to happen is you’re not going to do A one year implant course and be able to do everything. Like what people say with regards to your BDS. Once you’ve got once you’ve done five years at university, we’ve got your BDS, that doesn’t mean you’re a good dentist, it’s a license to start learning, once you’ve done your basic implant course, is that’s a license to then start learning. I still go on courses, I’m still learning lots, I still read papers every single day. So what I would say is the journey of 1000 miles starts with a single step. So you have to take that first step. But also understand that this is not going to be done overnight, you’re not going to get to the end of a one year course. And all of a sudden, people are efficient. And the other thing that I hear as well. And this happens a lot in America, where people like, oh, I’ll go to the Dominican Republic for a week, I’ll place 15 months in a week, and that’s gonna make me a great surgeon. No, because you don’t have the follow up of those patients, you don’t see the mistakes. You know, I’ve still got cases from a few years ago, when I’m only just fixing now, which have cost me an absolute arm and leg because I thought I was proficient with full arches, I did a full arch, it didn’t go according to plan, the patient’s not going to pay me again. And this is what I said in my last podcast as well jazz, in that, you know, is if you do a an emo restoration on a lower six, and it breaks, we’ll find the patient comes in patients not particularly happy, you can really hear my restoration. There. Imagine what happens when you do a six unit implant retained bridge, and you put in three or four implants. And that doesn’t work. And all of a sudden when your your implants is fractured, that correcting that is significantly more complicated. And it costs you a lot more money out of your own pocket. [Jaz]That’s exactly what I mean by you know, it becomes more complex, but then the the failures also become way more complex way more stressful, which is why some dentist saying you know what, I’m not ready for that. But I think what I’m trying to say is, is there a place for dabbling in implants? You know, I mean, like, you know, yeah, God tells me, can you just do the, you know, one implant a month or replace a lower molar, and then keep it at that [Pav]some of the most successful dentist, and these are the ones where there are general dentists that require a lot of different things. But what they will do very, very successful is they’ll do an implant course. And then we’ll pick cherry pick and choose the easy cases, the more complex cases they will either refer out or they’ll get somebody into the practice to do it for it, just because it is the same as ortho jazz, you know, if you’re doing orthodontics, there’s a very big difference between, you know, our we’re going to do, we’re going to do short term, although because the patients have a little bit of relapse, everything towards the back is fine, I know that this is within my skill set, we can get it done in about six months, okay? versus You know, this patient is orthognathic surgery patient, you know, you don’t do an ortho course, and all of a sudden start being orthognathic surgery cases. And it’s the same with implants is, you know, you can do you have ridges towards the back of the mouth, what’s the most commonly removed to the mouth, it’s upper and lower fast motors, because they’ve been in the mouth longer, they’ve had more time to students, you know, so if you’ve got a lower molar that’s missing, there’s a ton of bone in his heel, great, absolutely go for it, there’s a lot of business to be done. And it’s less stress as well jazz, because it’s out there, the smile line, it’s nothing complicated. And then if you get something in that needs a sinus lift, get somebody in or refer the patient, you know, the patients will actually respect you more if you turn around and say to them, Look, I can’t do this point. This is more complicated, but [Jaz]I think that’s a great message for those who like me sometimes think ah, is it worth it, but if you do, just like they do on the ortho courses, you start with your class one base relapse cases or in the implant world, the sort of analogy would be or the similarity would be a lower and upper first molar out of the smile zone and build from there, you never know that might be something that interests you more and more and then you end up doing more courses, soft tissue courses moving to anterior or you might just stay as keeping that as part of your larger skill set. And then you can do that but you have people to refer to so I think that really does help actually and I think I’m hoping that’s gonna help a lot of people listening as well in terms of who are afraid young dentists are afraid to get involved with implants because they know that the field can be famous for or infamous even for its complexities and and litigation or the justifying the higher fees of indemnity because I the flip side of that Pam, and I’m sure you know loads of these as people who have done the one year course for implants or people who’ve done an MSc and then never went on to place an implant again. [Pav]Yeah, you know, I hear it all the time. You know, people do MSC, they’ve placed four or five implants, and they still need mentor and all that they just don’t do it because they haven’t built up that confidence. You know, okay, let’s say stop somebody start placing the simple implants and all of a sudden they want to progress. And they think right, the next thing for me to do is to learn how to do sinus. Well, sinus lifting is complex in itself, you know. So, first, you got to go on a finance lifting course, which is going to cost you three, three and a half 1000 pounds. You’ve then got to get the same as Medicare and there’s different lists for different indications. Then you need to go to your indemnity indemnity is going to tell you are essentially right as soon as you’re going into sinesses, right, we’re adding two and a half 1000 pounds into the premium. You know, if you’re doing one or two lifts per year, is it really worth it. Whereas if like what we do at Evo, if you’re going into the science 234 times a week, then obviously it is worth it. And you build up that skill set, there is no harm at any point, turning around and saying this, I’m comfortable with this level, I don’t want to go beyond this. But I’m going to get better at this level. And then when you start to find a niche is that that bubbles just automatically start to grow as you think to yourself, Well, actually, I am seeing enough patients to be able for me to warrant doing sinus lifts and learning about them and adding them to my to my feet. Because you know, I’m having to refer three or four hours a month, then that’s obviously a different ballgame. But don’t don’t be afraid to start the journey. But just don’t also be naive to think to yourself, this is a this is an issue jazziz. Because the way that I look at it is how many courses would sell is if the people who are running the courses turn around and say to actually no, we’re going to charge you X X amount, but by the time you get to the end of it, you’re only going to be able to do the really simple cases, you know that what, there’s a little bit of embellishment, I’m not saying people are being malicious about it. But people want to run these courses. And these courses are sponsored by implant companies. And these implant companies, they’re gonna want you to buy their implant systems, there’s pros and cons to each implant system. You know, you need to understand what you’re buying, and make sure that you understand the data, so that you’re comfortable with it. You know, I did a podcast with Bill Schaefer a few few weeks ago, this is one of the things that we were saying, there are some really crappy implant systems on the market. There are some good implant systems. And there are, there are certain important systems, which I know are good, but it doesn’t fit in with my working style. So the implant system that I’ve used, I’m comfortable with it fits in with my working style. And in addition to that, I’m happy with the data, the scientific evidence behind it as well. So you’re absolutely right, there is so much to it. [Jaz]It’s really overwhelming. I just found whenever I’m looking at you know what I’m thinking is it time to to move up the gear and the implant stuff. I just get totally overwhelmed. Come visit the Avon hang around the corner, man of course. Yeah. [Pav]Yeah. spend the day with a well sorted out. But he’s like, No, you don’t have everything’s overwhelming. You know, it’s overwhelming to me. And no, on any level whatsoever. He’s overwhelming, no else is overwhelming to me. Because Because I’ve not done them for such a long time. Now that I do. That’s a that’s a feel stretched such channels in implants. And I deliberately made them a different color, so I can see them in case I ever need to retrieve it at a later date. So we can’t be professional at everything. Don’t think we can do professional, everything you know is is we can have a very good abroad subset because we keep going back to this super GBP. One, they are considered super GDP, Roger Ahluwalia, he does some absolutely beautiful, beautiful work, okay, he sends us work to do here, because he’s just like, not the set up. But you guys have got there. This is just like my patients are going to be better off going there. So you know, it’s Don’t be afraid. And don’t be worried about saying to yourself, here’s my limitation. I’m going to study to expand that. But also, if you say to yourself, here’s my limitation, I’m not happy with that, because I want to do other things as well. That’s absolutely fine. And don’t let anybody tell you your power cannot do something. You know, it’s you’ve got to always put the patient’s interests first. But it’s a continual learning curve. [Jaz]Amazing. Have you got time for one more question path? Yeah, absolutely. Okay, so my last question is, if someone wanted to start their implant journey, maybe they’re two, three years qualified, that found their feet a little bit the progress enough that they want the next challenge? Is it right, this whole mantra of learn how to restore implants first? Or do you think they should be actually learning how to do the surgical aspect as well as same at the same time as doing the restoring what what is your beliefs and thoughts about this, that when is commonly abandoned around about learn how to restore an implant first, then progress? Is that the right way? In your opinion, [Pav]you don’t necessarily have to be able to proficient at restoring implants first, but you need to understand the restorative process first. Okay. So there’s two things that I would say to that the best implant surgeries that I’ve seen, understand restorative, the worst implant surgeons I’ve seen, do not understand restorative. Okay. It really is that simple. And the other thing that a lot of people ask is, why is there no speciality in dental implants? Because it’s too large and too complex the field. You know, if somebody turned around and said to you, right, we’ve developed a specialist training pathway. This training pathway is 15 years old people gonna go Forget it. I’m not interested. But what a lot of People start to discuss when they when they start to become professional implants, is implants is a restorative is a prosthodontic process with a heavy surgical element that makes sense. So they are putting, they’re putting the restorative first. Why is that? Why is that important? Just because patients don’t want implants, they want fixed teeth. That’s more important. And the implants are just a method to achieve that. So understanding the restorative process is critically important. There is no reason why you can’t learn the restorative and the surgical at the same time. But don’t make the mistake, I’m just going to go down the surgical route because we’re not being your patients. [Jaz]And what do you think about this whole concept of young dentists who can’t section and elevate, then going on to an implant course, like people who just can’t extract teeth provisionally starting surgery, because that happens a lot, I feel, [Pav]yeah, you’re gonna, you’re gonna get your fingers burned. And they’re gonna be expensive mistakes, you need to start to, you know, whether it’s at your local hospital goes, you know, get a part time job, raising flowers, removing wisdom teeth, taking out broken teeth, you have to have those surgical skills, okay? If you can’t take out teeth, a traumatically. All that, all that’s going to happen is you’re going to get your fingers burned. And you’ll get one of that patient’s breathing down your neck. So patients are going to come in, we’re going to say, right, so why does this implant? Why is it taken, or what you’ll do is you’ll start a process and understand it’s way more complex than what you thought it was going to be. And all of a sudden, you don’t have the skills to be able to help that patient. You need to understand that restorative process, you’ve got to start to build your surgical skills as well. [Jaz]Amazing. You’ve raced through all my questions, but you know, it’s easily been 45 minutes easy, very easy talking to you. I think we’ve covered so much there. I think me and you’re both naturally quite fast talkers lend ourselves to podcasting and stuff. So I think there’s about there’s about 90 minutes of content in this 45 minutes, I think. So I think that’s been a really good path. Thank you so much for your time to share. How about how your journey of niching down I think it’s gonna inspire a lot of young dentists who maybe think that I don’t know how to go about this or that maybe they’ve left it too late. And I think your your story is sensational. So thank you for sharing it with us. [Pav]Thank you jazz for, you know, encouraging me to get into podcasting and I’m really enjoying it as well doing [Jaz]great things you’ve had great I mean, just the other day I listened to Paul homily, one communication, your your your natural path, your natural and I’m enjoying it. And I think for those people who really want to learn more about implants and or you’re already an implant geek, then you know, paths podcast is the podcast to go to. So do check it out, hit that subscribe button. And let us know we thought this episode when it’s out. And similarly, anybody [Pav]listen to my podcasts, please look at jazz as well, because he does a lot of great stuff not just focused just on implants, but on general dentistry. And it’s the protrusive Dental podcast, so jazz, etc. You know, this is great seeing your career progress from from, you know, when I first made a few years ago, I’m very happy for you. I’m very proud of you as well, I think you are also a very good example of what passion can do for dentistry. So you know, it’s when people just chase the money is they’re going to they’re going to they’re going to end up unhappy long term is that you’ve got you’ve got to be passionate about what you’re doing that that obviously comes through in everything that you do. Jaz’s Outro: Thank you guys for listening all the way to the end. I hope Dr. Pav Khira brought some value to you whether you’re considering dabbling into implants and you hear that will kick up the bum to get started. Or maybe you resonated with my story about hesitations about giving more time to implants because it might mean that you are having to focus less on other areas of dentistry which you enjoy. So I’ve actively made that decision to not dabble with implants or to not get into implants because I feel as though that it’s such a huge steep learning curve. But I do feel off that chat with Pav today that perhaps there is a role in learning how to restore implants first and go follow that sort of pathway to be able to provide that service to your patients because implants is just dentistry. It’s another part of dentistry is on the tool. If you enjoyed this episode, then do check out the dental implant podcast by Dr. Pav Khira. And just a bit of news for you. So many of you joined the whatsapp group that we’re kind of full. And I’m really gutted for everyone who didn’t join the whatsapp group because we’re getting messages all the time now saying hey, what happens to whatsapp group is full. So we’re starting a telegram group, which apparently has a lot more capacity in a group. So I’ll keep you posted on that do join the protrusive Dental community Facebook group to get updates for that. Now the second bit of news I have for you is for those of you who’ve been messaging me about when we’re taking the next cohort of splint course delegates. Well that’s happening on the seventh of June as it stands. If anything changes I’ll let you know but as it stands it is seventh of June and all you have to do to sign up is splitcourse.com just leave your email address. And so when I’m ready to launch, I’ll email you. And this time it’s gonna be a two week window, and I guess I’ll email you all the different bits of information about what this course entails, the monthly coaching, the Facebook group, the case support, the handouts, everything you need to know for it. So if you’re interested in Split course and you missed out in the first cohort, do check out splintcourse.com register or DM me on Instagram @protrusivedental, and I’ll give you some useful information from there. Anyway. Thanks so much, and I’ll catch you in the next episode. Same time, same place.

George Cheetham, known as George The Dentist, is a restorative dentistry expert and social media educator. In their discussion, he shares insights on the growing trend of composite veneers versus simpler alternatives like teeth whitening. George emphasizes effective patient communication and the significance of documentation in practice. He also delves into the pressures faced by young dentists today, offering tips on enhancing online presence. Plus, he shares thoughts on the importance of humility and collaboration in delivering quality dental care.

‘An average Dentist working with an excellent Technician can go very far’, was the message my old training program director gave me. Technicians are often the unsung heroes whilst the Dentists collect all the praise and accolades. Who do we blame when things go wrong? Our technician, of course! Not fair at all – this is why I welcomed RDT Graham Entwhistle of Trueform Dental Laboratory to air his frustrations at Dentists – you will pick up some great tips here to improve your working relationship with your dental technician! https://youtu.be/NRDdRCg-9QI How to work better with your dental technician Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Use websites like Loom or even Whatsapp to communicate with video and voice with your technician. Great, clear communication will ensure expectations are met for both parties. SPOILER – the 5 things that Technicians wished we Dentists knew: Dentists need to improve their communication! Back to basics – if you want better work, you have to fill a better prescription form. Even just the lack of basic info drives technicians mad! We also discussed about Ivoclar Ingots for your ceramic Make sure your tooth preparation is appropriate for your material selection! Decide the material BEFORE you prep the tooth! Your impressions need to be clearer please! Do you always check for distortions, drags or voids? Could you consider trying Impregum? Shade guides – they can vary and can discolour over time. It’s important to ensure the shade guide matches your technician’s and the materials they use. Acrylic shade guides will discolour over time! We share some shade taking advice for Dentists Do you etch your own ceramic? If not, why not? Take control of your bonding, consider etching yourself to prevent ceramic over-etching. You can’t hold your technician accountable for your bond strength! Check our Graham’s work on Instagram! If you liked this episode, you will also enjoy the classic with Jason Smithson on eMax Onlays and Vertical preps! Click here for Full Episode Transcription: Opening Snippet: So do you trust your tech and if you ask for your etching to be done in the lab and then obviously the ultrasonic clean everything here but you're gonna hold me accountable for your bond because i've done the etch but then you've tried it in and you've had to re-etch i don't think your tech should ever be accountable for your bond i think that should be down to yourselves and when it comes to itching again back to communication tell me what you want and I'll do it... Jaz’s Introduction:When I was a foundation dentist, my training program director was Raj Rattan who some of you may have heard of his speeches, his stories are famous in the dental circles. He was a great guy, and he gave some really good advice to me. He said, ‘Jaz make sure you pick your technician very carefully.’ Because an average dentist with a good technician can go very far. Hello, Protruserati, I’m Jaz Gulati and welcome to this episode about five things your technician wish you knew. This episode is all about some things that we can learn as dentists from our buddies, the technicians, who honestly they work so hard and do such a great job for us. It’s such an important job, we’re the ones who take that final photo and upload it to social media. And we get all the accolades and the applause. But it was actually the technician who made those veneers or technician who made that beautiful crown and made it blend in with all that natural anatomy. So I think technicians need to get the praise that they deserve. And I’m hoping this episode, they can actually contribute in another way. i.e., I want Graham who is the technician. Graham Entwhistle, I want him to share his frustrations with us our basically learn what it is that we can improve so that it makes our technicians lives easier, and produce better work for us overall. So I actually didn’t send him any questions in advance of this episode, I just said just run through your five pet peeves, or five things that you wish dentists knew. And that’s how this episode was born. Protrusive Dental PearlSo before we join Graham and what he has to say on those five points and five lessons, I want to share a very relevant Protrusive Dental Pearl with you. It’s about how we can communicate with technicians better. Now we live in an era of WhatsApp and Instagram then why don’t we use it? In fact, the way I like to communicate with some of my technicians is via WhatsApp and on WhatsApp, I can send not only voice recordings and photos but I can actually show him videos of my patient, my patient smiling speaking so we can check the phonetics. And sometimes for my splints, if there’s an issue with one of my splints, I will make a video and I’ll send it to my technician say ‘Hey, can you please make sure that the OBD is increased or decreased or whatever.’ So I think that is the highest clarity or highest level of communication we can have. It’s so much better and less wordy than email, which we used to do. So I am a big fan of doing videos for communication. So I would encourage you all to do that. Now, if you don’t go the next level. I have mentioned it before in that episode with Finlay Sutton on Chrome dentures. If you haven’t checked that one out already, please do sensational content from Finlay on that one. We talked about the use of something called ‘Loom’, which is loom.com as a website where you can record your screen and record your video with a presentation for example. And you can share that very easily with other dentists, your patients, technicians or whatever. Now sometimes if you’re doing digital smile design and you want to involve your technician in it, and if you go to loom and if you start recording the photoshopped smile design or start adding your lines in or [lensing] you can actually do that while the video screen is recording, and you could be speaking over it. So your voice is also recorded. That way, it’s another dimension of giving your technician videos and you giving your voice instructions for how you want the future work to be. So again, the level of communication is so much higher. And one thing I was taught many years ago is when you do videos, your technicians you can put your emotions, your anger, your frustrations, your desperation for things to go right in that video and it makes it so much more human so I hope you enjoyed that pearl and let’s join Graham Entwhistle and five things a technician wish you knew. Main Episode:Graham Entwhistle welcome to the Protrusive Dental podcast. How are you my friend? [Graham]I’m very good. Thank you. I’ve been there haven’t had a hectic day but nice to be settled down and just chilling talking to you. [Jaz]Well I appreciate you joining me this evening and you are away from your family now if I remember correctly you have five kids? [Graham]Yeah just literally, just turned five children we had a baby girl on New Year’s Eve so yeah, hopefully the last one of the clan. [Jaz]Well congratulations for the latest addition. Tell me about is it was a boy or girl? [Graham]It’s a girl our first one was a girl and our last one is a girl so the rest of it all boys in between fight anymore boys. I think I would have taken a little one way ticket somewhere. [Jaz]What’s her name? The latest addition to the clan. [Graham]Hope. I think it’s quite suiting for the times that we’re living in as well as being a beautiful name. [Jaz]This podcast itself is about is more where you get to vent your frustrations in a good way, in a banter way, obviously, I’m going to make sure we don’t lose any clients and stuff. But like everything that technicians ever wanted dentists to know. But before we get to that, I just want to, for you to give an introduction about yourself, tell us about where you work, how long you’ve been a technician for, what your main interests are, in that sort of field. [Graham]I’m a one man band, basically, I have my own lab, it’s just me, I do everything start to finish on my own. I started Trueform Dental up in Harley Street originally with a friend of mine at [152 100 mile inshallah.] And yeah, he got rich on Bitcoin and decided that he was going to take some time off, and I took the brand, and I just bought our home pretty much. So I’m now in East Sussex, close to my family, I decided that I was never going to lead the sort of way that I’ve seen many technicians do, and not seeing much of their family and spend all the time in London in basements. And especially in the West End, everyone’s mainly in basements. And this year, you’re paying through the roof for rent. So yeah, I decided to make the journey home. And I started almost from scratch. I had one client who joined me right from the very start, and I’ve built from there really, so we’re very grateful, she joined me. [Jaz]Well, that’s cool story. But I want to touch on that actually, as a father myself got one kid, and he’s so energetic. And I want to give him a lot of my time where I can, but it’s a busy lifestyle. We live as dentists and as technicians, how do you do it with five kids? [Graham]It’s ridiculously hard work. And it’s hard to plan because as a technician, we don’t have a booking in sheet or wherever, where you’ve got your patients coming in at nine o’clock. 10 o’clock, 11 o’clock, 12 o’clock. We haven’t got that. So some days, we’ve got nothing coming through the front door. And as a technician, you just start worrying sort of, like no phone calls, no cases come in, no impressions, no lower [terror or Trio scans.] It’s just like, what’s happening, and all of a sudden on Thursday, we get this absolute blog load of work, come through the door, and you’re just like, right, now we expect you to do all of this. Now, in our last three days work, pretty much. But the thing is, even if you’ve got little dribble of working, and if you’re not there getting it done, then that happens. And then you find yourself under the [cosh.] And that’s when you just start working ridiculous hours. So just stick with it, keep going and the work will turn up on your front doorstep. [Jaz]I never appreciate I mean, thank you for giving us that insight. I never actually thought about it in that way, especially as a solo technician yourself. I can now put myself in your shoes and appreciate that your work comes when it comes. And sometimes you might have quieter days. And sometimes it might come all at once. So kudos to you for raising a family of a beautiful five kids, including Hope so that’s amazing, man, I’m so happy for you. As a father, it’s so tough, especially in your industry. So hats off and keep going my friend keep doing the time for both family and for profession. But this episode is going to be all about profession. So give it to us, Graham. Don’t hold back the five things that you wish dentists would know or start doing better start with number one, what is your biggest frustration with dentists? [Graham]The first thing and foremost is the communication that you get with dentists. And it’s not always there, some are really good at it, and some are really dismally poor. And you’ve got no control over that really sometimes and you might get a lab ticket, you’ve got no phone call, nothing got to tell you that the worst can arrive, you get the lab slip, and he says, Emax shade sito. And that’s it that’s the detail that you’ve got, a little [tooth implantation] most of the time, that little date return date box is filled, but it’s not always filled in, it’s just kind of so already, I feel like I’ve got to make a phone call on the job. And it’s just I’ve got the time to make like 10 phone calls, it’s just based on the lack of information that we’ve got. So yeah, lab tickets, I mean, I’m quite guilty on it to update my lab ticket because it doesn’t ask for enough detail. So, I asked for a shade, the stump shade, it would be nice to get some sort of patient expectation from that shade and any information on whether there’s any adjacent restorations, because trying to match in Emax, for instance to upon [post lane, Bonded Crown] can be really quite difficult. And you choosing the right [in guts] can be really difficult on that sort of side of things. [Jaz]I guess the ideal dentist for you would be I mean, with the whole date thing. Yeah, I mean, totally. They should always be giving you a date, because it’s just how the world woks. But when it comes to the lack of information in terms of all they said is A3 Emax and that’s it. That’s sometimes, it might be because the dentist may not feel they need to give any more than that then fine. We can discuss that. But it might be actually due to a lack of knowledge from a dentist, right? So let’s educate them right now. In one minute. What additional information can they give you with prescription that will really, really help you. [Graham]Any sort of additional features of the teeth. Whether you want a heavy contact and light contact or contact point, every dentist kind of has their own way of doing things. So especially if you’re a new client, or we haven’t done any work together on, I haven’t done much work to give as much detail as you can put onto those lab sheets, the better. Obviously, I’ve done crowns where I’ve just had to shade and I’ve done it, I’ve pressed it in a light, medium translucent ingot, for instance, and the core has been great. You haven’t told me that, but you expect the remake done for free? And it’s just like, well hang on a minute, is it really my fault? I don’t mind meeting you halfway, you know, seems it’s a first time incident. But if it happens again, then I’m going to have to charge you for price. So it’s all time taken out from myself. And like I said about other details, lead, return dates, if they’re not there, I have to ring you up. And sometimes I’ll get a return date. And it’s a week and I asked for two weeks. But you haven’t phoned me up to ask me about that. So I’ve now got to make that phone call again to see if I can actually squeeze down. [Jaz]Three things we can learn from that in reverse order. One is if you want a quicker turnaround, it’s just common courtesy to call your lab and almost like book it in like ‘Hey, heads up in three days’ time, impressions coming, I want a one week turnaround’. It gives you an opportunity, Graham to actually structure it and fit it into the right slot so it gets the right time. So that’s for sure. In terms of the ingots that some dentist might be listening to this young dentist and they weren’t they might not be familiar with this, Graham, it’s not actually common knowledge. A lot of dentists don’t know that Emax or lithium disilicate from Emax from Ivoclar, it comes in different Ingots. So like there’s high opacity, medium opacity, medium translucency, low translucency that there’s five. So sometimes, maybe if you haven’t heard about this, that make this episode, the turning point where you’re going to go and find out that information, maybe I’ll link to something on the Iveclar website for that, which would be good because that will help your technician. And the third thing we can learn from what you just said that is give an occlusal prescription is not okay to just say, this is the shade, this is the crown, it helps a technician to say there are [shimstock called] on these teeth, put the crown it lightly inclusion in MIP with shimstock. And then you have something to follow as an occlusal prescription. Do you think I’ve summarized that well? [Graham]Yeah, I think that’s quite a fair summarization, really, especially if you’re looking for a top end job. If you want everything just a drop in place. And I’ll come on to this a bit later on. Especially when you’re just dropping things into place in some of my clients, they like just have everything ready, and they pop it in. And they don’t have to touch anything. But that’s because they’ve given me the right details, or we’ve been working together for a long time. But yeah, some dentist, obviously, you’ve got to try these crowns in first, make any adjustments that you might have had, and every dentist got their own way of doing their own impressions, they’ve got their own ways of doing their temporaries. And sometimes, the temporaries are swelling, you know, and pushing the adjacent teeth slightly apart, or they’re just shy of that. So didn’t the restoration of made doesn’t quite fit as well as it should. But we’ll touch some of this as we go along. [Jaz]I’m going to flip it around for you, Graham, and this is not against you. Because the fascinating thing about this podcast recording is and with respect to you, Graham, I really appreciate that you’re a solo worker, I know you’re a busy guy, and you’ve got lots of clients and stuff. And if anyone wants to use you again, great. But I know that’s not what you’re on here today. I think you’re on here because you’re passionate about I’ve got you on because you’re a passionate technician, you haven’t got anything to sell. And that’s why I want to bring you on as great we can have this discussion, but I haven’t used you yet. And there’s not say I might not use in the future. I haven’t used it before. But so this is not an attack on you. But recently, I sent a resin bonded bridge to a lab, and I wrote my prescription and I can tell you now it’s a long essay, I write for these resin bonded bridge, because I want them done and specifically. So I am almost like a dream client for you with the information that I give. But I wanted the technician to cover over the premolar with the resin bonded bridge retainer. And I gave that very clearly in prescription but sometimes it doesn’t come back and then I have to send it back to labs like no cover, do what I said. So sometimes technicians when we give these a detailed sort of descriptions and whatnot, sometimes technicians will read it, they will not follow our instructions. So that’s me airing out our frustration. What do you say to that? [Graham]Well, I suppose it depends on where you’re sending your work. If you send it to a sole trader, like myself, and the content is good. I mean, I use a lot of WhatsApp, if I’ve got anything that I want to do differently to your sheet. I will use WhatsApp and leave a paper trail I’ll ask you the questions. You’ll verify it with me. If you verify it and say ‘yeah, that’s okay.’ Or then there got it in writing. So when it comes to fit, and you tell me ‘Oh, I asked for this different I’ll just write well, actually, we said this, that’s what it’s about. It’s about everyone taking responsibility, having that communication in place. But yeah, if you’re going to say send it to sort of lab work. [Jaz]So what I like about that Graham is that you said about the WhatsApp, right? So you would send the framework for example, right. But you maybe send a photo or a video the framework? [Graham]Yes, or send photographs, anything like that. Although, with WhatsApp recently, I know the kind of the privacy is changing, so I’m going to probably have to swap that as well. But yes, we live with paper trail, you can send pictures, you can send a video if you need to give someone a little walkthrough or talk of what it is actually you’re looking at and why you can’t do it that way. And give someone a justification for doing or suggesting to do what you’re doing. [Jaz]That’s a great one. So if you have a technician that you work closely with to exchange on WhatsApp is really good. [Graham]Yes, from your point of view, if you send some work to a larger lab, for instance, you’ve got four or five technicians there. Sometimes things can get lost in translation. And that’s where you end up not getting exactly what you wanted. [Jaz]I do agree with you, Graham, I think that’s what it was. But it got sorted in time for the patient, but it just yeah, an opportunity to have that kind discussion with you, buddy. Hit me with number two. [Graham]So number two, is kind of to do with material choices and prepping. So basically, does your prep, accommodate the material choice for your restoration that you’ve chosen for that, and I say this because going back to Emax again, unfortunately, Emax does not like it doesn’t like sharp edges, and it doesn’t like knife edge preparations. So now it’s down to mainly the particle size of the Emax particles. And if you polish them down trying to taper in nicely, so you haven’t got a step. Sometimes, because the particle size is quite large compared to Zirconia, for instance, you can just polish it away, and then you end up shot at the margins. And you end up with cracking and- [Jaz]So yeah, absolutely. So as a dentist, we should be having a better command over materials. But you know what Graham, sometimes it’s a tough call, I say that. But I think there are some dentists out there who may begin a prep of a tooth for a crown. And they haven’t already decided in their head, which material the crown will be. And I’m guilty of this in the past. When I was a newly qualified dentist, and through lack of experience, I sometimes start prepping, and I’ll be thinking, I’ll see what the prep looks like at the end. And it was a lack of experience, lack of knowledge at the time, many years fast forward, you know that you have to begin with the end in mind, because only then can you create the correct preparation. So as a sweeping statement, Emax, you summarized it beautifully, no further edges, and no sharp internal line angles and sharp bits in general. So make sure it’s nice, smooth and flowing. Any other tips you want to get for any other material? [Graham]So when it comes to bonded crowns, as well, if you’re looking at leaving knife edge margins, don’t expect a nice back fit with the ceramic, you will probably end up with a slight gray line. So unless you shamfed for these things, or give us a porcelain back fit margin, then don’t expect a lovely looking fit onto the model. So, for instance, if you got a bonded crown, and you’re doing it supragingival, try and give us a little edge. And then we can blend the restoration in nicely without any gray area showing through. [Jaz]How much space do you want at that margin ideally to be able to get a more aesthetic result to be able to not get the gray show through? [Graham]So for metal ceramic, I would say at least 1.3 millimeters at that margin. That’s my preference. But with Zirconia 0.5, Emax 0.5 as well, really, and then you can get a nice [pressing six], they’re flush. And you get no defects. If you’ve got a good technician who knows what they’re doing. [Jaz]And with that Zirconia, we said, 0.5, would that be left monolithic? Or would you always layer it, any advice on that? [Graham]I don’t know the materials these days, especially over the last few years, the materials have come on leaps and bounds. So we’ve now got all these almost layered Zirconias within themselves. So they’re multi layered. So you’ve got the core and the enamel, are dependent on how they’re set in the disc, and they’re in the software themselves. And you can get some really nice results. So on the original multi-layer, though, I would say that, you had a graduation line. But now this is kind of tapering out and you get some really nice ones coming through, and they’re blended really nicely. So I tend to use something called [ADA] for quite a few of my restorations and it’s a bit softer on the occlusal compared to some of the really hard zirconias that are out there. So it depends on the lab you’re using, you really got to ask them what is the county as they really use and what they’re suitable for. So again, this comes down to communication. So I tend to use some really hard zirconias for bridgeworks. And I tend not to go past two pontics together as well. So big abutment, pontic. If there’s another Pontic you can’t ever work from me. It’s going to be a bonded bridge all day long if you’re going to go for a bridge, although I’ll still think fit Fix bridges. They always fail over time. But yeah, that’s just my point of view as well. [Jaz]Amazing. Great points there. And one thing I want to add on for the dentist listening to this is grooves and slots generally a no, no, for zirconia. I think you should go for more rounded hollows than actual traditional slots, which are better suited for metal work and gold. Would you agree with that Graham? [Graham]I agree, especially with the smaller style slots, you got to think at the end of the day, the [Zirconia always nailed.] So you’ve got to think all these little tools that go in and mail out that they only get to certain sizes. And obviously, if they’re slightly bland, and they don’t quite get in there, then it doesn’t fit down quite properly. And then the technicians got really all that next thing you know, it’s loose, and it’s just like wobbling everywhere. So yeah, it’s not really ideal. And to put all the grooves in just something nice and almost parallel, just a couple of degrees like a customer, [Batman,] for instance, would be ideal for in Zirconia. [Jaz]Amazing. I’ve enjoyed those two so far. Material choice as well covered. Number three, hit us, Graham. What are the next frustrations that you want to ease out with dentists? [Graham]So your impressions, almost everything, you can be great and spectacular, that you’re prepping. But if your impressions don’t match that sort of standard, then unfortunately, your lead words going to come back and be nowhere near that standard. So please always check your impressions for any distortions or drags. Or if you’re not getting to grips with certain types of light body and putty sort of impressions, why not try if the situation suits you, why not try Impregum, that there’s one thing that I have never had problems with Impregum impression given to me that prep is always pretty much spot on. [Jaz]What are the most common errors that you would get from impressions that you mentioned a few there? But what is the biggest bugbear? [Graham]Biggest bug bear? There’s a few things really. And again, it just depends on expectation from yourselves as dentists, lots of people hate triple trays, for instance, and some people love them. But I would say they’re great, and they’ve got their place in dentistry. And they can be used to good effect, but don’t always expect your final fit to be perfect, because obviously, you haven’t got all the excursions of the whole arch and is for the occlusal function is not there for you to see or use. So, yeah, if you can use a triple tray, don’t expect the occlusion to be smack on. But everything else should be pretty well. [Jaz]I think the internal fit would be fine that it’s more about, yeah, like I said, the excursions were triple trays, which may not be on point. Well, there’s a live stream I did. And people can watch it on Instagram or on triple tray. So you can check that out. Sorry, Graham, I interjected. [Graham]The other thing is mainly drags, especially around the preps and adjacent teeth as well. So sometimes you can affect the emergence profile, because the drags come down off the adjacent tooth and your contacts as well. So if you check your impression, you can probably always check your prep, but do you do check those adjacent teeth. So for the contacts, if you’ve got a drag on that, then obviously, on playing guess, guess how with you and you could end up being shy of the contact at the fit with the patient. [Jaz]A really good tip I learned once was when you’re taking your final definitive impression. Let’s say you’ve got multiple preps is all around if you’ve got some big undercuts, some big embrasures spaces between the molars, block them out with either wax or ptfe tape anything you can to get a better path of withdrawal, that’s not going to put stress on your light body. And that is a good thing that I think Jason Smithson taught me that. So I just wanted to throw that in there for the dentist listening because that will help to get a better impression, less distortions, less resistance to removing and then less of this sort of breakdown about impression material. I think. [Graham]That’s a nice tip. Yeah, also, when you’re doing sort of overlays and onlays, the detail underneath your prep line is also very important. Because if you want me to keep the harmony of the natural tooth that’s already there, and bring it back to kind of its normal life position, then obviously that detail is also crucial. So yeah, depends on how good a job you would write down with the case. [Jaz]Obviously, with the onlays. We want to be supragingival because we should be especially if they’re Emax onlays we should be doing them ideally with ideal isolation under rubber dam. So we will be supragingival or maybe equigingival or deep margin elevation, that kind of stuff. So in those cases, yes, it’s important to give you as much detail beyond the margin so you can get that proper emergence profile. So I totally agree with you on that as well. Number four, we do well for time Graham, I’m impressed. [Graham]How long have we been carried for? [Jaz]25 minutes and this is good. I was worried that you’ll be ranting and then complaining about us, dentist all day long. [Graham]I’m not here to complain, I’m just here to give you guys some pointers, you know? [Jaz]No, no, I appreciate that you are helping us so much, you are helping us so much, please keep going. [Graham]So number four is shade guides and shade taking. So say for instance, you’ve got a shade guide, it’s a generic [v to classical,] just like my one. But it might not be like my one, your one could be 10 years old, you might have left it in the sunlight for a while, and these things discolor over time. So not every shade guide matches another shade guide. So it helps if you for instance, have I try and supply my dentist with a shade guide that belongs to the lab, and also matches the materials that I use. So it becomes easier then to match these things up. But obviously, if you leave these things in random places, especially if they’re made from acrylic, they will discover over time. So yeah, before you’ve been your technician see how odd you show guide is and see if it matches up to your technicians one, give him a chance. [Jaz]When you send your clients, the shade guides, do you send them the generic ones? Or do you actually send like samples of porcelain like from the porcelain that you use. Is that something that you do? [Graham]Well is close to that I would love to be able to spend the time giving everyone the porcelain firing and do porcelain fire in every shape. I don’t have the time for that, unfortunately. But what I do is the company, I mean, I use GC products, use lots of them. And it’s quite a generic fill. Across the materials, everything’s got the same name, whether it’s like Lisi or whether it’s metal ceramic, or whether I’m using Gradia Plus, everything has got the same name. And it’s got pretty much the same color. So far, give everyone a set of shade tabs for that, and they pick a generic shade, and then they pick an enamel to go with that, then that’s great, because I know then I’ve got to match, maybe an A3 and a more with the A2 shades, we can get better results. And you can a generic, classical straight guide. Obviously, if there’s any internal details, I’ll give you a whole load of colors that are on there, just pick out a shade tablet, if you’re looking through, you see the color in the tooth. And instantly if your eyes seen that color, that’s true, pick it out and put it in the bag or put it in a box. Because if you start looking again, you’ll actually find that your eyes trick you and tell you that that color is not there. So you look on the next one, you pick out the next one. So yes, that one is it probably was one before because that’s what your eyes have seen. First, your eyes are drawn to it. That’s true. So yeah, hopefully there’s a couple of tips there for you. [Jaz]There certainly are. Have you have you dabbled with the eLAB protocol? [Graham]I haven’t actually, I do everything myself, I can take shades, I don’t mind taking a road trip, as long as it’s not too often. But a lot of photography really helps in the right type of light. And obviously, you’re holding the shade tabs up against the adjacent tooth that you want to kind of match, not the temporary that you’ve got in there. And also talking about if you already taken a shade match or shade tab with a temporary there, you’re probably wrong, you should take the shade first before the teeth are dehydrated, otherwise, you get a shade discrepancy at the end. So if you take your shade first, then that’s the best way to do that. Take some pictures of some shade tabs in there. And obviously, if there’s internal details, take some nice pictures tell me the random colors that you’ve seen in there. And I can mimic that to the best of my ability and generally good success rate. And I’ve heard that a lab and you know others don’t have the success rate that they maybe should have. So overrated software. [Jaz]Brilliant, I appreciate that. And it’s want to give a dentist a little tip on composite work actually, the shade guide that we have for composite a lot are made of acrylic so they’re not true representations of the competent itself. So I’ve actually got a little kit, I got them from style or style italiano, you can actually make your own custom shade guide with a dentine and enamel using whichever composite system you want. I haven’t actually built them yet because I still haven’t found my go to composite. I’m still in that phase where I love my genial I use it. But I’m getting to a stage where it’s going to be out of date soon. I bought it some years ago now. And I also want to use what my principles are by me as well. But I think as a practice, we switch to one and then we all like that system. It will be it will just work better. So I’m waiting, I’m almost there. But that’s one system that I like to use to master that system and then I’m going to be making these custom shade guides. So I’m quite excited to get that done. Sounds very geeky. I know. But yeah, just that’s why I rely so heavily on putting little buttons of composite and curing them before I choose my shade because that gives me so much more information than an acrylic shade guide would do. So just want to throw that in there for the dentist. And then number five, my friend Graham, please tell us what is your final frustration with dentists? What do you wish that we all did better. [Graham]I was actually talking about this with a fellow technician the other day as part of my support network, great tech. But we were talking about etching restorations for your dentist. And why do we do it? Why do people ask for it to be etch now, either you’ve got a great trust with your technician, like I was talking about earlier, I’ve got a couple of clients who just like to just pop them in, without even checking, so that’s fine. If you want the matched, then I expect you to be pretty much doing that. But if you asked for them etch, and then you go and try it in the mouth, you make some adjustments, and you take it out, and then that etched layer is then compromised. So you then have to clean it all off yourself and re-etch it. And then at this point, you can over etch and you can end up with a really gravelly, grainy, fit surface. And depending on the translucency of the material that you’re using, it can start having an effect on the actual shade, and color of the restoration. So do you trust your tech, and if you ask for your etching to be done in the lab, and then obviously, the ultrasonic clean everything here, but you’re going to hold me accountable through your bond, because I’ve done the edge, but then you’ve tried to in and you’ve had to re-etch. I don’t think your tech should ever be accountable for your bond, I think there should be down to yourselves. And when it comes to it, again, back to communication, tell me what you want. And I’ll do it. [Jaz]I think it’s good to be prescriptive with the etching as well. Because what I like to tell my technicians to do is I will say use 5% hydrochloric acid for 20 seconds as per the protocol that I learned I use I hope I’m not putting you on the spot too much. But is that the concentration? Is that the time that you’re doing? Or do you follow a different protocol as per manufacturer’s guidelines? [Graham]It depends on the manufacturer guidelines or the acid that you’ve got yourself. So the acid etch always comes with its own set of instructions, and some is generally about 20 seconds, I do all of mine for 20 seconds, but some of the 30. So ultimately, I suppose it depends on the concentration of the etch liquid that you’ve got yourself. And obviously these over time span as well. And they vary, they get stronger and weaker over times. [Jaz]I respect that massively. And I’m glad you do that, because there was a technician or chain of technicians I was using some years ago. And the onlays would come back and they’d look like super rich, they look like really chalky and I email saying, which concentration are you using? How long using for? Are you following my instructions? I didn’t tell him what my instructions were because I write them in every case. I said how long you’re doing for the email back a photo. They said, yeah, we used to do it for about 60 to 90 seconds. I’m like, No, you’re re-etching it. So totally, it’s totally worth picking up the phone emailing and just confirming make sure that every technician within that chain knows what it is that you want. So that I think the ideal way is exactly how you said it. If you can be anal about bonding, which we should be we should be anal bonding, then perhaps it’s time to do your own etching. [Graham]Yes, yeah, I agree. If you want to be 100% in control, do it yourself. That’s the only way to do your job properly. Especially if you want to do your try and have the crown [slashed,] you should be in control of that. And just let your lab send it to you, cleaned, steam cleaned or in the ultrasonic. [Jaz]Amazing. Graham, that’s it. that’s a five. And I really appreciated that we did it in a really good time actually, this will make for listening will episode some I absolutely mammoth 90 minute ones. And sometimes you’ll feel bad for the listeners. So this could be great. I think what we’ve covered was really impactful, I think was really fresh, I think it was a real opportunity for technician then to sit down and just talk things out. And I’m hoping that hundreds, thousands of dentists out there will now be in a position to pick up the phone and have a better relationship with their technician. And hopefully, you picked up a nugget or two from Graham and myself to improve your technical work Monday morning. [Graham]I do have one more nugget, if you want to. I have missed it out. [Jaz]Please, please. Let’s have it. [Graham]So if you’re interested, it’s goes back to your prepping, basically. So it’s about emergence profiles and your contact areas. And we did touch this contact area thing earlier. Now sometimes you get an overlay that comes into the lab, and they want their contact areas, nice but then again, you find yourself that the gaps quite large between the sort of like mesial contact point, but then you’ve got a really, really high prep line. So trying to get it across to that you’d end up with a big over contour and creating a food trap, which is probably what helped cause the problem that is totally in trouble for in the first place. Now the tip that I’ve got is if you drop all these distal one mesial margins lower, you can change the emergence profile of that. So to then come up and bite against the contact nicely. So yeah, that would help myself and yourselves no ends if you can then pick up and do all that. [Jaz]That’s a fantastic tip there and I’m going to make it extra tangible for the young dentist who may not have got that I think you explained it. Well, I just I think if I was one or two, you’re qualified I might have thought, I don’t understand what that quote means maybe. And basically, imagine your crown comes back or an onlay comes out and overlay comes back. And there’s a big distance between your prep and the tooth behind. But in the situation that you described, you get like almost a pregnant appearance of your overlay because it has to stretch all that way. But you can put, like you said, If you prep a little bit more South a little bit more gingival, it allows you to get a less pregnant looking contact, that actually has a better emergence, hence, the term emergence. So that, Graham, I’m so glad you mentioned that. Because I think, when we come to prep, and looking at our contacts that we’re hoping to achieve these contact areas, it will be so much better now. So, Graham, with that, thank you so much for coming on today and sharing your time. And thanks for following as a technician. I mean, when I made my podcast, I never thought that technicians would listen. So honestly, so flattering, and I really appreciate you being a supporter of the podcast. And I wish you and your family all the best. It’s amazing, this busy life you live, and I’m so happy that you’re able to give up some of your time to join me today. [Graham]Yeah, that’s been great to come on. It’s been nice just to have a little change of what I do from day to day, I’m lucky as a technician, I get to have breakfast with my kids, because obviously, I work just up the road from where I live. So I get to pop in and out almost as in when I like, which is nice. But just to have something different than the current climate is really nice for me to stick as well. [Jaz]Are you in a position to accept more clients? I know you’re very busy. But some people might have listened to this today and thought you know what? This Graham guy, he sounds really nice seems sounds really good. I’d like to send him some cases. Would you mind dropping me your details? So I could put on the website? Graham, is that all right? [Graham]Yeah, you can put Trueform Dental up on a website, on Instagram. Obviously, that’s probably my primary source. Although I do have a website. I’ll give that to you afterwards. But yeah, I do have some limited space for some clientele. So anyone who’s interested, I like to focus on quality. And that’s what I’m about everything is done by myself. And if I can do it. [Jaz]nyone locally to or even obviously, you can accept scans and stuff, but anyone local to have that relationship that can visit you as well. That’d be a really good opportunity for a dentist who’s keen, who’s looking for that technician. So definitely check out Graham is at @TrueformDental. And again, I will link that in the show notes on protrusive.co.uk. Graham, thanks so much. [Graham]No problem says, Have a nice evening. Jaz’s Outro: Thank you so much for listening all the way to the end, I hope Graham brought you some value there. If you want to check out his profile, I’ll put it on the website. So you can go to protrusive.co.uk, find this episode, and I’ll put a link to all his profiles, his lab, I know he’s super busy, so he probably can’t accept too many more clients. But I’m sure be happy to help you out where he can. I know I’ve mentioned it before, but we are having a Protrusive Dental community or Protruserati WhatsApp group, if you want to be in on this, you got to join the Protrusive Dental community Facebook group, if you can just search it on Facebook. And once you’re in there, there’s a whole thread about the coming upcoming WhatsApp group, you just put your mobile number there, and I’ll make sure I get you on I’ve been promising this for a while. It takes a long time to add every single person as a contact and then make the group but I am getting some help with this soon. So hopefully by time you listened to it, you’ve joined in the party. And eventually we can have that WhatsApp group that some of you have wanted. So do join that if you’d like to take part. Otherwise, I’ll catch you in the next episode, which I’m going to keep a secret, but I’m going to tell you this, this episode is going to absolutely blow your mind. It’s going to be sensational. It’s someone with some very famous and you will absolutely love it and I’m going to keep it a secret. So I’ll catch you in the next episode, same time, same place.

Lower Complete Dentures are the bane of Removable Prosthodontics. I know many Dentists who ‘hate making lower full Dentures’, likely because they are difficult to master. So difficult that I got Dr Rupert Monkhouse to give the Protruserati a podcast masterclass on how to improve in this frustrating area of Dentistry! https://youtu.be/cW41CHiLgGI Why won’t you stop floating, damn you! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: The power of silence! When you present your patients a solution or treatment plan, or tell them the fee, there may be a silence. Embrace it. Expect it. Don’t panic. This is normal! DO NOT but in with a ‘why don’t you just think about it…’ In this episode we discussed: How can you predict if a suction lower denture is anatomically possible? What materials Rupert likes to use What and how to adjust at the Try in stages of complete dentures How to get the wax try-in to stay in the mouth! Communication pearls surrounding lower complete Dentures If you enjoyed this topic, why not also check out the Master himself, Dr Finlay Sutton on Troubleshooting Chrome Dentures! For details on Rupert’s Denture course, DM him on Instagram! https://www.instagram.com/dentistrupert/ Click here for Full Episode Transcription:  Opening Snippet: I think pros actually is quite not easy but it's it has a few basic concepts if you master those and then sort of extrapolate them you can work out more difficult cases you know. Jaz’s introduction: Now we all know how annoying lower complete dentures can be. I could probably think about four dentists in the entire world who liked doing complete dentures. And the secret is because they’re good at it, right. And one of those dentists that I can think of is Rupert Monkhouse, who is doing some sensational things with his patients, with his photography. It’s just absolute art. And I’ve got him because he’s so good at removal prostho. So today we’re talking about exclusively the bane of our existence in removal prostho, which is a lower complete dentures. In this episode with Rupert, we’re going to ask about how to get more predictability, if that’s even possible with the lower complete dentures. What are the signs that actually you may be onto a winner and that you may be able to get a suction lower denture, that elusive suction from a lower denture, which you see flaunting on Instagram, I probably achieve this twice in my career so far. We’re able to get the lower denture suction, and both times you pull the camera out, you record it because it’s such a proud moment, right? To get suction on a lower complete denture.So I’m going to ask Rupert, is there a formula? Or is it all luck? As well as that we talked about all the different stages that Rupert utilizes to help him get a really stable, lower complete denture. Protrusive Dental PearlThe Protrusive Dental Pearl I have for you is a communication one. It’s something that I think as a profession on the whole, we’re not very good at and something that we were never taught. And now when I learned this technique, I guess it’s a technique in communication, it really made a huge difference. And I remember one time in Reading, we were doing an Invisalign open day, and I had two other dentists in the room while I was doing a consultation. So we were taking turns, one person was right in the notes, the other person was filling like the radiograph requests, that kind of stuff. So we’re working as a team for this Invisalign open day. And I went through my entire spiel, I showed the before and after’s I listened to the patient’s wants and needs and how we can help this patient to have a better smile. Now, when it came to the close, i.e., it’s going to cost this much and this much time, is this something you want to proceed with? Right, so that’s called a close when you close a treatment plan. When it came to a close, there was a silence, i.e. I finished speaking. And now there was an awkward silence. Now what happens? Imagine you’re going to a patient, you’re going to say to a patient, you need an implant and three restorations and the cost will be 6000 pounds. Okay. And then once you said that, what happens next? Well, usually there might be paused for like, a couple of seconds before what happens usually after that pause? Usually the dentist might say, okay, you can think about it if you want, or the dentist might say, does that not make sense? Because for some reason that pause is something that we can’t fathom, is something that we can’t tolerate, is something that we kind of panic from that pause. Right? So the lesson here, and what I did that day, was that I just let the pause happen. Okay, I zip my mouth shut. I said, it’s going to cost this much. It’s going to take this much time. Is this something you want to do? I just paused. And it was around about a 20-second pause, right? Imagine three dentists in the room and the patient, and there was a 20 seconds pause, that 20-second pause, seemed like probably like five minutes. It was it seemed like an eternity, right? And the patient said, “Okay, fine, I can do it.” And then she’s now having Invisalign with one of the dentist at the practice. So the lesson we can learn here is A) respect the pause, he or she who speaks first loses, so don’t speak first, let’s give that patient the time. And the way I learned is that patient needs that time to just figure out “Oh, which day can I come in? How much money do I have? How can I afford this? Is this the right thing for me?” In the patient’s head, they’re probably thinking they’re taking about three or five seconds to respond. But they’re in like a trance. They’re really just thinking about a few things. And once they’ve made up their mind, they will then answer. If you rush the patient, or if you interrupt the patient it’s so easy to say to them. Think about it. And what happens is they go home and they think about it, and the rational brain takes over, because why? Cosmetic dentistry Invisalign is an emotional purchase. Okay? And when they say, you know what, I rather go on holiday, and that’s it, they won’t be having the treatment anymore, which is a shame because who loses out? I think you lose out but the patient also lose out because how many patients do you know who’ve had cosmetic treatment from you? And regretted it? Very few, probably none, because they all want to have a better smile are so grateful. And quite often you hear this time and time again. They always say I wish I’d done this treatment sooner. So that’s my elaborate communication Protrusive Dental Pearl for you. Start respecting the pause. Don’t panic. Give the patient the time to breathe and the time to think. Hope you enjoyed that one and I hope you enjoy the session with Rupert Monkhouse. I’ll catch you in the outro. Main Episode:Rupert Monkhouse, Welcome to the Protrusive Dental podcast. How are you my friend? [Rupert]I’m good, man. Thanks for having me on. I’m really excited to be on having a chat with you, [Jaz]Man, I am so stoked to have you on mine. The level of dentistry, level of just removal prosth that you do like it’s similar to what I said about Finlay because I know you listened to it, the Finlay episode is like the same thing I said to him, I say to you, you are making removable prosth sexy, right? Because sometimes I wonder and we were just having a chat before we started recording, I actually thought you limited your practice to removal prosth, but then I found out you did extirpation today, you did some fillings or whatnot. And just it’s amazing that the level that you’re doing this and the way you’re documenting. So the first thing to know is for the listeners, test a little about yourself and how you got into removal prosth. And why not composite veneers? Why not facial aesthetics? Why this seemingly specialized rule of prosth, which you’ve made sexy, which is great. [Rupert]Yeah, I mean, I graduated in 2017 from Kings. And that’s really where it sort of came from. Mainly as my third year tutor we did removeable started that in third year. And I just had one of those tutors that’s just so passionate and such an incredible teacher. [Jaz]What’s the name of the tutor? [Rupert]Andreas Antonopoulos. He’s out in Cyprus now. But he was running [maxbox] prosthodontics as well. I think he still pops over to guys to do that. And so yeah, he was my third year tutor and just got me sort of sucked in with it. I went and did my FD up in hole and they had the sedation contract for the area. So we’d have once a month loads patients coming in for sedation. If they didn’t have complete or immediate dentures, they got sent to the FDA to make up a pair pretty [sharpish], I got loads of experience there. And we had an in house lab there as well. So I was always popping in with a technician and we had a CDT there. So yeah, it’s just sort of really thrown into it. And I just like the amount of change you can get especially like completes I think I said on a post the other days, it’s a blank canvas, you’ve got a lot of control on what you can do. And yeah, I just find it enjoyable. I do all general dentistry, but my practice on Instagram is limited, removeable is at least. [Jaz]Man, your passion just shines through. And I love hearing people’s origin story. Because a lot of people, a lot of dentist ask how do I know what my niche is? How do I know what kind dentistry I want to sort of niche down into it? And I love your story that hey, you had an influential tutor in dental school. And then you were in, you happen to fall into a practice whereby there had this contract with sedation, and you were seeing tons and tons of removal prosth, which obviously just fueled your passion more and more. And now you’re in a situation where you’re really taking wonderful photographs and these brilliant cases. And listen, today is all about suction lower dentures, right? Because lower dentures are the bane of all dentists. And it all came about because recently on my Instagram, I posted one of my few cases I have where I managed to achieve suction on a lower full or lower complete denture. And in the comments on someone there and said, bring Rupert on I think that’s how it went. I was like yes, totally this this sounds amazing. So I’m happy to have you on and I had Mark Bishop on, we talked about all things complete dentures. Then I had Fin about Chrome dentures. So I’m being a bit harsh to you. I’m giving you the most difficult thing to discuss in removal prosth, but let’s go with it. So the first question I have is, how do you know which case you have a chance? Right? When do you know Okay, you know what, I’ve got a chance, or do you always have a chance? Or are there some situations where maybe you want to throw in the outward classification something that you think you know what it is impossible to get a suction lower denture. Give us a flavor of that. [Rupert]I wouldn’t want to ruin the episode straight at the start and everyone logs off. But I don’t think you can know, as you say, like outright, this one’s going to be great. This one isn’t. Because I’ve seen like the full range I’ve got a couple of videos on my page was probably ones that you’ve seen or people have asked to see. And the one chap he’s got the most beautiful ridges, big wide awesome ridges, great upper no suction and then I’ve got a lady’s got these non-existent inverted and it’s got suction as well. And so you’ve got the two extremes and you get it but I don’t think you can ever know for certain. But as you say, I think you can achieve it with any ridge you just got to sort of back yourself and go through with it. [Jaz]So, Rupert, what percentages do you think is luck? And what percentage do you think? It’s because I put it down to luck when I get it. I was lucky. I just got lucky. Right? But how much a skill on a different patient that might not work but on this patient, it did? Is that a fair question? I don’t know. You tell me. [Rupert]I think it’s 50-50 to get it [where you don’t isn’t it?] So now I think you’ve got to do everything the same all the way, that each time you do it. And then it’s sort of it’s going to even itself out over the course of it. But I’ve had patients where they’ve come in and thought oh this is going to be an awesome good chances suction here and I’ve text my technician with the primary instance they are they made this going to be a good one. And we haven’t quite been able to get it. But I think actually though it comes down to is suction actually important to what is going to make it a successful treatment for the patient as I’ve never had a patient come and say I really want a suction lower denture, please. They’re gone. My lower denture is not that great. I want to make a new one. So it’s great to have but I don’t think it’s not the be all and end all. I think a supportive denture is probably better, because then you’re more likely to get that stability, which is what they really need. [Jaz]Brilliant. And by supported you mean, like some implants. So Implant Supported dentures, you mean? [Rupert]Just supportive in terms of that would be if you go right back to my third year tutor, and you’re saying he had the stability triangle. So your stability is your balance of your support and your retention, resistance away from the tissue support, resistance towards the tissues. So particularly for the lower gravity is helping you I think issues that patients have is when they’re biting and there isn’t that much support, and it brux it displaces you’ve lost the stability. And no matter how much suction or retention you have, if you’ve got rubbish support, you’re going to lose your retention anyway. Because it’s not going to be able to overpower that see soaring or whatever it is. So I think actually, I personally, I don’t focus on getting retention, I focus on getting support, because I think I know 9 times out of 10. If I make a really nice supportive denture, it’s going to be better than what they walked in with to see me at the consultation. [Jaz]Make that really tangible, Rupert, like what do you mean, how can I make a- Because I test for retention, I test for stability. But there’s a poor concept to me is yes, we read about and stuff, but it’s not something I looked at denture. I thought, okay, how well is it supported? What do you mean by support? You mean, how well the lips and soft tissues rest over it? Or how well it just sits? Give me a bit more about the support and how we can improve the support of our dentures. [Rupert]Sure, I think your support in terms of finger resting on the side on the fives and sixes regions pressing down, is it resisting against it? Is it feel like it’s rocking? So let you see those little mini complete dentures where the flanges essentially like the width of the teeth, when you know they’ve got buccal shelves, they’ve got a lingual extension, because we all have that even when there’s that full resorption you might lose the height, but you’re still going to have the width of the mandible bone that’s not going to go anywhere, it’s going to shrink downwards, but not necessarily inwards. So I always look at seeing how far I can get it out towards the cheeks. Yeah, that’s then going to play into your support of the cheeks and the lips. Because we’re not just replacing the teeth, we’re replacing the bone, the hard tissue that’s been lost as well. So if you’ve got those kind of nice, extended flanges, posteriorly, you’re going to have a much better support and it’s not going to move around. And that’s going to improve that stability, which is actually what the patient means when I don’t have a tight fitting denture or at least that’s what I think. [Jaz]Brilliant. That really helps. There have been some times in the past especially the DCT. I made loads complete dentures back then. And sometimes I had overextended and if that’s the right word so basically in the lower molar region of my complete denture, I had gone too far buccal or too far towards the cheek. So how can we how can I minimize that problem? And how do you know where your special tray should end in a buccal direction in terms of how far does the periphery go in terms of the buccally if that makes sense towards the cheek is that only landmarks are used to draw that out. [Rupert]I wouldn’t definitely say [Lamaze], I think your frenal attachments are going to help you because obviously there’s not going to be a massive extension beyond the frenal attachment. So you can be a little bit realistic there. I think I always deliberately try and overextend the primary impression, one to make sure I get all the landmarks that are going to help me so if you want to get support all or even retention, if you’re looking at retention, you want compressible tissues, posteriorly your retromolar pads, you want to get the buccal shelves, you want to get a lingual extension. So you want to make sure you get all that in your primary impression anyway, so I do try and overextend it, and then I look at trying in my tray, making sure actually there is a free bit of sulcus around it that we can work into. So when we do a functional border molding impression, we’re going to have the suitable thickness of material there. And we’re not overextending it so if you’ve tried to try-in and it’s absolutely cutting into the cheeks and yet the patients have wrapped the lips around and it’s knocking your you can feel it moving around you know you’ve overextended that. [Jaz]Awesome that helps. So I think next is find out step by step. Okay, just talk us through, obviously, you can you can go on three, four days teaching about this. There’s not some you can learn a podcast episode, let’s just give a flavor. Just give us some step by step some things that you think have been instrumental in helping you to get better supported, better retentive, better stability from your dentures. Lower dentures. [Rupert]Just stick to the lowers and yeah, so I think first off, like assess the patient fully. I think Mark covered it really well in his episode, it’s like it’s not just a treatment plan about lower complete denture. Have a good look at the patient. Have a look at what do your ridges look like? Is it really flat? Is it nice and wide and thick? Is there a bony undercut? Does the patient have a large tongue? Have they not had a lower denture and the tongues and floor the mouth has expanded in and things like that, look at those landmarks that you’re going to get. I was looking at what the patient has already what their denture is, like, if they’ve got one of those little tiny dentures or thing, happy days, I’m probably going to be able to improve this if they’ve got one with really nice looking flanges or start to get a little bit worried. And assess other things, what’s their saliva like? Because if they’ve got bone dry mouth, you’re not going to get anything there. You need that from [filmer] saliva. And I think you need to assess how good the patient is at wearing dentures as well. Now, I had a lady recently, just when we came back from lockdown, and she came in and she was a full denture wearer and she’d been wearing for 40 years, and she just went, ‘I just want something that looks nicer.’ And I thought happy days because Ricardo will sort that for me. And she had no bone at all. And her lower denture when I was asserting, it was absolutely swimming around all over the place. And I was like, ‘how are you with that?’ And she was absolutely fine. She’s one of those. I like to use that analogy, like riding a bike, when you’re riding a bike, you’re super stable, but one legs going out one legs going down. But you’re super balanced, and you’re fine with it. And she was riding the bike, this denture is moving everywhere, but she was absolutely fine. So if you’ve got a patient like that, happy days, you might improve it, but it’s not really the end of the world to them. [Jaz]I mean, that patient has a superior neuromuscular adaptation, right? That patient is a good denture wearer it’s like you said, so these patients are kind of sometimes, don’t never get complacent, but they kind of home runs where they’ve got this crappy denture and they are wearing it. And those are ones that I like to take on. And when it’s not that criteria, I like to refer them to you. [Rupert]I’m only down the roads, you know where to find me if you want to. [Jaz]Absolutely.[Rupert]Yeah. So I think those I think those ones are as you say they can be the homerun, I think the toughest ones are patients that are transitioning like perio patients transitioning maybe from a partial to a complete or like [add a chat,] the ones that I’ve been sharing recently, the fancy signature ones where he’d actually never been wearing a denture yet a really bad gag reflex. He’d never worn dentures, but he’s been edentulous for 10 years. And that’s like, you’re saying, you’ve really you’ve got to learn this, like it’s a skill. And I use that riding a bike analogy. And I think they sort of get that. Those are the tough cases. And especially in a media when they’re not everywhere, and their lips are pushing it all out already, because they can’t move them. I think those are the challenges. We’re the ones where they’ve happily worn for 45 years and the expert denture wearers, happy days. [Jaz]Sweet. So you talked about the patient profile, like what you just said, you talk about your primary impressions where you’re trying to get overextended on purpose. Let’s move on to maybe some pearls in the special tray, because that’s really such a key appointment to get your final impression. You mentioned greenstick. And I didn’t think that you mentioned border molding. But my question now is, can you describe your technique for border molding? Do you use green stick? [Rupert]Yeah, so one little thing that I didn’t mention earlier on the on the primaries as well, I think just use putty. Don’t just stick alginate in there, because you’re not going to get that retraction of the tissues. You mentioned green sticks and stuff there as well for your secondaries. You want to make sure you’re attracting those tissues, because you’re not going to get the buccal shelves, you’re not going to get it back to the retromolar pad and you’re going to end up with that, that tooth wide denture again. And the secondaries, I don’t use green stick, I just don’t like using it. It’s just really fiddly. I prefer using putty, but actually do my secondaries in a three stage impression. So I do the first stage might be a little bit different to what sort of people do so I’ve deliberately overextended not massively, but overextended. So I know where the frenal attachments are so recorded and cut them back. And then what I’m doing is I’m placing that tray in and checking it, seeing that I can see that I’ve got my two to three millimeters of free sulcus. And then what I do is I take a little bit of putty, and for a lower, I’m going to do three balls of putty in the tray. So I’ll do one each side in that sort of buccal shelf retromolar pad area and I’ll do one in the incisal. Place the tray in, get just patient relax, place the tray and check that I can see all the way around my three millimeters of buccal sulcus and just leave it there for it to set. Once that sort of half set or mostly set you can take that out because it’s just as a guide. But what it means then is every time I place it back in, I know I can push down and I’m not going to push it too far in and overextend it. And also it means that every time I put it in for the other two impressions, it’s locating in the same spot every time. [Jaz]That is awesome. And that is a fantastic pearl. I’ve never thought through that for so I’ve definitely learned something there. I’m going to write that down. That is a beauty right there. So what next, so you got your putty balls, you’ve got like a triangle, something that’s quite stable, like you said, and you can visualize that three millimeters which is genius. What next? [Rupert]So next I’ll do my border molding, I’ll do the main body of it again in putty. So you could do green stick. If you want to do green stick, like Happy Days go for it. I just prefer the sort of the feel and use of putty. So I’ll do putty around the edges, get my good border molding. So then I know that when I placed this in, and the putty’s got that thickness of three millimeters, placed it in, get a functional impression going, and I personally do it completely patient driven. I don’t like doing lip pulling or anything like that. I think that distorts your sulcus shape. If you pull a lip, you’re going to have the muscle being long and thin, whereas a muscle in function actually is shortening and fattening. So it will make it’s probably only a marginal gains thing that your sulcus shape is going to be slightly different. So I’ll place that in my receipts or my soft tissue stops or stopping it from overextending, then wrapping the lips around the ooze, the eeze opening wide, obviously for a lower moving the tongue around left and right forwards and backwards, and then they’re compressing and pushing that back up. So then hopefully we’ve got exactly the functional depth of the sulcus rather than just the static depth of the sulcus. And I think it’s really important with if you’re doing that kind of patient driven border molding that you’re really I really get into it, me and my nurse end up probably doing it under our masks as well. But you sort of really hype them up and explain how important is and you say, well, you know, if you don’t do this properly for me, every time we try and say all look at that your denture is going to pop out because your lips are pushing it up. So and really getting to exaggerate it and you can have a bit of fun with it really and patients quite end up laughing half the time which is quite good because most people hate impressions and things. [Jaz]That is great. And I think it’s so important to know these things that you say so ooze, the ease to get that sort of functional movement of the muscles. My favorite thing learning as a DCT from Professor Mike Phelan, are you familiar with the Professor Phelan? [Rupert]Hm-mm. [Jaz]So he is fantastic Irish accent I don’t know if I’ve said this episode before, but he’d say to patients smile like a politician, pout like a supermodel and all these things are just patients love that and it’s a great thing to make them laugh and stuff. So I think you definitely got the right idea. They’re brilliant. So you’ve done that with more putty now. You mentioned my green stick I don’t like using it. Have you used pink stick before? [Rupert]I haven’t. Talk to me about pink stick. [Jaz]Pink stick is like green sticks like sexier cousin like it’s so good. Like I used it at Guy’s are still ones because my consultant then [sarutobi a poor] our little hack was green stick is rubbish. Don’t use it use pink stick. It was so much better to handle and I never I don’t know what to order from I never order it again. I don’t do enough dentures. But check out pink stick. Let me know what you think might be cool to see what you think of pink stick but pink stick was- Please do let me know what you think, man. But cool. So you’re using putty in that way. You’ve now done your initial three balls, you’ve done your function, the ooze and ease, you made the patient laugh, you’ve made something out of it. What’s the what’s the secret sauce? [Rupert]And then the third stage, either I’ll use a light body and medium body, you can use an alginate. Again, if you like it’s just getting that fine detail. But I prefer using a silicon. So because what I think is if you use in the silicon, place that over wash impression style, and then exactly the same border molding again, hopefully you’ll get lice little sort of strips of light body around the frenal attachments, you’ll see it just about wrapping around. But again, yes, I placed it in mainly for lower, it’s going to be get the tongue up first so that you’re not trapping that and you’re sitting it down nicely. And I think if you have the tongue up and out of the way, first, you’re not going to, if you’re dragging that impression down against the tongue, you might be pressing material away and you won’t get the full depth lingually that you might be able to. So again to roll the tongue right back, push it forwards, left and right as far as they can get into press into the tray as well activate the anterior sort of floor of the mouth. And then you’re squeezing the lips doing your palate as you say, say in ooze, cheesy grins and E’s opening while wiggling the jaw left and right. That’s more for the other really get the coronoid processes and things like that. But then, light bodies like that, and the way the reason I like the silicon is actually I can take it out, put it back in, and I can assess almost straightaway. How reliable that suction is because I think you can do an impression if you put a load of alginate in there and there’s loads of saliva trapped and it comes out and it makes a lovely substance only thing happy days. But actually it might have been that it was just stuck in an undercut or whatever it is. But if you’ve you can repeatedly put that tray in two or three times. And you know that’s a reliable repeatable suction. [Jaz]Any concerns about any bony undercuts, is there anything we should be doing with the significant bony undercuts? [Rupert]Yeah, I think undercuts, I’ve not actually made a complete yet with sort of big mandibular tori or anything like that, that you obviously want to avoid them because they’re going to be sore particularly tori [but] the gingiva is so thin there anyway. So again, that sort of try and capture them in that primary impression. Make sure your technicians aware that you want to avoid those and get the tray if you’ve almost got to sort of do deliberately get it a bit wrong in the primary to be able to get it right in the secondary that you want to be avoiding that. Really because it’s going to just cause you a nightmare in terms of where you’re going to end up with extending it and you’re going to end up cutting about loads when it’s rubbing and it’s all like that they have not actually had that’s probably like the one sort of thing that I haven’t had yet for a load of I need to get so if you see one send it send it to me. [Jaz]You’re going to hate me, man. This is cool. I like what is going so you really described quite beautifully the impression stage I think loads of people are driving right now chopping onions running, and then next lower denture they’re going to be like impressions days that yes, I’m going to do exactly how Rupert described it. Because I think you described it really clearly. What are the other in regards to go exhaustively into other appointments, but just a few pertinent points in terms of what you think is important to getting a good lower complete denture? [Rupert]Yeah, so obviously, like you’ve done some good [imps] you’re going to do your read your appointment, gold standard, you want to do on an acrylic base, rarely one, if you’re doing that off your secondary impression, then you’re going to know pretty well how good your secondary impression is. And if you want to, you can always then rely on that if you concern light body so a whenever you want to do but also obviously having an acrylic base, it’s going to make it more stable, you’re going to get a more accurate registration. I think the best thing if you want to talk about the reg and stuff is go and listen to the other complete denture Episode [promarkers.] I think you nailed that. really well. Look at previous photos. I’m not sure if Finlay mentioned it in his episode, because it wasn’t really on a clip but he’s a big advocate obviously of photos from before. The classic class two patient palatal class two you may come class one for a complete and their lower denture keep pinging out because their lip is pushing it backwards because you’ve massively invaded the neutral zone. Check those kinds of things, if you can, that’s where like the photos are really, really good. If you see someone is a bond or palatal class two make sure that you’ve adjusted your rooms suitably and appropriately. And wax try in, there’s not really I wouldn’t say there’s much special stuff there. I think what I try, I try and avoid if the patient thinks it’s overextended in wax, I will say just bear with me and let me process it because I’d rather polish off in acrylic than accidentally lump off a massive bit of wax. I don’t know if he’s sort of agree with that. But I think sort of I’d rather have the control of a straight bur rather than sitting there with a wax knife and accidentally take off half the flange that I’ve worked so hard raising the tongue and doing an Rm 4. [Jaz]100%. I don’t want to see my wax work. I think that was my stressful moments. As always with a wax knife in hand, a Bunsen burner, and just a mess of wax on my nerves just looking at me like what the hell is he doing? So definitely share that sentiment. I think it’s good to tell the patient in that way. So really the wax try-in for you is more aesthetics and phonetics? [Rupert]Yeah, 100% I think, especially with sort of more of the cases that I’m doing sharing now is obviously there’s quite a high aesthetic component in them, or at least for me and my technician, we’re pushing the aesthetic side and patients don’t always appreciate their lovely for [an iris to] teeth and things but we do and but yeah, we’ve had a few cases recently with old photos and things like that, which are really fun to do. So it’s more checking that and, and yet again, you can get an acrylic base inside your wax try-in if you want to again, assess that stability, support, retention, whichever you want to sort of worry about the other one,[the orchestra] in Germany is my favorite appointment. You’re really anxious about it first, because you think it could all go terribly wrong. But generally, it’s like the easiest appointment there. Yeah, and if you’re a little bit worried again, just like if you’re feeling like your wax try-in particular, if you haven’t got an acrylic base, if you’re thinking it’s not feeling that stable, I’ll always just again, just put in a bit of light body seated in reborder mold, and at least then it’s going to be even if it’s just the fact that it’s in wax, and it’s not retentive, because it’s wax rather than acrylic. That’s just going to make it stable gives the patient confidence. If you send it back in and your technician looks at and goes, No, it’s fine. It fits fine. It’s not a problem. They can just peel it off. If they think oh actually that might be quite good. I’ll recast that and, and use it almost like a reline impression, then you’ve not lost anything. So I think that’s a little thing that I sometimes do at the wax try-in. [Jaz]That’s not a little thing that’s a massive thing, that is a huge gem. So usually I just maybe put some fixative in or something but the light body it’s just a genius idea because not only are you improving the situation then and there but then your technician might find that information useful. So that is a huge pearl. Really appreciate that. So use light body, that is wicked. Do I was just I was thinking the story. I remembered a patient I saw a guy’s hostel. And he’d had, he’s not a great denture wearer. He’s about 85. And he’s on his fifth complete denture in last six years, so you know where it’s going. The ridges looked okay. And it fell upon me as a DCT to inherit this case. So I started making these complete dentures and I got to the wax try-in stage on that day, my assistant just wasn’t around. So I was by myself, right And the patient goes to me, I wish there was a way that I can test if there’s going to be good. I know I want to eat something. And I thought to myself, is this [kosher?] I mean, can the patient try and eat something now? And you know, lo and behold, his [Kara] and him they had a peanut butter sandwich. So on his wax try-in upper lower wax try-in complete dentures, he started to eat this peanut butter sandwich. Do you know this is a good way of assessing anything? Or that’s an absolute waste of time, because I felt was a massive waste of time. And it probably just went back with like peanut butter residue back to the lab. But at the time, let’s give it a go. Why not? [Rupert]Yeah, I think I mean, Ricardo gets a bit touchy, if I let the patient bite down a little bit too hard, and the teeth have moved a fraction. So I think he’d kill me if I did that. I think the problem is with wax, unless you’ve got it like a processed acrylic base, the fits never going to be as you and I always say that before. Before I’ve even taken out the box for the workshops, I look, this is wax, it’s not going to be great. It’s not isn’t going to fit way, way tighter when it’s plastic, the saliva doesn’t work the same. And so I think if they’re worried and it could be a stability thing, I get a do a little cotton roll, pop it in one side, give a little bit of a bite, a little bit of a bite. Because then they’re not going to be really crunching through. It’s more just again, just testing that sort of support and stability. And I think if I sent Ricardo a peanut butter covered completely, he’d probably not work with me ever again. I need a new technician. [Jaz]Okay, I remember had flashbacks. But yeah, nothing I don’t advise. But for sure. I thought you’d agree with me in that sense, as well as a stupid thing to do. But hey, it’s something I did back when it could become the story at the wax try-in stage. What if you? Are you really thoroughly checking the occlusion? Because, like, are you checking for any interferences to centric relation, because at that stage, in the past, I have sort of just heated up my wax knife made some of the teeth, or the wax underneath the teeth a bit loose and get them to bite again, sort of intrude that tooth? Is that something you’re doing? Or do you do tend not to also mess with the occlusion until you get to? Unless is way off? Or how do you manage that? [Rupert]Yeah, I think the main thing I do try and do with wax try-in is I pop them in and just try and instantly start talking to the patient about something else and just let them sit with them in for four or five, six minutes. annoying, I’ve got a really big mirror in my main surgery that I work in. And I try and deliberately stand in front of it. So they can’t spend any time looking at it. Yeah, and just literally let this sit there and let them wear them for three or four minutes. And then see what they think obviously, if they’re falling straight out and you need to that little, light body, reline on them do that. But I try not ask too many questions or think about it too much. I’ve got the luxury of [ABS] I’m doing it all privately. So I’ve got loads and loads of time for my wax try-in and things I’m not squeezing in a 15 minute wax try but I think just let it sit and settle there for a little while. And then just ask them how does it feel? Is it comfortable? As you know, do you got the OBD right and I think have a good look at it. And yeah, if there’s an obvious point then absolutely, I’d do exactly the same as you hate the wax knife but sort of get it underneath allow them to then intruded themselves into a position that feels more comfortable. I think the main thing though, is photos and full face photos for wax try and even things it’s like a slight midline shift. But we had a case that we did and I needed like a nose to chin one. And Ricardo was fuming because he wanted some eyes in there to be able to because we felt the midline was slightly off and he managed to fix it because he’s that good but take photos of your wax try. Take photos of your wax rim with your midline because again I had as a window impression as you post about it as a window impression case I did and I drawn the line and you’re not going to like mount the patient and sit exactly in the middle of them I do I do it from the left or the patient’s right and align round and I’d done the midline and a slight angle probably five degrees or something when I looked at the photo when all that’s obviously wrong and center to recall we have everything in a Dropbox and things like that and we’ve got a full face photo and you can see that the top of the line is exactly right where the nose is and then it comes off to the side like that and he was able to just to adjust it and then it’s absolutely fine. So I think that’s the thing as well that take photos of everything. Wax rim, take photos of that in the mouth, and you can check your smile line you can check your interpapillary you can share your ala-tragal if you want to confirm the photos, I think even if you did a I’m doing a presentation. Middle of February for some undergraduates and I realized I don’t actually have any I didn’t have at the time anyway, any bite plane pictures of the patients. I just took them on a nurse and she was a little bit sort of class three. And at the time I took this side on for ala-tragal and it looked great. And then I put it in Keynote to do the slides and I drew the line ala-tragal, duplicated the line for the angle and dragged it down and she was off by 10 degrees and I was like oh I would probably would have thought that looked fine, actually. And I might have I done that with some cases. So that was a big thing for me is that I’m going to start taking the side on photos and confirming these things on keynote with no, either with Ricardo later, or I might even start doing in surgery. But yeah, I think lots of photos, because you can rescue a lot of things. But I try not to change too much or wax try-in. Going back to the original question. [Jaz]No, and that’s great. And to two main takeaways is take the full face photos because they’re so valuable. And also find your Ricardo. Everyone should have a Ricardo. It sounds great, man. He sounds like he in a banter way. But he pushes you and he gets you to do things in a certain way. Thank you, you guys be used to feed off each other. And you guys are both very passionate. So find your Ricardo. And at the end, you can tell us how you can find someone like that. But yeah, [Rupert]Yeah, we’re both as [sad] as each other. Really. I think that’s the thing. And he makes me look good. So definitely find yourself a Ricardo, but not mine, because he’ll get too busy. [Jaz]Shoutout to Ricardo but please don’t use Ricardo, or we might not see as many. [Rupert]Shoutout to the VRdentstudio. [Jaz]Due to the shattered population. [Rupert]I tagged him in everything. So VRdentstudio, I tagged him in every single post. So yeah. [Jaz]well, that’s very good of you. Because there’s some dentists there who post these beautiful veneers and stuff. And they don’t credit the technician where they’ve taken a monoblock patient to these beautiful tranluscencies, but it’s actually the ceramist, who’s on all the work or the or the complete denture cases. So it’s very good of you to shout out your technician, every case that you do, that’s amazing. [Rupert]100% I mean, we built up a really good relationship, and our cases wouldn’t be as good if it wasn’t with his work, as we sort of push each other, we understand each other. And it’s just about building that relationship. I think that’s the kind of thing with these kinds of cases is about consistency. It’s like consistency with how you take your impressions consistently, how you assess the case, what you ask for, with your lab work, and not with your technician. And it’s difficult when maybe you’re in NHS or in a mixed practice, and you send it to that lab. And it’s, you know, it’s a corporate lab with 20 technicians in it and you don’t know who’s getting it and you get one thing back from one person or one thing back from another and they never read the doc here, that person, it’s coming back from them because they’ve done the wrong thing or, and so I think even if you’re doing it, sending it to a lab like that, try and get to know someone there and because there will be one technician there that wants it. And it might be that, all the all the great technicians will probably work in a place like that at some point. So chances are, there’s probably a great technician in the making there and find them and go along for the ride with them. Rather than I’ve just sort of piggybacked on Ricardo when he’s already been smashing it, there’s always a chance you might find that person and work together and grow the I think Finlay covered that, didn’t he with sort of what he was doing. [Jaz]That’s it, he said, find someone roughly the same age as you and grow together. And I think you’ve given a good tip there. But even if you’re sending it to a corporate lab, like visit that lab, if you can and find that one guy who might be that dark horse that you know you’ve never met before you seen their name on the on the sheet before now you get say hello to them and say would you like to buddy up with me, we can do cases together and in only if you see that fire in their belly, and a twinkle in their eye that you can start saying, you send it to a corporate lab, but 123 but FAO, whatever their name is, and then you sort of you know, or that case will always go to them and build that relationship which is awesome. Someday we’ll cover that as well. So now on to the fit appointment, my friend, onto fit appointment, talk us through your workflow, like I know some dentists will try it in and see how it goes. Some dentists will straight away put on what’s that green stuff by coating the pressure spot indicator that straight away before they actually get the patient try and what’s your what’s your protocol? [Rupert]Yeah, I just similar to the wax trying-in, just pop them in. And again, try and instantly start talking about something else or not even thinking about it, like make it really matter of fact thing, we’re going to pop these dentures in happy days. See how they feel? I mean, I try and even not adjust them at all on the day if I can. Unless and this is an obvious sore spot. It’s definitely digging in somewhere or there’s an undercut that we’ve slightly gone into or something like that, then then obviously I’ll adjust that. But I think with these cases and we said keep saying about the little tiny denture with the non-existent flange realistically, I’m probably making something a lot bigger. And I’ve already said that to them appointment one, I think it’s really really important in that assessment appointment that you manage those expectations straight up. It’s going to be bigger, it’s going to take you some time to get used to you’ve got to retrain the muscles it’s going to rub, I use this like fit appointments all about like a shoe analogy. Yeah, even if I’m doing these super fancy signature characterized dentures, you say well, no matter how expensive pair of shoes They’ve always given me a blister, it’s going to take time to break in my 300 pound pair of churches or my 10 pound prime up pumps, you know, they’re going to rub either way. So give them a little bit of a chance. And it’s a new set of trainers, you’re not going to run a marathon on day one, you’re going to go for a walk around the block first aware around the house, you’re not going to head out and do a 42k straight off the bat, you’ve got to give them a little bit of time. And yeah, for those ones, where they’ve had a teeny tiny denture before, I sort of say, well, let me make it gold standard, or let me make it as textbook as I can give it a week, give it two weeks. And if we have to compromise, that’s absolutely fine. We can adjust it then. But then it’s a bit like the wax trying thing, I can trim it off, it’s a whole lot harder to make a flange longer after I’ve made it, I’d rather cut it back then, try and add it on again, that’s because that’s just not going to happen. So yeah, just try and get it in as best as I can. And if there’s an obvious, you know, source for Sunday’s polishing, then then fine, but I try not to touch it too much. Because you can sort of say, well, we’ve made it as, as potentially as good as it’s going to be textbook or whatever that is, and you sort of, it’s all about feeding that in throughout the entire process. And that’s where, again, having a technician that you know that they have accountability. Ricardo is mentioned in my first appointment, I mentioned by name because we’re going to do photos of everything, the pre op, full face photos at the first appointment, and you sort of you build in how much work you’re doing. And I think the way that I do them probably like your chat with five dentures, I doubt the other five dentures were made in the same way. So they sort of go Oh, there is a process here. Like, get behind that let’s do what he says let’s give it let’s give it a week. Two week review. And they believe in it more I think site like psychology is really really important in, in denture wearers. [Jaz]What percentage of your patients when they come back to you a week or two weeks afterwards will have an ulcer at the flange area? [Rupert]Probably about 20-30%. Usually lingually because I tend to really, really go for it lingually because that’s like, that’s a gimme, there’s loads and loads of sulcus steps there. And mostly that never ever had a denture there before. She said, it’s, he say the shoes again, you say it’s not only your new set of shoes, but you’ve never had a shoe that long before it’s going to rub. It’s going to rub in a different place. You know? I’d say probably about the 30%. Maybe. [Jaz]That’s remarkable. I mean, how many dentures? I mean, do you have you ever done a denture and maybe I’m sounding stupid here but were you have given the final dentures, they’ve gone away and they come back, everything’s fine. And you don’t need to adjust anything. For me. I just can’t imagine that ever happening. But maybe you’re going to prove me wrong. [Rupert]I mean, I’ve had two in the last three months that haven’t seen for review, because they just cancelled it and never came back. I’m hoping that’s a good thing. Because they’re happy. Yeah, we’ve been like in touch with one guy was work, work related COVID at work and things like that. So he’s been in touch. He’s like, No, I’m fine. I don’t need to come back. And yeah, a lot of the time they’ll will come back for a chat anyway. And I’ll say that I want to see them or do some more photos. Maybe particularly, it’s like an immediate. [Jaz]The review aka the photoshoot. [Rupert]Yeah, that more or less, that’s what the review is most of the time. Yeah. So quite often, actually. It might just be that it’s a slight Polish or they found at one specific movement. Maybe there’s a slight interference somewhere. And it’s just a little occlusal adjustment or something. But I’d say generally, probably about 30% need something doing but most of the time, they’re quite happy. [Jaz]That sounds crazy. That’s like witchcraft to me. So wow, that’s very impressive. Totally. That is wow, just remarkable. Tell us about when you have been able to achieve a suction lower denture? Is it obvious at that appointment? Or have they sometimes gone away with? You haven’t got that suction when they come back for review but they now have that section after review. Well, how does it happen usually? [Rupert]I mean that the I think the two videos that I’ve got on they are day of fit videos are literally just pop in here, the squelch say sit there for two minutes, give them a little squeeze together for me. And I think that’s really important. They don’t just pop it in and expect it to be suctioned straightaway. You’ve got to let it bed a little bit. So yeah, both of those they were straight in. But yeah, I’ve had a couple where one of the chaps that the guy who had the COVID cases work and didn’t come back that oh, the bottom one feels so much better. Now it’s fitting really nicely. And this is the child who’d never worn any dentures at all before. Then he had a massive tongue to be fair, which probably helps sort of keep it support it and balance it. Yeah, I think you can definitely learn to adapt the muscles because it’s more again about that stability and not displacing it. Learning to ride that bike not displacing or knocking it out which is going to interfere with having a continuous maintain suction but generally If you pop it down you and you hear a squelch, then happy days you’re probably going to be alright. [Jaz]Now for us normal dentist not at your level, Rupert, with complete dentures. One tip I want to give to the more average dentist at removable prosth. Is that one of the piece of advice that was given to me by [Linden Cabo] I think as a professor or doctor, Dr. Linden Cabo, he told me that sometimes as dentists when we give complete dentures, just have patients, we attempt to, we’re so tempted to do something, pick up the handpiece, do some adjustments, whatever, just let them go home with it’s like you do. And then sometimes they just need more time until the situation improves, and improves, improves and you haven’t done a thing and then suddenly, they’re able to keep it in. So sometimes they just need some more time. Is that a fair thing to say? [Rupert]Absolutely, that we said it before that muscular control that’s really, really important, especially for lower, that the upper, you’re going to, you can get that suction cup effect, and then you’ll be fine. But the lower you need some element of skill to maintain it, and even [seeds] and that you’ve got this, you heard the [swells,] right? And they go, yeah, and you say, well, it’s going to be lost because your tongues flapping around all over the place. And you’re constantly pressing it and moving it, you’ve got to learn that you’re sort of subconsciously realize that seal is wearing off, and oh, I just need to bite it down, or I need to press rest my tongue over the top of it. And actually, it’s that rather than thinking that you’re going to pop it down, it’s going to sit there quite happily forever not move is a no, no, you’ve got to keep updating that seal that suction, you’ve got to keep pressing it back down with the teeth. But you’ll get used to that you won’t have to think about that in a week, two weeks. And that’s where you get the improvement over time is that they’ve just been learning subconsciously. They’re not thinking about the fact that it’s got, it’s losing the seal, and it’s getting loose. They’re just biting it down. And that’s it. No, that’s definitely right. As long as they’re just trying send them off. Unless there’s a glaringly [obvious fit], that’s occlusally wrong, or definitely you got a flange wrong, and you haven’t got the extension right, adjust that. But if it feels pretty comfortable, and they’re good to go, I’ll just try and send them out the doors as well as you can. [Jaz]Amazing. Well, before we go, I want to ask about some of the educational stuff that you’re putting on. But before we get to that last question, because we can’t do an episode on protrusive, without talking about the occlusion. Just tell us about the fit appointment, and maybe the review, what’s the most common thing that you might do for the occlusion? I mean, do you actively look this BULL rule, buccal on the upper and lingual of the lower do try and do that, give us a bit of a minute or so on the recipe for success with occlusion. With dentures. [Rupert]Obviously, you’ve taken that from your reg appointment, make sure you’re getting your simple things, right, you’re ala-tragal plane, you’ve got it, getting a nice lower lip line and the things that that so that everything is where it should be and you’re not making the patient work harder than they should, in terms of the fact that the angles off and they’re getting contact too early, or you’ve got this odd shape lower, that’s having to work with the sort of wrong occlusal plane of your upper, I think really, it’s about making sure they’re comfortable and get them in a protruded or position that feels comfortable for them. Make sure that they’re happy with it. And then make sure they’re not a blatant class two, or class three that you’ve missed. And just set them up. And I think as well, maybe it’s a NHS mindset of, for appointments, get it done, but I don’t mind doing three wax try-ins, four waxed try-ins to make sure I’ve got it 100%. And you say that to the patient, you say we’re going to do the first try-in, and even the fit appointment half the time, I might say, we’re going to try it in the plastic, or we might still want to make some changes. And a bit like, you can sort of set for crowns as well, we’ll try it in and we might need to, alter this little bit and send it back and like you would with maybe an implant crown. But I think yeah, like don’t be afraid to do another try-in, and make sure the patients are 100% happy as well. But I think you can sort of tell quite quickly occlusion wise, the worst is when you pop it in and you’ve suddenly got like a two unit midline shift. And they’ve got a complete [scissor] by on one side of saying you think what have I done here, but it’s just because suddenly they feel like they’ve got a denture in rather than a wax block is that they suddenly bite in a completely different place. And I’ve had that a couple of times, not like not quite that drastically, but where it is just a little bit off. I think, see, if you’re happy with the upper. Get set, make sure the upper set, right, I think Mark said in his the upper is the beauty, the lower is for the function, and, you know, I do a lot of taking the posteriors off the lower. If I’m happy with the effort the posterior is are 4, 5, 6 don’t put sevens on, don’t put sevens on completes because they’re just going to give you more problems. Take the 4, 5, 6 off, leave the incisors if you can, and potentially just rearrange them at that point because they’ve got an incisal. Hopefully the incisors then might go into the correct place. You can reg them then and just get them get your technician to reset it up there. If you completely off. Dig out your wax room. Hello waxaa and hopefully they haven’t destroyed it. But yeah, I think it’s Don’t be afraid of doing multiple waxed try-ins and build it into cost of private treatment or, yeah, and just again, be upfront about the whole thing, you know, be super upfront early on, because if you start making, if you start saying things are difficult at the white shrine, it’s an excuse, if you told them three appointments ago, or they go, Oh, you did say that, we might have to try in a few times. It’s all about just not being negative or pessimistic, but just being reasonable. and managing those expectations. [Jaz]Brilliant, because the communication is half the battle. Now, Rupert, as you know, with protrusive, I’m a massive promoter of education, and with people like you who just do so much for our dental Instagram community, and you post these beautiful cases, and I’m sure we get DMS all the time that hey, you know what, can you help me with this case? or How can I get photography like yours? or How can I get dentures like yours? I saw that you promoted a course recently. Please tell us about that. Because I know a load of the Protruserati, it will be interesting that so give us a flavor, man. [Rupert]Yeah. So we announced it was a couple of weeks ago. Now it’s Ricardo and myself. And we’ve teamed up with [Roger Thomas] I’m sure everyone will know who Roger is. Because actually, Roger was a big inspiration for me and how I do the secondary impressions I do. So I’ll see in some of the pictures that he was putting on. I know he’s got that name, sort of known for it on Instagram. But he’s got he takes some incredible impressions and made some amazing dentures. And I sort of looked at what he was doing and tried to reverse engineer it and experiment. And so we did his art of resin course, which is awesome. And we started talking about dentures there. And yeah, so we’re looking at running a course it’s called the art of completes. And the plan is that so it’s a two day course take you through start to finish with a live patient with Ricardo in the technical stuff in between as well, which try to cover that start to finish on how to get hopefully, a reliable suction things. I’m hoping I didn’t give too much away in the secondary impressions, chat that we did, otherwise, I might get it. [Rupert]But honestly, we really appreciate that. I think we really appreciate I think anyone listening should really appreciate that the level of detail that you’re going to give us so much there. But there are so many, many steps in gems, that it’s impossible to give out in a podcast episode, but you gave massive value there. So guys, if you like Rupert’s content support him in the course I have no doubt in the world would with yourself involved and Ricardo that’s going to be a highly educational really supportive course on something that just doesn’t get taught well enough. At dental school because of a lack of cases, we just don’t do enough cases. And before we start getting fancy, it’s about getting those foundations right, would you get are so good at covering. [Rupert]Yeah, no, I think I actually had someone write to me today saying that are there a recent graduate and they you know, they’re worried about x, y, and z and reorganizing the OBD into it, and I was just like, just like wind it, wind it back a sec. And just, I think prosth actually is quite not easy. But it’s, it’s has a few basic concepts. If you master those, and then sort of extrapolate them, you can work out more difficult cases, you know, think about balancing your support. Just think about those three basic things. And then you can do more challenging cases like big fibrous rich upper, we’re talking low as well, you know, big fibrous Ridge, that’s just that you got across your cross your Ridge, you’ve got an imbalance in the support. And if you just put one uniform piece of plastic there, it’s going to rock in rotate. So how can you get around that and that’s why I like his eyes problem solving. And it’s just yeah, working through things like that. But I think Yeah, work on the basics, and then that will open doors for yourself in doing more challenging things and talk to your technician as well. If you’ve had any cell saying about the occlusion and things like that, I want to do my normal copper answer on Instagram, which is my technician actually sorts most of it. So I asked him and he’ll be able to point you better because yeah, I think that’s probably asked their opinion and because it’s a team thing at the end of the day. [Jaz]Amazing. Rupert, thanks so much for bringing so much value on suction complete lower dentures. I hope everyone listening got a lot of value from that. I know I did. I picked up a few gems I wrote down so excited on my next lower denture, which might be a year away. As you can see, I don’t do that many. The next really crazy one I get is definitely coming your way. So thank you so much. [Rupert]Cheers, man. Thanks for having me on. Jaz’s Outro:Thank you Protruserati for listening all the way to the end. I hope that helped you to be more confident on lower complete dentures. Do check out Rupert’s work on Instagram it’s absolutely amazing. His Instagram handle his dentist Rupert do also follow at protrusive Dental if you’re not already, and just check out the quality of his photography, the quality of the treatments he does. He takes these fantastic portrait photos of before and after. And these dentures I tell you, they make these patients look about 20 years younger. So Rupert, keep up the amazing work you’re doing and I hope you’ll catch me in the next episode, which is Five things your technician wished you knew.

Dentistry is busy. How can we make sure that we live a balanced and fulfilled life in our hectic profession? As an associate, I am already struggling with time, I often wonder how practice principals and specialists play this game?! I am joined by my dear friend, Dr. Ricky Bhopal Specialist Prosthodontist to discuss how we work smarter and not harder. https://youtu.be/KpsHgDR2q6M Work Smarter Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Do you carry out virtual consultations with your patients to discuss Orthodontics (Invisalign) or Smile Makeovers? How do you make notes for this? I am enjoying using Otter.ai to transcribe our Zoom virtual consultation In this episode we discuss: Ricky’s top tips to be productive and overcome procrastination How to make time for our loved ones and hobbies What is green space and why is it so important? How can we live a more fulfilling life as a Dentist? If you enjoyed this episode, you will enjoy How to Win at Life and Succeed in Dentistry! Click here for Full Episode Transcription:  Opening Snippet: The way what you want in life changes. So you just have to listen to what you want to do as opposed to looking at other people who may be doing nine to five days or working six days a week or if you're crazy enough to do seven days a week. So it's just whatever you find comfortable for yourself. So, which goes on to my first point which is getting true with your mind and your body. What are you capable of? Jaz’s Introduction: Are you feeling just a little bit overwhelmed at the moment like one of my friends dentist, he said to me that I just wish things would just slow down like after the lockdown. After everything that happened during COVID when we experienced some sort of anxious tranquility. I feel as though now things are getting really busy for us and a lot of us are experiencing that huge dump to being overwhelmed and burnt out. If this is you, it certainly hasn’t me in many moments. And that’s not just because of the podcast right now that there are so many things in life. We try our best as dental professionals, as family members, as friends and colleagues to make everything work. And in such a busy life things can get really, really, hectic. Hello, Protruserati. I’m Jaz Gulati and welcome to this episode entitled Productivity with a Prosthodontist with my good friend Ricky Bhopal, because I wanted to learn myself like how does Ricky who’s a young associate recently qualified specialist prosthodontist. I look up to him as someone who is just full of systems and tricks and wisdom and knowledge in terms of how to live a fulfilled and productive life. I think now, we need to stop working so hard and start working smarter. So this episode is very much focused on getting that connection between mind and body, but also strategies to help improve your workflow, how to fit in those treatment plan letters that we’d write to our patients how to make sure we make time for our loved ones. I loved it when Ricky covered that actually. So this episode, I’m hoping to be very useful for all of us in terms of being able to enjoy life more, but also get more done. Protrusive Dental PearlBefore we jump into this, what I hope will be a very impactful episode for you is the Protrusive Dental Pearl. The one I’m showing you today is an add-on of the previous pearl I’ve shared which is the Otter app. So the Otter is the website is www.otter.ai. That’s O-T-T-E-R. And what this is, is a transcription service. This is not sponsored, I don’t get anything from this, this is just me sharing something that’s really working for me. So as you know, some of you know that I do some virtual consultations or Invisalign and smile design consultations, just to see who’s suitable and who’s not. Because there’s no point of seeing someone who really needs a full examination to come to see you in the practice for a Invisalign consultation as a waste of chair time. So I find the system of Invisalign consultations, very useful. Now, while I’m having these consultations, I’m recording the video on zoom with the patient’s permission. But I’m also, I’ve got otter.ai running in the background in my Chrome tab. And what I’m doing then is I’m having that conversation, the patient, I’m asking about their goals, I’m giving them information, how much money is likely to cost him how many months the treatments gonna take importance of retention that kind of stuff. But as we’re having this conversation, everything that we’re discussing is being transcribed to a pretty, I’d say 95% accuracy. And obviously, with dental terms, it struggles, but I literally don’t have to write any notes. I don’t write any notes for my virtual consultations, but you should be right, we should be writing notes. But i.e., my transcription is my notes. So I just email that over to my clinic. And they put it in the contacts of the patience. So therefore, I now have a full like transcription of the entire conversation I had with the patient. So I don’t know about anyone who’s doing this. Hopefully, some people will start doing this now that I’ve told you about it, but a system that works well for me, so I don’t have to then log into my sort of system and then start writing everything that we discussed with the patient. I can now just send over the transcription. So I hope that pearl helped you. So let’s dive into the episode with Ricky Bopal. I’ll see you in the outro. Main Episode:Ricky Bhopal, welcome to the Protrusive Dental podcast. How are you my friend? [Ricky]I’m good. Thank you, Jaz. Thank you for inviting me to this podcast. [Jaz]No, thanks for making time, man. I appreciate it, buddy. I mean, you are all about well, you are a prosthodontist but you can’t call yourself that until the people it’s time I’m hoping to upload this episode. By the time that okay, it’s all [kosher] with all the governing bodies if you’d like. So, essentially, \you’ve done your exams, you’ve done your special training at Guys and your MID. And the reason I had you on the show today is because you’re a massive dental geek and I love it right you were like the geekiest in the best way. I don’t mean that the nerdy way I mean, like, wow, man, you so full of knowledge and hunger. I love it. I mean, you are definitely cut from the same cloth and I loved. I chats that we have very geeky chats that we do have. So I had to bring you on. Because I know you’re so busy like you did your specialist training, you’re working in practice. And you can tell him on a moment about what kind of split you did. You did a lot of your own lab work, I believe. And then also you managed to have work life balance to some degree, or how best you can as a specialist trainee. So tell us a little about your journey over the last few years and how you balance everything. [Ricky]Sure. Before I go on to the actually, the way that we actually became friends was exactly we, I think we met at dentinal tubules. And we started talking about occlusion. And then at that point, we would literally just like friends for life, with the [M in dent], and the work life. So one of the things that I found at the very beginning was it was really, really hard to kind of adjust to doing practice, as well as staying this really intense course. So quite early on, I did struggle and I did try so many different ways to try and figure how am I going to balance this, if you spoke to some of my friends, admittedly, they would joke and say Ricky would say stupid things like I’m going to the library to go and relax. You can’t relax in the library, guys. But on reflection, you definitely can’t do that. But compartmentalizing is really important. But it’s important also just not to have a regimented life. I look at life as like a pie chart. So you have your work element there, you have your family, you have your partner, you have your hobbies. And if you’re focusing too much on one thing, the other things are going to suffer. And I actually experienced this myself. So I was focusing so much on my studies, that the other thing started slacking. And it was run by is kind of towards the end of my first year, beginning of my second year where I realized this and I was like, I can’t do this. Now, a girlfriend who was in Liverpool, during my training, she moved from Liverpool to Kent to North Hampton. So trying to find balance to see her and spend time with my family was really, really hard. But eventually, I figured out a way to try and work out my weeks in a way that allowed me to do that. [Jaz]Okay, so you figured out a way to somehow fit everything in. So what I’m sensing here is that you had to eventually come up with almost like a calendar of certain things you would do at certain times. Is that right? [Ricky]Exactly, and some people might think it’s really sad. But my girlfriend actually made a shared calendar. So I think communication is really important, not just within our profession, but also like in everyday life as well. So my family actually didn’t make a calendar for my family as well, she’s stuck on the fridge. So coming from quite a big household, everyone’s in and out of the house, lots of everyone doesn’t know when everyone is at home. So just communicating with each other, I think it’s really important to really understand where you are in the day, and when you’re going to see that other person because that’s important. If you if you don’t see your loved ones for a few days, how do you feel? Down. [Jaz]But I love the fact that you had that desire, like you had such a strong desire to make it work that you went to lengths of having calendars that both that your family and your better half could see. And that’s great. And actually, funnily enough to two to three months ago, Ricky, I actually made a switch myself from to do lists to calendars in the sense that before I’d be very quick to write things down in my to do list. But now instead of most things now, instead of writing my to do list I’m actually allocating that a slot in my diary. And I just find that when you allocate time to a task, you’re much more likely to get done effectively in time, compared to just writing a to do list. Is that something you found as well? [Ricky]Yeah, it’s actually one of the tips that I was going to give at some point today. [Jaz]Let’s go for it. Your What are your top three productivity tips? [Ricky]Okay, so the first one would be get in tune with your body and your mind, get out of the slump. So I used to do this a lot. How many times would you get a task and say, yeah, I’m going to start tomorrow, tomorrow will come and say, actually, I’ll start tomorrow, I’ll still have time. Sometimes you just actually start that task, whatever it is. So wherever you need to do, you need to do it to get that pen to paper. And more importantly, make a plan of whatever it is that you’re doing. If you just go at something without having a plan of attack, you’re more likely to fail at something. One of the things that I did to try and get into this habit was I adopted a 5am morning stop. So might sound a bit strange. [Jaz]I’ve done that as well. I did you read any books that inspired you? Because there’s a book I read that inspired me to do that. Which one was it? [Ricky]Robin Sharma. [Jaz]Okay, so you read Robin Sharma, what’s his book called? [Ricky]The 5am Club. [Jaz]That’s the one. So I read Miracle Morning by Hal Elrod, similar thing. They also talks about the beautiful things that happened when you started at five at 5am. And for a long time I did that since becoming a father. So sleep is so much more precious. Because if you’re in the 5am wakeup club, you’re also in the nine am sleep club, you see. [Ricky]Now that makes sense. That makes sense. So yeah, I’m glad you’re doing the same thing, buddy. Why 5 am? Because it’s the time of least distractions, and you have so much peace in the day. So when I actually started this, I did something cheeky, I use my younger brother who’s 17 years old, and I used him as a guinea pig. So I thought, you know what? I’m going to do this. But there’s no point me doing this by myself, and how best to get into a routine, make someone else do it with you. So in this sense, he was eager to do it, you can’t make someone something if they’re not willing to do it in the first place. So I basically I didn’t even propose the idea to him, I just explained of this is what I’m going to do. And then eventually is ‘hell I’m going to do that as well’. So we started doing it together. [Jaz]I liked what you did directly, because instead of saying someone, you should try this, you sort of said, hey, I’m doing this and you sort of made them desire it. [Ricky]Mass manipulation. He’s been doing that, and he found that really helpful because he was studying for his A-levels. So in this book by Robin Sharma, he discusses the first hour of the day and talks about the 20-20-20 rule. So I adopted this, I don’t stick to it. So strictly but the first 20 minutes you do exercise, as you wake up, you drink a big glass of water replenish all the water that you’ve lost during the sleep time. Sweating actually releases brain repairing neurotropic factor, which actually helps create new neural pathways. So if you get sweaty in the morning, in a way, that’s when I was working [gal think,] the more I’m sweating, the quicker my thinking is going to become an obviously the better you’re going to look and feel about yourself, then the next 20 minutes should be reflection and meditation. Meditation is really important. As you know, we are both from the Sikh community. So I like to do my prayers in the morning. And this really helps to kind of reduce your cortisol and reduce your stress levels. And then the final 20 minutes should be doing something, learning something. So I always used to make it a habit that I’m not leaving the house unless I’ve actually read something for 10 to 20 minutes, something that’s fresh in my head in desire to do some work as well. So I actually– [Jaz]Where do you get your 20 minutes of learning from? What was a quick, easy win that we can get in the morning at 5:40 in the morning? [Ricky]So it could be like you have say for example, a dental article that you’ve had on your to do list to read. You don’t have to necessarily read every single word but look at the main content that’s within that in the article. You can read a chapter in a book, you can watch a YouTube video. I mean, we’re in the era of social media and videos, you can listen to Protrusive Dental podcast for a while. [Jaz]We have a winner! I was waiting for that. The best. [Jaz]Hi guys, it’s me again, I’m just interfering with this little message. I just want to say a big thank you to Ricky Bhopal because he was actually one of the beta testers. For my splint course I had about 30 beta testers who gave me really valuable feedback to make sure that the splint course was going to be epic. So please, that people all over well, from USA to Australia, New Zealand, Taiwan, Singapore, India, even Scunthorpe became delegates on the splint course and we’re having monthly coaching calls and the secret Facebook group and I’ve been supporting everyone and people have been just sharing and learning so much, which is which has been great. And one of the things that Ricky had to share about the splint course was the following. ‘I love how you can see the passion oozing out of you. It’s very engaging and easy to follow. All your explanations are amazing. This course is so legit. You could teach someone a dentist who knows nothing about occlusion, nothing about splints, all about bruxism and occlusal appliances. So Ricky, thanks so much for that feedback on the course. And there are basically two reasons why I share that with you in this little message. So reason number one is a lot of people were messaging me when the enrollment period was open for splint course. And they were a little bit worried about coming on and joining us, because they thought that they needed to have a lot of knowledge, a lot of prior experience when it comes to splints, and occlusion knowledge, and they didn’t feel worthy of it. Well, I’m hoping that with that testimonial from Ricky, all you’ll see that actually, I really, really started from the basics, like even if you don’t know what centric relation is, or what a Tanner appliances is, or what an AMPSA is, I take you from the very beginnings from diagnosis to splint delivery to follow ups. And of course, we go through your own case as well. So it’s for everyone, no matter what level you are, you don’t need to have been on like five different occlusion courses or anything like that. I mean, I do cover some occlusion there. But it’s primarily a splint course, which I don’t think there’s anything out there that’s like this, because there’s so many occlusion courses that just cover splints, like a tiny bit, and it leaves everyone confused. So I devoted to the many, many hours to put this together. And you can get like, minimum 12 hours of CPD every month, we have the monthly coaching course. But the second reason I want to share this with you is in June, the first week of June, we’re going to be opening enrollment again, for the second cohort of splint course, if you missed out in the first time, no worries, you can join the second cohort, all you have to do is go to splintcourse.com and register with email address so that when it opens, I’ll be able to email you the launch offer for the second cohort. So I hope you join us on the splint course.com. If you’re still not convinced, go to coursekarma.com., in the search bar, we can find all the courses from all over the world in dentistry. So it’s coursekarma.com, you type in Splintcourse and just read the reviews for yourself. And let me know what you think. So hopefully, I’ll catch you in June on Splintcourse it’ll be really awesome to have you. [Ricky]Yeah. So in the morning, the first thing that I will do is I’ll actually use this time to create my daily tasks. So the night before, I would say okay, this is what I want to be doing. But in the morning, you may not be thinking the same thing you were thinking the day before. So you want to make realistic goals and realistic targets. Otherwise, you constantly let yourself down. So when you look at your to do list, as you were mentioning, you’re going to be like, ‘Damn, I haven’t done this,’ then you feel bad. And then you get into this kind of downward spiral. So for me exactly what you’re saying, I don’t like to make, particularly in a to do list, I would say, okay, today, I’m covering this, I look at the day before, okay, is that realistic, or cool? Let me do this, this and this. And then I actually would keep, unfortunately, I’ve taken all my calendars down, but I have a huge calendar. So I’ve tried to go digital with everything, then the same thing, I’m still a bit old school like pen to paper. So I would keep like a big yearly planner, and on that yearly plan on my wall, I could just look up and be like, okay, on this day, I know I have to have this done by this date. So say for example, I’m covering like a topic, say implants or removable prosth. I know that by this date, I need to have this done. And I have to do everything I can to get to that stage. But because I’m documenting everything that I’m doing, I’m able to keep track of everything as well. So which comes on to my next thing as well. [Jaz]Before we move on to the next one, I just want to share my spin on what you said there often mean, you both will see some patients or a new patient examination. And we’ll have letters that we may want to write these patients, right. And what I used to do is I used to put my to do list okay, write a letter for Mrs. Smith. Her review is in two weeks, so make sure you get it done by then right? Problem is, you want to do it tomorrow, then you can skip it, skip it, skip it, skip it, and eventually what happens the day before the morning of the appointment, you’re quickly making a treatment, which is not great. So now what I did, by switching to the diary zoning in my calendar, I’m able to allocate between 3pm and 4pm, every three days or whatever, like I’ve sought allocated days where childcare is sorted, and I can just crack on. And that’s where I do all my treatment planning, if you like. And that’s how I made the switch where it was, it was quite similar to you and sense that you know your endpoint and you will slot it somewhere within your diary. [Ricky]Yeah. And this actually really nicely comes on to the next point of what I’m saying as well. So I’m keeping a journal of exactly what you’re doing, keeping a journal of your daily tasks, your goals. And then there’s actually a course I did a few years ago by [Asif Said] and it was it was discussing about having a day in the week for green space. So you just use that time to not do anything work related and just focus on admin only. And what I’ll do is I’ll have basically a table of all my tasks and then at the end column have where am I up to up to this task, okay, what’s the next action that I need to do? So in that time period, I’ll basically say, okay, I’m going to sit there I’m going to look at all of my patients from practice. Look at my invoices, look at my, the way that I’ve been doing my dentistry, look at photographs, and then also look at my life as well and seeing how am I progressing. So I think having that one day is really, really important. Because if you don’t have that green space to kind of focus on yourself, then how you’re going to continue to improve, you’ll constantly be saying, Okay, I’m going to reflect on that another day. And then it all builds up. And then at the end, you’ve got this big batch of things, which eventually you’ll say, copy off to do anything now. [Jaz]And then you go on holiday, and then you’re busy with that. Yeah, I’m a huge fan of having that [end to fast] since I made the shift to a shift pattern type of work. So before I used to work very traditionally, before I used to work in Oxford, I’d reach Oxford at 7am, because I’ll to miss all the traffic. So from London to Oxford, right, I miss all the traffic, play squash from seven to 8am. Okay, and then I’d get changed, how shall I go to work 9am to like, you know, by timing on your notes and stuff, 6.30 or something, then drive back and get home for at half, seven, I’ve been out the home from 6am, back home, half, seven, okay, and you’re shattered and destroyed. But now that I made the shift from either working the mornings, from like, 8am to 2pm, or I’m working the evenings, to 2pm to 8pm. So essentially, I have in my diary, some green space almost every day, which I have just found. So uplifting, so great. And so wonderful for the effects that had on me and my family, to be able to spend more time with my son, my son can see me every day, undivided attention when I have those sessions off, which has been just phenomenal. [Ricky]That’s amazing. Because speaking from my own experience, like when I was younger, my mom was studying to be a general nurse. So she was at university for when I was a really young child. So we really get to see her a lot. So I’d spend a lot of time with my grandma. That’s how I learned like my amazing Punjabi skills. So yeah, I didn’t get to see her much. So the fact that you’re able to do that with your son, that’s amazing. I’m sure that he will remember these times when he’s actually older. The thing that you said was, you basically have switched around your times and the clocks within your day. So one of the things that I found with this tip of keeping a journal is you’re able to kind of keep a record of what your productivity levels are, as you’re progressing through the day. So when I was actually doing my revision for my exit exams, I would keep a record and monitor my day. And I’d find that between 1pm to 3pm was my unproductive hours. So this is obviously during COVID. So sometimes, you do things where you have a knock on effect. So for example, if you are watching a TV series late at night in bed, and next thing is impacted your sleep. The next morning, you’ve had impacted sleep has a knock on effect, you’re not going to have as much productivity the next day. So for me, I looked at this and said, but I don’t want to stop watching these programs. And I was watching umbrella Academy, which is an amazing show, by the way. I thought no, I don’t want to do that. So what I did was I figured out that between one and three is my unproductive hours. So let me slot in my series then. And then I can actually sleep that night and get a proper night’s sleep. So similar to what you’re kind of seeing there. With now that I’ve completed my course. So how do you apply this to dentistry? So as you mentioned at the beginning, I’ve just finished my training. So I’ve split my time up between basically two practices. So I’m working on a Tuesday on Monday or Tuesday, Thursday, Friday and every other Saturday. So I purposely have done it in a way that I have a Wednesday off. So midweek, time off, I could do my admin is during the week. Just get on with whatever tasks I need to do and it’s during the working day. So I’ve done that strategically to allow me to do that. Sometimes it’s important that we start focusing on what other people are doing and just do yourself and your brain will actually love you for it. Because what may work for one person may necessarily work for someone else. So all throughout my undergrad training, I was a night owl. I’d be doing like night shifts, work into the early hours of the morning, going to university sleeping during the day. And I thought to myself for a long time, there’s no way I can become like one of my buddies who would wake up super early and kind of adopt what I’m doing now. But the thing was, at that time, it wasn’t conducive for the way I was basically going about doing things but as I’ve progressed through life, the way what you want in life changes, so you just have to listen to what you want to do, as opposed to looking at other people who may be doing nine to five days or working six days a week, or is crazy enough to do seven days a week. So it’s just whatever you find comfortable for yourself. So, which goes on to my first point, which is getting tuned in with your mind and your body? What are you capable of? Okay, so there was a quote that I wanted to share with you, Jaz is by Michael Gerber. And it basically means it what he says is, the difference between great people and everyone else is that great people create their lives actively, whereas everyone else has created their lives passively waiting to see where life is going to take the next. So the difference between the two is, someone is living fully, whereas the other person is just existing. So I think when it comes to wherever you’re doing whatever profession you’re in, for us, as dentists, like, if we want to become something, we need to actively do something about it, whether it’s going on a course, speaking to the right person, networking, going to conferences, listening to podcasts, all of these kinds of things, you can’t do things by doing nothing, you’re not going to get anywhere. And maybe some people do, and they’re very lucky. But for the vast majority, we need to actually do something activity [Jaz]100%, you have to make your own luck, and the language that you use there, actively and then just respond to what happens very much similar to being proactive and being reactive. And so that, for me, it was like yeah, definitely a parallel there was one of those sort of sayings I’ve had, I’ve come across for like, are you living life proactively? Are you making the changes? Are you trying to sync your diary with your better half and actually try to make time for your family? Or are you just waiting for by chance for times to work out and most likely they won’t work just work out automatically. They won’t just work out in this beautiful way where you get to see it get the best of everything. You have to work hard to make some strategic sacrifices and actually graft towards that. [Ricky]Yeah, no, exactly. And I think that is the key to success, in my opinion. [Jaz]Awesome. I love it. [Ricky]Jaz another thing that I want to discuss is, why do we never live in the moment and be happy with what we have at that specific moment in time. And there’s so many times I myself has done this, I’ll be happy when I get into dental school. Then you go for dental school and you’re slogging your way through and then you finish, I’ll be happy. If I get a [df one] position. I’ll be happy if I get a DCT one path mfds. But we never actually enjoy that moment. And it’s something that I was really thinking and reflecting on a lot of a lot about since I finished my program. And I was thinking to myself, yeah, that was a really tough journey. I loved every second of it. There were ups and downs. It wasn’t all hunky dory and good times all the time. There are going to be bad times. But that’s what life is like, isn’t it? I learned so much. I did the thing that I love to do. I made some amazing lifelong friends, met some amazing people. So it was just and I grew as a person. And me, it’s like, okay, you know what, I really enjoyed that. Okay, that chapter of my life is now closed. Okay, let’s go on to the next chapter. So rather than thinking, Okay, what am I going to do next, that’s going to get me happy. There’s no point doing that. Just go with where your life is going and enjoy that journey. Otherwise, we will constantly be chasing happiness. That makes sense? [Jaz]100%. That makes a lot of sense. I remember actually, a few years ago, having the same reflections. I was with my then fiance now wife, got one of her interviews, DCT interviews. And I was speaking to these guys who just had that interview, and they’re ready to sort of find out where they got a DCT. And they were sort of saying, using language in sentences, like, I’ll be happy if I get this place for DCT or I’ll be happy once I get to a situation where I can do this type of dentistry or I’ll be happy when I can place implants. But like you said, you’re always chasing that next [hype]. And professionally for people like me and you, who are so passionate about a profession, it’s so easy to get caught up and lost in that, right. So I think you showed so much sense that you’re speaking in terms of time for happiness is now and it’s so good that you had such a great time that you can reflect on your training and not be like, okay, I made it and now I’m happy. But actually, I’m only going to be happy when I get to this next level, because you can easily just chase the next level Ricky, but you you’re like, okay, you know what, this is a journey. I’m enjoying it now. [Ricky]Exactly, Jaz. You can apply this to kind of how you’re going about progressing in your career as well. So it’s okay. Like you said, I’ll be happy if I could place implants. So what a lot of people that I’ve seen over the years is they’ll do one course and then jump on to do another course and then do another course. Something that I I’ve kind of always done from the very onset was I do a course and then if I don’t implement that in the next time I’m in practice, then I’ve just wasted my money. And so I was kind of in that mindset. And I mentioned a course earlier by [Asif Said] sided two of his courses, [FFQ and PYP]. And he actually does discuss this element within the course as well, which is quite nice. Because as okay, because there’s other people who are thinking the exact same thing. So what you’re saying was, when you want to learn something, don’t just do every single course, do one course, learn that skill perfected, until you are like, you can do it with your eyes closed, then move on to the next thing. And that way, you’re constantly getting all of these skill sets into a category where you are really competent with it, rather than, spreading yourself thin and doing so many things, but then never becoming a master at all of them. That makes sense? [Jaz]You reminds of the phone chat we were having last week, actually, you tell me about the whole is it column one, column two, column three, right? Yeah, essentially, it’s stuff that you know that you don’t know. And then you can move it up to next column was like, okay, you’re working on it. And only once you’ve mastered it, you put two column three. But if you keep putting too many things stuck in column two, and you’re sort of doing too many courses, nothing will ever move to ‘I can now do this competently.’ [Ricky]Exactly. And I hope Asif doesn’t mind me showing that gem, but it was a really a life changing thing for me, especially. And I found it was really helpful. And I think that a lot of people should. [Jaz]Absolutely. And Dhru Shah also talked about this in one the passion and values episode I did, maybe last year, and he talked about how young dentists can choose their next course, will each actually be introspective and look at what you’re good at what you’re not so good at. Have you actually mastered anything yet? If not, maybe once just hone your skills in and focus on just mastering at one aspect before jumping to the next course. I think that’s very apt what you said and it’s going to help a lot of people in terms of deciding on what’s your next but also just reflecting that before just continually chasing different highs to actually master that one sort of craft at least. [Ricky]I agre with that. [Jaz]Ricky, any last tips, because that’s been you’ve given a real good overview, and we talked about how switching from tasks to calendars. In the interest of time, I have to really push you that one last golden gem, if you had any. Maybe talk about your procrastination technique you told me about over lockdown. [Ricky]Oh, man, okay, this is really bringing the geek out now. So during my revision period, and one of the things that I found was I’d be sitting there, reading some notes, whatever it is, I’m making some notes even and then all of a sudden, I get something come into my head. Remember to go get the dog’s vaccinations. And then all of a sudden, next thing, I’m on the internet googling everything about dog vaccinations, what’s the best one? Well, sometimes you get lost in the dark areas of YouTube, or you might end up being upside down. So procrastination, for me is like a really, really, really hard thing to overcome. So I thought to myself, okay, this is really annoying, I need to stop this. So I kind of do it. So I coined a term and made this thing called hot desking. I don’t even know if that’s the right term for it. But basically, it’s just having a piece of paper, or in my case, I like to use a productivity app. And I basically just made like a page, then it’s literally just labeled hot desking. So what I’ll do is, when these things would pop up into my head, I would go and click on that. And then I’d write the timestamp, and then write whatever it is. And then it’s crazy how many times you think you’re going to procrastinate within an hour, I think there’s about 10 times or something on one of the days. And then what you do is at the end of your day, you then go back to that link and you have a look at it and you say okay, these are the things I would have procrastinated doing. Do I really need to find out about, is there life outside this galaxy in this universe? And it’s procrastination in itself, but you basically you’re making it smaller. So rather than going on to the website and doing all those things, you’re just clicking on that link quickly writing something. And then when you’re doing that, that active task of going on to that thing or going to that piece of paper and writing get it will make you think, okay, I’m wasting my time. Let me get back to doing my work. Same thing you can adopt when you’re on social media. I mean, I used to be one of those people. I’d wake up in the morning and just be scrolling through Instagram, Facebook or wherever Pinterest and then I’d sit down. Say actively say to myself, this is not making any difference to your life, stop it and get off, do it in a time when you’re on the train, or you’re waiting for something. Why you’re doing it now in your productive time? So that’s amazing. [Jaz]It’s very similar to something I posted a recent episode up about how to maximize your learning from dental courses inspired by someone called Jim Kwik, who wrote the book limitless. And what he talks about was exactly what you said. It’s about when you have a distraction from what you’re what you’re concentrating on, because your brain can’t process a negative. Like, for example, suddenly, we’re having this chat. And suddenly, I’ve thought, the dog that I don’t have, but they might need some vaccinations, right. And suddenly, now that’s bothering me. And now, I’m not actively listening to you anymore. I’m not with you in the moment anymore. But if you actually quickly write it down, you’ve now dealt with it, you can come back to later. And that’s, you know, the same concept with your brain can’t process the negative now that you’ve processed it is done, it’s going to become a positive. And it goes in like the to do later pile. So thanks so much, Ricky for sharing that. And all the gems you shared, I’m probably have to bring him back for part two, because we had to sort of whiz through this one today. But when you start working as a prosthodontist, maybe a year down the line, I want to do maybe a follow up episode, see now that you’ve actually entered the big bag world of a full time work pretty much. How are you coping? What have you learned last year? That sounds like a really cool thing to do. What do you think? [Ricky]Yeah, I would be up, buddy, pretty anytime for you, man. [Jaz]Awesome, buddy. Thanks so much, Ricky, for coming on set and sharing all these productivity gems with a prosthodontist. [Ricky]Thank you very much for inviting me on. Jaz’s Outro: Thank you so much, everyone, for listening all the way to the end. I hope you found value from that. I hope you can take something away from that as an actionable step that you can do tomorrow to make your life more productive, make it more fulfilling, and get more enjoyment out of life. And remember, life is not a race. It’s a journey, right? You won’t be happy when you can start placing all on four you won’t be happy, then you’ll be happy now. Now is the time for happiness. So thanks so much for joining me. Check out the Instagram on @protrusivedental and do leave a feedback review on Apple if you listen to Apple because that really helped me to find more listeners just like you who find this valuable and we appreciate you listening. Thanks so much.

We wrap up STRAIGHTPRIL with a HUGE one – what makes aligners predictable? How can we make aligner treatment protocols efficient starting right from the planning stages and the Clincheck. I am joined by a fellow podcaster and specialist Orthodontist Dr Farooq Ahmed who is a wizard with Aligners! https://youtu.be/FL1nDqYX7Ls Make Aligners Predictable Again – Donald Trump Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: Use floss to create loops and use a chain retainer, like Ortho-Flextech which has made it much easier in my hands! In this episode we discussed: How to pick the winning cases Which movements are tricky and how we can overcome them (including deep bite!!) Should we overcorrect expansion? What is Farooq’s take on elastics and aligners? Clincheck golden nuggets! Do check out Farooq on Ortho in Summary Podcast! If you liked this episode, you should check out IPR for Dummies with Dr Devaki! Click here for Full Episode Transcription: Opening Snippet: So that was the premise of the question, we have to know what is predictable in orthodontics, right? So if we can put aligners to the side for a couple of minutes, it's the fact what can we do put it to be with fixed appliances with other types of appliances. And the truth is, there's nothing which is 100% predictable. So we've got to start off with a golden truth that is not 100% predictable as a science. Jaz’s Introduction: Like with all things in dentistry, case selection is so, so, important and we all know that orthodontics, including aligners has a very steep learning curve. That’s why in this episode, I brought Dr. Farooq Ahmed to talk all about the do’s and don’ts of aligner treatment. I mean, I wish I had something like this when I was starting align treatment because it helps you to get more efficient treatment. I mean, I made a few mistakes, nothing serious, but it gives you that magic word which is PREDICTABILITY. That’s what we want in all our treatments. And in particular with aligners. Hello, Protruserati, I’m Jaz Gulati and welcome to this final episode of STRAIGHTPRIL. I hope you found this month interesting and stimulating and it’s going to help you with your future orthodontic cases. I want to also take this opportunity to apologize to you for not emailing you guys like usually I did my newsletter full of the episode, I started off by doing a per episode. So now I do like a roundup of some of the bigger episodes. So maybe I’ll do one for straightpril, all the orthodontic series in one email. But emailing has been very difficult for me because I’ve moved house, it’s officially happened. It’s been a roller coaster, I’m sure any of you who have moved before will be able to relate with me. It’s been funny, I moved back from Singapore, back to the UK in 2017. I lived with my parents, it was nice living in a very traditional Indian household. During the pandemic, it was brilliant to have six of us including my son living in the same household. I think as a bubble during the pandemic that was really special. I think I’ll cherish those memories for the rest of my life. But I think it’s time to now flee the nest. So we have our own space now. And it comes with its own challenges of childcare before I just give a shout out to my parents and have some more free time to do this kind of stuff, but I don’t have as much time anymore. But that’s fine. That’s the beauty of being a father beauty of having a family and everything just has to fit around that right? So before we join the main episode, we’re going to look at the main things that make aligner treatment predictable, which kind of movements are favorable, which ones are unpredictable, and how to program your clinchecks to overcome that. Protrusive Dental PearlNow before we get to that with Farooq Ahmed, I’m going to share the Protrusive Dental Pearl which is a retention one following on for that awesome episode with Dr. Angela Auluck episode 069 do check it out if you haven’t listened that already, is regarding fixed retainers. Now, Angela talked about placing an indirect labmade fixed retainer. But sometimes I like to place a direct one. And what I didn’t like and I didn’t enjoy the outcomes was using the sort of braided wire that you have to sort of bend yourself and apply to teeth. I could never get that perfect adaptation. So maybe it’s my hand skills or whatever. But I felt as though there should be something better out there for GDPs or orthodontists who want to do direct fix retention and do it really well and more predictably. So what I found I learned through Mohammed Al Muzian is using the ortho flextech chain retainer. Now this is a chain retainer. So it just has this wonderful contour to the lingual surfaces of the teeth. And what I do is I get my nurse to what I put the floss between the lateral and the canine let’s talk lower, and we make a little loop through the loop goes through retainer on each side. So left and right. And so the nurse pulls it not too tight just gently so that the wire retainer adapts nicely. So if you’re watching this on YouTube or Dentinal Tubules or wherever you can actually see the video of me actually doing this. But if you’re listening just imagine the loop floss, the retainer going through it the nurse just gently pulls it so now you have this lovely chain retainer adapted very nicely on the lingual. That retainer has just made things really easier for me when it comes to doing direct fixed retention and placement is better nicer. I overall really enjoy it. So do check out the flextech, ortho flextech chain retainer. I’ll put some links on the protrusive.co.uk website so you can check it out. Also on the Protrusive Dental community Facebook group if you’re not on there, why aren’t you on there? Anyway, hope you will enjoy this episode with Farooq. I’ll catch you in the outro. Main Episode:Farooq Ahmed, welcome to the Protrusive Dental Podcast, my friend. Final episode of a straightpril, horrible name, I know. I keep reminding what a crap name it is but I needed something. Welcome my friend. How are you? [Farooq]I’m really good. And I’m glad to be here guys. This is going to be a takeover podcast because I have my own podcast. And Jaz has finally got around to inviting me to be here. So I’m going to try and make this entertaining. I’m going to give you the content. I’m also going to try and make it awkward for Jaz because I know what he has to do to make this podcast work. And I know their exact thing to say they’ll make it awkward for him. So guys, we’re going to have a great episode. [Jaz]Oh my goodness, I’m scared. I’m actually really scared. But let’s see where this takes us. Well, usually if I’m allowed to for it, usually the way I do it is I would give my sort of crappy introduction of the guests to me, we spoke over lockdown, you were thinking of starting a podcast and it’s just been wonderful to see your orthodontics and summary, podcast grow and grow and grow. I think you’ve got some great people around the world orthodontist feature, you do shorter episodes, you do longer episodes. So do tell us about that for anyone who wants to get their geek on an ortho. And of course, you’re a consultant orthodontist, and you do some lecturing, mostly around aligner therapy, take it away Farooq. [Farooq]So that’s my thing. So I mean, I qualified as a recent consultant 2018. And I have been really engaged. I’m really lucky to be an orthodontist, guys. The academic side, the clinical side. Like it’s all come together for me, and I really enjoy what I do. And it’s led me on a journey of education, not just for the specialist train that we can park that to one side, especially aligners, it’s all been a post qualification journey. And for me, it started on the clinical side. And then I’ve started looking at the academic side and starting a little bit of research, because I’m trying to answer the questions. And part of my role as a teacher at Guys hospital, so I lead on teaching aligners to post graduates people want to be orthodontist and kind of for me, the journey has come about through me doing treating patients in practice, yes, but also teaching people want to learn and you know yourself, Jaz with your resin bonded bridge course with the splint course, which is just amazing. By the way, guys, you’ve got to check this out. I mean, this courses are just immense, well organized, planned, nothing like my podcasts. And the idea when you’re teaching is that you are as we spoke about on the [parapet], right, so you’ll get questions thrown at you that you do know, you don’t know, and unhinge what your theories are. So it leads you to have to reflect and really be honest with yourself and say, what is the truth? And that’s led me to where I am now, where I have a regular source in dentinal tubules, where we talk about aligners with a really expert panel of dentists and orthodontists. And it’s led me to kind of now starting more research to type questions with my role of a Guys hospital. The podcast itself, though, that came about through lockdown, and I was really bored. And when I’m bored, bad things happen, right? So I had to do something to prevent some evil coming into the world. So this podcast filled that void of time for me. And guys, what happened is I started really following Jaz then. So it’s like, no one’s done this in orthodontics. I want some more I want to follow someone. So then I remember Jaz. Guys, if you don’t know Jaz’s fame. Yes, he’s got this podcast and the courses. But Jaz’s fame started with all of [D]. So this is like a boy band of parody videos for dental students. Right? So guys, Google it, it is his biggest hits. By the way on YouTube, I noticed. And I’ve told us this before we interview I know more about him than he knows about me. So he can seem a bit awkward. [Jaz]I can’t believe he already got that mentioned. That’s crazy. [Farooq]And it was actually the guy who made Jaz has a great video of him in a [later hosen] doing the Harlem Shake. And like it was great. Like this guy just made it. So I knew Jaz. So I started following him and he’s got a great podcast, it’s got a great website. So wants to replicate really the structure but also mean that’s a super positive. And it is all about learning and accepting ideas and thoughts and they may conflict but actually it’s all good because we’re professionals and we’re friends at the end of the day in dentistry as a brotherhood, as a sisterhood. It’s just a community right? And that’s what I like to try to replicate that to a degree in orthodontics where we don’t have this. And that’s kind of where things are today. But this is to be honest, this is really just at the end of straightpril, scraping the barrel he can’t find another orthodontist. So he had to you have to reach out to me and I will take it with both hands. [Jaz]Not at all that way that we know we say we save the best for last Farooq and this is going to be such a hot topic like people want to know more and more about aligners, especially the Protruserati because the Protruserati is mostly listened to by gdps and GDP is a lot of us are doing orthodontics. I know at the end, I’m going to slip it in there just your take on gdps and orthodontics. Where’s the limit? How do you feel as an orthodontist? Where do you draw the line kind of thing. So we’re going to touch on that. But I think the main theme we’re going to tackle today is aligners. How to be more predictable, and how to identify and dodge risks. So it’s great to have your expertise on this. So if you don’t mind, I’m going to shoot the first question. Which movements are predictable with aligners and which ones are not? [Farooq]Okay, it’s a big question. And so that was the premise of the question. We have to know what is predictable in orthodontics, right? So if we can put aligners to the side for a couple of minutes, it’s the fact what can we do predict to be with fixed appliances with other types of appliances? And the truth is, there’s nothing which is a 100% predictable. So we’ve got to start off with the golden truth that is not 100% predictable as a science and as a clinical specialty, and we have to acknowledge that when it comes to aligners. So when we come to looking at the types of movements possible, we know the most predictable one with aligners are tipping, or what we tend to use in the form of alignment, which is great, because most of the cases we’re doing tend to be alignment cases, if I was to give you the numbers from the literature, we’re looking at around about 75%. So that’s where we are. So it’s good. It’s not perfect, but it’s there. And then we kind of start to scale things down as to other types of movements. So next, I tend to look at what allow us to want to clinically tend to do. So expansion tends to feature quite highly, an expansion is an interesting one, we tend to have some literature that says about 80% is good. Others that tend to say around about 40% to 50%. And I’ll come on to that kind of got topic a little bit later. [Jaz]Farooq, just to use percentages, just to make it tangible, these percentages, right? Is that like, let’s take the alignment one you said 75%? Is that like you treat 100 patients, 75 of them will reach the desired movement or you reach 75% in the way most of the time? Or can you just make that tangible? That figure, what does it actually represent? [Farooq]So that represents anterior alignment of the predicted tooth movement versus what’s achieved. So that is, if we wanted to rotate it to say 45 degrees, we’re going to get to around about 37 degrees. That’s what that information is telling us if we add it all together. So the 100% mark isn’t really there. And we see that in clinical practice, because we tend to go to refinements to some degree or another to then get the rest of those bits done. And that sounds quite bad when it isn’t, it’s kind of well if you can’t do the job, and what’s the point of doing it? Well, it’s the same with fixed appliances, right. So if we translate it, it’s nearly impossible to finish the fixed appliance case without doing some customization at the end. Whether it’s through wire bands or changing the bracket positions. It is how orthodontics works. And it’s because not the appliance is bad. It’s because of the natural variation. These things are planned through a computer an algorithm. And the reality is biology doesn’t necessarily follow that. So we have to have an awareness in orthodontic journey. Although we’ll plan it quite a lot at the beginning specifically with aligners. It is still a continuous process. And we have to allow for that changes with refinement at the end and so forth. And then that’s there, we’ve got expansion and then kind of towards the other side, we’ve got extrusion and intrusion movements, with extrusion being the least predictable. So again, if you were to look at some of the numbers, there was a paper by [a senior] in 2015. The idea is it’s the least predictable movement about 30%. So if you’re going to plan to extrude, a tooth five millimeters, we’re only going to get about a millimeter and a half of that predictably. Now, these movements that I’ve just described to you, the tipping, the expansion, extrusion, intrusion, that’s looking at true movements. So if you took a model, and you just looked at the movement taking place in that one plane of space, but hopefully what was a divert this conversation today, we’ll see actually, there’s ways around that process. And we can talk about overcorrection, and other things that can then make your treatments predictable. So the way I kind of break this down is that aligners themselves will do most of the job, but the rest of the job is done in our planning. And that’s what I would like to get across the Protruserati, is that we can get predictable results with our aligners like we can get with our fixed appliances. But it comes down to our planning and our understanding of aligners. And that’s why I’d kind of want to end that question on. [Jaz]Brilliant. And I think one thing to bring it home is the whole thing about the clincheck. Let’s go with the aligners, you know Invisalign as a very commonly used system out there. So what I learned in my journey was that I used to look at the clincheck. And I think that’s not going to happen, that’s not going to happen. That’s not going to happen. But then I sort of started to realize why dentists were programming it in. Because exactly what you said in the first answer is because if you’re only going to get two millimeters of the five millimeters of extrusion, you over exaggerate it on the clincheck, to be able to get a little bit closer to where you expect it to be. Is that a good way of I guess, setting up the clincheck to sort of with the knowledge of which movements are predictable and which aren’t. So you all almost it’s that cartoon orthodontics, right? You’re just seeing the animation, but you’re playing it to your advantage. Is that a good way to summarize it? [Farooq]Absolutely, it is. The clincheck is not a visual outcome objective. Clincheck is a representation of which teeth you’re going to push with the aligner. And there’s some pushing movements with aligners that are great like [alignment as we described some of the answer are great, so we have to push a little bit harder. And extrusion and intrusion movements are those classic movements. So at the end of it and I when I do show patients, my online setups, whether it’s clincheck, or the system is that I will usually stop it before the last couple of hyenas because by the time you get to the end, it doesn’t look right. But actually that’s what I need to deliver that prediction of aligning those teeth and correcting the malocclusion. So you’re absolutely right. It’s about interpretation. And I’m working with some really clever [bots]. And we’re trying to create an envelope of aligners. So we can hopefully publish this information where you can see what movements are predictable to do with aligners. So you know what, what will work usually, and then what to do if it goes beyond that envelope. And then you start to use auxiliaries like elastics, and so on to then make that process more predictable. And you know aligners, they general perception amongst the orthodontic community and it is changing was that it’s not proper orthodontics. And that process is starting to change now with the use of auxiliaries and getting predictable outcomes to treatment. So we are going through this kind of change from the [old guard] where we are starting to look at aligner proper braces, but when we’re engaged with that concept is about predictability because that’s the fundamentals of orthodontics. [Jaz]On that point, one of the movements I shy away from or one of the cases I shy away from with aligners is deep bites. So I want to ask you Farooq, am I right to be concerned with deep bite patients? Or has something changed in the generations such that deep bites are becoming more predictable to treat with aligners? What’s your stance because classically, I know that aligners are favorable for anterior open bite, for the molar intrusion and correct me if I’m wrong. You’re the expert here. Tell me about deep bites, are my concerns correct? [Farooq]I shall do this two things got to mention here, guys. So one is that Jaz has done deployment orthodontics, right? So Jaz is well equipped with some of this information. So he will correct me if I’m wrong. Two, the thing that the hard thing about podcast guys is making a link between the first question the second question, and Jaz has got a quick so Jaz will use the word brilliant, quite a lot in his podcast. And I don’t be wrong. I’m all for doing this. Like I am really bad at linking one question to another question. But it’s good to hear Jaz, and he does it so much better than I do. So it’s great to hear it for me. So yeah, I mean, the intrusion cases coming back to the question is that and I know Jaz is most likely to cut out my bits. Just stick to like a 10 minute podcast of content. Is that your right? So intrusion in deep bite cases are a challenge. And again, like my approach to orthodontics integration was don’t dispute that I need to fundamentally understand what’s going on, I can learn about having my crown prep, so it is parallel sided, or six degree taper, whatever it might be. But I need to understand why before I can almost believe it. So let’s just go back a stage. Deep bite cases with aligners. The challenge with them is the comparison to fixed braces. So naturally, an aligner has an intrusive effect, it’s going to push all the teeth downward. And if you take into account the back teeth are going to be intruded as well. A bit if we talk about the third, they’re kind of the class three lever, like a stapler, for example, right? If we’re going to intrude all the way across, then actually we’re going to get an increase in the bite at the front. So that’s the nature of an aligner. Now that is the opposite for fixed appliances, where their nature is to extrude teeth. So they are much better and perhaps more naturally equipped as a better phrase to use for deep bite cases. So with aligners, they don’t have the natural tendency to it. However we can correct for that. So there was a recent study by [Al Bahar], and he showed that around about 50% of deep bite cases delivered the intrusion. Okay, does that sound great? But actually, there’s a way around this process. And it’s about having overcorrection, as we spoke about kind of in the last question. So when it comes to deep bite cases, I’ll aim to finish with an anterior open bite from the clean checking on the online setup, it doesn’t look great. But actually, I’ve now over corrected for that knowing that the aligners is not very good at delivering that force all the way. And at that stage, the patients do have a correction to their deep bite. But let’s be clear, if a patient’s got a complete bite, and there’s no lower incisors show at all, where the doing with aligners or even fixed appliances is going to be a struggle to crept in the adult patient. So it does come down for the average patient, we can do it and it’s fine. But actually for the extremes in any dimension, whether it’s vertical or horizontal and large overjet actually, appliances have their limitations to the orthodontic envelope of tooth movement. So we’ve got to bear that in mind. I think it is possible to do. But it requires some planning to overcorrect. You mentioned that different generations. And I think that’s really interesting, because Invisalign have got the G5, they’ve recently introduced the G8. And these are just the generations of Invisalign and new features to their product. From the back, you can see that if Invisalign have tried two different types of features to correct this. It’s a difficult one to do. And I think we have to understand that. And one of the key things that they’ve changed is trying to work with Anchorage. So I want to try and make this straightforward. When we tried to push the lower incisors down. There’s a natural tendency for the aligner to push up at the back. And that’s how the process of intrusion works. One of the problems with aligners is that they don’t retain that too well. So if the aligners has been pushed out to the front, it’s going to get pushed up at the back, the aligner simply lifts off and doesn’t pull on the teeth, or push on them. So the way that aligners and are not getting around that is by using large horizontal attachments on the back teeth, right, so it’s stopping the aligner lifting up at the back. And it helps to deliver that force in the anterior region to intrude the lower incisors. So as we know, the nature is great for it, we are finding ways to work around it. And those are the two key ways to get a predictable deep bite case. [Jaz]That was so elegantly put forward. Honestly, that was so elegant. [Farooq]I’m waiting for the brilliant. [Jaz]I have to change that to make it elegant now, and it was more than brilliant, it was very elegantly put. And I think the real pearl we shared there is those early in their career, playing with Invisalign, the clincheck I think the take home point is which I learned a few years ago, and I wish I’d learned earlier in my journey with aligners is don’t be afraid to get the end of the clincheck. And it look weird, or it look like, you’ve gone completely the other direction because that’s the whole point of overcorrection. And we need to be willing building that in so none more so than a deep bite case. So a great gem he shared that was, be prepared to overcorrect but also manage expectations. And also just realize that not just like you said that case we got 100% overbite. That’s not going to be a case that should be doing or will be even easy with fixed appliances, let alone aligners. I think you’ve covered that really well. Also, if you move on from the intrusion, extrusion and deep bite case to expansion as the next point. You mentioned already that I think you mentioned 80% to 45%, depending on the literature in terms of how much expansion is expressed. Expansion is a tricky one, because when I’ve seen people’s clinchecks, I get really concerned when I see overcorrection and expansion. A stability comes to mind about afterwards, be about recession, because I’ve done it before and I’ve got little bit recession. So it’s never nice to see recession, I guess. A guide that I use is to do not expand beyond the second molars. But where does that fit in to the whole overcorrection and expansion? And what guides or helpful tips can you give dentists who are looking to expand? [Farooq]Yeah, so I mean, this is a topic which, if I was to translate it into dentistry, I would say that this is a topic like veneers, right? So we have some areas where we’re going to use veneers where it’s very clear cut, right, we’ve got a hypoplastic upper incisor. WE all appreciate that veneers are going to be the best one for that one, but health wise, stability wise. But actually then there’s a large area where it’s really quite great. Where there’s questions about aesthetics questions about lots of dental substances, question about well, is that the right thing to do for the patient long term wise and people sit on different sides of the fence? So for me expansion fits into that topic, the answer to your question is that we can expand and aligners can deliver a degree of expansion, I want to try and get to that literature because a bit nerdy, as you understand that, from my general appearance and demeanor, but to make it useful is that that number of 80% is to do with the intercanine distance. So it’s essentially anterior expansion, right. And the further back we go, that’s when it drops down to about the 45% mark around the first molars. So we’ve got this kind of weird kind of, if you do parallel expansion on the aligner, across the arch, you’re going to get most of it in the anterior and far less posterior [John Morton], he’s one of the clinical, I think he’s a second in charge of the clinical development with Invisalign with align technology. And he was recently given the lecture and I do follow him, I do troll him a little bit as well. And he said that we don’t, we can’t, we know we can’t achieve expansion on the second molar, or we do with aligner, if we do rotate them. So from the top, this information is clear that posterior expansion is not that predictable. But actually anterior expansion is one which can be delivered reasonably well. Now, if you go back to that analogy, I gave off the veneer for the anterior tooth is that there are some cases we know we’re going to get expansion, and it will be stable, predictable, healthy for the patient. And the classic is a posterior crossbite. So there’s a functional issue potentially there. And we can correct that through expansion and it will retain itself it won’t be unstable. And it will meet that criteria of what we want when it comes to the other cases. So let’s talk about why do we do expansion with aligner of cases really, we’re trying to create space within the arch for our alignment or correction of malocclusion. So way to create space, which is less complex and destabilizing far less complicated extractions. So it’s kind of a neat way around that as a process. Or we may be looking to widen the patient’s smile. Okay, cool. The argument to support that is that well, it’s made your orthodontic alignment easier. The arguments against it are several fold. So the biggest one, as you’ve already mentioned, is a relapse. The question why is it going to relapse? If you’ve moved the teeth, surely the teeth can retain themselves. And the argument always goes back to this is the neutral zones, this is our prosthodontic days, right that the teeth, we should try and position them in the neutral area between the cheek and the tongue is the same when it comes to dental positioning. So if you push the teeth towards the cheeks, the cheeks now have a greater force trying to push them back. And that’s a continuous process, which will remain until they get back to that neutral zone. So there’s always that risk of that occurring. Now, when I gave you those numbers about the literature, what we know is that those numbers are working within the predictable parameters of about two to three millimeters. And there’s a great paper by Weir, who was in 2017 in the Australian journal, and it was quite a nice breakdown of two to three millimeters predictable, three millimeters, okay, you have to work a bit harder, four millimeters with aligners is not a predictable movement in any sense. So if we were to stick to do you want to do some alignment, expansion or cases, when we go back next weekend, the idea of two millimeters, you’re pretty comfortable delivering that, it’s going to be tipping movements that aren’t going to be bodily movements with it. And that’s also been shown by a paper by [Sue] not too long ago. And that’s exactly our fixed appliances work by the way, guys. So again, this isn’t aligners is not doing the job properly, which I feel sometimes the reputation takes them in that direction. It’s this exact same with fixed appliances, if we’re going to do expansion, we will tip those teeth in our adult patients. And the only way to get a bony changes is to doing surgical intervention, or for a younger patients doing it before the sutures fuse. So it’s the same. And we know from fixed appliances, again, we’re delivering up to three to potentially four millimeters of expansion. But then after that, we know it’s not going to really take place. So we need to kind of put our orthodontic type hats of limitations on that we would do with fixed braces and apply that to aligners as well. And I would say two millimeters is know what we can deliver. But actually going beyond that we shouldn’t. And I know, Jaz, we’ve had a conversation about the [wala align]. [Jaz]I was just going to come to that actually. [Farooq]Yeah, so the [wala align], it’s an interesting one. So this was kind of by the one of the founding fathers, if I could call him Larry Andrews. And the idea that at the mucogingival junction, there’s a relationship between that kind of horizontal point, relative to the midpoint of the crown of the tooth and the labial face [Jaz]Best observed from like an occlusal photo, right? It’s the best way to word the way I was taught, right? [Farooq]Absolutely. And the idea that there’s a distance, which is essentially safe for expansion, if you were to maintain that. And if you want to increase the expansion, if as long as you stay within those limits, it should be relatively sound, I think that’s a great starting point to get used to visually assessing cases using the [wala align]. And the idea with aligner is I feel it’s got an advantage over fixed appliances, because the basis of this line is that you have a custom arch form. So it’s not replicated the same, it’s not the same, you shape it just getting wider, it follows a patient’s initial U shaped arch, if that’s what they have, and it kind of grows in that same shape to maintain it on all the teeth. And I think it’s a good reference point to use, combined with knowing that two millimeters unless you’ve got a functional reason should be your predictable amount. Anything beyond that, you’ve got to be asking yourself, is there a more predictable way to gain the space for this particular case? [Jaz]Well, would that two millimeters though, because you know that two millimeters are predictable? And maybe that also aligns well with your objective and what you’re hoping to achieve? Then, even with the expansion, would you then program in three to four millimeters expecting to see that two millimeters? To what extent do you overcorrect when it comes to expansion as well? [Farooq]That’s a great question. And looking at the way the process of expansion works, essentially, you’re going to get that two millimeters delivered predictively with the aligner. So this isn’t the deep bite type case where we need to start overcorrecting from the outset in our plan. It’s not that realm is the fact that two millimeters will happen, right. And actually, when it gets to the third millimeter, it’s not going to happen that well. And the fourth millimeters is going to happen less predictably. So actually, overcorrection is probably not going to do you any favors. More so it’s going to do detriment, because in your space plan, you’re going to predict you’re going to get more space to be able to align the teeth. And if you haven’t managed to create that which you most likely won’t actually then you’re not going to align your teeth fully anteriorly. So actually, it’s really good idea to actually say no more expansion than two millimeters. And I’m a great one for actually with my aligners now is isn’t the preset features is switching off expansion as a method of correcting the occlusion, see what the setup comes back with and then add a small amount to it of two millimeters when it comes back. Rather [nose working] with the other way around. Because I feel as though we get lured into this self-false sense that actually I’ve expanded or not needed to do much IPR really, really simple. But actually we’ve gone down a relatively unpredictable road at that stage. So that’s kind of my tip at the moment is to try and remove expansion from the cases, see what it looks like and then add some into afterwards. [Jaz]If anyone was multitasking, while Farooq just said that you need to rewind 60 seconds, and listen to that, again, that was a real, real gem right there. I think that’s really, really cool. I think that’s going to help a lot of people. And I just wanted to ask one more question on the realms of expansion, because it’s three or four more areas I want to hit. But before I actually even get to this next one is I want to say that you are officially the geekiest guest to ever come on Protrusive. Dental Podcast. Yes, officially over overtaken Nik Sethi in a number of references, you’ve actually said and we’re just about halfway or something like that. So the references are flowing in nicely. So you are officially the geekiest guests, which is amazing Farooq, I expected no less from the host of the Orthodontics In Summary, guys, you should check that one out, what’s the website for the for the podcast? [Farooq]www.orthoinsummary.com. And you guys will go there. And actually the most popular podcast topic that I have is aligners. If it’s into this, we’ve got 19 of them. And I’ve kind of gone across the spectrum with it. So I’ve tried to go to I’ve looked at Invisalign, of course produce a lot of content. And I think education content is good guys, I’m not trying to dismiss them. But I’ve gone to some independent aligner or authorities and we’ve listened to them speak and we’ve captured their key points, and only five minutes long. So I think you can gain hopefully, a rounded understanding. And a lot of I’ve expressed to you guys today about how aligners work. And you know what the reality is that we’re still at the learning stages of this science. And I don’t think we should be ashamed of that. I think some orthodontist, because it’s not you will have the evidence we’ve got for the fix. But we also growing and developing. And I think actually I feel that gdps have very much helped that process to accelerate. And I’ll be honest with you, Jaz, like I qualify as a specialist, I just got my MOrth exam, which is the bar exam for orthodontics in the UK. And my first aligner case, I contacted my cousin who’s a general dentist and said, ‘Look, man, I’ve got this clincheck what is happening on this cartoon?’ So I don’t think it’s restricted to a speciality or what have you. I think we can all understand things together. And some of my general dental practitioner claims as fundamentally phenomenal questions, which do question how the science works. And we then have, I feel responsibility, at least in my setting, as an educator, to then find that information out and share it like we’re doing today [Jaz]That’s a really wonderful perspective. Now I’m going to come on to a final question on expansion I was an asked, which is, I can’t, just to critique my practice, which is that I commonly do like to lock and make the second and third molars unmovable, because I feel you know that you can predictably expand it and also to impart a degree of Anchorage? Is that something that you do is that a good protocol to follow? [Farooq]I think it’s a great idea to have in place. Now, it comes down to it. And again, I always like to draw analogies to dentistry is that if we looked at the free-end saddle situation, right, so we’re going to make ourselves a partial denture, we’re going to free-end saddle, we know that actually, the compression of the tissues is quite difficult to get retention because it’s better posterior, and we don’t have that in a free-end saddle situation. So it’s the same when it comes to aligners, we just don’t have enough to be able to move those back teeth predictively. So therefore not moving those is a very good way of stopping unwanted tooth movements and having less predictability. So for example, if we were to program in a rotation to second permanent molar of 15 degrees, okay, it doesn’t sound too horrific. But as it’s starting to push on that tooth, it’s struggling to do it, that has implications and how well that aligner fits further forwards. And actually, we may not be able to align up our anterior upper canine because the aligner is struggling to sit in that posterior quadrant. So actually, and again, it’s one of my things that I’m going through at the moment is expansion is one but twos I go through the teeth and get in a bit of a nerd or look at the tooth movements of each tooth in all six planes. I’d love it. I love it. I’m not going to lie to you. It’s like what it’s like reading code or read in the matrix. Let’s try make a cool, Jaz. Let’s try it. I look at the numbers. This best when I’m doing it with my postgraduate trainees at the Guys hospital I say put the two staple I look at it like I’m just the architect. But actually, yeah, anyway, I will give you all my secret. So the idea of it is that I will then remove movements I feel as well it’s automated this process I don’t need torque in my upper right seven like it’s not needed for this case. I wouldn’t do it for fixed it’s an unwanted movement. I’ll just remove movements from my posterior segment in all dimensions and not let the computer dictate that and it’s going to give you more predictability on where do you want it. So I think not locking six and sevens are good and seven and eights are good. The only time I probably do something different is if I’ve got a crossbite posteriorly and just the sixes in crossbite, which isn’t the most uncommon situation. And actually sometimes I want to have the aligner think of having some reciprocal movements taking place. And that just gives me a bit more push on the six which is buccally and crossbite to allow it to align. Even though I know the seven and eight are unlikely to move because it’s two teeth versus one tooth. That’s the only exception for me. But I think it’s a great starting point until you’re going to get start looking at more advanced movements. [Jaz]Excellent. So you see, I’m changing my words that I’m using now so that you don’t catch you with brilliant again. But you did remind me with the mention of torque there that I read somewhere, or listen somewhere, probably this listen, that when you are doing expansion, that is good practice to also check that as the molars are expanding, you’re adding in some palatal root torque, so that it somehow imparts more of a bodily movement rather than just tipping. Right? No, sorry, buccal root torque my mistake. I meant buccal root torque. So that it comes to it comes like a bodily movement, rather than just tipping like that. You want to be the roots with it. So it almost makes it familiar, like a bodily movement. Is that something that you follow? [Farooq]Yeah. So I mean, I do. And it’s now a feature within the G8 as well. So they’ve introduced this, I think aligner users were already implementing this as a process. But it hinges on having a buccal attachment, just on the square attachment horizontal on those buccal teeth, to allow that movement, that expression of force to take place in the tooth. Again, it’s great conceptually, and it does deliver, but it doesn’t deliver 100%. And that’s what we’re finding. And to be honest, again, it’s quite true with fixed appliances, is that we can deliver buccal root torque to posterior segments, but it takes a long time to actually deliver it. And how predictable it is, is always a question mark, I think the aligners are the same. If you kept a case in of aligners in a line of say, for an extra six to nine months at the end, just to put in this buccal root torque, I think the likelihood is you will deliver it. And again, when we look at fixed appliances, and what cases do take a very long time. So actually, we’ll add in some buccal root torque because we’re going to be streaming for another nine months. So we then see it happen. I think it’s we’re comparing the scenarios in two different realms. And actually, if you do want to deliver expansion, you want to make it predictable, you’ve got to make the treatment much longer to account for that to ensure that you are going through the refinements process as well to get these roots upright. Whereas I think if we then looking at just creating expansion for the purpose of creating space within the arch, so we can do alignment, I think there are other ways to achieve that in a more predictable way. Let’s do what we can predict to be with expansion. Okay. But let’s look at some of the other ways so we can live with this case, perhaps in a relatively shorter timeframe. Not trying to cheat the system here. But let’s just work with that envelope of movement with the aligners. [Jaz]Speaking of timeframes, you just reminded me of another useful question for dentists is that sometimes I’ve started to play around with my clincheck requests in terms of velocity, velocity of tooth movements. And sometimes if I find that my lower alignment is taking 26 aligners and upper is taking 16 then I will sometimes say well, why don’t you slow the upper ones down, so that they’re both taking a more equal amount of time overall, in terms of how many aligners are going to be active? What’s your take on that? And do you ever make this request of either speeding up the velocity to the max or slowing it down? And when? And when not? Is that a good idea to do? [Farooq]So I think this is such a great point. And again, guys, I’m going to be humbled here and say that I picked up this tip from a general dental practitioner colleague, and we were looking at a case together and I was trying to show off and he said, Well, you know, why don’t you just increase the number of aligners in the upper arch to match the lower. And it’s something that I’ll do all the time. Now, the idea of slowing down tooth move is about increasing predictability with that movement. We have compliance potential issues that are there, we’ve got some move teeth that may well be stubborn for whatever reason. And actually, the slower we do anything, when it comes to orthodontics, the more predictable it is. And again, guys, I’m going to relate this back to the fixed appliances exactly the same. We know if we go through a slowest space, changing our wires, and slow amount of space closure taking place, we’re taking teeth out, it’s far more predictable, less side effects, more predictable position. So I absolutely do that. And I think it’s a great way forward. I think actually, if we really wanted to live it every case put it to be would slow down the movement in every tooth, but then there’s a timeframe and so forth to it. And for me that feature is that if we’re doing the average, if I’m treating the average case, actually, that’s something I’ll bear in mind when it comes to refinement. So if I’ve had an issue with several teeth not moving particularly well, in my refinement, I will say can you actually give me twice the aligners for this particular case. Now the case I’m treating recently, which is a an older lady, she’s in her late 60s, and we’ve had some periodontal issues historically, she just finished with a periodontist. And she’s come to see me we need to do quite a lot of work. She’s had a tooth taken out, we’re going to move all the teeth into that space, and we’re going to use aligners to deliver it. And we have now gone from having only 18 aligners, I couldn’t see how that would happen in that timeframe, double that up to 36 and I was looking at something which will work more predictably take into account the fact that she’s had history of perio, I want to keep the forces really light and also the amount of tooth movements she needs. It looks like a lot to me on the on the clincheck. Now in both respects, we’re now making them to a safe one. And like a colleague of mine from from Kuwait, he got caught out with a perio case where he didn’t change the velocity of it. And actually the case then developed in such a way that there was mobility at the end, that was a real worry in the state for a period of time, we just not respect to the biological boundaries. And in some respects, fixed appliances may have an advantage, because there are really light wise that we generally start off with, which usually deliver a really low force, and we increase the force as we’re going along with aligners, it’s like a one set force, it’s kind of going to do that for each type of movement. So we’re perhaps a little bit more likely. So we’ve got to be more tuned into that. But yeah, when in doubt, try and increase the aligners and I know some of my colleagues will try and reduce the aligners trying to get to certain price brackets and packages. And guys, I mean, that works out great from the financial perspective, right. But on the other side of it, guys is that that’s when you then start referring your cases onto somebody else there for the job. So it’s one of those and I don’t mean that in a negative perspective to general dental practitioners, please that’s not what I’m saying. I’ve had a consultant colleague do the same thing. To reduce the number of aligners price point, it gets to the end, the teeth aren’t straight. So I think we have the ounce of duty to deliver the case. And then the rest of it will follow and you’ll get a bigger discount by having more patients. How about that? [Jaz]Well said and it’d be amazing to see the stats from Invisalign in terms of how many aligners are needed for each patient, I’m sure when it gets to seven and 14, there’s a big spike. It just happens that this malocclusion needs 14 layers. And it’s I’m sure there’s a huge spike, because they’re trying to make it financially feasible and all that kind of stuff as well. One thing you’ve covered all the main questions really well, the rest are almost like accessory questions and the whole theme of do’s and don’ts. So recently, I had Robin Bethell on the podcast as part of straightpril. And we talked about the long and short of elastics. And he completely surprised me that we were talking about this, he rarely or seldom uses elastics, like class two and class three elastics. And I think the paper he quoted did mention about the whole skeletal changes not being possible, which we kind of know already. And we knew having a chat afterwards on Facebook. And I feel as though you have some good thoughts and some input to add in this debate because maybe for dentoalveolar reasons and certain cases elastics may have a role. Now we did say that for extruding naturals, most common time, the bootstrap techniques are go back to the episode you have listened already. So that’s a given. But tell us about into maxillary elastics. When do you use them, Farooq? [Farooq]This is this is a great topic. And one that I’m still learning more and more about. Now elastics, I think, again, I got to take a step back and say, why are we using elastics? And they have multiple uses. And it’s a bit like a flat plastic like you can use it for so many procedures, I don’t think any of us will say Actually, it’s just used for one procedure. So elastics, in the broadest sense, are used to help control tooth movement. So that’s the premise, it’s going to help us deliver a movement more predictably. So we can use it to stop unwanted tooth movements. So say we want to prevent teeth proclining, for example. We can use it to create active movements. So we can have an increased overjet. And we can use it to reduce the overjet. And as you mentioned individual tooth movements through things like bootstrapping, we take one tooth, elastic goes over it and extrudes one tooth into the aligner. So there are those kind of three components to it. Now I think we have and it has been mentioned by Robin’s podcast you did with him and I was listening to it is that yet skeletal moves aren’t possible with them. And when they are shown there is no strong science to support issues yet isolated cases and social media cases where we have questions about it. So for me intermaxillary elastic, so what are we describing here, so the class two elastics, essentially the pulling from the front of the upper teeth to the bottom back teeth, and that’s where the direction of forces taking place. We’re pulling the top teeth back, we’re pulling the bottom teeth forwards. Now this is where we’re going to start now talking about well, what’s the purpose of it? Are we doing it to stop unwanted movements, or we’re going to use the word anchorage and I appreciate that terminology goes into be of orthodontic wizardry. And I don’t wish to use a [smoke and mirrors] but essentially, I’m going to say we want to align want to align our upper incisors, and we don’t want to procline. So we’ll use some class two elastics to stop that unwanted tooth movement. And then we’ll talk about correcting and overjet. So we’re going to use heavier elastics to do use an active force to bring back the upper incisors, maybe procline the lower incisors if we feel it’s appropriate. So those are kind of how it works. And the way that you make the difference between ‘Am I doing it for anchorage or to stop unwanted movement versus active movements’ is the amount of force and how long the force is therefore, so the most common type of elastic to use and again, I’m going to go into some numbers here is a medium force which is three and a half ounces and usually a quarter of an inch. Now that information kind of is relatively in the background. But the idea that’s the most common used elastic in orthodontics, I’ve got a reference [Mansour] 2017. And so it’s essentially just show that can be it’s a very versatile elastic can be used in most situations for class two and class three. But the idea is that I’ll get patients to register at nighttime if I want to stop the unwanted movement. If I want to get active movement, I get into wear it more often. Now we spoke that might not be a skeletal so these are dental alveolar changes again, just translating the orthodontic kind of terminology, we’re just going to retrocline the upper incisors and procline the lower incisors. So if a case warrants that and can have those changes, class two elastics are fantastic at achieving it. And I found myself more and more using elastics with my aligner cases from the anchorage perspective. So to control which way the teeth are going to straighten essentially, either going to straighten by coming forward, kind of stopped them from coming forwards by using the elastics. And again, it’s just a nighttime usage, the same elastic. Nature is helping me to control I want the teeth to straighten, how’s it now going to happen, and I feel so that’s a lot of what orthodontics is, the mechanics themselves will do the job. But then we kind of tweak it here, tweak it there to move it left to move it right, and so on and so forth. So that’s my take on elastics I think the great tools, there’s a guy who I covered in one of my podcasts, [Calver] is a professor in in Brazil. And he just uses elastics all the time. And his cases are phenomenal. But he still respects the biological boundaries. And where it’s not where proclination to the lower incisors is a bad thing. They’ve got recession, that he won’t use them. So they aren’t the tool that solves all problems. And by no means are they tool to work. To stay away from I feel as though actually having a go with him is a great idea. And next time you guys are treating an aligner case. And you feel is actually incisors may procline, I don’t want that to happen. I would say build in some class two elastics. Get the precision cuts on the upper canines, [top tick] precision cuts upper canines, cutouts for the lower sixes and then just put some buttons on them. Or you can buy the ones from AutoCAD, there’s loads of buttons, you can buy metal or clear and get the patients to wear them evening and nighttime patients are really cool with them. Especially when you’re using a nighttime they’re really up for what they like the idea of using something at nighttime to help the case progress and get a better predictable result. And they commit to them quite nicely. You’ve got if you haven’t had the typodont I think Invisalign a [greatly] because they actually have the cutouts on the typodont. So again, guys, if you have got that from the aligner, and I think most people get that when they go on the course is that you’ll see the cutouts, get some elastics just have a play, I would play putting them on. And I do think it’s something to try and incorporate into regular practice. [Jaz]One of the advantages I think clear aligners has compared to fix appliances that what I’ve done fixed planes, I was trained in fixed appliances. And the whole thing that for example, you place a wire and it expresses a force. And then if that force gets expressed for too long, perhaps you lose control of the case, or you get too much of a movement that you perhaps didn’t want. Whereas with aligners, it can’t go beyond the realms of the aligner itself. So this whole concept of preventing too much proclination, I almost don’t understand it with aligners, because surely the tooth cannot procline beyond the actual position of the aligner itself. So really, how is elastics helping in that case? Do you see what I mean? [Farooq]I hear what you’re saying. And you’re right isn’t advantage of aligners. They’re a closed system, essentially, nothing can move without everything moving. That’s how the premise of it works. Well, it’s fixed appliances, each tooth has individual force, as you read correctly described, and you can get on what a tooth movements, so fixed appliances, like spinning a plate, you kind of have to keep it spinning, you have to keep engaged with it. And if you don’t, then things are gonna start to fall off. Whereas aligners, they will stop at that certain stage and not fall. So there is that advantage when it comes to the planning stage. We’re coming to answer your question as to Well, why would that happen if it’s a closed system is that unfortunately, the prediction of aligners from the software isn’t 100% accurate. So when they’re talking about aligning the upper anterior teeth, is that you may think they don’t align posteriorly. But actually, if you’ve not created enough space to do that, or if the software hasn’t managed to do that, what’s actually going to happen is that the teeth are going to straighten, but the upper incisors going to procline, they’ll still stay within that same system, but actually things have moved spatially forward in the patient’s face. And that’s part of the challenges when we try to interpret our online setups is that although they put the arches together, these forces acting independently on these open their arches, and actually, you can move a whole arch forwards and not be aware of that den taking place in your plan. So the idea of having the class two elastics and I’ll probably [typify] it and say we’ve got a slightly increased overjet right, we’ve got a five millimeter overjet and mild crowding upper and lower. This is a classic case of me and want to align the upper teeth and lower teeth and we’ll do some IPR and actually if I weren’t to, I know use some nighttime class two elastics. Now that will hopefully maintain a five move to overjet may improve it ever so slightly, but it’s not going to make it worse. Now, if I didn’t use class two elastics, the chances are the overjet will increase by about a millimeter, as is the nature of teeth as you start to procline, lowers to procline upper teeth are bigger as they procline, it will make a bigger overjet. So the idea of having that elastic in place is the insurance policy to not deliver that detrimental effect. And as I say, the closed system is great as a concept, but it doesn’t mean it’s all anchored at the back, or the teeth experiencing a force and it can push things forward as a result. [Jaz]Thank you Farooq for clarifying that confusion. I think you answered really comprehensively. That’s brilliant. Farooq on IPR do’s and don’ts of IPR please tell us. [Farooq]So guys, IPR is such a topic where fields deserves session in itself. [Jaz]Dr. Devaki, orthodontist. She came on, actually to talk about a whole episode on ipr actually recently, which was awesome. That was some episodes ago now probably locked down one, and she covered it wonderfully. I’ve got lots of messages from GDP saying, Wow, they really need that I think I called the episode IPR for Dummies. So we covered that, but I want the Farooq special. I want your masala on IPR because everyone’s got their sort of way of doing it and their philosophies. [Farooq]Yeah. So the one message I would give about IPR is that you have to be perpendicular to the surface that you want to cut. So you got to be 90 degrees to the surface that you want to reduce. Now that then translating it into how does that clinically practice if we have a rotated tooth, for example, lower central incisor, it’s 45 degrees rotated for argument’s sake, is that I will go in typically with a hand strip, because a hand strip is flexible, I can contour it, single surface cutting to make sure it’s perpendicular to that interproximal contact point, right. Now, with IPR with when it comes to hand strips, we can deliver 0.1 millimeter pretty predictively with the different thickness. And if you double it up, then you get 0.2 millimeters. So that’s kind of my thought process when it’s quite a malalign tooth. Then we’ve got the discs and the reciprocating strips and the burs, I do use all of them, they’re all kind of there in my armamentarium. But they don’t get used as often. So if I wanted to use a disc or reciprocating strip, actually is quite difficult to get 45 degree angle at rotated incisor and to get that instrument in because it’s a stiff instrument, actually, when we put it interproximally, it’s going to go 90 degrees to the adjacent teeth, not to that rotated tooth. And that means when I’m using it, I’m going to go and I’m not powered up perpendicular to that surface I want to reduce, it’s always going to make it an oblique cut, which means I take some proximally, I’m going to take some labially as well. And that is the issue with using these heavier instruments for IPR. I will then wait until the teeth are aligned, and then I’ll go in with my heavy IPR. Now again, I’ve tried to make my life a bit simpler, because it’s simple because you know, who wants to have a complicated life. So I generally tend not to do beyond 0.3 millimeters of IPR in the labial segment 0.4 in the posterior segment, and I won’t go any further back than the six five contact point. So for me, those are my limitations, one because I want to ease my life, two, because actually, now, I can do most of the IPR with hand strips. And if I’m going to do 0.4 millimeters, lower right three quadrant for example, I will then ask the aligner company to stage it. So one 0.2 from the beginning, the next visit, I do the other 0.2. And I can easily deliver that. Now there are some more complex cases where I’ve needed to do 0.5 millimeters are really quite involved digitalization cases, and so on and so forth. And that’s when I take out the bur. And the bur for me is that is the get out of jail for the complex case. But I don’t use it for my average case, because I don’t feel as though I need to be delivering it. predictively managing it, I would say the next thing to take home from the perpendicular positioning of your IPR strip or disc or whatever you’re using is then to use an IPR gauge. Because no matter how good you think you are eyeballing it, and how predictable you think your instrument is of being a measurement tool is not going to be as accurate as using an IPR gauge, and then make a record of what you’ve done. And my third tip would be is if you do stage your IPR, you get everything for me this is like this is like this, I was going to do this as a course now I can’t do because I’ve given all to you, Jaz. So the third one is to measure the contact point if you’ve staged it before you do the IPR because you may already have some space there. So you need to be predictable to what you’re delivering now when I’ve worked with some of the companies and I’ve done some teaching for different companies, is that the biggest bugbear the laboratories have is practitioners under doing the IPR, they’ve just not done enough. They’ve essentially taken a hand strip, they’ve run through the contact points. And they’ve kind of given it a day. So I’ve done IPR, it’s not the case, it does take a while to deliver 0.1 millimeters, IPR, you got to go with the light strip, you go going heavy strip, you got to check it sometimes to double up to make sure it’s there. So be honest with yourself that you’re doing it. And I can’t stress enough how important it is to be perpendicular to that surface, because you may do the right amount, but you’ve done it the wrong surface. So even when the tooth straightens, you haven’t aligned it because the space isn’t where the company has planned it to be. So on those accounts, those are my top tips, making sure you’re perpendicular. If you can’t do it, use a strip, you will be able to do it, making sure that using a gauge when it comes to it. And when you’re staging your ipr, if you’re doing a lot of it, then make sure you’re measuring it before you do that the second time. And for me that is something which has worked really well. [Jaz]The interesting thing that happened when we released that episode with the Devaki on IPR was that a lot of dentists messaged me saying, ‘Thank you, Jaz for making something simple and easy to understand, because and this is what they say they said, because I thought when they were asking for 0.5 like, and you’ve got like a rotated tooth, they were actually a lot of time. So what people told me is they’re making 0.5 at that place, whereas actually, you want 0.5 from the contact point area, which sounds very simple. And obviously, it sounds very obvious. But when you got rotative, people were taking off, you know, a bit of labial as well. And just because they they’ve achieved that 0.5 space, it’s not in the right area. [Farooq]We had actually planned kind of conceptually to deliver an IPR hands-on day kind of this is unfortunate, just lockdown. So never really materialized any further than the concept. But it’s something which I feel really strongly about. I think it’s something and again, guys, I’m not going to say it’s because of all the bells and whistles in the titles. It’s To be honest, a lot of it’s for my own experience, I have made a mess of IPR so many times with all instruments that I’ve described, even hand files, where I’ve taken off the wrong surface, because I was using the wrong side of it as simple as that. And all these things have kind of made me quite humble in the process of delivering IPR. And to be frank with patients and with myself, if I haven’t done the right amount. I’ll do it the next time. And I think all of those things are how you deliver predictable results. And for me, aligners are about respecting the boundaries of the biological limits, and also the delivering the correct amount of forces to the teeth and creating the space the right way. So I think if we get those two together, we are all really producing predictable results with aligners [Jaz]Farooq, we’re coming up to that Magic Hour point. And I just want to say, Wow, you’ve added so much value, I think a lot of people are gonna go away, feeling a lot more confident, feeling like they’re gonna make better choices when it comes to clinchecks and, and case suitability. So I think you’ve got given so much value and so many references that who knows how many people will to keep up but you got if you guys want more, please do check out Farooq ortho in summary podcast, if you like his style, which you should, because he’s such a, I love those analogies. You know, you gave so many good tangible analogies, which I love. So thank you for sharing those. But I just wanted to finish on one thing, which we did discuss beforehand, which is where do you think the role of gdps is in terms of orthodontics? Where is the limit? How do you feel about us dabbling? How do you feel about us doing comprehensive cases? [Farooq]Okay, so I mean, this is a question where I’ve had different opinions of times going on. And to give you the longest short of it, I started off saying it has to be theoretical knowledge based, and then say, no, it has to be experience based, you have to have a certain number of cases. And I’ve settled on, if you know how aligners work, then you should do it. And that for me branches, so many different equations that can take place, and it still comes back to the same answer and this a friend of mine, [Mandy Gosl], he’s a specialist orthodontist. And he’s got his own course, on diploma. So he’s a great guy. And he posted on Facebook recently about how diamond providers, I won’t use the expensive but essentially they there’s no guarantee that they’re giving any reasonable quality because a penny drops at different stages for different people, you can make the same mistake 100 times, you can make mistake once and learn from it. So I think it’s incumbent upon us to learn about how they work, be honest with ourselves. And I can’t say that enough for somebody who has made mistakes and has to come to terms with having to ask for help for cases, and then not allow those unknown unknowns to exist. And that’s my stress. And I was really fortunate to be involved with [C fast] and delivering some of their teaching with the aligners. And what I loved about those guys, is that they said at the end of the course, this is your beginning of your journey in aligners. Next, go on this other company’s aligner course, go in this company’s aligner course, make sure from this course once you’re certified to use all clients and blah, blah, blah. You now go and learn some more information about it. So you don’t have these unknown unknowns. And I think that’s a really powerful company who encouraged you to use other products, especially educational ones. So you’re not tied into them. One, you may not be loyal to them two. But three is that they know for you to do that job predictive, but you need to know about it. So I would suggest for people to go and learn more about the process, when it comes to what can gdps do, I don’t think there should be limits imposed on that. We are honest as orthodontists as practitioners as to what we understand, and we should stick to that as our process. But having listened to conversations like ours today, for example, hopefully some people have gone away with some pearls from it. But listen to the people’s conversations as well, like we did like Robin’s talk, we may have had a different opinion when it came to use of elastics. But I mean, it was really cool to see how what he thought and how bootstrapping was working for him. And having these conversations is how we will grow. And again, we may be talking about experts and so on, but we are community of people. And as we grow, we will grow as a field as well. So the more we know, the more questions we’ll ask them what answers we’ll find, and we’ll all get better at doing our jobs. And I do feel as though we are summations of the people around it. So I hope we can share this information. And general dental practitioner colleagues can carry out orthodontic treatment within their sphere of understanding and I tried to keep it to that I don’t think there should be limitations on products. I don’t think there’s limitations on tooth movements. And I like when I was applying for the dentist as a general practitioner colleague, Nadeem Younis, who’s involved with the [Bard], the aesthetic Academy, there’s a lot of composite course and so on. He’s not a specialist. He was my mentor when I was going through training applications for training for orthodontics, he delivers an orthodontic contract. But there are people out there who are very good may not have the bells and whistles associated with their name, but the definitely people out have my family members treated by so I don’t think you should be restricted. But what I would say is that the discrepancy I feel between specialists and general practitioners who are carrying out this treatment is comes down to the online setup. And the clincheck if you want to talk about Invisalign, is that I feel as though the orthodontist is is more kind of in tune to question to know what movements are biologically predictable, and which ones aren’t. And I think that’s where I do hold the companies to account at the automation process. I really feel in be doing it now with the trainees is that we give them just an online set up with the teeth not straight and see where it goes. You straighten the teeth using the software. So they know what they know what movements they’ve put into the process. It looked at each individual tooth movement, and they’ve put it in themselves. So and then also well, was that predictable? Is it not predictable is a biological sample. Whereas a company’s through automating it have negated that process of understanding about which tooth movements are taking place. So that I feel as though is an educational issue, a convenience issue from a corporation perspective, but actually I think the Dentists have lost out in that process. Was orthodontists have got that from the other training. [Jaz]The most eye opening moment for me, Farooq, was when I went to I’m not going to mention any names or anything, I went to a lab. And they were doing these orthodontic setups for clear aligners. And I just sat and I observed what these technicians were doing, right. And they just highlighted the circles around each individual tooth. So digitally, the tooth is cut out, and they just made them look pretty. And that was it. There was these guys aren’t dentists, they’re just putting them roughly where they think they should go, and then they send a dentist to approve. So I completely echo everything you said in terms of understanding what is possible, what is predictable, taking into account biology as well. And I really look forward to your envelope of aligners, you could be the next prophet. So when you do get that out, please do share it with us all. We’d love to have that and do join the Protrusive Dental community. It’d be great to have you on there as well as our sort of aligner expert or one of our aligner experts now. And I think you really wrapped up very nicely with so much humility, so much geekiness. And so many knowledge bombs, Farooq thank you so much for all your input today. It was absolutely brilliant. And thank you for embarrassing me as well. [Farooq]It’s an absolute pleasure to be here. Really, I’ve been waiting for the call up is taken far longer than I’ve been messaging before. But either way, I appreciate it, my friend. It’s been an absolute honor. And I and again, guys, I just want to say I am really indebted to Jaz. He really helped me direct me as to how to set up my own stuff when it came to orthodontics. I do see him as really as somebody to aspire to when it comes to positivity when it comes to education. And really, I think you’re leading the way, Jaz. So look forward to seeing what you’re going to do next. Jaz’s Outro: I appreciate you so much, man. Thanks so much for coming on today. Hope you enjoyed that episode. Thank you for listening all the way to the end. I think Farooq is such a humble specialist, I mean, I love people like him who you know, he’s practicing a really high level like he’s a consultant. He does so much for the profession and education. He’s so down to earth and he’s so with it with a GDP so Farooq man, keep doing what you’re doing. We love it. Thank you so much for helping us gdps and also helping the profession of orthodontics. I think you’re really you’re advancing orthodontics, man, you’re spreading knowledge, you’re helping them run out. So I respect that massively. So from the next episode, we’re no longer in straightpril mode and the next episode I have for you is productivity with a prosthodontist with my good friend Ricky Bhopal. I hope you enjoy it and I’ll catch you then.

As you get more experienced with clear aligner therapy you learn a universal truth about those pesky lateral incisors that will refuse to extrude! I am joined by Dr Robin Bethell from Aligner Nation to help us learn more about the use of Elastics as auxiliaries for Clear Aligner protocols. https://youtu.be/mOADKbT1uyo Dr Robin Bethell might surprise you! Need to Read it? Check out the Full Episode Transcript below! Protrusive Dental Pearl: The Bethell IPR Technique! Click Here for the Video of how Dr Bethell uses the bur for IPR Interestingly, Dr Robin Bethell has not used intermaxillary elastics for over 3 years. He primarily uses them for vertical movements. I personally have used them extruding lateral incisors, which works very well. Here is the video to share how to extrude lateral incisors with elastics: https://youtu.be/eAsbJBvYA2I 1/8 inch and 3.5 Oz would be ideal We also discussed: Common causes of Posterior Open Bites during aligner treatment How to manage Posterior Open Bites (the key is diagnosis) The role elastics play in clear aligner treatment Dr Bethell’s views on GDP Orthodontics Here is the link to the evidence base Dr Bethell referred to Be sure to follow Robin Bethell on Insta and check out @protrusivedental for more if you enjoyed this, you will also like Comprehensive vs Compromised Orthodontics as part of the Straightpril series! Click here for Full Episode Transcription: Opening Snippet: Over the years i've realized what is best for me to do and what isn't. I think that a lot of general dentists get in this and because invisalign looks like magic. It truly like it's amazing that plastic can do this. They get in over their heads a little bit and i can see why some orthodontics get upset... Jaz’s Introduction: Hello, Protruserati, I am Jaz Gulati. And welcome to another episode in this orthodontic month. This episode is focused on Invisalign and elastics. Like one of my most popular episodes before was IPR, like getting into IPR and the nuances of that. And I feel that one of the biggest pain areas of dentists who are getting started with aligner treatment or even experience with aligner treatment is using elastics. Now whether it’s to extrude lateral incisors, which is the way that I learned to use elastic with aligners, or to use them in intermaxillary. So from across the arch, so for example, class two or class three elastics, we’re going to cover that with someone really cool. His name is Dr. Robin Bethell. He’s based in the US. He runs the Facebook group aligner nation, which is just phenomenal. You guys should totally follow it if you’re not part of that already. And I’m going to ask him the nitty gritty details. Now, this episode is an amalgamation or a marriage of part one and part two, because when we first record, it was going really well. But then there was a storm in Texas of all things. And this storm in Texas meant that we had to cut short because he was having signal issues. So we rearrange, and a few weeks later, we thought we’d take two, but the biggest shocking thing you might hear today is the fact that actually, should I ruin it or not. Should I continue shall continue saying I’m saying, Okay, fine. I’ll give you the spoiler. Okay. But there’s more to it in this episode, I promise you, but Robin basically said that the wealth of evidence that we have, and the position statement we have is that intermaxillary elastics, like class two and class three elastics, they don’t really add very much into your aligner treatment. So that was a massive shocker. Because you know, every time I have a guest on a podcast, and I prepare like three or four questions, my first question was, Okay, tell us about elastics and aligners. And then the second and third and fourth question was like the nuances, okay, which ones do you use for class three? And lastly, how do you stage it and that’s quite kind of stuff. But can you imagine how shocked I was one of the first question he says, Now, don’t bother using it. I haven’t used it for three years. I was like, What? It’s, that’s crazy. The protrusive dental pearl I’m gonna share with you is a video technique, like the most commonly asked question I get sometimes based on the IPR episode is Hey, Jaz, can you just like make a video of IPR and never get around to doing it? Because that was like a big pain area when I was starting using burs for IPR. Like, as a general dentist, like I love enamel, you will love enamel right, and won’t be as conservative as possible. So when I got to terms of using a mosquito bur, I was really worried initially is Oh, my gosh, you know, I’ve seen some example radiographs for where it’s gone totally wrong, right. So I’m going to share with you the guest we have today Dr. Robin Bethell. His ‘Dr. Robin Bethell Texas IPR technique’, which is basically using red mosquito bur and it’s just a way he does it like if you’re starting IPR with burs, if you watch this video, it will give you a bit of clarity. And you still need to use magnification you still need to be careful, I think, but sometimes by watching someone else do it. But in the video is good enough quality that I think you get the gist of it essentially if using the bur in a certain way, and then doing the rest of it in what he used a space file, sort of strip and you can use any sort of IPR strip you want. But you open up the embrassures with the bur, and in the final bit of enamel use IPR strip. Hopefully I’ll get to video at one day as well. But since Dr. Robin Bethell, our esteemed guest today has already done that hard work for us. I’ll be more than happy to share that. So Dr. Robin, thank you so much for all this amazing content that you make. I’m so stoked that we have him on today. So this was done live guys. So excuse any shoutouts. And again, if you’d like the live stuff I’m doing, do check out the facebook page, which is a protrusive dental podcast Facebook page, if you’re not already following the Instagram, it’s @protrusivedental. So I’ll catch you in the main episode. And I’ll see you in the outro. Main Interview: [Jaz]Thank you Dr. Robin Bethell. You’re based in Texas I believe we’ve never met before. But I appreciate you so much for agreeing to do this. Because what you set up with the aligner nation community is just brilliant. I’ve been practicing this line for about four years now. And yours has been the best resource for aligners. I found some of your videos, your energy on there, your level of education, it’s just great. So thank you to producing all that stuff. But tell us a bit about yourself, where you practice, how you got into aligners and how you become one of the top Invisalign providers in the US. I believe [Robin]That’s a killer intro and thank you. I am in Texas. I went to school in San Francisco at University of Pacific. I was trained in aligners by Robert Boyd back in 2006. And I became a Invisalign provider. I’m gonna say that in quotes, because there’s not a high standard in the United States to become an Invisalign provider. You just take a weekend course and they say you’re ready to go teach you how to take impressions. [Jaz]It’s the same in the UK. [Robin]Yeah. And it’s part of the great thing about aligners in this era, and also the problem, and that we are so naive to how they work biomechanics tactics, and there’s not a lot of literature, clinical literature to support a lot of the things we’re taught. And so we’re kind of in this new frontier, we’re discovering things as we’re going. And I was definitely trained in orthodontic fundamentals, and that gave me a foundation to go out and feel confident in treating people with aligners. And I was, let’s just say, rudely awakened. My first case is my father. [Jaz]Your first aligner case or your first orthodontic case like with the fixed appliances? [Robin]Aligner case. Yeah, it was my dad, and it went terribly wrong. Yeah, I trusted that. [Jaz]Tell us the details. What went wrong? What was it the classic posterior open bite afterwards? What was it? [Robin]A little bit of everything. My biomechanics setup was awful. I trusted the Invisalign assist program at the time, you submit your impressions, and they give you a clincheck. And you’re supposed to, you know, submit a new impression every four to six weeks. And he was a class two crowded case. And I had everything from elastics buttons on every teeth that I just said, we’re gonna trust the system, I had no idea. You know what was going to happen and it did not work, teeth didn’t [track] canines didn’t rotate, elastics did nothing. And in the end, he just burnt out and stopped and his teeth just went back to where they were. [Robin]You know, in 2014, I treated him again, and we got them lined up, his teeth look better than ever. He’s never had aligned teeth before. He’s very grateful for it. [Jaz]Brilliant. So you shared that very nicely to share a failure, isn’t it? So human of you to share that. And I think with aligners, beginners can make this mistake. I remember the first time I got a clincheck, I didn’t know what to do was okay, this looks pretty good. Does that mean it’s good to go. So that’s a classic mistake for a beginner to make. And then when you learn that, hey, actually, the person at the end of it, who’s engineering everything is not a dentist, you are responsible and you’re in charge. And I think you’ve went on that journey and I think what you’re sharing now everyone on the aligner nation group and stuff, some of the videos you make, I think you might want to set a crushing clincheck. I love the title. It’s honestly your energy and your vibe, and you’re really put yourself out there as a great [edge] going in aligners for me, I’m so excited because most of my meet about 70 to 80% audiences UK based. So for those guys in the UK, I know you’re gonna love Robin’s content. So Robin, we’re gonna dive in to the main theme of today’s episode, which I’m so grateful to have you for is elastics. Right. So I’ve been doing aligners for four years. But I know I’m gonna learned so much from you about elastics. Because a lot of my peers don’t know much about elastics when it comes to the use of elastics in aligner treatment. So it’d be great to get the main fundamental. So if we start with the basic question, what percentage of your patient Robin, are you prescribing elastics for? [Robin]that’s a great question. And it’s a very important question. In my cases, and I treated last year over 700 cases, less than 10% are in elastics. And there’s a really good reason for that. And not that there are 10% of my cases are skeletal or class one or class two or class three, it’s that elastics when use with aligner systems are only useful and predictable when they’re moving specific vectors or specific to specific vectors. They are not useful in the American Board of orthodontics published there, she made the AAO publish a study in November 2020 saying that, that the success rate and the ABO success of class two treatment with elastics in Invisalign aligners is it really bad, like less than 20% success. So elastics to treat a class two cases skeletal problem, don’t do it. Elastics to extrude a tooth that’s not tracking properly order to give anchorage to the molars while you’re moving the anterior segment distally that can be done. And that can be helpful and provides a specific support system to allow you to achieve those movements. But the main takeaway with elastics is you have to know your diagnosis. And you got to look at the patient’s face, you’re not going to change a patient skeleton by putting a rubber band between an upper and lower arch that’s wrapped in plastic. [Robin]Well, in these class two cases, then if you’re saying that the success rate of the elastics is not so good. So using class two elastics, can we just rely on the aligners to do that bit within reason. And then the elastics is an unnecessary step? [Robin]I would say globally? [Jaz]Do you just use them anyway? [Robin]No, I don’t use them. If they’re not going to provide a benefit. I don’t use them. And globally there are people are prescribing them unnecessarily. I see it all the time. I think many clincheck go through the algorithm and everyone has to know that Invisalign. There’s two tracks that your cases go through. First they go through an algorithm. Basically, the computer makes a align down the center access of a tooth and it makes all those teeth parallel, and it aligns them up. And it does it in a matter of seconds. It’s just a computer algorithm. And then it goes to a technician and they read your preferences, and they try to modify the algorithm to fit your preferences. And then it comes back to you in the form of a clincheck. 0% of those are right the first time in my practice. So if you have a, you know, an algorithm that makes a class two person with the maxilla is out here into a class one person, the algorithm will kick out elastics, they will automatically put class two elastics on I’ll put a little cutout on the canine and I put a little cut out on the molar or a slit that you can hook elastics to and what you’re assuming and what the algorithm assuming is that you’re going to advance the mandible with the use of elastics. And we know that that in a non growing patient doesn’t happen, certainly doesn’t happen predictably. And as someone that’s growing, yeah, the mandible could grow forward. But that’s a surgical case. And if the maxilla if you do a cephalometric analysis, and you determine that the maxilla is protrusive, it’s too big, you’re not going to get the whole maxilla to you know, come back by putting on some 100 or 200 gram elastics on a case. Now, if you have blocked out canine a three, that’s, you know, you didn’t have room for and you push the teeth out, you expand the arch by tipping the crowns, and you make room for it. And then you hook an elastic on that canine and you anchor it, and you put 100 or 200 grams of force on to pull it down, that will certainly help get the canine to come down. So those kind of cases I use elastics for to close down more. [Jaz]I’m getting more local factors rather than for what we traditionally would have thought, you know, class three elastics class two elastic. So that’s the take home, they’re basically that actually they are over prescribed maybe by the clinchecks, and they maybe have more of a role in localized movements. Is that Is that a fair way to put it? [Robin]I think it’s an excellent way to put it, I think that I use them in localized movements only. And if, for example, a great question is, you know, you got a posteriorvopen bite where the bilateral or unilateral you got molars and bicuspids not touching, and people will come back and they’ll see these clinchecks where they have attachments on every tooth or button cut outs and every tooth and they’re trying to close down the posterior. That’s an incorrect use of elastics as well. And I think that what you’re really have is anterior interference. And if you can get the interference out the mandible auto rotate and then get the teeth to come together. It was a poor diagnosis. [Jaz]That was actually one of the questions that it might just one set the theme for this. So yeah, one common thing is definitely happened to me. And it’s happened to so many people, right, where you finish your cases, it’s typically going to be a class three tendency case where they got crowding, and then you resolve the crowding. And then what you didn’t get enough of was overjet. Because overjet is king, so you didn’t get enough overjet and please correct me Robin, because I trust you far more than I trust myself when I’m saying this, okay, so overjet is king, you don’t have enough overjet. And because just like you said, you have that interference, you have this posterior open bite this is not because the aligners were intruding the molar where as you know, to the extent it’s more because you have that interference, if you create more overjet, you get rid of the interference. So what some people do is they like you said, put buttons and use elastics, like box elastics to extrude it, but what you’re saying is actually even that scenario, let’s ditch the elastics. And let’s actually deal with that interference, is that a fair way to say? [Robin]It’s exactly how to say it. And then the main point using Invisalign, or whatever aligner system that you use, is you’ve got to know your diagnosis, you got to know your sort of why before you start trusting a computer screen, which is just teeth floating in space in a theoretical system. And I think once people accept that responsibility, Invisalign gets a lot better, a lot more fun. [Jaz]Well said in the UK, a popular approach and in Europe actually, just a final, a popular way to approach that situation where maybe you have got a bit of a posterior openbite I’m not talking about a crazy amount I’m talking about less than a millimeter is that some conditions, we’ll cut the distal of the canines for the lower aligner and allow like some dahl type movement or over eruption of the lowers or premolars and beyond, and then maybe four weeks later to then just retain at that level, is there a place for that in your practice? Have you seen that work? Do you know anything about that kind of way of resolving? [Robin]Absolutely. And again, that works. If you have your diagnosis correct. If you have somebody that has a prognathic mandible, and you know, they have that square shaped jaw, they’re mandibular plane angle is not very high, and you just cut the elastics expecting for the molars to [super up], it won’t happen. And so people were like, Well, that doesn’t work. Well, it would work if you had your diagnosis correct. There is this theme and this concept and you know, I don’t even like using this term, because it’s not been proven, but we think that plastic causes passive intrusion of the molars. Now if a patient has a steep mandibular plane angle, maybe that dolicofacial profile that we see, long face and they’ve steep maybe they’re class two. And they’re more force on their molars because the molars hit first and you add a quarter millimeter of plastic to them, thus increasing the force on the molars. Yeah, yes, you could get some intrusion forces on those molars. Yeah, so they get more force on the molar is an intrusive force and the aligners will actually intrude that the molars, and then if you cut the aligners within a day, the molars erupt back and you get occlusion on the molars. So when you have a patient back in your chair, and you notice they have a posterior openbite you have to do some analysis, there’s a lot of different ways to check and understand there are four different types or four different causes for posterior open bites. And the most common sense it is, or the most likely, since it’s an anterior interference, you try to uncrowded the [material] without the overjet. And now you’re just hitting in the front, or you’re trying to create a class two person and you had you had this expectation that you know the mandible was going to move or the maxilla was going to or a class three tendency patient, and you didn’t get any skeletal movement because you’re not going to get any skeletal movement. And then now the patient’s just occluding on their anterior teeth, or you didn’t achieve the anterior intrusion, you’d level the occlusal plane like the clincheck showed and now you’re still in deep bite but the anterior teeth hit that’s the most common posterior openbite and cutting your aligner. So to fix that won’t fix it. [Jaz]They have to have that. Well I like to think about it is when I’m doing the dahl concept. Essentially, it’s all using that. But if the patient doesn’t have any eruptive potential in the area, it’s never gonna happen. It’s a bit like a patient with an anterior open bite. Why don’t their anterior teeth overerupt naturally and meet because they don’t have that potential to so I think it’s a great way to put it. I’m gonna just go to the next elastic question, which is the most common use of elastics I have ever had to do which is for those pesky lateral incisor so quite commonly, they will not track anymore. So I want to ask you any tips for lateral is not tracking or we just got to accept that that’s the way it is and naturals will always be annoying and pesky in that nature. And can you just talk through and describe how someone might go about the first time they counted it what the steps are involved in extruding a lateral incisor using elastics? [Robin]That’s a great question. And it’s one that we get all the time. And yes, laterals can be very pesky with aligners. They’re like trying to grab a wet watermelon seed they’re slippery, they’re small, not a lot of surface area. The extrusive force on a lateral incisor First, the biggest tip I have when diagnosing whether or not a lateral needs to extrude look at the CEJ is the CEJ of the lateral incisor where it should be in the face a lot of these clincheck they will move they’ll extrude the laterals to make the incisal edges even with the Centrals when in fact the best diagnosis to me is get the CEJ level with the Centrals or even a little bit lower than the Centrals and then you can bond or add [length] because the the size of the lateral is the problem not the position of the lateral biggest tip I have is don’t extrude laterals that don’t need to be extruded. That’s number one. And when you have to extrude the lateral. Then you have to extrude a lateral. I’m really, really like this smart attachments. There’s John Morton research in the G7 series of attachments. They made this really large active It looks like a smiley face. It’s called a optimized support attachment. And you put that on the facial of an aligner or excuse me, the facial of a lateral incisor and it really helps a elastic engage the active surface, there’s a little dimple on it and you will get a lot of eruptive incisal vector of force on that tooth to help and if you still can’t get it, you can use elastics and I’ve used the bootstrap technique with some success and a bootstrap technique is basically cut the aligner on the facial. You put a little button I like these clear buttons that you can buy on reliance orthodontics, you put a button on the tooth, and then you have slits, you cut little slits into the back of the aligner and you put an elastic, high force small elastic where I was going with that as I hooked the elastic to the front of the attachment that the button that we put on on the front of the tooth and I wrap it around the aligner and then I hooked the elastic onto these little slots I cut out of the aligner on the back and I call it a bootstrap and it applies in adds another 50 grams of force to pull that or extrude that lateral incisor. I’ve had some success with that. [Jaz]The question I ask is on the fine detail is on the back on the lingual or the palatal part of the aligner, are you making like an L shape is an L shape that you’re making? [Robin]No I actually I cut two little slits looks like a little v. So if you imagine you’re on the the palatal part and this is the incisal edge I’m looking at the palatal I cut like a slot this way and a slot this way. And I hooked the elastic around that it kind of cinches down Hold on to the distal lingual and then it wraps around to the front hooks onto the button. Okay. [Jaz]Welcome for part two. Robin Bethell is so great to have you on Dr. And how are you today? [Robin]I’m doing great. Can you hear me? [Jaz]I can hear you just fine. A little bit of lag. But I think we can cope with that. Hearing you well though and looking great. So last time there was a storm, there was a storm in Texas. And then we had to abandon the initial bet you gave a lot of value. So I know people be coming back to join this part. So we’re going to spend the first 5-10 minutes just recapping what we covered in the take one and then we’re gonna wrap it up with the tape two. But just remind everyone, okay, well been a little bit about your background, how you got into aligners and what you love about aligners, and are you and I didn’t actually ask you this. Are you limited to aligners or do you do fixed as well I didn’t actually ask that last time. [Robin]Well, now I’m just doing aligners in our general dental practice. But I started out doing fixed in aligners for many years and I love orthodontics. I somehow feel like I should have been an orthodontist. But I love using orthodontics as a part of comprehensive dentistry now and I work really well collaborate with other orthodontists for a lot of cases. Because really orthodontics is it’s the foundational part for setting people up for lifetime oral health. And it’s a little bit too much to do everything all at once. So we kind of focus on the stuff that I can do efficiently and work with orthodontists for the things that they can do efficiently and better than me. [Jaz]That’s a really good point. And we might touch on that actually about maybe towards the end we’ll touch on, what is the limit of aligners because I seen some of your cases and I think no way can you do aligners and you seem to be pushing boundaries along with a lot of other doctors are really pushing boundaries in aligners, so it’d be interesting for me to find out maybe towards the end about where does Dr. Robin Bethell draw the line in the sand? Right. So that would be really cool to know, I think everyone will want to know that. But let’s pick up where we left off. You threw an absolute bomb on the last episode, where we started because you actually shocked me because here I was the three four questions I had written down. And you almost raised all my questions, because when I when I asked you, Is there much value in using intermaxillary elastics Invisalign? You said? [Robin]I said no. It’s it confirms suspicions from many years of using Invisalign aligners and AAO published a paper in October this year, basically saying that elastic used to correct skeletal sagittal plane movements is not effective. Not advisable. [Jaz]So you don’t do it. Just to recap, you you don’t use intermaxillary elastics for class twos or class threes at all? Or do you? Do you still do it because it makes you feel warm and fuzzy and good inside? [Robin]I do not do it at all. Not even once anymore. And the last three years, I use elastics. But I use them for other things which we’ll get into, but not for class two class three movements now. [Jaz]That’s crazy. So someone asked last time Hey, didn’t use it in this situation or that situation. So someone asked last time, do you use it in these mild class three situations to help to retract lower incisors? But the answer is no. Because he just said it. The answer is no. That’s crazy, right? That’s crazy. Let’s see, I use some elastics about probably three or four weeks ago, just before we had that episode. And I felt was okay, I’m helping you. I’m helping. But there we are. You’ve told us that it doesn’t work. And I’ve seen the cases you do. And if you haven’t used intermaxillary elastics in three years, then that’s something to be said about that. So there we are guys elastics in terms of the intermaxillary ones, the ones that go in between canine to molar, molar to canine that kind of stuff. We’re not using it so much and there’s no significant evidence for efficacy. I think Robin are trying to say so let’s get on to when you do use these aligners and we touched on extruding laterals and we will just recap the technique a little bit because you know as dentists we love the nitty gritty details of exactly which elastic to use. How long do you use it for? We love those minute details. But other than extruding laterals? Which other scenarios do you use elastics for in Invisalign, or with aligners? [Robin]you know, I like to keep it simple with the aligners make it as predictable as possible. And I think the number one use of elastics in aligners in my practice is for vertical movements intruding or extracting a tooth, and usually it’s a single tooth, not an entire arch. Now I’ve seen some doctors do entire arches by placing mini implants or TADS. Like for example, if they want to impact the maxilla move it up, they’ll place TADS and they’ll use elastics from the buccal across to the lingual and an aligner to intrude an arch. Dr. Frost does this with Damon brackets. It can be done with aligners, but you’re getting into some really [uncharted] waters here when you start doing that. But what I like to do is if I have a single tooth like a lateral incisor that I’m trying to extrude and it actually needs to be extruded, and I make that need based on a facial diagnosis. But I’ll put a little button on the cervical third of a tooth and I will either bootstrap it. So take the button put an elastic on, wrap it around to the lingual and attach to the lingual over an aligner to pull it and I’ll share with you the specific elastic that I use for that, or even more effective is a cross arch, where I’ll put a little hook on the lower like a triangle style. So put a one hook on, for example, if I’m trying to move number 10, I’ll put a little hook on like 23, and a little hook on 22. And I’ll make a little triangle with a three eighths inch, five ounce elastic and get some forces to pull that down. [Jaz]So those are both techniques in, for example that you could use in extruding a like single lateral or single canine like, when would you use the bootstrap technique whereby we’re going to get a little bit more in fact, with the nitty gritty details, but when did use the bootstrap and when we use this, the second technique you mentioned whereby you’re going intermaxillary [Robin]Well, you’re going to get a lot more force intermaxillary. And, you know, bootstrapping, you got to think that elastic needs to be stretched out for it to generate force, and a bootstrap, you’re only moving it maybe, I don’t know, 10 millimeters to go from the buccal across to the lingual. And if you’re using cross arch, you can get that 20 to 30 millimeters of stretch to get the forces you need to generate an extrusive force. You know, Dr. Sandra Kahn, she published a book and she talks a lot about elastic use in that book, How to pull down those pesky laterals, and canines and things. And she’s a big advocate of cross arch. I’ve used cross arch, I’ve used bootstrap for a canine, I wouldn’t use a bootstrap because you need to generate 100 grams 200 grams of force to get a canine to extrude. Anyone who’s tried to do the, you know, the chain on a wire technique, you know, you got to keep that wire tight. And if you don’t do it tight, it’s not going to budge. So I wouldn’t recommend doing a bootstrap on a canine but a little lateral with little, you know, little roots, you can bootstrap and get a millimeter or two of extrusion. And I’ve had some success, but it’s less predictable than cross arch. [Jaz]Thank you very much, Robin. So just for those people listening, we did cover a little bit about bootstrap last time. So one way I’ve done in the past, and I quite like the bootstrap way better than Robin described is that the way I’ve done the past is on the front, we have a button just like Robin suggested. But on the back I made like a almost like a L or a T shape inside where your elastic can slot into. But the bootstrap IE actually looks like a bootstrap. So you make a little cut like this and like this, like a triangular and then you allow the elastic to grip onto it. Tell me if I perversity in any way, Robin? That makes it easier cut to do it makes a lot of sense. So which elastic are you using? I think you mentioned four or you haven’t just tell us, which elastics we need to buy. Because and it’s funny with the elastics they’re named after countries, named after animals. So we get really confused with the different brands you see. [Robin]That’s right, yeah, Ormco does the animals, you can get them on Plak Smacker with different types of animals. Really what you want to look out for a bootstrap, you want to small elastic. Now, the smallest that you can find is 1/8 inch, they’re hard to find the more common small size you can get is 3/8 inch. And, you know, you can get up to quarter inches and things like that for cross arch. But you never want to use a really big one on a bootstraps, you want to use a small one. So you can stretch it out. You can find a 1/8 inch, or they probably do metrics, too in other areas, but we use the inches in in the United States. But you can use a 1/8 and a like a 3.5 or 4.5 ounce. The bootstrap you also want a small elastic you because you’re trying to loop it around to the lingual you don’t want to have rubber band between the plastic and the tooth creating friction. You want it to be as small as possible. So a light elastic, small light elastic is the best way to go. [Jaz]That’s really good. I didn’t I never really considered that. So that’s a good little pearl there. Thank you. I’m just gonna want to do them. So check them because I’m encouraged any questions coming in. I’ve got a few more questions on myself to ask as well. But if there was any questions about that, do ask away. So I’m just gonna open up the live on here. So no one said any questions just yet. So that’s fine and keep going. So Fine, you’ve covered that. Let’s talk about the button. So when you put the button on the label surface of the lateral incisor, you’re drilling away or cutting away the cervical third area is there a preferred button that you like because I’ve heard actually some dentists what they do is they use an elastic module filling up with flow of composite to make this sort of shape have it in my hands that doesn’t seem to work so well. I actually like to buy the buttons but which buttons do you recommend? [Robin]Yeah, I like to use the little metal ones even if it’s a lateral incisor I’ll still use the metal buttons I buy them from a website called Plak smackers why because it’s their easy. Reliance orthodontic makes them to you don’t have to have a an account signed up like with Henry Schein ortho, Ormco to buy them you can just buy them online [Jaz]I didn’t expect you to say that with the metal but there we are. Yeah, you’re coming to find out or using a self cure adhesive or I guess what the method you probably there’s not that much distance you probably could get away with using light cure. Imagine you’re using a self-cured adhesive, right [Robin]you know I use it to light cured adhesive. It’s composite, you etch and bond and you use a resin composite, just a bracket glue and you’d like your it. [Jaz]Excellent. So we know which elastic we’re using, we know that it’s about 3.5 ounce or not something not so heavy, because you want you create that friction with a heavier elastic. So that makes sense. Sorry about the lag. Guys. By the way, this is a bit of lag. But we’re still getting to the questions quite nicely. So the next thing to talk about is posterior open bites, which is like one of the most common things we might see for a newbie, it’s happened to me before is I’ve seen it in other people’s cases before we see a person and aligner nation a lot now and again ‘ah guys what I do, I’ve got posterior open bite’, and we sort of touched on it last time where it’s usually an issue with the diagnosis at the beginning. And we can definitely touch on that. I’d like to learn a bit more about that from you. But tell us when we are at that situation. How do you prevent it in terms of diagnosis? When it does happen, is there a place for using box elastics to correct it? Or do we need to go back to your additional aligners and actually do some more IPR in the lower incisors or correct it but you tell me what you think is the best way? [Robin]There is a best way for each type of posterior openbite but you have to know why you have a posterior open bite. You know the four most common reasons. Number one is you’ve anterior interference, which is usually you try to ensure that lower incisors is a deep bite case, and you’re uncrowding and you end up with anterior interference. And now the back teeth aren’t touching. No box elastics are going to fix that. I’m sorry. It’s just you’re going to be trying to extrude both arches to touch together in the back. It’s not going to work. And you know, I don’t know I said you know that you’d want it to work. If you have a posterior open bite caused by some passive intrusion or some iatrogenic intrusion of the molars. Sure, maybe a little box elastic will work. But you know, what people like to do is cut the elastics [slab their] molars to erupt or settle into occlusion to much better scenario. And you can test for this by checking with bite paper at the end. If you only have anterior contacts from you know, from three to three on the anterior, you’re not going to want to, you know, try to let the molars passively erupt. Now if you have a single tooth interference, you check it by paper, it’s like only on 22-27. Then I’ll go into the clincheck and remove the interference by moving the teeth and then you’ll see the teeth settle back then together with just the rotation of the mandible. So it just depends on the type. So I went through I briefly just touched on the two types of passive intrusion and an anterior interference. The other common cause of a posterior open bite is iatrogenic movement, unwanted movement of the molars. You program in a translation mesiodistal of a molar, you know you’re trying to collect a skeletal class, let’s say class three to try and distalize the molars, but instead of them translating, they’re just tipping back and you end up tipping them out of occlusion. Same thing with buccal lingual translation instead of them translating buccal lingual because there’s no bone there, you did the wrong diagnosis, you ended up tipping them and then you tip them out of occlusion. The only way to fix that is tip them back into occlusion. I don’t think that boxing elastics to get your molar to touch then is the best way to go. Does that make sense? [Jaz]It does. You’ve certainly covered all those four types. And I love that and they’re really it’s really impossible without knowing exactly which diagnosis it is for your patient to actually figure out exactly which of those four techniques won’t work. But am I right in saying that perhaps the passive intrusion might be more the most common iatrogenic curse types that we see? [Robin]Yes. And let me I like talking about this. And I’ve talked about this a lot. In the orthodontic community we say we call it passive intrusion. That might not really be what’s going on. And I was thinking for a long time. For the longest time, I wondered what was causing this ever since 2016. When we switched over to the new, more elastomeric plastics away from the older thicker plastics that Invisalign used to have. We saw a lot more posterior open bites, and I was thinking maybe it’s because the molars are pounding on the plastic. Iatrogenically intruding them. But in retrospect, it may not be the case we don’t know if it’s from molars occluding and pushing with the extra quarter millimeter of stretchy plastic is just pushing the molars in and we don’t know if it’s that or we have so many deep bite cases now when we’re trying to intrude the molars we’re actually causing equal and opposite force in the posterior that’s in causes other movements we don’t want you pushing down the front side of the front actually moving the molars are doing something iatrogenically as well we don’t really know what causes this effect. But we do know that a lot of these cases we don’t put bite ramps on them. We were ending up with you know, quarter millimeter of open bite in the posterior really light. So it’s hard to say exactly what causes this but we think we’ve talked a lot about it being from the molars hitting and occluding and pushing the plastic is pushing the teeth in intrusively. Yeah, it’s tough to say oh What exactly causes this but using bite ramps is the prevention. And it’s really common. [Jaz]Brilliant. So that’s the Golden Nugget that to try and use bite ramps when appropriate to to help to prevent that which makes complete sense. But in that situation I’ve heard my colleagues, some colleagues advocate the following techniques. So just let me know we think about this following technique. So when you have that situation, and you’d like the posteriors to couple a bit better because they’re just slightly pulling the articulating paper to cut the distal of the lower canines of the aligner and give it around about four to five weeks. Is that okay? Or is that risky? [Robin]I don’t think it’s risky. It really works. It doesn’t take four weeks. If you’ve compressed the ligament space on a molar because of the extra plastic and that mandible, let’s say it’s a dolicofacial profile, they have a steep mandibular plane angle and you’re pounding on plastics on the molars, it will compress the ligament space, you’ll take the aligners off at their appointment for their check. And you’ll see that they have an open by literally cut those aligners probably in four hours, they’re including back, you don’t need four weeks. It happens very, very quickly. Yeah, it’s just allowing the molars to settle all you’ve done is compress the PDL space. And physiologically, when you think about it, if you have, you know, it takes up to nine months for PDL to regenerate if all you’ve done is compress them, it’s just going to take a couple hours for them to settle back in. If that’s the reason why you have a POV. So if you’ve gone for weeks, and I think it’s really important to note if you’ve gone for weeks, you’ve cut the cut the distals of your plastic off and you’ve gone for weeks and they still have a POV. It’s not from passive intrusion. There’s another problem [Jaz]That’s probably the anterior interference or one of the other things we talked about. Excellent. I’m just gonna go ahead and check any questions James saying hello on the live. Priyanka is asking, when do you use intrerarch elastics to extrusion and what size plastic we use? So you mentioned that already. So just recap the details with size elastic, just for Priyanka. [Robin]Again, when everyone cross arch, like a five ounce, three quarter or excuse me 3/8 inch elastic, if I’m going from like a lateral or canine trying to extrude a tooth, cross arch. If you’re doing a bootstrap, you want a smaller elastic 1/8 inch. You know, that works too. [Jaz]Great. Jeff Skinner asked him out why you want to use a lighter elastic. Now I was listening and I’ve learned something that you want to reduce the friction. Am I right in saying that? [Robin]Yeah, when you bootstrap, you try to get a big elastic on, you can get around the button. But when you go on the lingual, that you ended up getting the big rubber between the plastic and the tooth. And in my mind, it seems like that could be a frictional force that we don’t want to extrude a smaller elastic. It’s not that I want it to be a light force. It’s just that I want a smaller rubber elastic. If I you know you can buy 1/8 inch elastics and four and a half ounce, that’s probably the best way to go. [Jaz]Brilliant. Jeff, I think the optimal question about where the friction is coming from. [Robin]And I want to just say that amount of cases that I’m trying to pull down a canine with, you know, elastics, it might be one and 50. And really, if there’s their diagnosis, let’s say we have it blocked out canine number six or 11 is totally blocked out. And it’s way buccal to the arch. First, you’re going to expand or make room through either IPR, extraction, expansion something to make space for it. And then the tooth if the roots in the right position, it’s not going to take a lot of force to bring it down. I would use cross arch, all you have to do is remove the obstacle for that to erupt into position. [Jaz]Brilliant. Thank you. We’re getting a few more questions now. Which is great. Steven Shark very geeky question. I like it. Stephen is Do you know the name of the paper regarding the inefficiency of interarch elastic? [Robin]It’s the AJODO journal. I wish I could share it. It’s on the AJODO blog. [Jaz]I’m going to type it and you say AJODO blog [Robin]AJODO blog. American Journal of Orthodontics and Dentofacial Orthopedics. [Jaz]I’m gonna link in there when I actually launched on the main podcast, I’m gonna have it in the show notes. When we can until we’re done. One of us will probably Robin, it will link it on the actual main feed of this as I’m typing it now as well. So we’ll make sure we do that. It’s a good question. It’s good to know actually. So we’ll do that later, Robin. Priyanka has asked another question, which is, do you see more molar passive intrusion on dolicocephalic patients? So these are the long face patients, right? [Robin]Yeah, you would imagine that would be the case, especially if you’re conceptually thinking that it’s caused by molars pounding on each other, you would think that a steeper plane angle would generate more force than a molar whereas in a flatter parallel to the Frankfort Plane, kind of a flat angle job would create less force on the molars. That’s what you think but no, I haven’t in the hundreds of cases I’ve done last year, I have not found a correlation between dolicofacial and, you know, prognathic profile coincidence between for passive intrusion of molars. [Jaz]Brilliant. Thanks so much and Priyanka thanks for that question. No, no, no, I see what you mean. But I think that answered the question. So, last few bits Now, just to wrap up one is like a journey question, right? Like your journey. So you’re doing obviously a lot of aligner cases, which is great. And I love the fact that you’re flying the flag for general dentist cuz you’re not a specialist. Have you ever felt that the specialist community has ever looked down on you or given you any sort of hate in any way, because of the level of orthodontics that you’re doing? And you ever felt any friction amongst the specialist and the kind of work that you’re doing that maybe encroaching on that? If you know what I mean, with all respect? [Robin]Absolutely. This is a tricky question. And really, I mean, all I have tremendous respect for orthodontists and at this point in my career, now I’ve realized how much I don’t know still to this day, I do get a lot of friction. And there’s still a lot that I can’t participate in, even though I want to because I’m not an orthodontist. I’ve always thought it was a cottage industry. And they were just trying to keep me out because they didn’t want the competition. But realistically, the people the genuine people that the good orthodontic got to know, the real reason that they didn’t want general dentists doing a lot of orthodontics, because they understand how complex this is that you cannot treat patients with a clincheck you have to have X rays to understand facial growth, you have to understand a lot going on. There’s genetic issues, you have to take into consideration. There’s skeletal epigenetic issues. I mean, a general dentist takes a weekend course in Invisalign, you can do a lot of harm. So I think that the honest orthodontists were concerned about patients being treated incorrectly and especially growing patients that have a window of opportunity to correct some of these skeletal problems. And they would block me out now then there’s other ones that are just, you know, angry and a little bit bitter for sure. And then I have many instances where I’ve had been kicked out of groups or, you know, I had one guy share my name in my face and in orthodontic groups, because he thought I was doing harm to dentistry in America. And he’s like, doxxing, publicly talking bad about me telling where I live and stuff and you know, but it’s interesting because now where I am, I have the best relationship with orthodontists in Texas, one of my best friends in Austin. He told me that the biggest windfall he’s had to his practices working with me and training general dentists, he has more referrals, I now don’t treat complex cases alone. I work in collaborate, I refer 40% of the patients that come to me seeking orthodontics, not because I don’t know how to treat them, but because I don’t treat them best or efficiently. I have to do hygiene checks, I’m doing comprehensive orthodontics and comprehensive treatment planning. I’m doing restorative plans, veneers, he sends me cases to finish, I get cases started orthognathic surgery cases I don’t you know adult with a skeletal problem, I like to go at the surgical route now. I don’t set them up surgically, the orthodontist do that. Over the years, I’ve realized what is best for me to do what isn’t? I think that a lot of general dentists get in this. And because Invisalign looks like magic. A truly like it’s amazing that plastic can do this. They get in over their heads a little bit, and I can see why some orthodontics get upset, especially when we got smile direct club and companies like that out there. It’s like [Jaz]I love the community and the fact that you know, you admit that you know, 40% of patients that you might be referring because there are people who are more suited for that type of case than where you are. And I love the fact that you know, you have this great relationship with a local orthodontist. So that’s brilliant. That’s exactly what I want to hear. I think that’s really encouraging. And it’s a shame that you went through what you went through, but I hear about that happening a lot. In fact, next month in the podcast I’ve got like loads of orthodontists are pre recorded with I’m doing a live with you today. They’ve got pre recorded episodes with orthodontists and wonder the core conversations I’m having with orthodontist is when do they think it’s okay for gdps to do treatment, which with some orthodontist will could classify as compromised, which such a dirty word right? But nothing is perfect. And if a patient wants, I don’t know what the scene is in the US. But in the UK, we’ve come to accept that if someone wants to treat the social six, there is a place for that. And I think as long as you’re not doing major harm, and you’re sort of staying within your boundaries, then there is a place for it in Europe. Do you find that there is a place for social six orthodontics in the US just want to just have interest. [Robin]I there’s tons of cases that I’m only moving canine to canine Absolutely. But this is the really important thing. You still have to have a diagnosis. You can’t just treat patients from a scan or a clincheck. If you don’t know where the bone is, if you don’t know what the face looks like, it’s irresponsible. And that’s I think that’s the big line in the sand is, yeah, I can, if someone has number 8s to stick it out a little bit, it’s protruding. There’s a little bit of crowding that can be corrected with some minor dentoalveolar tipping and realignment, social six ortho is awesome. And there’s many, many, many cases that we treat as social six. I think the most important thing in my practice, especially as I mature, is that I first have a diagnosis of functional health. If I know a patient has good occlusion, their function is good. A questionnaire that in advance and a quick evaluation confirms that their bite is stable and good and they’re not damaging or wearing teeth or causing TMJ problems. Yeah, so six ortho easy and predictable. But if I treat somebody who has got pathology, you know, whether it be a bone pathology, there’s perio, that he’s undiagnosed or a functional pathology, let’s say for example, they have a frictional or constricted bite, and I throw on some aligners and I make it worse by trying to make a very common problem which is a class a super class one we call the class one molar, but the incisors are completely retro reclined, and they’re rubbing down their teeth they have TMJ problems, basically their mandible has continued to grow. And then you try to straighten out and uncrowded the lower incisors. And what you create is more problems, more frictional, more constriction. You know, you can’t get that from a stand. You have to get that from an actual evaluation of your patient. As I say, there’s nothing wrong with a class two or class three skeleton, you know, just because you’re a molar class two, if you’re functionally healthy. Why are we trying to correct that? So an orthodontist, it’s like, oh, you’re doing limited orthodontics was like okay, well, now you started doing distalization of molars or impacting the maxilla or trying to do other things. And now you’ve created a functional problem, you know it sometimes it’s better not to open that can of worms [Jaz]Very well said and [echo], we want to say, because when I started in Invisalign journey, I realized that I wasn’t as hot in my diagnosis I wanted to be, so then that’s when I embarked on my diploma in orthodontics, so that for that reason that I can really pick and choose my battles a bit like you, I have way more to do to catch up to you my friend, but it to pick and choose my battles, and to learn the art of diagnosis, so that I can provide the best care, most efficient care and the safest care for my patients. And I think that’s it, you know, I think we’re, we’re singing from the same hymn sheet, they’re also just want to say that [Kelly Tyrael] has said that I look up at Red Robin and co are always a big fan. If you can do the work, you’re an expert in my eyes, and we’re all lifelong learners. So that’s a very nice sentiment there. And I think, also Matthew, Sandra says, Well said, Brother, it all comes down to proper diagnosis, which is exactly what you’re echoing so that’s brilliant. So Robin, we’re coming to the end of the podcast, cuz we got the part one that we did take one, I’m gonna marry with this part. So thank you for giving up your time. But can you leave us with two things? The two things I want to leave us with is, what’s your biggest tip that you haven’t already given us? So you’ve talked about the importance of diagnosis, the elastic stuff. So what’s the biggest tip that you haven’t already given us because we’re very greedy. And the second thing I want to know is, how can we follow you more? Tell us about your Instagram, the Tesla, the aligner nation group, some of my listeners who don’t know about the aligner nation group? I’ve been pilot for about two years now. I’m not so much of an active poster. I’m a lurker, but I just love the energy. So please, tell us those two things. [Robin]I want to say, you know, aligner nation is a community that’s been fantastic. And it’s kind of grown unto itself. We have people sharing cases, we have some of the world’s leading experts. I mean, [sanitising], they’re commenting, we have [Marge Masari], we have you know, Jonathan, because he sees that all contribute some of the best of the best in there. And I’m super thankful. But I’ve been kind of I’ve gotten a little insular lately. I’m back to learning again. I’m taking more courses. I’m doing as many cases that can this pandemic has increased to my caseload and I’m learning from everybody else, as well. So if you want to learn from me, I mean, there’s a lot of platforms that I’m on. I’m always happy to answer any questions dms. And I’ll add a nation so you can follow me there. But the last tip, I think I’ve I don’t want to give and as I become more prolific in speaking, as well as in doing more aligner cases, I’d say that the art of aligners is to subdue the patient’s concerns with as little effort as possible and make it simple. Always start with the teeth that don’t need to move first. What I mean by that is look at a patient smile their face with a full Duchenne exaggerated smile. Look at where the teeth are. Find out are eight and nine in the right place. If they are in the right place. Right click on a clincheck don’t move them. Move the rest of the teeth to those reference teeth. I don’t like to move molars if someone’s functionally healthy. Leave them alone, right click those make them unmovable. And then when it comes to the bicuspids, canines things like this, especially lateral incisors, we know it’s very difficult to extrude a lateral incisor we know that ask yourself does it need to extrude is the gingival [Zenith] where you want it to be in if it is, I would rather trust my you know, composite skills and make it longer than try to pull it down and pull the gums down with it. Get an uneven gingival Zenith profile, especially someone who shows their gums as a high risk, you know, the show a gummy smile. I would rather do some bonding. So make your aligners easy, and don’t try to tackle every case, you submit a case and you get a clincheck back and they’re doing skeletal changes. And you know, you It looks like a miracle just happened. It’s probably not the case you want to take you want to control the variables not move as many teeth. , [Jaz]Amazing. Robin, thank you so much for giving up your time. Again, I know you’re busy guy. So obviously it’s great to connect with you from across the pond and get this out on the podcast very soon as well so the main listeners can listen to it. But thank you so much for adding to the conversation. Giving you equities on the aligners and sharing those little tips and tricks that we struggle with elastics but you really shocked me in the sense that actually intermaxillaries don’t have as big of a place aligners that I thought they did. And to be fair with you I’m so happy that I could put away my buttons and elastics now so I thank you for that but I’m going to focus more of today’s chat. I’m going to focus even more on nailing the diagnosis and picking the right battles. And also I’m gonna start right clicking more and start not moving teeth more as well as you said at the end so thank you so much Robin for coming today really appreciate my friend. [Robin]Of course. Thank you so much look forward to doing this again. You’re the best Jaz’s Outro: Guys thank you so much for listening all the way to the end I hope you found value from Dr. Robin Bethell. He gave some great tips especially at the end when asked him for his top tip like some of those gems he gave were phenomenal and it’s almost like sad to hear his struggles quote unquote struggles and sort of frustrations and how he was almost defamed by an orthodontist. But these are the struggles that a lot of general dentist face. I’m hoping I’ve covered a lot of those themes this month in orthodontic month. I hope you gain a lot of value from orthodontic month. So if you know someone who started starting out orthodontics, and this episode series this month is all helped them, please do share it with them. And as always join the protrusive dental community Facebook page and leave me a review if you thought this was valuable. I’ll catch you in the next episode, guys. Thank you so much for listening all the way to the end.