- All right, so now that

we're back from the break,

what I'd like to do is a continuation
of the conversation that we were having
about dots, and distribution in load,
and reduction in sheer.
So as we're looking back
at what we finished with,
we finished with this shot,
which is sort of a review of Dr. Dawson's
and may other books is,
where those dots were
in the books that we got
when we were in dental school.
But I'd like to talk about,
more about the why they're
in different locations.
So if you look at this tooth here,
or you look at this partial quadrant,
I have a sixth that's been
delivered a little while back,
and what you can see is an
application of those principles.
You have the landing pad
in the distal of the tooth right here,
and you have a landing pad there
in a flat receiving area,
and you have a little
touch on the cusp tip,
and hopefully that is a smudge.
And if it's not a smudge,
it's something that can be adjusted.
Crystal clear on what you're looking at.
I guess that's what I'd like to point out.
Here I'm using 19 micron
articulating film.
And I'd like to differentiate
a little bit about that,
as we move forward.
There are things that we say in dentistry,
whether we intend to or not,
and we say articulating paper,
and we say articulating film,
and they are night and
day different materials.
Articulating paper is a paper where,
in some cases, practically
a piece of cardboard,
that has ink soaked through it,
or thickly, very thickly
painted on top of it,
and when you're looking at
some of the 88 and 120 micron varieties.
Articulating film is not paper.
It is either a plastic Mylar sheet,
or it is a very thin metallic Mylar sheet
with an ink emulsion
that is very, very thinly
painted on top of it.
To give you an idea,
non-marking shimstock,
non-marking metallic shimstock
is either nine or 11 microns thick.
Articulating film that goes up from that
is either 14, or the next thickness
is usually 18 microns thick,
so you're really just looking at four,
three or four, or seven microns of ink.
So, we're going to talk about that.
I just want to bring it up right now,
because what you're looking
at and how you apply it.
So if you look at the
restored tooth on the six,
the seven's also restored,
but the four and the five are not.
So when we talked about
distribution and load,
and why that was important for
axial load and compression,
what I'd like you to look at,
is on the four and the five,
is where the contact is on the incline.
So if you saw in the previous videos,
little cartoon animations,
you either had teeth
that went into fremitus,
that is when they hit,
were hit by the opposing
teeth, they moved.
That is fremitus,
when your teeth get
loosened by occlusal trauma.
Or, they don't move and the teeth break,
and you saw a very dramatic picture
of the cusp fracturing off.
What you see is before
that fracture happens,
and what you're seeing
here on the four and five,
is you're seeing Chris
the orthodontic patient.
'Cause what you're
seeing here is a thinning
of the enamel, and you can
start to see the darkness
of the dentine showing through.
At some point that dentine
becomes thinner and thinner,
where it doesn't have
the bulk of structure
to bring it strength, 'cause enamel is
a very, very, very strong material.
And with strength comes
brittleness if it's thin enough.
And when it's thin
enough, you get fractures,
and that's what you have over here
is where you have the exposed
dentine happening there,
is you start to have the enamel
actually shatter, and fracture,
and then you have the dentine exposed.
Once the dentine is exposed,
dentine will wear 10 times, potentially,
faster than enamel.
And the dentine will cup out,
even ahead of the contact,
and then at that point, as that continues,
you have these walls of unsupported enamel
that shatter and break off.
So, in the absence of an acute, traumatic,
blunt fracture, of biting on a rock,
or getting hit in the
face with a cricket bat,
what you're usually doing, as I said,
at the beginning of the morning,
is this progressive cyclic failure.
You're progressively stressing
a very strong and brittle material,
until it wears, until it
shatters, until it's unsupported,
and then it breaks.
So when we look at that, you
have preferable contents,
which are axially loaded,
that bring in the greatest
strength in the material,
or you have inclines,
which you would think
are loading contacts,
but actually are
instantaneous, sheer contacts.
And that is where we start
to see the material failure
of the natural dentition.
So that begs the question
is, what do you see,
and what are you going to do about it?
What do you see, and what
are you going to do about it?
There's a famous clinician
in the states, years ago,
passed away a number of
years ago, Dr. Henry Tanner.
He says, "We treat what we see, we know,
"so what do you see?"
And I will ask you here,
what are you going to adjust?
'Cause you have blue everywhere.
You have blue in the central loading area,
you have blue up the buckle inclines,
you have blue down the palatal inclines.
And when we were back at
Marquette University with Dr. Pry,
Dr. Pry said grind all
the blue spots, GABS.
It's a joke, but that's how
we were taught occlusion.
It was take away whatever is touching.
We were literally taught to
adust teeth out of occlusion
that we restored.
Why do we do that and why did it work?
Because we were one-tooth dentists,
and we took them lightly out of occlusion,
so that they could magically
float into occlusion
and be in the right spot.
That is the disconnect in
all of our occlusal studies,
is that we were taught
how to make teeth touch,
and then we wiped them out,
and we just hoped that they,
when they started to touch again,
that they would be in the wrong spot,
and that is the dirty little secret
of the occlusion that we
learned in dental school
and how we applied it.
So I'd like to move past that,
and past grinding all the blue spots,
and I'd like to talk about
inserting a single crown.
Because inserting a single crown
can be a one-tooth rehabilitation,
and we're one-toothodontists,
or you're a full-mouth rehabilitationist,
and this is where you start checking.
Because if you're doing 28 crowns,
or let's say 14, or six,
the first thing you do
is not throw in 28 crowns,
or 14, or six crowns
and check the occlusion.
You put in one, and
then you put in another.
Or you either put in one, check
it, you take that one out,
you check the next one,
if you have an existing occlusal stop.
So if I'm doing maybe four and five,
I take off my temporaries, I put in four,
I see how it fits, I take it out.
I put in five, I see how
it fits, and take it out.
What I'd like to show you is a refinement,
a high-level refinement of that process.
Because this is where
accuracy in occlusion starts,
is understanding how to insert a crown.
Because we put said crown in the mouth,
we put a piece of articulating film in,
and we get some dots.
The only thing those dots tell us
is if that crown is hitting.
It doesn't tell us if it's
high, or how high it is.
So the protocol that I like to approach,
is when I have a patient back,
and we can do the same thing
with a direct restoration,
but here we're going to talk
about indirect application,
is when you have a patient back,
and they've been in a provisional crown,
you take the provisional crown off,
and you try in the articulating film
on the existing dentition.
But, there's a step before that,
and if I could, take a moment to rewind.
Because the first step
of checking occlusion
is not checking occlusion.
The first step of checking occlusion,
there are three steps.
The first step is you check your margins.
Because if you don't know that
the crown fits the margin,
you can't evaluate the fit in the mouth,
or on a solid die.
So the first thing I do,
when I get a restoration
back from the lab,
is I take the die pin out,
and I try the crown on the die pin.
And I can rotate it around,
and I can look at the mesial
margin, the distal margin,
the lingual margin, so on and so forth.
I need to know that,
because that's an end-point
in the crown going in.
So the second part of checking occlusion,
is not checking occlusion.
The second part of occlusion,
checking occlusion,
is checking proximal contacts,
'cause now you know on a
die model that a crown fits.
Now you need to put the die model,
or using a solid model,
and you need to put the crown onto that,
and you need to be able to see
that those margins fit once again.
Not only do they fit, but
your proximal contacts
are how you like them.
Do you put a pice of shimstock in there?
It just flies out.
You hold it up to the sunlight,
and you can see that there's
a millimeter gap in there.
We're not even ready to check occlusion,
because their fit is not acceptable.
Open contact, that goes back to the lab.
We need better contacts,
or if we have our own
porcelain oven in-house.
Second one, is I try to
put that crown on there
and it's too tight, and I can
see that the margins are open.
I'm not ready to check occlusion.
I need to adjust proximal contacts.
My personal preference is I
put non-marking shimstock in,
I seat the crown, and
that's on the mesial.
It tugs, but it slides.
That is, it will hold with
friction, but it will slide out.
What your personal preference
is, whatever yours is.
You're like, "No, I like mine to hold,
"and not slide out."
Well, we're talking a difference
of probably three or four microns.
It's really whether you like to
push your crown in a little hard,
or you like it to sit
seat down without it.
Regardless of that, when
I do seat it in the mouth,
I do like to have some nice floss snap.
However you get there, you're
all experienced clinicians,
I'll leave that one up to you.
But, we have evaluation one, margins,
we've evaluated two, proximal contacts.
Now we're ready to check
occlusion on the crown.
And the first thing we do
in checking occlusion on the crown
is still not checking
occlusion on the crown,
is checking occlusion on the other teeth
that hit without the crown in the mouth.
Because if you do not know
what the teeth hit like
without the crown in, you
will not be able to know
what you want to get to
once you seat the crown.
So when we put that articulating paper in,
I get two red dots.
And by that, I am specific that
that articulating film is red.
And there is an efficiency
reason to that approach,
because black will overwrite red,
but red will not overwrite black.
And I'll show you what I mean by that.
So the next thing that I do, is I finally,
finally you can put the crown in.
Put the crown in, and
then using black or blue,
whatever color your film is,
you put that in the same place
that you put your red
articulating film previously.
And you can end up with a
couple of different scenarios.
If I had red marks here,
and I had red marks here,
and I put that crown in,
and I get black or blue
overwriting the red,
the next thing I do, is
I look over at the crown.
Is the black or blue overwriting
the red on the crown?
Because if I'm hitting
here, and I'm hitting here,
and the black or blue
is overwriting the red,
I'm hitting in the same places
with the crown in and out,
within 19 microns.
For me that's ready to go to the clinic.
What I can also do, if I want
to get real picky about it,
then I can put in, with the crown out,
I can put nine microns shimstock here,
and feel tug tug.
Put the crown in, put nine
micron shimstock here.
Do I still feel tug or I feel slide?
Because if I marked it 19,
but I slide with nine micron shimstock,
I know that I potentially
have 10 microns of adjusting.
I know that this may
sound obsessive to you
if you haven't thought about this before,
or thought about this approach.
But I'll tell ya,
and I'm betting there are
some people in the room
that have been there.
I've been there before, and
I'm going to be there again.
You go through a about of
lack of self-confidence.
And I don't know whether it's you,
or your impression material, or your lab.
And it's not a full-mouth
rehabilitation you're delivering,
or a quadrant, it's one single crown.
And you literally just start to feel ill.
And you're going through a
bad about with your lab tech,
or your impression material,
or something is going
wrong that you don't know,
and you are just regretting
walking into that operatory.
This can take that stomach
acid, put it on the side shelf,
go, "Okay, give me a minute with myself.
"Does this fit?
"Yes it does."
Now I have a higher level of confidence
before I take this to the patient.
So what the benefit
is, I feel better here,
I have less stress here,
and I have more confidence here.
'Cause as I said, the
benefits of occlusion,
there are three great
benefits of occlusion,
is you can walk into that
operatory with confidence.
You can walk out of that operatory
with confidence that your restorations
are not going to break.
And the third thing, and
the most important thing
that stays intact in that scenario,
is your reputation with your patient.
Because when you come in with confidence,
deliver in confidence, look 'em in the eye
and say, "This is going to work well,"
they feed on all of those things with you.
And they talk far more
about how you made them feel
and the comfort that you brought across,
than the technical dentistry that you do.
People care far more about
how you make them feel
than the technical
dentistry that you provide.
So scenario two, what
if you've gone through
that crown try-in process
of how it fits without,
but how you've tried in,
and the red dots are still over here,
but there's no black
that's overwriting them?
And all of those black
dots are only on the crown.
Now you know that crown is high.
So what you can do, and what
you need to figure out is,
how high is that crown?
So now I can take the 19 micron shimstock
and come over here.
Does it hold?
Nope.
I double it, and it becomes
38 micron shimstock,
and it holds.
Ah, I'm only 19 microns off.
I can adjust that.
That's pretty easy to do
so with a polishing point.
What if that was 72 microns?
What if that was 144 microns?
What if that was 288 microns
that you had to put 10, 20
pieces of articulating film
between here, until this tooth held,
when you're in contact with the crown?
That might be the time
to say, "You know what?
"This is not the day
to deliver this crown.
"This is the day to send the crown back."
Because I'm sure we've all been there,
and you're in there in the op,
and you check it, and it's high,
and we start backwards, right?
Ah, it just needs a
little polishing point.
Polishing point becomes a red striper,
and at some point you're frustrated,
and you bring out that big, huge, black
extra-coarse diamond, and
you start wiping it out,
out of frustration, and you realize that
this no longer looks
anything like a tooth,
and you have to send the
crown back to the lab
to be restacked.
This is a process and this is the protocol
that helps you avoid that.
So it could be two strips,
it could be three strips.
So the other one that I brought up,
and I'd already mentioned this.
What if you get your black
dots over the red dots here,
but you don't get them
on your restoration?
Same thing, one strip doesn't hold.
Two strips, it does, 19 microns,
I'm pretty okay with that.
I think I'll deliver that crown that day.
What if it's 38?
What if it's 72?
What if it's that gold crown
that you could visually see at
the beginning of the morning
is one to two millimeters
out of occlusion?
That's the one, if you can just take this
two minutes of protocol,
of checking your laboratory
cases into the lab,
you can avoid all of that
frustration chairside.
You can help avoid that stress
that you're feeling in your stomach.
You can avoid damaging your
reputation with your patient.
Because broken restorations can be fixed.
Broken reputations are far,
far more difficult to correct,
and in many cases, that would be the time
that the patient actually
leaves the practice.
So looking at these, whether
it's a one-tooth application,
two-tooth application,
three-tooth application,
quadrant, full-mouth, what have you,
it's a simple protocol to approach
to evaluate your occlusion.
So when we look at
different articulating films
and articulating papers,
that are commercially
available on the market,
this is something that I
see all over the place.
I see this on different Facebook groups,
and I see this in different lectures,
and we check the occlusion.
And, not trying to be too cheeky,
but what are they checking
the occlusion for?
That we can put a whole mess
of ink all over the tooth
and not know what to adjust.
So that's 88 microns.
That's 63 microns.
It still looks pretty similar.
That's 19 microns.
What you're looking at, I
want to back those two up.
That's 88, that's 63,
and you're confused about what to touch,
and that's 19.
That is the same crown, that
is the same articulator,
that is the same mounting.
Materials matter when you're
evaluating your occlusion.
So when we look at this,
and you get this back from the lab,
and you evaluate it,
there's one other one that
I'll toss into the mix for you,
which I don't know if
you have heard about.
Have any of you heard of
white articulating film?
This is eight micron
white articulating film.
It's from Bausch.
It is absolutely lovely
for using over gold crowns.
You know how when you're
looking at gold crowns,
you try to put black on there,
and the light is so shiny,
you can't actually see the black mark
even though it's there?
Sometimes you have to
take it out of the mouth,
and you have to turn it around,
because all those reflections
look like black marks?
Well, there's a little bit of a difference
in black and red, and
it's not just the color.
It's the nature of the emulsion
that black actually marks
easier than red does
on smooth surfaces.
I've talked to the engineers at Bausch,
and they've explained why that is to me.
And not only can't I remember it,
I never understood it to begin with.
But I'll accept it that there are people
that are smarter than me on the planet,
and the Bausch engineers
are some of those people,
and I will pass that one I told you so,
on from the patient.
So if you look at what
I'm showing you there,
is this is that flat
receiving area landing pad,
that's that flat receiving
area landing pad.
There's a little bit of one there.
I could probably take that
smudge off the incline,
and I've easily achieved
what I want very quickly,
because I'm using materials
that are accurate enough
to show me what I'm looking at,
and not putting GABS,
not putting blue spots
all over the occlusion
and having me guessing.
And that's where our confusion began,
and I'll go back to dental school.
And I'm not busting on dental school,
and I'm not busting on our
dental school professors.
We just did not have a long enough time
to explore all the clinical applications,
and we did not have failure
that went along with it,
for us to appreciate the
lessons that we were learning.
So when we look at the,
and when we look at all
these different colors,
and how they got tossed on there.
Give you a look again,
and these are the materials
that I use in my clinic.
So I use 19 micron black,
I use 19 micron red.
Both of them mark on both sides.
And then I have 11 micron shimstock,
which is non-marking.
So if you look down here at the bottom,
what you're looking at is 18 or 19,
37, 63, and 88.
So you are looking at just
a try-in of one patient.
But I want to have you look at that
in full arch application.
I just grabbed a random patient here,
and said do you mind if I
put ink all over your face
and take a couple of shots?
They said, "Sure no problem.
"That's what I was expecting today."
So, there's 19, 37, 63, 88.
That is not diagramatic.
That is a pure representation
of the differences between thicknesses.
So in the size, if that top
piece of green strip up there,
it measures 19 whatevers tall on my slide,
the next thing measures 37 whatevers tall,
63 whatevers tall, and 88 whatevers tall.
If you have any of these
materials in your clinic,
try 'em in your mouth
next time you go home.
Just put in whatever
you use, and double it.
If you use film, double that,
and you can keep walking up.
And compare the differences in those two,
and you realize that
sometimes your other teeth
just aren't not touching.
You'll also notice a
fairly significant shift
the thicker the paper is,
because when you get up to papers
that are honestly 88, 128, 144,
there are materials on the market
that go up to 240 microns.
240 microns.
That's like putting well over
10 pieces of articulating
film in your mouth,
and close, tap tap,
and see how that feels.
So here is 37,
here is 63,
and there is 88.
And that is the difference between
knowing what you're looking at
and having the confidence to
knowing what you're adjusting.
So it may seem like a silly thing
to come into an occlusion lecture
and have to be retaught
about articulating film
versus articulating paper,
but as Dr. Tanner said,
"We treat what we see,
"we see what we know, so what do you see?"
We need to recalibrate all
of you for what you're using.
If I could give you one
thing to take home tomorrow.
Well not tomorrow, the day after.
Not the day after that, Saturday,
unless you're working on Saturday.
Whenever you go back to the clinic,
use something so that you know
what the heck you're looking at
so that you're not guessing,
like I was with Dr. Pry,
whether which parts of those
teeth were even occluding,
and which part of those
teeth were even adjusted.
19, 37, in this case
55, and in this case 88.
Jumps up quite, quite quickly.
19, 37, 55, 88.
So I think I pounded that
to death a little bit.
So let's do a little bit more.
Here is the case and application.
Case comes back from the lab,
whether it's a full arch impression,
or whether it's a triple tray.
And what I do is I take my red shimstock,
a red articulating film rather,
and if this is a one-tooth case,
I don't care which arch the crown is on,
that arch goes on the bench top.
Because if you're restoring
a one six or a two six,
and you put the crown on,
it's going to fall off or
it's going to be loose.
I know it seems obvious,
but it's the little steps that matter.
So if you're doin' that
one six or three six,
just turn the articulater upside down.
Second step, do not,
do not do this.
(clapping hard and loud)
There are two reasons, one,
you're going to smash your stone,
and the other thing is
articulating film and articulating
paper react differently.
Articulating film is on a piece
of plastic that stretches.
That ink is not impregnated
within the material,
it's painted over it.
If you bang, bang, bang,
you will actually shatter the emulsion
and it will splatter everywhere.
The other thing you don't want to do
is hold it together and pull.
You will do the same thing.
You will actually stretch the Mylar,
and you will get splashes everywhere.
So even though you think
you're being accurate
at 19 microns,
you've actually just erased that accuracy
because you've pulled on that
and you have dropped the ink.
All right, so a couple things
I don't want you to do.
I don't want you to bang
bang your models together,
because you're either going
to splash the emulsion
or you're going to break your model, okay?
All that accuracy that
you've been striving for,
if you slam your stone together,
you're going to shatter the stone,
and your accuracy goes out the window.
And I also said I don't
want you tugging on it.
So what I want you to do,
is I want you to put the
articulating film on there,
put the models together,
and give 'em just a squeeze.
Just one squeeze is all you need.
And what you get, is you get
marks wherever marks are.
So next what we're going to do,
is we're going to go
ahead and put the crown
onto the model here, and we're
going to give it a squeeze.
And what you see is the landing pad.
So sometimes the landing pad
is very specific anatomically.
Here, we have a bit of a worn
dentition in the posterior.
It's not real pretty anatomy.
And the thing about where
these landing pads should be,
all dental anatomy is
based on dead white guys.
It is.
All of the dental anatomy
studies that you see
are based out of the UK,
specifically Scotland,
where they studied corpses.
They either dug them up or,
as Jeanine and I had a
wonderful visit there last time,
there was quite a black
market for killing people.
They literally had tunnels
from the poor part of town
through the alley ways
that led to the medical school.
And there's a very dark part of Scotland,
but they do talk about it today.
But anyway, when you're talking
about Bonwill's Triangle,
or you're talking about Monson's Sphere,
or you're talking about
class one and class two occlusion,
and you're talking about facial heights,
you can look around this room,
between all different
backgrounds of Caucasian,
Asian, Indian, what have you,
and all of us have
different facial thirds.
But all of the dental anatomic norms
were based off white Anglo-Saxon.
So, all that being said,
not everyone is class one regardless
of what I heard it should come from.
Sometimes teeth are rotated.
Sometimes teeth are tipped.
And that's why understanding the why
is more important than the how.
You're like, "Oh what, this contact
"isn't on the mesial marginal
ridge like Mike said,
"and like Dr. Dawson said."
Well there's no opposing
cusp that you can put there.
It's about finding a flat receiving area,
regardless of where that opposing cusp is.
So if you look at this here,
you can see that I developed,
or Lucas developed,
a very, very broad landing pad,
and as you look at it from the proximal,
you can see while we do
have very basic anatomy,
there is that very, very
nice flat receiving area
right in the middle of
that pool of anatomy.
So again, another case.
Here we have a bicuspid,
and what we've done
is we've put the articulating film in,
we've put the 19 micron
shimstock in there,
we've given it a little bit of a squeeze,
and we have an understanding
where the existing occlusion is.
So we have an understanding
of where the end point is.
If you decide to do this
with direct restorations as well, you can.
And the really frustrating thing
is you do this beautiful class one,
and you took that course,
or the course that's going
on downstairs right now,
and you build up all those cusp slopes
and you put it in, and
all they're hitting it
is on your composite.
But you have no idea how far to get down.
You can also do that, what I called
that lateral leaf gauge,
is mark it beforehand or you can double,
and triple, and quadruple
the articulating film
on your non-restored teeth,
as long as you knew they hit beforehand.
Because sometimes their
teeth are out of occlusion,
and you keep trying to
adjust until they touch,
but you know what?
You forgot to check if
they actually touched
before you started.
So just knowing what
your playing field is.
So here, we put the crown in,
and again, I just give it a light squeeze.
There are the red marks,
there are the black marks.
There are the red marks, boom, boom.
Whether they're on an incline slope,
that's where the existing occlusion is.
You put in the new crown, I
have occlusion on a cusp tip,
I have occlusion in a flat receiving area,
and I have it as a
known within 19 microns.
I'm not touchin' this.
Maybe I'll check with
nine micron shimstock,
but nine times out of 10,
this is more like crown off, check it,
crown on, check it.
Okay, this one's good to go to the lab.
And I'll have four or five cases that day,
and I walk back to the lab,
and I see a line of lab cases,
and I'll just sit down, and I'll say,
"Check this one," goes to the side,
"Check this one," and goes to the side,
"Check this one."
It's that two minutes,
it's that one minute,
it's that five minutes
that you spend checking
one, two, three, four, five cases,
that save you all that time
that you have to adjust
and polish chairside.
So here you can see,
this is that same case,
I have a touch on a mesial marginal ridge,
I have a touch on a cusp chip,
and I have a touch in a
central flat landing area.
This might need a rubber wheel.
This might need a rubber wheel,
or maybe it was just a smudge,
and maybe I did pull.
I don't know, but if
I'm within 19 microns,
I'm not going to worry
about it a whole lot.
If I want to, I could easily
rubber wheel it right there,
but that's going to be
your decision as clinicians
in your own cases.
One thing I want to bring up here though,
is the conformative anatomy aspect,
because there are two ways
that you can approach.
There are a million ways
you can approach occlusion,
but when you decide to move forward
with applying your occlusion,
are you going to do full arch impressions
in every case?
Are you going to be
okay with triple trays?
Are you going to take a face-bow
and a protrusive record in every case?
The reality of it in the United States,
98% plus of restorations,
they go through commercial
labs or triple trays,
and I'm pretty okay with that.
I know that's surprising
to hear from someone
that teaches at Spear.
I'm visiting faculty at Pankey Institute.
I've been the editor of
American Equilibration Society,
but I understand the limitations,
and benefits, and considerations
between those two.
Triple tray impressions are more accurate
than full arch impressions.
That has been proven out in the research,
because the more contact points you have,
the more air potentially
you have in expansion.
Where triple trays are not at all accurate
compared to full arch
impressions, is in excursions.
Because that has to do with
how far the hinge is from the model,
and Bonwill's Triangle, that four inches,
or 110 millimeters that all
articulators are based on,
and that John Kois's screwless
face-bow is based on,
is that average of the dead white guys.
Then you actually take a face-bow
and it's even more accurate.
But if you have this little,
triple tray ariculator
that has the hinge just
off the second molar,
instead of your arc of lateral excursives
being that four inches,
it becomes two and a half inches,
and you have very sharp
differences in how that goes.
But, back to the contacts
and excursions on a triple tray,
how do you deal with that?
Because this can be deadly
accurate in closure,
and that's where the triple trays are,
but they're not accurate in excursions.
So one thing that we do,
if we're using a triple tray.
Conformative anatomy is
looking at the existing slopes,
and keeping the existing anatomy
within the existing slopes.
So I will use triple trays
for fours, for fives,
for sixes, for sevens,
as long as I have a four,
five, six, and seven.
That is, I want a quadrant
of supporting teeth.
That being said, have I done
one without a seven there,
and I've done a six, sure.
I have a lot of little old ladies
that are in their 90s and 80s
that I cannot stretch a full
arch tray into their mouth
without hurting them.
So, conformative anatomy is just trying
to match up the slopes as best you can.
When do I go to a full arch tray?
Any anterior tooth, period.
Any anterior tooth, period,
because anterior teeth break
in excursions, not in load.
So then I need my
excursions to be accurate.
When else do I go to a full arch?
If I'm doing more than one
tooth in the posterior.
Have I ever done a triple tray
with more than one tooth in the posterior?
Yes I have.
I've had some people
that just can't tolerate
a full arch tray.
Maybe they're gaggers, or maybe
they think they're gaggers,
or maybe they're little old ladies
that I can't get a tray into.
It's very, very far, and it's
very, very, very few between,
but being realistic about it,
I'll tell you I have done it.
I do not prefer it, because
there is lack of stability
and there's lack of accuracy,
and there's increased
need for adjustments.
So here is that same crown
that you just looked at
at 19 micron.
There's that tooth at 37 microns.
The only difference here
is which piece of paper you're using,
and what level of confidence
you go to adjusting that.
It's a world of difference
just from that small amount of microns.
So 19, 37.
It's just about knowing
what you're looking at.
So, going to the mouth, finally.
Here is this one tooth,
and I put in the 19 micron shimstock,
have that marked in red.
You can see that there's that
nice, distal, margin of
ridge contact on the five.
We go ahead and put that in,
and you can see, I still have that
nice, distal, marginal
ridge contact on the five.
I have the cusp full
contact on the palatal cusp,
and I have the centric
contact right there,
and a couple of little smudges
that I'll probably just take
a little rubber point to.
Easy peasy day-to-day dentistry,
or you can deliver 'em like this.
And you're not sure.
And if you're not sure,
what are you going to do?
You're going to adjust it.
Or you're going to cross your
fingers, and hope and pray,
that that's really where
they're hitting or not hitting.
All the difference is,
is changing the thickness
in articulating paper you're using.
So, moving forward from that,
like to talk about treatment
planning a little bit more
and blending these two concepts together.
So, apologize for being a little dry,
but if you don't know
how to look at things,
you don't know how to evaluate things.
So now we're going to
try to look and evaluate.
So we have a real easy case here.
This patient setting.
These are the ones that you
have nightmare stories about.
These are the ones that they hit high on,
because that's the first contact in CR.
It's not.
It's just pretty straightforward dentistry
that you're lookin' at.
Tooth is broken, she wants it fixed.
So I walk into the operatory.
Meredith is in hygiene,
and I said, "Hey Meredith,
what's goin' on,"
and she goes, "Well I have this tooth
"and there's something chipped on it,
"and it doesn't feel right,"
and I said, "Anything else?"
She goes, "Yeah, when I
bite on it, it hurts."
I said, "Anything else?"
She goes, "Yeah, when I
get cold or hots on it,
"it also hurts."
"Does that linger?"
"No, as soon as the temperature goes away
"the pain goes away."
She does not have a goal right now.
She has things she's told me.
And I said, "What can
I do for you Meredith,"
and she goes, "Duh,
"make it feel like a tooth,
"make it not hurt when I bite,
"and make it not temperature sensitive."
That is an important
differentiator for me,
versus you come in and
you're a new patient.
I said, "What can I do for you,"
and you say, "Aw, my teeth
are real jagged and sharp,
"and they're kind of brown."
"Okay, smile makeover."
"Oh, I don't care."
Yeah, how many times have you
had patients laundry list
everything that they're aware of,
but when you get a treatment plan,
they don't actually want to do anything?
They just feel like they
need to laundry list you
everything they know about themselves.
So the difference between
an existing condition
and an existing concern
is the patient asking you to address it.
So it seems, like I said, pretty obvious,
but all I asked Meredith
is, "What can I do for ya,"
and she said, "Duh, make
it feel like a tooth,
"make it not hurt when I bite,
"and make it not temperature sensitive."
So when I look at Meredith,
I have to show you a view
that you haven't seen yet,
which is this one.
How do you make it fit?
'Cause when you look at Meredith,
what has likely happened here.
I know when I put this up,
a lot of people, I could
just see it on your face,
you're like, "Ah, first
contact in CR, plunging cusp."
Maybe at some point,
but what probably happened here,
is she probably had a restoration there,
'cause you can look at it now,
and you can almost
notice an occlusal prep.
And you can almost notice
that that composite is flecked out.
And how do you have a
high degree of confidence
that there was a composite in there?
Because there's a flowable liner in it.
So all those I think I
knows lead me forward,
but when I look at her in occlusion,
that's Meredith in occlusion,
and it's far worse than you
think for a couple reasons.
Look how short that
distal marginal ridge is.
The other thing that's
very interesting here
is remember that I said
dentine wears 10 times faster in enamel?
That tooth is not in contact.
I did a leaf gauge screen,
which we'll get to today.
That is not her first contact.
What she used to do, I think I know,
she used to be occluding on a composite.
That composite flicked out,
and now that palatal cusp
has started coming down,
and through food mulling,
she has started to hollow out the dentine.
As that progressed, she
has unsupported enamel
and she's starting to get
flexural pain on biting,
she has temperature pain, I think I know,
because of exposed dentine.
The endodontist also confirms,
and he confirms through my own probing,
there are no signs of a vertical fracture,
there are no signs of pulpal pathology,
and there are no signs of
primary occlusal trauma.
So you're looking at a, quote unquote,
straightforward restorative case, kind of.
So all I said is, "How
do you want it to look,
"and how do you make it fit?"
Easy, no problem.
This is how I want the tooth to look,
that's how I want the tooth to fit.
Thank you very much.
Case is complete.
Except for now it fits like this.
(students laughing)
'Kay.
This case, I absolutely love,
because it bridges the dot that
you learned in dental school
with full mouth rehabilitation,
even though it's one tooth.
Every challenge that you will have
as you move forward with
restoring the worn dentition
is going to be how to make teeth look,
and then how to make 'em fit.
And then you're going to
find some of those teeth
are not in the right place,
when you make 'em look the
way that you want 'em to look,
and you're going to have to
figure out how to make 'em fit.
So in this case, when we look at Meredith,
I have a mandate from her, "I
want it to feel like a tooth."
So, it feels like a tooth.
But it does not fit.
And we do not have distribution,
and if she starts hitting
on that, it's going to hurt.
So the question is, what are
the options to treat Meredith?
And this is the sticking point
that treatment planning becomes difficult,
because you start furling your eyebrow,
you start putting your hand on
your chin there a little bit.
You got like, oh you almost
started tapping the pen.
She almost like nailed the three initials
of where the heck do we start?
So, I've come up with a bit of a plan,
is how to organize that in your head.
Jeanine and I started using this from.
We developed this in our
workshops to help the people
that were scratchin' their head
and resting their chin,
and tappin' their pencil,
but what I realized,
it actually became our
protocol for our office.
It's a very simple way to organize
the way we look at patients,
is why do they want,
what are the options to achieve the why,
and within that how process,
what are the benefits and
what are the considerations
to that approach?
So what I call this, is
I call this the three Ps,
purpose, process, and presentation.
So the purpose for Meredith is
she wants it to feel like a tooth,
she wants it to not hurt when she bites,
and she wants it to not
be temperature sensitive.
That is her treatment plan.
What we don't know is
her treatment process,
because whatever the process is,
it has to achieve the purpose.
If the treatment process
does not achieve the purpose,
it is not an acceptable
plan to present to her.
So if you look at this,
you say, "It doesn't fit,
what are our options?"
well, we could shave down
the two seven to make it fit.
Let's try that one out, boom.
That's the two seven shaved down
without any alteration of the three seven,
aside from the wax up I did.
So I made the three seven
look how I wanted it.
In order to make it fit, all I
did was adjust the two seven.
Does this achieve her goal?
Yes.
Does three seven feel like a tooth?
Yes.
Does three seven not hurt when she bites?
Yes.
Is three seven not temperature sensitive?
Yes.
Those are also your benefits.
What are the considerations?
Two seven doesn't feel like a tooth,
two seven possibly hurts when she bites,
two seven is now temperature sensitive,
two seven might need a root canal,
and two seven might need a crown.
So when you look at that,
that's how that sheet works.
You can look at it as a stupid question,
or you can look at it
as a patient engaged.
I said, "Meredith, I have a concern that
"when we make this lower
molar look like a tooth,
"and not be sensitive to
biting or temperature,
"it's not going to fit the upper tooth."
And she's very thoughtful
insightful patient,
and she said, "Well can't
you adjust the upper one?"
And I said, "You know what?
"That's a great question."
Or I could have said, "You
know, that's a stupid question.
"You don't understand dentistry.
"Let me just do my job."
(students laughing)
But you've either been that person,
or you know someone
that does that approach,
and that makes Meredith, sorry.
That makes Meredith feel like an idiot,
that keeps Meredith from
opening her mouth in the future,
because you belittled
her and you insulted her,
or I can come over to Meredith and say,
"You know what, Meredith?
"That's a great question.
"It's something I've even considered
"in cases similar to this."
Third person removal, because now I can
talk about a different case
that makes her not wrong.
"When I approached a case like that
"in other circumstances,
"I was able to make the tooth like yours,
"look and feel right,
but we ran into problems
"with the one we adjusted."
"Problems, like what?"
"Well, it started getting
temperature sensitive,
"and biting sensitive.
"It didn't feel right, and actually
"it ended up needing a root canal."
"Well, does my tooth
need a root canal now?"
"No."
"Well that's a stupid idea."
By the way, Meredith is a large equine
veterinary radio oncologist.
I don't even know what that means,
but I think it means radiation in horses,
but she's the only one from
like Seattle to Minneapolis,
and that is God's country in the US
as far as ranching goes.
She is the only specialist like that
for things that cost $100,000 to start.
She is busy, she is crazy busy,
but she also is used to
making decisions very quickly
given the proper information.
Not all of your patients
will be like that,
but all of your patients will benefit
from the right information
to help them make these decisions.
So, not hurt when you bit,
make it look like a tooth,
quicker and possibly less
involved than other options.
You can't just say quicker.
It has to be quicker than something else.
Considerations may make
the upper tooth hurt,
may make it not feel right,
may make it biting sensitive,
and might make it temperature sensitive.
This is an approach that
I use in my practice,
and it's an approach that I
use for all of my procedures.
So you come in, and you
are missing a four six.
And we go "Blah blah blah blah blah blah,"
and it ends up being
implant versus a bridge.
And he goes, "Oh I don't know."
And I'm sorry.
Brian, Brian's like, "I don't know.
"I'm not even sure what to ask."
"Brian, would it be helpful for you
"if I just jotted up a quick letter
"that talked about the
benefits of a bridge
"versus an implant?"
"Yeah, yeah, that'd be great."
"And oh, Brian, help me
understand one more time,
"why did you want to get that tooth back?"
"Well I just can't chew over there well,
"and I'd like to be able to chew again."
Okay, now I have a purpose,
and I go into Pages or Word,
and I hit new document, I go to templates,
and I pick implant versus bridge,
I change Sue, to Brian,
do not forget to do that.
(students laughing)
You change the date, you change
the specific tooth number,
and you already have
all of these written up.
I have these letters written
up for implant versus bridge,
bridge versus partial,
partial versus implants,
porcelain versus composite rehabilitation,
phasing versus not
phasing, and what I have is
I have this volume of form
letters and templates,
that all I do is click it open,
change the date, change the tooth number,
and change the patient
name, and then I say,
"Brian, I'm going to
stay after work tonight,
"and make sure I get
this written up for you.
"Would you prefer you
come in and discuss it,
"would you like it emailed,
"or would you like me to snail mail it?"
"Oh just email it, that's fine?"
"Is it okay if I email it?"
Because I'm getting
permission to actually do
a HIPAA, or whatever
you call it done here?
Patient protected information
on non-secure transfer method?
So I've actually gotten confirmation
that I can mail him a sensitive letter,
and I write that in my chart.
So that's becoming,
everywhere in the world,
that's becoming bigger.
So I do stay after work, 42 seconds,
(students laughing)
and I write that out.
And I'm really good about
getting all my letters together,
but I tell you, talk about the difference
in case acceptance, and Lincoln is just,
Lincoln Harris is just so fantastic
about talking about this at RETP,
rapid, efficient, treatment planning.
The efficiency comes with repetition.
I have all that repetition
in all of my letters,
and all of the various
ways that Lincoln and I
have developed the way we present cases.
And why is Lincoln so confident?
Why is Lincoln so effective?
Because he does it again,
and again, and again,
and he has a protocol.
This is my protocol,
even though I'm starting
with one tooth with you guys.
So, Meredith says, "Well, couldn't you
"take a little bit away
from the bottom one
"and the upper one?"
And I tried that.
And I said, "Meredith, you know what?
"I tried it, but when I did that
"I was still concerned that
"the amount we took away from the upper
"is still going to lead
to all those problems,
"and not only that, what we
take away from the lower,
"it's not going to look
like a tooth anymore."
And Meredith says, "Oh,
well what can we do?"
I said, "Well what we could do
"in order to make three
seven look like a tooth,"
always bring up their benefit first.
I'm skipping the other two.
Make it look like a tooth
and have all that structure.
What we can do is relocate and reposition
the upper molar,
so that there's enough room down here
so that it can look like a tooth,
not hurt when you bite,
not be temperature sensitive,
and we also will not need
to grind on the upper tooth.
"Oh that sounds great.
"No root canal on the upper?"
"Nope."
"No crown on the upper?"
"No."
"Cool, how do we do that?"
"Braces."
But we talked about all of the
benefits and considerations
of how we got there before
we talked about process,
because if you talk about process
before they understand
how it benefits them,
the only way they will
be able to evaluate that
is on how it's done and how much it costs.
So, as I said, you can't
have occlusion stand alone.
I need to be able to
talk about communication.
I need to be able to talk
about treatment planning
to make it relevant.
Otherwise, it just becomes this very, very
long, boring procedure
of pedantic academia.
So, in Meredith's case,
what we did was we
extracted the two seven,
and it looks like.
No we didn't.
(students laughing)
What we did here, was we
did a one tooth ortho setup,
is I cut the tooth off,
and I repositioned it,
on a triple tray, of all things.
And I went to my orthodontist with this.
Now it looks like a tooth.
Look how much difference
there is in my ortho setup.
Remember, this cusp here before
was all the way down here.
Fairly significant intrusion.
When do you take models?
When I need to see something.
If I cannot see something,
and explain it to my
specialist and my patient,
I need to take a model.
When do I need to take an X-ray?
When I don't have X-ray vision
to see a periapical
radiolucency or bone loss,
or I can't see caries.
When do I need to take photographs?
If I can see the smile that's possible,
but the patient can't.
It's not about every
time you do these things,
although with new patients,
I certainly have a protocol,
but any time, as you're developing
what you need to do and
when you should do this.
When should I take models?
When should I take photograph?
When should I do this?
If you can't see it, you
need additional information.
If you can't explain it to someone else,
you need additional
resources to show them.
So, in Meredith's case, I looked at this.
Purpose, exact same thing.
Make it so it doesn't hurt,
make it not hurt when
I bite, hots and colds.
Exact same thing.
This time we're crowing the three seven,
we're intruding the two seven.
All of the things up here are the same,
except for more conservative,
reduces risk of fracture,
reduces future treatment needs.
Those now, are all benefits,
because you've actually looked
at other treatment options,
and those were the negatives of them.
The negatives of the
other treatment options
actually become the positives and benefits
of this treatment option.
What are the considerations?
It's going to take longer.
Someone will say, "Yeah,
and more expensive."
It's not more expensive
if you need a root canal,
or a crown lengthening, or an extraction.
So all of those things is,
you can talk about more
expensive in the short term,
less expensive in the long term.
Ortho is going to be more expensive now.
It will cut down your
treatment needs in the future.
So if you want someone to
look absolutely at you,
like you are clearly insane,
have your orthodontist, Steve Lemery,
sell his practice to a new orthodontist
that's newly qualified,
first week out of school,
and walk over to his
office with a triple tray,
and a one tooth ortho setup,
and you're his first referring doctor.
Luckily, he knew who Jeanine and I were,
and he knew the level
of care that we brought.
He knew about Chris,
the other Chris's case.
He knew that we focused a lot
on adult orthodontic restorative care
in unique manners.
So when we went over to Dr. Paventy,
what Dr. Paventy did, was he
bracketed up the quadrant,
he threw a tad in the buckle,
and he threw a tad in the palatal,
and he straight up intruded the seven.
Backing up from that a little bit,
before Meredith left that day,
the tooth was not in contact.
Etched, bonding agent, teeny
little bit of Flowable.
"How's that feel?"
"It's not as rough."
"How does that feel when you bite?."
"Ah, it still hurts."
"How about when I blow air?"
"That's a little better."
She winced but said,
"That's a little better."
So each time that she
went to see Dr. Paventy,
the tooth was intruded a little bit more,
and each time that happened,
either Dr. Paventy, or Jeanine and I,
added a little bit more composite.
And each time that we did that
it felt a little bit better to her tongue.
It never fully resolved
biting sensitivity,
so I was open to that perhaps
just being a direct
composite, restoration.
What I was firm about,
was it would look like a
tooth, feel like a tooth,
not be biting sensitive, and
not be temperature sensitive.
When we got to the final stage,
we had fully resolved the way it feels,
we had fully resolved the
hot and cold sensitivity,
but we could not get over
the biting sensitivity,
so a full coverage
restoration was indicated.
So when we look at that,
that's how much we intruded the tooth.
You're looking at the
postoperative maxillary
against the preoperative mandibular.
So none of that composite
that I just told you about
is there, but I wanted you
to have some realization
of what the alterations were.
So here you see the
preoperative diagnostic
one tooth wax up,
and you see how that is
the final restoration,
and that is the final gold
restoration that we placed there.
And she said, "I try to correct myself,"
because she did not say
"look like a tooth,"
she said "feel like a tooth."
Aesthetics there were not
important to her, longevity was.
So we went with a very
basic gold restoration,
even though you're looking
from an occlusal aspect.
You can see the basic conformative anatomy
of the six and the seven,
and that we're not trying
to recreate a six year old,
freshly erupted, or 12 year
old, freshly erupted seven,
but rather fit it to
the existing dentition.
So, we need a goal,
we need to visualize an outcome,
we need to figure out a process,
and whether that process is
reshaping, repositioning,
restoring, removing, all of those Rs
are the Rs of equilibration,
because equilibration does not mean grind.
Equilibration means balance.
And you may balance teeth by moving them,
repositioning them, reshaping them
either reductively or addititively,
but that's another one of those words
that we get caught up with,
is when we hear equilibrate,
we hear chainsaw.
It's like (mimicking chainsaw).
Everything needs to buzz down,
and as we're going to see
in cases this afternoon,
and as we're going to see
in cases all day tomorrow,
we're moving past these
one tooth applications,
and I want to get to two teeth,
I want to get to sextants,
I want to get to full mouth
rehabilitation, almost,
because the funny thing, I'll tell you,
is the easiest thing about occlusion,
is a full mouth rehabilitation,
because you control absolutely everything.
The most challenging thing about occlusion
is when you don't,
and that's where you really have to bring
all of your skills to bare,
because you have to
balance all of those sheer
and distributed forces
that you can't, quote unquote, idealize
to Dr. Pete Dawson's
book of dots and lines.
So, goal, visualize an outcome.
Figure out how you're going to do that,
do that, and then we restore.
(students laughing)
No, go ahead, take all
the pictures you like.
I told you I could.
Any questions at all?
- [Female Student] How
are the other teeth?
- The other teeth are pretty
much what you're lookin' at.
She almost had no
restorations in her mouth.
If you look at the six,
you can see that there's
quite a bit of acidic erosion,
and maybe fruit mulling,
but I'm thinking more acidic erosion.
'Member, large equine radio oncologist.
Imagine how hard it was
for her to get to the top of the class
to get vet school, and from vet school
get the one position in a program
in almost the entire West Coast.
Her diet consists of Red Bull, Rockstar,
cortados, gummy bears,
and anything she can grab
and throw into her mouth
while she's running
from farm to farm,
'cause people do not bring
two and a half ton steers to you.
You go to the barn at
three in the morning.
So she's running around.
Her house calls may
consist of 10 hour drives.
And when they do need a
lot of the radio oncology,
those people come to her
whenever is possible.
She is the one that's there to take those.
She has a garbage diet,
she tries to do as best she can,
but she has high acid, low sleep,
high parafunction, and
her teeth are still doing,
I think, relatively well.
We mitigate what we can,
we accept what we can't,
and we move on.
- [Female Student] Would
you give her a splint?
- Sorry?
- [Female Student] Would you
give her an occlusal splint?
- Would I give her an occlusal splint?
Yes, we did, yep.
And when she wears it, we'll see.
(students laughing)
If you picked up something, I love quotes,
and one of my favorite quotes of all times
is by a dentist that
passed away far too early,
passed away in his mid
40s, Dr. Robert Barkley.
I doubt any of you have heard of him.
But he said, "Our job is to
help our patients get worse
"at the slowest rate possible."
Because we can do whatever we can
at the highest level we can,
but the higher the risk factors
that exist for the patient,
the less successful we're going to be.
And I will caution you,
as you want to pursue
treating the worn dentition,
they broke it before,
they will break it again.
They broke it before,
they will break it again.
Our job is to help our patients get worse
at the slowest rate possible.
"Brian, I would love to provide
"that full mouth rehabilitation for you,
"so you can chew and smile confidently.
"What I want you to be aware of,
"is all the forces that led to you being
"where you are right now still exist.
"So as we move forward,
"I would like to help
you break your teeth,
"your new restorations, as
infrequently as possible,
"and as few as possible at a time."
And Brian's going to say,
"Wait, are you kidding?
"I'm paying $40, $50, $60,000 for this."
And I'll say, "Yes, you are,
"and I need you to know that going in."
And I think that one of
the biggest transitions,
'cause I've known Dr. Lincoln Harris
for a very long time.
Our learning curves have
kind of gone like this
in what we learned, and what
we forgot, and what we needed.
And sometimes he learned something first,
and sometimes I learned something first,
but we always shared those lessons.
And I think one of the lessons
that I just talked to
Brian about is that one.
Honesty.
If you have, forget about scripting.
If you have intention and honesty,
everything will fall
out of your mouth right,
because it will fall out the
way that sounds like you.
And you don't need a script to be you.
All you need is integrity.
So getting back to the point
that I was saying about Lincoln.
I got slightly sidetracked in a good way,
is Lincoln and I got to the point
that we realized that while
we may be able to fix everything,
everything we fix is not going to last.
Most important things that we
can provide in that regard,
is that information to our patients,
because if they don't know that,
they think, "Oh I thought this
was going to last forever.
"I thought I only needed
to pay for this once."
I'm not sure where Lincoln is on this.
Jynni and Gayle could probably clarify.
Once I started describing my
rehabilitations like this,
my case acceptance actually
went up astronomically.
'Cause the patient
said, "Are you serious?"
I said, "Yes."
And he said, "I actually believe you."
And he said, "The last guy said
it would never break again.
"And I thought, well how could that be?
"I broke it before.
"How's it not going to break again?"
And they think about that,
and they can sense that honesty,
that integrity, and that
interest, that true interest,
in the patient's well-being.
Not just only in the
short-term in our pocket book,
but in the long-term in
their continuing care.
Yes and yes, yes.
- [Female Student] If the the patient says
"I just want to be out of pain
but, I don't care if the tooth
"doesn't look like a tooth,"
then what would you do?
- I'm sorry, can you
speak up a little louder?
- [Female Student] If the patient's goal
was just to be out of pain,
but didn't care if the tooth
didn't look like a tooth,
then how would that change
your treatment plan?
- It would be very similar,
except for I would leave
out, feel like a tooth.
Because if I looked at this tooth,
and I thought about, I'm sorry,
it would be very similar.
If I looked at this
tooth and not want it to
worry about feeling like
a tooth and just not hurt,
I could overprep it, and then the margins
would be about three millimeters
subgingival on the distal.
Because if you look, there was
only about half a millimeter
on the distal marginal ridge,
and there was a fracture.
So you need to get rid of the fracture,
and then you need to get down there,
and then your occlusal table
would actually be at the gingival margin.
So what's the issue with
that, is that down the road
that person could need crown lengthening,
and because the aggressive
nature of the prep,
that could lead to endodontic therapy,
and because the aggressive
nature of both of those,
that could lead to
tooth fracture and loss.
And then they'd be looking
at implant restoration,
and all of the existing
conditions would be the same.
So from a communication standpoint
I would talk to them and I would say,
"You know what?
"That's a completely
understandable question,
"I know you'd like to get this
done as simply as possible.
"The concern I have is what you perceive
"as the simplest approach,
"could actually lead to
the most complex needs
"down the road, which are
far, far more expensive
"than what we could do now."
What you notice there, is I
did not bring up a procedure.
I brought up considerations,
and a lot of 'em.
And what I want them to
ask me is, "Like what,"
or, "When?"
And then, because as soon
as they ask me the question,
I can provide the answer,
and it is an answer to a question,
rather than a mon, than a mono--
- [Female Student] Monologue?
- Thank you.
(students laughing)
Who said that?
- Me.
- I owe you.
(everyone laughing)
Rather than being a monologue lecture,
and being perceived as me talking to them,
this is me talking to you.
Does that answer your question?
- [Female Student] Yes.
- What remains with your question?
- [Female Student] So I'm just
trying to get my head around
thinking like you because it's,
I see what you're doing
but, I can't do it--
- Practice, practice, practice.
It will be easier for you
in 45 minutes, when we get.
No it won't, because
we're talking about CR.
Forget it.
(students laughing)
It's going to be easier for you
by the break at mid-afternoon.
It will make more sense to
you by the end of the day,
and I'm betting by mid-morning tomorrow,
you'll actually come up
with what I'm about to say
before it comes out of my mouth,
because all things take practice.
Verbal skills take practice.
Believe it or not, my weakest
point is communication.
I was a terrified public speaker.
I would black out
introducing other speakers
at continuing education venues
when I was in the Academy
of General Dentistry.
Why can I stand up here right now
and have basically no
fear of public speaking?
Reps.
Whey did everybody get so
good at Lincoln's course
this last week, when I
was on the next floor?
At the beginning of the
day they weren't so good.
At the end of the day I
couldn't tell the difference
between their preps and Linc's?
Because he made them
reprep for sixteen hours.
Reps, reps, reps.
Yes.
- [Lucy] So this case is sort of isolated
in that they lost a resin,
so the tooth over erupted
and that's how this
has happened over time.
In a case where people have
particularly lower sevens
and both of the distals are quite worn,
do you do anything in
particular differently
in those sort of cases, or anything?
- And what's your name?
- [Lucy] Lucy.
- Lucy, so Lucy asked,
and make sure I'm clarifying this right,
so Lucy said, "This is a very basic case
"in that it it's isolated,
and that we're looking at
"one situation that's ditched out"--
I'm sorry?
- [Lucy] Not basic, a lot of--
- I was clarifying, and then
I'm going to let you clarify me,
because I knew I would say it wrong.
So this is a isolated case
where it's ditched out
and it's come down.
What if you're dealing with more teeth,
and some are flat, some
are really worn out?
That's where the same rules apply,
is how do you want it to look,
how are you going to make it fit?
The how are you going to make
it fit is going to change.
Is because you might
be repositioning teeth,
you might be restoring teeth,
you might be altering vertical,
which we're also going to go
through all of those scenarios
between this afternoon and tomorrow.
So giving, because this is where people
start to stop just listening,
and start to ask, "Why,"
and "What's in it for me,"
and why I paid this tuition?
Let's look forward.
I'm going to go over the next step
which is joint position
in CR this morning,
so that we can understand
how to move past this tooth
into other scenarios.
Because when you talk
about altering vertical
you have to take the
joint into consideration.
We're going to talk about leaf gauges
and how that plays in that,
and how it plays into looking
at just restoring one tooth,
versus doing inside, interior,
full mouth rehabilitation.
Then we're going to expand into looking
at anterior guidance,
and as we move forward
and fold there, as we
get more and more teeth,
what we're going to look at,
is how to alter vertical dimension,
not only opening it, perhaps,
but when you want to close it.
When do you want to treat to MIP,
when do you want to treat to CR,
and what are the benefits
and considerations
of each of those?
So, I'm not ignoring your question,
but I am, with permission, delaying it,
because I want to be able to
answer it with case examples.
As I said, everything about occlusion
needs application, or it's
just theory without relevance.
Good?
- [Lucy] Mm-hm.
- Okay.