Plant it Low, Let it Grow? Occlusion, CR and all things Confusing for Students – PS010

Protrusive Dental Podcast

It’s Friday and you’re fitting the last patient’s crown. It is completely shy of the bite – but it looks good. The patient says ‘it feels great! I can hardly feel anything!’

Do you cement it (plant it low?) and let it grow? Is that acceptable?

How about the ‘GABS occlusal philosophy?’

Is ‘centric relation’ full of unicorns and rainbows?

What is an efficient protocol in ‘checking the occlusion’?

https://youtu.be/Nmx1C8WDSjA

Watch PS010 on Youtube

Join us in this episode where we discuss some key techniques to help ensure we are managing occlusion as a primary focus when dealing with restorative treatment. This episode is packed with essential tips that are perfect for dental students and professionals alike.

Don’t miss the special notes on Occlusion, CR & All Things Confusing available exclusively in the Protrusive Guidance app! (Crush Your Exams section)

Need to Read it? Check out the Full Episode Transcript below!

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, be sure to recap PDP109 – Articulating Paper is Lying to Us

Click below for full episode transcript:

Teaser: Here we are, a little bit late, but this is the Protrusive Students version for Occlusion Month. We've got our Protusive student, Emma Hutchison, who once again has done a wonderful job to create these student notes.

Jaz’s Introduction:
You can download these for free on the community, there’s a special students area, and you can also catch up with the previous nine other Protrusive student notes, bespoke notes, just for students. Very visual and written by Emma herself, inspired by what she’s learning at uni and also what she’s learning online. Head over to protrusive. app to check that out.

Hello, Protruserati. I’m Jaz Gulati and welcome back to your favorite dental podcast. This episode is huge. Like when I was a dental student, anything to do with occlusion was mega confusing. Like even down to adjusting a basic composite. Like you’ve just placed a composite, and you’re picking up the bur, and you have no idea what you’re doing. Was it just me, or is that you as well?

Well, how about we cover in this episode for the benefit of students, and of course, anyone in dentistry, or dentists can actually learn something from this episode, I think. We need to talk about some specific protocols taught to me that I’m sharing with you guys, and we go deeper into what actually happens if you start leaving teeth out of occlusion, i. e. You restore a tooth and now that tooth is no longer actually touching the opposing tooth. It’s no longer contributing to the patient’s occlusion.

Is it always a sin? Is it acceptable? And how do you actually go about avoiding that? Like, how can you actually be more precise in your occlusal adjustment? We also, of course, talk about the influence of different thicknesses of articulating paper and why you should avoid using thick papers. There’s a lot to unpack here, so let’s join the main interview and I’ll see you in the outro.

Main Episode:
Okay, Emma, you just had some exams. Okay, so welcome back. How was it? How did it go?

[Emma]
It was okay. I think they’re always going to be a bit rough. This year I had two written papers. I had one multiple choice paper, which was okay. And then the second one was like a multiple short answer, which is always the trickier of the two, I think, for me anyway.

But they changed the format of our MSA short answer one this year. So it was just a wee bit different. They changed it from, I think, 20 questions worth 10 marks to 15 questions worth 13 marks or something like that. So it was just a wee bit different to what I’m used to.

It meant maybe things went a wee bit more into debt, which is difficult for dentistry because you need to know, I think for the exams, you need to know a wee bit about everything, and then sometimes that’s enough to sort of get you the marks that you need, but especially this year, less questions more focused. So it was a bit of a shock to the system, but I think it was okay.

[Jaz]
Good. And the OSCE was?

[Emma]
The OSCE was okay.

[Jaz]
So just because there might be some international students who maybe they don’t have OSCEs in their uni. I don’t know. Like, can you just tell us about what an OSCE is?

[Emma]
Yeah. So our OSCE is quite similar in the UK for your entry to dental school. You’ll have what’s called an MMI, Multiple Mini Interviews, I think it is. And you are in a clinic or a group of rooms, you stand outside the door and you have one minute to read whatsoever’s on the door. And it’s the worst feeling in the world.

And you have to go in, do this station. Sometimes there’s actors there, like paid actors that you’re interacting with, and you’ve got a clinician there who’s marking you on what you’re doing and in Glasgow. In third year you have 10 stations and each of them are five minutes long and then you get one minute each to read your instructions. So it’s just boom, boom, boom, boom, boom.

[Jaz]
So it could be like a Paeds thing, then a perio thing, then a restorative thing, like study models on the table. Give us an example of a one OSCE station that you remember.

[Emma]
I can tell you all of them. So this year I had rubber dam. Three to three on the upper, canines to canine, and you had five minutes to put it on wedjets in each side and floss ligatures on the two centrals.

[Jaz]
Nice.

[Emma]
And we had the exact same station-

[Jaz]
So, well, I think it’s impressive that as a student you’re doing floss ligatures. That’s pretty cool. Right? Okay. You don’t think so?

[Emma]
Obviously. Well, everyone got it finished. The thing is, like, with the OSCEs, you don’t have to do the station perfectly to pass. I think all of them are marked out of, like, 10 or 15. So last year, we didn’t have a nurse there to help us. So I managed to get the dam on, but I didn’t get any ligatures on at all. And it was my, I think it was, one of my last stations last year, I was fatigued.

I was tired. But this year it was my first station and I don’t think I’ve done rubber dam since my last OSCE a year ago. So I went in to this station and it was my mentor James Don standing there. I was like, oh no, what is this going to be? Some end of station ended on six stations. So I’m standing there and I’m reading it and it’s like rubber dam three to three. Floss ligatures, but we had a nurse there to help us this time, which was good. So like getting the nurse to tend to the dam for me, she helps me floss and I managed to see-

[Jaz]
You’re probably getting marked on also the communication with the nurse or how you are instructing them to help you. So that’s good. I think it’s really good that you got to do that in your OSCE. I never had a rubber dam station in OSCE. I remember having some orthotic models. No, it sounds like a good one. Is it like a phantom head? Is that what it was?

[Emma]
Yeah, bonafide some hedge, yeah. We had an ortho one as well this year, yeah, so writing a prescription for a upper removable appliance, yeah, which was okay.

[Jaz]
Lab prescription, yeah?

[Emma]
Yeah. Yeah.

[Jaz]
Okay. Very good. There was a four letter acronym or whatever, or the way to remember. What’s it called when you use four letters, mnemonic. There was a four letter mnemonic for-

[Emma]
We use ARAB.

[Jaz]
That’s it.

[Emma]
We use ARAB, A R A B. That’s what we use.

[Jaz]
Go on, you have to say now what it is now. It’s like Anchorage?

[Emma]
The first A, well in Glasgow anyway, is your active components. R is your retentive components. Then your anchorage and then your base plate.

[Jaz]
Yep, yep. Very good. Well done. Let us know how you get on with the results. I’m sure it’ll be fine. Well done. So today we are catching up after a little while because we had a little break for exams and stuff. Obviously this is coming out much later in the year. But you got some exciting things planned. Is it a good point to tell us about? Actually, I think when you come back from your elective, it’ll be good for you to tell us about how it went and what you got up to and stuff. But just give us a flavour of what you got planned for elective.

[Emma]
Yeah, so we have changed our electives in Glasgow to the end of third year rather than fourth year, so that you don’t have such a big gap in between your fourth and final year. So basically you get a mentor. As I said, my mentor’s name is Mr. Don, and he’s an endodontist. So I’m going to be doing, what’s the word, a literature review. I’m going to be doing a literature review about hypochlorite injuries. And putting together some statistics for that and hopefully constructing a guide for students and maybe other dentists on how to communicate this sort of risk with your patients.

So that’s mine. I’ve got friends that are doing all sorts of things. I’ve got friends that are going to the other side of the world, which I am going to be doing, but I’m going to be finishing my elective before I go away. And then I’m going to be traveling Southeast Asia. So it’s very exciting.

[Jaz]
Well done. Really important to do that when you get a chance as a student. I had great memories of doing my elective in Vietnam actually, and then traveling Thailand. It’s a great opportunity in life. It’s very difficult to get that time and opportunity in life, especially, being young and stuff. So well done for taking that opportunity, which is great.

So exciting. Today’s episode, and then you can tell us about the student notes you’re going to add on as well. But today’s episode is Occlusion. One of my favorites. So we have had a few episodes on Protrusive before when we talked to students about occlusion. So I’m interested to hear what kind of questions at this stage in third year you have, because the issue with being in third year, you haven’t seen enough cases, you haven’t seen things come back.

You haven’t seen a lot of the issues with occlusion, like the fractures that could happen, the fremitus, the tooth movement that can happen. So you are very much led by the textbook, but you crave that clinical experience to really connect the dots. So please, questions do you have?

[Emma]
So first question again, I always like to start with a bit of a broad question. We only recently started being introduced to fremitus at the end of our third year, and sort of when to conform to an occlusion and when to reconstruct. So just in terms of your experience at dental school, what were you taught about occlusion and how has your sort of understanding and your approach evolved since then? Like, what’s different?

[Jaz]
Okay, so at dental school, not that it was sold to us or taught to us this way, but dental school, it was the GABS occlusal philosophy. Do you know about GABS?

[Emma]
No, no, I don’t.

[Jaz]
Okay, so GABS stands for grind all blue spots. Someone taught me, I went to Chicago recently and he mentioned this and I was like, oh my God, that’s, it’s genius because it reflects my own experience because I don’t know about you, Emma, but when you’ve done a restoration. And then, okay, let’s take it way back. When you are doing a restoration, before you pick up the handpiece, do you check the occlusion?

[Emma]
I do now because I’ve worked with you for a year.

[Jaz]
You do now. But I’ll tell you what, most dentists, okay, I want to say most, a lot of dentists, especially younger in your career, me, myself included earlier in my career, you pick up the handpiece first, you fix the caries, you do the restoration, then you pick up the articulating paper, then you have no reference or baseline.

So the first thing is that we went, okay, maybe I was taught or not, but I wasn’t doing it as a student. I wasn’t checking the occlusion. And then when you place the restoration, I pick up the biggest, thickest paper in the world, the 200 micron Bausch articulating paper. I don’t know which articulating paper you have in your dental department.

[Emma]
Similar. It’s pretty thick. Yeah.

[Jaz]
Yeah. And so do you know what the issue is, Emma, with using thick paper versus using thinner paper?

[Emma]
I don’t know. I suppose it, is it just not as accurate? You’re not going to get that sort of those pinpoint blue dots that you want to see. I don’t know if it’s too bright and you’re just going to get so much contact.

[Jaz]
Perfect. You’re going to get false positive. You’re going to get ink smears, which aren’t really representing a tooth contact. It’s just the ink was in the way. So imagine you’ve got something that’s 200 microns thick, which is the paper, let’s say. Now your filling is out of the bite by a hundred microns, but because you’re using something that’s thick enough to fill that hundred microns plus more, you’re going to think, ah, it’s an occlusion.

Just giving you an idea there. So by using a paper like that, you get too much data and that’s an issue. And so I did not use that in practice, eventually when I learned about the different papers that exist, I realized that actually we should be using thinner papers. So I have access to 8 micron paper, which is TrollFoil, it’s a brand, but my day in day out is something called AccuFilm, and it’s 25 microns, and that gives me nice, neat, pinpoint marks and reduces the chance of false positives.

So going back to GABS occlusal philosophy, grind all blue spots. What I meant by that is you place a restoration, you check the occlusion, and then tell me about what are you thinking? What are you doing when you’re adjusting that composite?

[Emma]
In terms of where you see the blue spots?

[Jaz]
Yep.

[Emma]
I don’t know really, it’s, I don’t know. Like you’re just-

[Jaz]
I was the same.

[Emma]
I suppose as soon as you start grinding away the ink goes away and then you just, I don’t know, I find myself using articulating paper so much and watching other students do it because as soon as you put the bur over it, the ink goes and then you just have to do it again and again and again. I don’t know.

[Jaz]
And then when do you stop?

[Emma]
Yeah. When do you stop? When all the blue spots are gone. I don’t know.

[Jaz]
That’s it. That’s it. Right. So that was my understanding of occlusion at dental school because I didn’t know what was going on and you do it. Okay. All right. How does it feel when the patient says it feels great. It feels as though you’ve hardly done anything at all because you’ve now put this restoration in hypoocclusion, not hyper, hypo.

It’s now shallow, it’s shy of the bite. So you have to think then, okay, is that really doing your patient justice? Is that a precision dentistry? It’s not, right? So moving on from dental school, learning about these things, using the correct papers, being trying to be a bit more precise, really looking at the anatomy of the teeth, studying the anatomy beforehand to make sure.

That I can minimize the adjustment, but at the same time not be proud. So when you go thinner, you are less likely to grind things away and also, what you can do at that point is just check bit by bit. So for example, really top tip I can give you is if you’ve just done a restoration on the right side, the first thing to do is use your articulating paper, let’s call it a hundred microns, to make it maths easier.

So you’ve done the restoration on the right side, you put the a hundred microns on the left side, you get the patient to bite it together, the patient is now holding the paper, i. e. you cannot pull the paper out. It’s scrunched between the teeth. Okay. So what this tells you is that the left side is touching, but it’s touching within a hundred microns.

Now what you do, is if you get your 50 micron paper, you might find that actually the left side is pulling. Emma, what does this mean? The 50 micron paper is now, you’re able to pull it out. There’s no, the teeth aren’t grabbing on the left side. What could this mean?

[Emma]
So there’s maybe a discrepancy between 50 and 100 microns.

[Jaz]
Yeah, spot on. But what is causing this discrepancy?

[Emma]
Your restoration that you’ve just done on the other side?

[Jaz]
Perfect. Right. Yeah, exactly it. Right. Exactly it. So because the 50 is pulling, 100 was biting between 50 and 100 microns. Why is this information useful? Because it tells you how close or how far you are, which will guide you already in terms of what grain of diamond bur you’re going to pick up.

So I can pick up the softer red one or the aggressive blue one. And if you’re out by like that much, I’m probably going to pick up the blue one in that case or the red one, just spend a bit more time, press a bit harder. It just gives you information. And so then when you’re biting on the left with something like eight microns of shimstock foil, for example, then, you know you’re pretty much almost there.

And that gives you a nice little guideline. So little tricks like this I picked up along the way. Lots of mentors taught me, including a hat tip to Dr. Michael Melkers, who taught me a lot of my foundational stuff, Dr. Riaz Yar as well. So I think that’s how it evolved. It’s an evolution you’re always learning, but just getting the simple tap, tap, tap, correct. Even that was a learning experience moving out of dental school.

[Emma]
Yeah, definitely. And I think having all your armory of articulating papers would definitely help with that. And once I’m out of dental school and I’m away from the 200 microns, we’ll be getting all the three, four or five different types of articulating paper.

[Jaz]
Absolutely. But just to clarify, you don’t need more, you just need shim stock foil, which is eight microns and something like a 20 micron, 25 micron paper. That’s genuinely pretty much all you need. So yeah.

[Emma]
Yeah. Okay, cool. So what are the consequences of if you do go into this hypo occlusion and you’ve taken this restoration straight out of the bite, what does that mean for the patient?

[Jaz]
Great. Have you heard of the term, or the saying, plant it low, let it grow?

[Emma]
Yes. Over eruption?

[Jaz]
Exactly. You’re absolutely right, Emma. If you actually have it in hypo occlusion, i. e. you plant it low, usually some over eruption will happen, some tilting of the molar will happen, and eventually you’ll find that in six months time it’s gone in the bite.

Is this a massive sin? Maybe not. But imagine every time this patient has a filling, right? And the tooth over-erupts and the tooth over-erupts. And then by the end of it, they’ve kind of lost control of the occlusion. They’re kind of in all sorts of non ideal positions. So it’s not a good thing to aspire to.

It’s not level of dentistry we want to do, but that’s kind of what happens. But then you have to think a really important thing is every patient is different. Imagine that a patient has an anterior open bite, meaning that the front teeth don’t touch and there’s a big space between their front teeth, right?

So only their molars are touching. Imagine actually only their second molar and first molar touching on each side. So even the premolars aren’t touching. So you’ve seen anterior open bite cases like an ortho teaching and stuff, right?

[Emma]
Yeah. Yeah.

[Jaz]
Good. So now imagine you need to do a crown on one molar on the right side. You do the crown and you notice that it’s completely shy of the bite. For this individual, right, they only had four occluding pairs, right, now they’ve only got three occluding pairs left. Now, you’ve actually demolished 25% of the occlusion. That’s a lot in one go. So maybe what’s going to happen with them is their muscles are going to go a little bit funny.

The joints are going to seat a little bit more on one side. So you have to think about the greater articular system. And so what I’m trying to say is that if someone’s got a really nice occlusion, lots of teeth, lots of contacts, I wouldn’t cry if your tooth is in hypo occlusion because as long as your intention was there to be precise and you learned something from that case.

And usually when we’re shy of the bite, we’re only like, 10-20 microns shy, which is really not too bad. When they’re chewing food, it’s going to be irrelevant, right? But in the long term, you don’t want to do sloppy dentistry where you’re doing GABS, you’re getting rid of it all because yes, there was some overruption that’s going to happen.

You might introduce some inclined contacts, meaning that it’s not contacting the middle of the tooth anymore. It’s contacting halfway up and that has consequences like cusp fractures and stuff in the future. So it’s not something good to aim towards.

[Emma]
Okay, okay. So I suppose best practice, yeah. Don’t do, grind all blue spots. No, I’ll definitely keep that in mind. Because I suppose then, if you do that over and over again, on the same tooth, more and more restorations, I suppose could you end up getting sensitivity in the future? Like if your teeth start to over-erupt, is that something that could happen?

[Jaz]
Not in my experience. I don’t think the over eruption per se is going to cause that. If you look at studies whereby a molar has been removed and you look at the upper molar, in the first two years, I think it is, right? You get over eruption. I think that the reference is Craddock. Let me just find this for you guys.

Craddock studies. Which is the name that comes to mind when I was doing my DC training. Craddock overruption. The data on eruption is pretty cool actually. So let’s see. Okay. Craddock et al found overruption of a maxillary first molars after loss of opposing mandibular first molars, right? So this is, yeah, so it’s called a study of the instance of over eruption interferences and unopposed posterity. So imagine you lose a molar, how much will that opposing molar overrupt? Okay. So let’s have a look. 81 males, 74 females. One thing you’ll learn in the future is the how to read a paper and software. Just looking at the abstract, looking at the mean age, let’s see.

83 percent of sites displayed overruption. So more than likely, right? Overruption will happen more than likely. So that’s the first thing. The next thing to know from the study is it ranged from half a millimetre to 5. 4 millimetres. Okay, so that’s a lot, right? Do you know sometimes you might see in a case where the upper molar has completely now grown down to touch the gum of the lower?

So that’s in those cases where it happens so much. So the reliability of the observation was found to be good. A total of 51 percent of unopposed teeth were involved. The takeaway here, yeah, 83 percent of unopposed teeth will over erupt and the extent can vary from memory though, when I looked at this paper in detail, it says, yeah, 0. 5 to 5. 4, but the average is around about two millimeters from memory.

So this is the eruptive potential of the teeth basically, but when we’re doing restorations, we’re not leaving them out. I hope by two millimeters. It’s usually a much finer degree. So it’s quite predictable that most of these teeth will over-erupt basically into position again. But again, that’s not ideal of it happening. It might actually swing one way and it might mess up the occlusion long term every single tooth that it happens to.

[Emma]
Yeah, that makes sense. And I suppose if you can avoid that, then avoid it as you can.

[Jaz]
It’s all about taking the joy in being a bit more precise and actually making it like, I’m trying to do my best here and you don’t cry about it when you get wrong. Cause actually trying to balance a 32 legged stool is a bit difficult when you think about it. So, if you’re off by a few microns, it’s okay. The PDL will just sort that out for you. But if you’re consistently half a millimeter shy, then I worry about the level of precision you’re working at.

[Emma]
Yeah, a 32 legs still. That’s funny. I’ve never heard of that. The other thing I wanted to talk to you about, Posselt’s envelope. I know that’s your thing. That’s your jam. Retruded contact position versus centric relation. We had a lot of zoom discussions, like revision discussions with like me and my friends going through questions, et cetera, et cetera.

And I know that there’s a difference. I just, I honestly didn’t know how to explain it that well. The only reason is because of doing premium notes on past episodes with yourself, and I know that there’s a difference, but I just don’t really know how to explain it very well. So you could help me with that?

[Jaz]
Absolutely. So the question is a difference between RCP and centric relation. Is that what you mean? Is that the question? RCP versus CR. Is that the question?

[Emma]
Yeah.

[Jaz]
Okay, fine. So, they essentially are the same thing. The intention of the person who writes it in their textbook or how it’s used, they mean the same thing. However, retruded contact position is a very old term. It comes from a time whereby we used to think that the position that the condyle was supposed to be in was up and back. So distal most uppermost kind of thing. So we used to think that, right. I think it was like seventies, eighties, and then eventually progressed to actually nowadays is superior anterior.

So to use the word retruded means that someone’s got to retrude their condyle. Actually, it’s a term we don’t tend to use anymore. You’ll see in the older textbooks because actually we don’t think of it as that anymore. So the newer terms actually are stable condyle position. Okay, I know it gets confusing, all these terms stuff, but stable condyle position is a more accepted term.

Centric relation, these are all similar terms. Essentially, they describe the condyle. Okay, the condyle, it’s all through the condyle. It’s nothing to do with the teeth. Okay. It’s all through the condyles when they are superior, anterior, and they’re up against the articular eminence. And they’re like in a nice snug place where they can nicely rotate and the shapes are roughly matching. And it’s a nice, like, it almost like snugly seats inside, like an egg into an egg bowl. So if you think of it like that, it’s a nice stable position.

[Emma]
Yep, okay, okay. I’ll need to dig out that, that question that we were looking at because it was a multiple choice question and fair enough we don’t have like past papers or anything at Glasgow so it was questions that other students had written and it was something about the different choices were like RCP, centric relation, ICP.

So I’ll need to dig it out and see what you think of that question. Nothing like that came up in our exam actually. But yeah, I’ll dig it out and I’ll see what you think because I like did not know the answer and just praised that it didn’t come up in the exam and it didn’t.

[Jaz]
Good it didn’t. But you know what? This is highlights an issue that’s worth spending a few seconds to talk about, which is, the number one confusion when it comes to occlusion is the definitions, the changing definitions and the difference in how people interpret those definitions. So for example, C O, right, it actually means two different things, two different people.

You have two different people in the room and you say centric occlusion. One person will think it’s the MIP, it’s their normal bite. The other person will think it’s the first point of contact when the condyle is in centric relation. So this is why we need to really start trying to understand where someone’s coming from and maybe move away from these older terms and speak in a way that’s a bit more universal and everyone understands where we’re coming from.

[Emma]
Yeah, yeah, I think that’s what’s tricky about Occlusion, Posselt’s Envelope. There’s a lot of terminology, but I know that you’ve got a lot of good teaching out there and definitely lots of episodes that I’ve taken part in with the premium notes and watched myself, so those are definitely things to have a wee look at if that’s something that’s just like myself, it’s just a bit overwhelming sometimes.

[Jaz]
Totally. And I’ve got the whole student video section. So we’ve added two videos so far. The routine checkup, we’ve added a full one. And also we added another one recently, a rubber dam one that was requested by Mohamed Abo-Basha. And I’ve also got like simple infiltrations, ID blocks, that’s all coming as well, basically in there.

And so anything inclusion related that you could think of, just ask me, we could do that. But when it comes to the Posselt’s envelope, which you mentioned, are you happy with what that envelope represents?

[Emma]
I think I’m relatively comfortable with Posselt’s Envelope. A few of the definitions I know like we were just talking about can be a bit overwhelming, but like as far as I’m aware, Posselt’s Envelope, mid sagittal view of your maximum border movements.

[Jaz]
Well done. It is. So basically the extreme positions that you’re lower incisor can go. All the way open, all the way protruded, and tracing all the way back, basically, the extreme border movements. But you’re right, it’s mid sagittal, but actually, the Posselt’s, it’s actually a 3D thing. Because there’s a side to side as well, right?

And in one of the Scandinavian unis, which Posselt’s was, I believe, a professor at, they have like a statue of Posselt’s envelope 3D at that uni. Exactly. So do you know which one it is? Yeah. Is it Gotham or not? Is it Gotham? That’s from Batman, right?

[Emma]
I couldn’t, I couldn’t tell you. I couldn’t tell you where it is, but I’ve seen a picture of it because I know Dr. Alani, who I know that you know. We had him in first and second year for a lot of occlusion type things, tooth morphology, and I remember him showing this, a picture of that statue in one of his lectures. So yeah.

[Jaz]
Good. And so people confuse it for the Posselt’s envelope of function. It’s not to do with function at all. It is just anywhere that the lower incisor could be in space and time, it’s just like a diagrammatic representation of that.

[Emma]
Yeah, I think it can be quite overwhelming, especially because there are three planes of view. But definitely in Glasgow, we very often get quizzed on our mid sagittal plane, but no, it’s very interesting. It’s very interesting, but we’ll pop in maybe a wee, a wee picture of that statue and we’ll find out where it is. Not Gotham.

[Jaz]
Definitely not Gotham. Batman would not allow it.

[Emma]
So in terms of, let’s say you’re choosing to reconstruct a patient’s occlusion for whatever reason, for reasons that I probably don’t understand yet. We’ve not really gone into anything too in depth about reorganizing occlusion.

[Jaz]
And you wouldn’t, it’s more like a postgraduate thing anyway, so.

[Emma]
No, yeah, no. But just out of curiosity, what measures would you take for long term stability and sort of maintenance of those occlusal outcomes for your patients? Like, are there specific follow up protocols or patient instructions that you would give to your patients to support that? Or like, what do you do?

[Jaz]
Good question. Okay. So firstly, even before you start cases like this, it’s important to do phase one. Bread and butter, oral hygiene, carrier stabilization, perio, make sure they’re dentally fit and well before they do any complex work like crowns, onlays, changing the vertical dimension, that kind of stuff.

Imagine you’ve done all that and you’ve placed your crowns and dentures and everything and maybe they’ve opened up the bike because there was severe wear or whatever. At that stage, okay, we need to then explain to them beforehand actually that what you are buying from us, what we’re doing for you, what we’re doing in the form of care that we’re giving you is you’re buying a very fancy car.

Okay. You have a Ferrari in your mouth, right? Therefore, we need to make sure we use a different oil for this Ferrari than any other oil. Okay. We need to make sure that you have your servicing. Your servicing is going to cost a lot more than the Vauxhall one, but it’s going to be something that’s necessary to maintain your Ferrari so you can actually enjoy it for the rest of your life and get as long out of it as possible.

So you kind of have that chat beforehand. They know what is involved and they know that there’ll be a maintenance regime. So for example, if In terms of like a warranty in a way, a lot of letters that I do will explain that it’s really important to me to do good work. So I’m going to honor, like if something happens the first five years, I’m going to honor it, providing that you’ve been attending your hygiene visits and an individualized recommendation for that patient, twice a year, three times a year, whatever, depending if it’s got peri or not.

Are you going to see me for two checkups? One of which might be a longer checkup. Okay. So instead of the usual 20 minutes, it might be 45 minutes and they’re paying a bit more and then they know upfront, this is like their annual service. So they have that. So what you’re then doing at that point, you’re checking like we talked about the routine checkup before in the previous episode, you’re checking for changes and deviations.

You’re checking the radiographs for the restorations. Is the marginal seal good? Are the muscles happy when they bite together? Do they have any complaints? Are there any occlusal changes? Is there any fremitus? Is there any movement of teeth which you didn’t plan for? Sometimes you need to pick up the bur and refine the occlusion.

And just make it happy. Sometimes you need to smooth a few things. Sometimes if it’s composites, you need to just polish and rebuff it. And once you’ve had that upfront conversation and got that maintenance plan, you just have that 45 minutes, you do the full check, you do your usual basic periodontal exam, you do some polishing of the composites, and that’s a good way to monitor it.

The other thing which I recommend thinking about is, if the reason they ended up needing a rehab, the reason that they ended up needing a reconstruction, if you think about it, a lot had to go wrong in their mouth before they need this reconstruction. Therefore, if part of that was attrition and bruxism, and they’ve spent a lot of money on their restorations, then it would be prudent to protect their investment with some sort of appliance at night time.

So they should bring their appliance every appointment for us to check, okay, are they still wearing it? Is there anything we do to make it more comfortable? How’s it going? Is it starting to show cracks in wear that perhaps we need to start thinking about replacement? So, those are the very rudimentary checks that we do, but the most important thing is, are they comfortable?

Are they happy with how it’s looking still? Have we noticed any changes? Because a lot of things will be signs. Signs come before symptoms. So the patient might not feel anything, but we’re the first one to find that actually there’s some pocketing now, which has been completely painless. We’re the first ones to see that there’s some fremitus.

Oh, do you notice that your tooth’s moving a bit? It’s a bit mobile. The patient’s like, no, I had no idea. So we’re basically looking for all the usual signs of health that we look for. And then we manage each sort of deviation as appropriate.

[Emma]
Okay. Okay. That makes sense. So yeah, something that you would definitely prep patients on, and this is definitely going to be an investment and something that you need to follow up on afterwards.

[Jaz]
This is a big deal, you know, and so we want to make sure that it’s not just like they go into your normal checkup and hygiene protocol, right? It needs a special eye and therefore having that upfront conversation, the whole thing about a service for your car, your service, your mouth, that’s a little bit more involved because you’ve got a lot more going on in your mouth and the maintenance of that will be a little bit more involved.

[Emma]
Yeah, of course. And would you say that that sometimes would put people off that sort of a treatment plan if they’re not up to it? Or have you found that?

[Jaz]
Not really, because I think when they’re spending that much money to just tell them that there’s an upfront maintenance fee. Patients understand. Patients buy cars and they know that they’ve got to take it for annual service. So they’re kind of used to that and they understand that. And they know that every so often they’ve got to do their kitchen again. Every so often they’ve got to change their carpets. Every so often they’ve got to change their mattress.

People are understanding of that. So that, I wouldn’t say it puts them off. But I would say that if any patient is put off by the hygiene visits that they’d have to maintain the visit that they’d have to maintain to keep everything healthy and happy, then that is a red flag patient. So if they’re not playing ball with that, then you thank God that you didn’t end up treating this patient and they didn’t become your problem because when things start failing, they’re the ones sending that email saying, hey, this tooth is now playing up.

I’m not happy. This is happening. That’s happening. You check their record. They haven’t been for two years. So that’s the kind of patient you don’t want on your books. And so if someone is not happy with that, then that patient’s mindset is an issue and therefore you don’t treat that patient. They don’t deserve complete dentistry from you.

[Emma]
Yep. No, that makes sense. But I suppose the patients are aware they need all this change and they’re briefed on it appropriately, then they’re so much more likely to comply as well. So that’s good to know.

[Jaz]
Very true. Amazing. Emma, thanks so much for these questions. I like the fact that you picked slightly different ones to the previous student occlusion ones. So well done for trying to keep Protrusive unique and fresh. For anyone who wants to check out the previous episodes, please do so as they’re all on the Protrusive Guidance. Remember, we have our own section, a student section on Protrusive Guidance as well. That’s also where we’re uploading Emma’s famous notes. Emma, which notes are you providing for this month to help our colleagues?

[Emma]
So this month’s notes are going to be about Posselt’s Envelope. We’re going to do your occlusion, your basic occlusion, your skeletal classification, molar classification, incisors. We could do some TMJ anatomy as well, so I’ll pop that all together. And that can be this month’s notes.

[Jaz]
Amazing. So we’re loving what you’ve provided so far and the team have been doing a good job of making them nice and neat as well. So it’s a good team approach here. And so looking forward to inclusion ones. I’ll have a look at them as well and see what we can add. And by then, by the time this episode comes out, the video section of Protrusive Guidance for the students clinical video section will be a bit more full of videos because your requests are coming in thick and fast.

So we’re trying to keep up and make it really valuable to you. So thanks for sticking all the way to the end. Emma, welcome back. It was nice to have you back from the exams and we’re all rooting for you. I hope it goes well and we’ll catch you again next week for the next month’s episode after that to catch up a bit more about what’s next week’s episode or next month’s episode even.

[Emma]
So next month we’re going to be talking about radiology, how to diagnose from radiographs, sort of how to orientate yourself on radiographs as well, which can be really tricky and just some tips and tricks on how to read radiographs as well on the notes. So.

[Jaz]
Great. And you’ve got some premium notes for that, so student notes for that as well to help them with that as well.

[Emma]
Yep.

[Jaz]
Amazing. Thanks so much, Emma.

[Emma]
Yep. Thank you so much.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end, especially with a dry topic like occlusion, but I’m hoping we made it tangible. I’m hoping we answered some questions that were niggling in your head. We start to make a little bit more sense.

We’ve got a lot more occlusion based episodes on this podcast. They’re a little bit heavy. I think they’re not so student friendly, which is why I’ve started to create these student friendly episodes. Once again, head over to Protrusive Guidance, our app, make an account on protrusive. app website. And email student at protrusive. co. uk to let Mari know that you’re a student. Prove it to her and she will gift you something. I promise you it will be worth the email.

And lastly, if you’re finding this student series useful, can you comment, let us know if we’re doing something good. Is this something that we should continue? And if so, please do share it with your colleagues.

This is how we grow. Thank you so much. And I’ll catch you same time, same place next week. Bye for now.