The topic tonight, as you know, is appliance therapy. It is a topic that is also near and dear to my heart, as many things are.

Maybe a slightly different twist tonight on it, because it's not just a piece of plastic. We're gonna talk a little bit more about why you would pick that design, what your hopes are for appliance therapy, and how you can apply this when you start actually doing the dentistry and no matter what that looks like for you. So, let's just roll into it. When you think about appliance therapy, as I said, there are a lot of if if you said, you know, bite guard, night guard, orthotic appliance, you know, appliance therapy, that can mean a lot of different things, which it does.

So tonight we're going to really focus on why would you pick a certain type of an appliance and maybe there'll be some favorites as we go through. And also when you think about appliance therapy, how does that correlate to what the patient walks in with and how can you help the patient understand what's going on with their occlusion? Why would you want to have an appliance? What are you hoping to gain and compare from where they really are?

And also a better understanding of just occlusion in general. You know, when you look at this heat map, you know, one side is definitely hitting different from the other side and what is the patient feeling and what would you like them to feel? We're going to dig quite deep into this, but maybe appliance therapy, as you see here, whether it's on the top or on the bottom, can help the dentist, you understand occlusion better and help the patient understand what's possible better and everybody gets a better understanding of what occlusion can be is possible, what is possible, and how we can move in that direction either with appliance therapy or in the mouth or both.

Right? And when you think about appliance therapy, it really does impact the whole system. And so in today's day and age, we are all starting to understand the stomatognathic system better because we are combining our CBCT and our scans and function to understand what's going on, and appliance therapy can really help all of us understand that a little bit better. For instance, on the bottom, what you see here is a shift from what we're gonna call CR to MIP.

That's the same thing you're seeing on the top. Right? That subtle shift is something that we want to we want to intentionally be aware of and mention during appliance therapy. And so when I talk about intentionally mentioning or applying things in appliance therapy, I would be remiss if I didn't just have one slide with this term at the top, co discovery.

Because for me, one of the gifts of appliance therapy is really helping the patient understand and take ownership in their condition and see what's possible.

But you do that because you're engaging with them, not just telling them this is what this is what you need or this is what's going on with the appliance. You can engage with them and ask them what are they feeling? What's their understanding? Partnering with them rather than parenting, telling them what they need and when they should need it and how they should do it. It's we're going to use appliance therapy to engage and partner rather than educate and parent.

All of this together helps everything be more predictable. So how can appliance therapy help everything be more predictable? Well, the, completed, case, and, yes, that's a completed case on the right and a diagnostic wax up, and, yes, that's a diagnostic wax up in the middle. We're going to use this case tonight.

It...

Appliance therapy helps us be more comprehensive. It helps us be more patient centered. It helps us look at their entire health system. And, of course, it's very occlusion driven.

Well, if we take all these into consideration, I promise you things are going to be more predictable for you, and your anxiety level will go down. Your burnout level will go down. Everything's gonna feel better for you. I know that's a big promise, but it's true.

And so this is the patient we were just talking about that walks in with a broken, cusp off of a lower second molar, and we can all certainly treatment plan a crown lengthening, a build up, whether you need a root canal, mean, and whether you need a post or not and a build up and a crown around that, and you could fix that tooth.

But what I want to do tonight is with appliance therapy is combine both an understanding of what's going on, the clinical findings, having a clear vision of what we hope everybody gets treated towards optimal treatment, and who is the patient and what is their desire, and how can appliance therapy help us get clarity around all of these, all three of these at the same time. And so appliance therapy helps us understand the chewing system, have us help share what's possible optimal treatment plan and engage the patient. We're doing all three of those at the same time.

That is when I would say that we are doing dentistry to help our patient move towards optimal health in a way that is appropriate for them. Appropriate, not forced, but appropriate. I have to have just one or two slides real quickly. I'm not gonna share all my personal, you know, all those slides that some people do, but you do need to know where my bias is and my influence is and where this comes from.

I was highly influenced in the mid to late nineties by Frank Spear. In the early two thousands, I completed the curriculum down at the Pankey Institute, so there's a definite influence in there. I also do really enjoy academia. While I had my practice in Oregon for all those years, I also was, dedicating a lot of my time to teaching and learning as an educator.

All that to be said that in about 2013, was asked to move down where I live right now in Scottsdale to work at Spear Education, which was a great time of my life to be, very transparent. I no longer work there. I'm not connected with Spear at all, but you do need to know, this is my disclaimer or my conflict of interest slide, that I still teach at Pankey three, four, five, six times a year. And I do have my own business called K Squared Facilitation and Dental Education, where I work with dentists just like you to coaching you to help you integrate the things you have learned in clinical dentistry with more intention, look at the business side, leadership, etcetera.

So you need to know that is my conflict of interest, although I don't think it's really conflict because I'm happy to always promote myself.

It's one thing that I'm mostly good at. So let's move on then and talk about those three areas. Well, when you think about putting a piece of plastic in somebody's mouth, an appliance, wouldn't it be nice to have an understanding of what is actually going on in their stomatognathic or chewing system when we start?

I would say so. I hope everybody's nodding their nodding yes right now. And so when you think about your exam, your 150 comprehensive exam, what are you really looking for? And to treatment plan and to help us understand how we might use an appliance, again, I've been highly influenced with always integrating these categories, aesthetics, but it's not really aesthetics. It's really where are the front teeth in your face function. That's occlusion. That's a big part of appliance therapy and what's going on in the patient's current condition when you do your one hundred fifty.

The current structure or condition of the teeth, obviously the biology, gums and bone, and then airway. So you might call it aesthetics, function, structure, biology and airway, but obviously there's some nuances in every one of those.

With respect to appliance therapy and understanding how that orthotic appliance might benefit us as a dentist or the patient, one of the things we want to look at, and we're going to talk deeply about this, you know, in the next forty five minutes here, is actual the temporomandibular joint. Because any piece of plastic or any restoration even that you put in the mouth, as you know, is going to impact the whole chewing system. And if it's not, if you're not intentional about it, you're going to create some issues, potentially with the temporomandibular joint. So my hope is that we can do an exam that gives us our best guess as to what we think is happening underneath the skin by palpating, feeling, watching the movements of the joint, and listening, whether it be with our fingers.

And then we're gonna have our best guess as to what we think is going on underneath the skin because we can't really peel the skin back. Right? So when we think about feeling, again, just like any other part of the body, if if I was to touch your shoulder right now with three to five pounds of pressure or your knee or your elbow or your gut, if with that amount of pressure you felt any tenderness, then I would say, oh, it sounds like you have some inflammation there. So we can feel for inflammation.

The other thing we can feel for is, again, what do we think is going on underneath the skin? I can feel for inflammation on the outside, right, the lateral pole. I can also put my finger literally in your ear and get to the backside of the temporomandibular joint and ask you, do you have any tension, tenderness, or discomfort? Just any obvious inflammation around the joint.

That would be good to know before we do treatment or the things we're gonna try and prove with appliance therapy. The other thing with respect to the temporomandibular joint is you can just watch your patients open and close. It's the hinge that opens and closes the jaw.

Does the jaw deviate to the left? Does it deviate to the right? Does it deviate to the left and then do sort of an s curve when you close? Right?

And why would the body be doing that and what might change with appliance therapy, right, when the body's not having to compensate so much anymore, which we'll get to in a few minutes. The other thing with appliance therapy when we put a piece of plastic in somebody's mouth is how is that going to impact the current condition of the joint? So we have to, again, know the current condition of the joint. I put this slide in because just to be clear, when you bite together right now, you and all of your patients, for the most part, the pressure on the temporomandibular joint when you rotate is really on the medial pole.

But when you open, the pressure actually moves from the medial pole, the brain side, to the lateral pole, the outside. Why is that important? Because the other thing we can do besides feeling for inflammation and watching how the hinge is opening and closing is we can listen with our fingers or a stethoscope for sound. Well, what is that sound?

And what...

What's what's what's...

What is a piece of plastic going? How is it going to impact that sound? So even if a person has just a little piece of the lateral pole or the the lateral side of the disc off just a little bit, sure, it's gonna have a little pop or a click. But why is it popping or clicking?

Mostly, it's because right as it's trying to get back on the top of the head of the condyle, I'm gonna go backwards with that. So, again, you've got a little piece that's off. And right when it's trying to pop back on, where is that pressure going? It's going from the medial pole right to the lateral pole right when that piece is trying to pop on, which is why sometimes we've got a pretty good pop.

And it's like, well, that's okay. That's just that little piece of fibrocartilage trying to get back where it belongs at the exact wrong time where there's some pressure. Okay. Now we've got a good idea as to what's going on underneath the skin.

The other part of the temporomandibular joint exam that I'd be remiss if I didn't mention is what we call a load test. It's really just shoving the ball up into the socket. And if you look at the illustration on the right hand side, you can see sort of what I was just talking about. When you bite together, the pressure is really on the medial pole, the brain side, not straight up.

So when we do a load test, which is really shoving the ball up into the socket to see if there's any tension, tenderness, or discomfort, that's a load test. Really, what you're testing is mostly the medial pole, the brain side of the temporomandibular joint. How do we do that? Well, as opposed to just shoving the ball up in the socket using bimanual guidance or old school, we'd call it bimanual manipulation, there's an easy way to do this.

We use a leaf gauge to help the muscles shove the ball up into the socket. So a nice visual for this is if you have a literally a leaf gauge and you have the patient slide forward and then back, because there's no back teeth touching, basically, if you slide forward and back on anything like a leaf gauge here, as you slide back and gently squeeze like you're trying to bite on your back teeth, you are in essence shoving the ball into the socket. That's a load test. And then we say to the patient, do you feel any tension, tenderness, or discomfort as you slide backwards and squeeze gently like you're trying to bite on back teeth.

If they say no, that would be what we call a negative load test, a good thing. You have no findings. That's what you see on the left hand side here. Why would that happen?

Excuse me. Because there is a piece of fibrocartilage on the medial pole. Right? We said we still...

We can't really pull the skin back, but you're like, oh, good news. The odds are that there's a good piece of fibrocartilage at least on the medial pole even though I hear a click or a pop.

Why might it hurt? That is the illustration that you see on the right. If the whole disc is off or a big portion of it, especially on the medial pole when we're loading the joint, then aren't you really shoving the ball into the socket into that retrodiscal tissue where there's blood vessels and nerve endings? And the answer is yes.

Right there, I'm like, oh, what type of an appliance do I want, and what am I looking for if that's the case? Right? So we can certainly feel for inflammation, watch the hinge movement open and closed, and listen with our fingers for sounds in the joint and have a best guess as to what you think is going on under the joint. Now if you think there's something going on, oftentimes, I'm not gonna dive deep into this tonight, you will want some imaging.

You will want a CBCT. Now, again, you know, yes, I'm a big fan of Pearl. I won't, again, go into detail for all the thousands of reasons that I'm a big fan of this company, But I do need to promote tonight completely selflessly that they just...

I think it's a month ago. Chad will verify at the end that that it's been almost a year that they were waiting for clearance for the FDA for three d AI evaluation. And so that literally just got launched, I think last month, and there's a pretty good deal, if you will, that's gonna be offered for this part of Pearl AI at the end of this presentation. So it's a great way to even better understand what's going on with the temporomandibular joint and, you know, the head of the condyle and the glenoid fossa specifically.

So let's move on to the other part of the chewing system that is really going to be impacted by the piece of plastic that we're going to pick the appliance and that would be the muscles. And why would we evaluate muscles or what's it going to do to the muscles? Well, muscles tell us one thing, one thing, main thing, the reason that I promote doing any type of a muscle exam and it is if in fact you are...

If you go to the gym on a regular basis, right, which is sort of what this patient is doing here. If you go to the gym on a regular basis and move any part of your body with any pressure, that is going to do...

Have some response with the muscle. Either the muscle is gonna get big or it's gonna be sore or a muscle on one side is gonna be different from a muscle on the other side or one side is gonna be sore and one side isn't.

So when you do a muscle examination during your o one five o, your comp exam, what you're really looking for, in my opinion, my hope for you is just an understanding, is it big? Is it small? Is it different on one side than the other side?

And what exercise do we think you're doing? And how is an appliance gonna impact that? Or what are we gonna learn from an appliance with respect to the muscles? The third thing during an o one five o exam that's gonna really have an impact when we get into a...

The piece of plastic we're gonna pick and what our expectations are is if we have our patient just bite together. Right? What do they feel when they bite together? What teeth do they feel, and where do they feel it?

And then when they move their jaw to one side as far as they can and their jaw to the other side as far as they can and end to end and even past end to end, what teeth do they feel touch? And what's an appliance going to change for us? And what would we expect to see happen with that appliance. But we need a baseline of what teeth are touching and where are they touching.

Hence, this photo that I shared right when we started just about fifteen minutes or so ago, well, ten minutes or so ago, I wanna have an understanding of what teeth are touching, where they're touching, where they're rubbing so that I can have...

I can help me and the patient anticipate what we might find with this piece of plastic and why we picked a certain piece of plastic again. I'm gonna say that over and over tonight because I wanna have an understanding of how I want to adjust a bite and what I would like to have the patient feel on a piece of plastic, even simultaneous posterior contacts lighter in the front and when you move side to side, what do you expect to have them feel? So basically what we just said is we are going to assess the joints how is...

What's going on with the ball and socket, and the muscles, what's happening on the right side versus the left side, and how are the teeth coming together and rubbing against each other, And of course, what is the condition of the teeth and the bone and gums that hold it in? All of this is going to help me decide what appliance I may or may not use or why I might not want to use an appliance. Right? So what we're starting to describe then is a chewing system that is in harmony.

Right? And, again, your chewing system is your joints, your muscles, your teeth, and your periodontium and how they're all working together. So a system in harmony, wouldn't it be that when you open real big, the ball actually comes out of the socket and the disc comes with it? But when you bite back together, the ball goes back in the socket where it belongs and that the muscles on the right hand side are working in harmony together with the muscles on the left hand side to pull the ball back up in the socket and bring your lower jaw up to your top jaw so that all of your teeth touch evenly and simultaneously like they're supposed to.

And when you move your jaw in any direction, your front teeth are in the right place in your head to do the job they're supposed to do, which is to protect your back teeth to make them come apart.

That's my hope.

During the exam, we're going to find out how well your patient is doing in these categories, which means during the exam, we're really going to assess the chewing system not to see how broken they are and not to tell them how horrible their long term prognosis is, but to say, oh, your chewing system is not completely harmonious. There's a little bit of disharmony going on. And what happens when there's a little disharmony? Again, let's just say if front teeth aren't doing the job they're supposed to do to protect the back teeth, then you might have a back tooth that's wobbling trying to be a front tooth. That might be creating some tenderness, bone loss, fremitus, migration, class five non caries lesions.

And now we're starting to think, oh, if I put an appliance in, it might help me prove a hypothesis that something could be better and even help me come up with a treatment plan that is appropriate for my patient.

Because our bodies are always adapting. Right? I mean, no matter where you're sitting right now, how you're standing, wherever you're listening to this or watching it, your body is adapting. It's trying to find the most comfortable spot, and you don't even know it.

That's why it's adaptive. Right? It's doing what it needs to do to stay alive, to stay comfortable, to reduce pain. And you're gonna do that without even thinking about it until when?

Until you move beyond your adaptive capacity into the danger zone, which would mean you have some signs or symptoms that would tell you, oh, you've moved beyond your adaptive capacity. So with the chewing system, what would that be? Right? Well, the middle of the zone of adaptability would mean that you are not having to compensate.

Your chewing system has the ball and socket where it belongs. Your muscles are helping your lower jaw close to your upper jaw where it belongs with the ball and socket to have your teeth all touch evenly and simultaneously.

And that when your teeth move side to side, your front teeth make your back teeth come apart the way they're supposed to in a smooth, shallow manner, and that the gums and bone that hold your teeth in are disease free. That's the middle of the bull's eye right here.

But oftentimes our patients come in and their body is adapting. Well, we can find that during our 150 exam. How is your body adapting? And is there anything that you're worried about because your body is adapting?

And if so, we have an opportunity right now before it gets to the red to move back into the middle of the zone of adaptability. Instead, and I'm speaking for all of us, what we do is we go, oh, you're doing okay. See you in six months. And they come in in six months and their body's adapting and it's doing an okay job adapting.

So we think there just are no signs or symptoms yet. But if we would have looked and done a more thorough comprehensive exam, we would have found, oh, your body's adapting. We should probably help you move to the middle of that zone of adaptability before when, before we start to see signs or symptoms or some small signs and symptoms get worse. So again what we're looking at when we do the examination is all of these categories.

Where are the teeth in the head? How are the teeth functioning? What is the condition of the teeth? What's the condition of the gums and bone?

And how is the airway doing?

Right? And, again, this is not just pancake. This is not just spear. One of my other favorite influences in my life is John Coyce.

And I like to...

I love the way he uses the good, fair, poor, hopeless. So my hope for you is at the end of your exam, you can actually...

And these are the same categories. Right? B, biology, s structure, f function, e aesthetics, and a for medical precautions or airway. My hope is that you have enough information to where you can look at each of these categories and say, is it green, orange...

No. Green, yellow, orange, or red, good, fair, or or hopeless? How much in disharmony is your patient, and how could we...

What do we need to do to take a closer look at that? Well, one way that this is gonna help us get to our appliance therapy and help us start to build our appliances, we can actually find out...

Take a closer look at how much your body is compensating, your patient's body, their chewing system, or how much in disharmony it really is by taking a bite record. A bite record with the ball in the socket to see what teeth touch with the ball in the socket. So said differently, on the right hand here is probably almost all of our patients and it's probably you.

Your body is finding the most comfortable spot to get your teeth to touch. To do that, the ball's having to come out of the socket just a little bit. You see those green lines don't line up, so it's not going back into the socket. And to hold the ball out of the socket a little bit and to line your teeth up as best as they can, as comfortably as possible, your muscles are having to hold and stabilize the system there. And so your patients and you are compromising right now, which is great until when.

Right? Until it's not.

My hope for all of our patients is to move from the right to the left so that when you open, the ball comes out of the socket. But when you bite together, the ball goes back in, and all of your teeth are touching evenly and simultaneously.

Right? So your body's not having to compensate. Well, so here is most everybody now. You see a sort of slide right there.

The teeth came together. The ball came out of the socket. That muscle that's in pink is a lateral pterygoid, and it's holding the ball out of the socket. But what we can do is we could use any little piece of plastic.

It could be a Lucia jig like you see here. By the way, isn't that a type of an appliance that we're gonna talk about? It's something that goes only in between the front teeth. Now we can use that because it keeps the back teeth apart so your body doesn't feel like it needs to compensate for anything.

We can release that muscle, that lateral pterygoid, to allow the ball to go back up in the socket. Wouldn't that be great?

But sometimes that muscle isn't... We'll use a term to programming or releasing. It's not happening really fast. Well, you have another appliance that we're gonna talk in in more detail about here in just a little bit, and that is a larger lucha jig or it's a larger some piece of plastic that keeps the back teeth apart. Keeps the back teeth apart so your body doesn't have to compensate, and now you can allow more time for that lateral pterygoid to deprogram.

So if that lateral pterygoid is now easily...

More easily deprogrammed or you've proven that it can be deprogrammed, Now you can use another appliance, right? It's a leaf gauge. It's something that goes between your front teeth. The same idea.

And now we can have our patients slide forward on the leaf and then slide back. And we're putting the ball in the socket because the lateral pterygoid is released. We're just going to keep taking a few leaves out, slide forward, back, squeeze, slide forward, back, squeeze. The ball's going in the socket every time until the patient feels something touch.

And they're going to slide forward, back and squeeze, and they're gonna feel a tooth touch, or it could be multiple teeth touching. But that is either the tooth or the teeth that touch with the ball in the socket. And now we have a bite record to where we can mount some models, whether it be in the analog or digital world, and we have a replica of the patient. Those on the far right, you can see those those dark dots.

Those are the teeth that touch with the ball in the socket. Well, it's not all of them, is it? Which means that this patient is compromising or is accommodating. There is a compromise, but the patient's body is accommodating, which is great.

Until when? Until you break a cusp and it's and it moved beyond its adaptive capacity. So now you start to see that we can take a bite record. As you see on the right, there's only a couple of teeth touching.

Those are the teeth that touch with the ball in the socket. And on the left, you can start to see you and the patient can see, oh my gosh. So when the ball's in the socket, there's those teeth in the back touching. But to get your teeth to touch, your jaw shifts slightly forward because it's a more comfortable bite.

That's how your body is accommodating. Wouldn't that be great to know for everybody? I'm gonna throw one more thing in because you're thinking, oh my god, Kevin. How do I actually document all that?

That's ridiculous. That's too much. I'm gonna go back and, again, it's been a couple of years coming, and it was just a few months ago that it was released. And I am telling you, I am addicted and so excited that AI is here.

A lot of you are using it.

Pearl's voice is grabbing whatever template you want for your exam, listening to your whole appointment, and putting it in the categories that you want because you're giving it a template. It's making the world so easy for us to document all these findings, and so you have more time to do the things you want to do, which is to adjust an appliance, which we need to get to here in a couple minutes. So speaking of that, now that we've got our clinical findings, we have to have an idea as to what we want to move towards, which is the optimal treatment, is it? Isn't it? Well, I've given you some of my words for my hope for all of our patients.

I'll tell you some words that you might trust even more, which is Pete Dawson's words. My hope for everybody is what you see here, the bullet points. Freeze them from disease freedom from disease and all mastatory system structures, maintainably healthy periodontium, stable joints. We've talked about that.

Stable occlusion. What does that look like? Maintainably healthy teeth. They probably have to be in the right place in the head.

Comfortable function. Definitely the right place in the head. Optimal aesthetics, which means they're probably gonna be doing the job they're supposed to do. The one thing that I would add that was not in his book, TMJ to smile design is you can breathe through your nose.

To get more into depth in this, again, I...

When we talk about restoring to optimal, there are a lot of camps out there.

Again, I've talked about John Koys. We just talked about Dawson. I'm affiliated with Pankey. We've talked about Spear.

I just want you to have the system that you're not bouncing all over the place. I love all of these because they make sense for me, and that's sort of what I do. I make sense of it. So for me, when we treat and plan, no matter what the patient walks in for, we start with evaluation of and what's it going to take to get the front teeth in the right place in the head to do the job they're supposed to do.

Again, wait for appliance therapy for a couple more minutes here. Because when the front teeth are in the right place in the head to do the job they're supposed to do, they will disclude or separate the back teeth in a very smooth, shallow manner and not break themselves in the process.

That's aesthetics.

We need the teeth to be in the right place in the head so that they can actually protect the back teeth. And when you bite together, I want all of your teeth touching evenly and simultaneously. Your front teeth are gonna guide them there so that all of the back teeth touch evenly and simultaneously in the right places, cusp tip to flat landing area on the top and the bottom, obviously.

And your back teeth touch just slightly harder than your front teeth because they're your chewing teeth. They're your squeezers. So I want the front teeth to touch just slightly lighter than back teeth as you see here, but be in the right position to protect back teeth when we move. That's the beginning of treatment planning.

Are your front teeth in the right place in the head to do the job they're supposed to do? If they are, now we can move on and we can get to function. But at first, every patient, we want to evaluate how close are they optimal. And if they're not optimal, what is it gonna take to get your front 12 teeth in the right place in your head to do the job they're supposed to do?

That, again, is the beginning of function. So with function, now that we've got the front teeth where they belong, we now can say, oh, they're doing...

Are they doing the job they're supposed to do? I call that the...

Lots of people call it the outside in approach, starting with anterior teeth. So if we've got models and, again, think about the piece of plastic we're gonna use here in a couple minutes. If we've if we've got models, we can start to recontour teeth, add wax, do whatever it is to get the top six teeth where they...

The top six front teeth in the right place. Same on the bottom.

Now we're starting to create a blueprint of what we might want on our appliance and in the patient's mouth at the same time. So we get to double check. Are those front teeth protecting the back teeth, or are there still some back teeth touching? We would call those interferences.

Right? And especially we don't want balancing interferences. Interferences on the opposite side that the jaw is moving. We know that that's going to have our body always compensating.

And maybe we could create something on an appliance that doesn't do this and help our patients experience that. So we get the back teeth out of the way so the front teeth can do the job they're supposed to do. Now it is really smooth. Cuspid rise all the way to one side, cuspid rise to the other side, and end to end.

And you're thinking right now, I don't want the analog world. Well, no matter what you're scanning with, no matter what software you're using, it's the same process.

You're always thinking, where do I want the top six teeth in the head to do the job they're supposed to do, top six front teeth, and where do I want the edges of the bottom six front teeth to do the job they're supposed to do?

And whether you're on an analog or virtual articulator, we're gonna move side to side and front to back and make sure that there's no back teeth touching. And if there are, we're gonna get those out of the way. This is the process. The reason I'm showing you this is we're gonna do this on an appliance, and we're gonna move that to teeth all in the next twenty five minutes here.

So now we're gonna talk about back teeth. Back teeth is easy now. All we need to do is keep the ball in the socket, have all the back teeth touching evenly and simultaneously, have the forces directed down the long axis, cusps tip to flat landing area so that the chewing system doesn't need to adapt or accommodate. So we can certainly just look at the back teeth and initial...

Any...

Initially evaluate what teeth are close to touching in the right spot.

We look from the inside and the outside, and then we can make some notes. What...

What's really close already? What cusp tips are already close to some flat landing areas? And that's gonna help you start to treatment plan and apply what you might wanna do on your appliance, which is can I recontour teeth, or what teeth are so beat up or disfigured that I'm not gonna be able to do that? And the ones that I'm not gonna be able to do that I'm gonna refigure those with wax or, again, on exocad or three shape or any of those so that I've got this visualization of what optimal is.

Once we have that blueprint, now we can pick the material. Right? This is treatment planning. And then we make sure we have the foundation, and then we make sure they can breathe through their nose.

It's after we create the blueprint, which is aesthetics and function, which is when I do wanna sit down when I talk about structure, biology, and airway, how can I get there? This is when you sit down with all of the people who are smarter than we are. Now now that you've got all this down, what could you be doing at the same time as all of this? You could actually be helping the patient feel this. Because what do you think this patient is feeling right now?

Yep. You see all those cusp tips touching, looking pretty evenly and simultaneously. The front teeth are making the back teeth come apart because on the other side is a piece of plastic. It's an appliance.

And that appliance is not just a piece of plastic because, again, this...

Let me go backwards here. You see here that this is most everybody that's listening to and watching this webinar tonight. Your body is accommodating, which is great. Until when?

Until it's not. So what we can do is we can create a piece of plastic. One of the appliance designs that we talk about is a piece of plastic. This could go on the top, but that a lot...

That is designed so that all of the back teeth touch evenly and simultaneously with the ball in the socket as you see here. But when you move your jaw in any direction, front to back or side to side, that your front teeth are making your back teeth come apart to protect them.

What is your patient experiencing right now?

Optimal, where your body's not having to accommodate so much.

How about this patient? Right? This is the same one. What are they feeling? They're feeling pretty comfortable. And when you start to think about adjusting this, it's actually... Talk about getting good at occlusion, how appliance therapy can help you. You are adjusting occlusion, but aren't you only really having to adjust half of the contacts?

Because one piece is... Want the piece of plastic is just receiving areas. So, really, you're learning occlusion on half of that.

It's a great way to build your confidence and competence and make adjustments that the patient can feel pretty quickly.

Here's the same patient. It's...

Is it really just a piece of plastic? Because this piece of plastic happens to go on the bottom. Same idea. I don't care if it's on the top or the bottom.

It's designed so the ball goes in the socket. And with the ball in the socket, when the patient bites together, all of the teeth touch evenly and simultaneously, back teeth slightly harder than front teeth. And when you move your jaw in any direction, the front teeth make your back teeth come apart to protect them because that's their job.

What would that look like? Just like this. It's a lower appliance. What is this patient experiencing now? And, again, what do you have to adjust? You only have to adjust the landing areas on the bottom, which means things can... You can feel things pretty quickly and so can the patient and you can gain your confidence and competence because it's only half of that.

So let's let's dive deep into it now. Now you've got sort of the foundation, Why would we do appliance therapy? Well, we've been talking about it for literally thirty five minutes right now. Why would you do appliance therapy?

Well, might be tooth protection. But what else do you want to do with tooth protection? It might be to help help identify or control muscle and joint stability. Okay, what type of appliance you think you'd want for that?

It might help you diagnose what is going on with the muscles and joints. How do you help diagnose that? It might be for you to say, wow, how are these teeth rubbing together and how can I better work with the patient, right, for your education? And finally, one is for the patient maybe to feel what is possible and to compare what's going on in their mouth to what is possible for them.

So that's some rationale for appliance therapy. But then everybody's like, well, what type of an appliance should I use?

Well, again, you see a a picture of one here that is creating optimal.

But why would you wanna do a flat plane? Is there a reason for that?

How about what some people call a universal? Oh my god. There's so many names. What about maxillary anterior guided orthotic?

Is it gonna go on the top or the bottom? What about a Tanner appliance named after Henry Tanner or sort of the one that's called a Taniversal? There's so many names. Or is it just anterior by an anterior bite plane?

Is it an NTI? Do you want it on the upper? Do you want it on the lower? Do you want it to be soft?

Well, let's talk about all that right now since you're starting to understand that we can have a lot of goals for an appliance, but aren't there really just six reasons to use an appliance? And we just talked about them. It's to diagnose muscles and joints. It could be to deprogram and treat muscle pain.

It could be because you're having some kind of joint pain when you move, when you go beyond, rotation into translation.

Or what if it's when... Because you have tenderness when we loaded the joint that we talked about a while ago. Right? So we're like, oof, that's probably on a medial pole. Or is it to create an occlusal experience, or is it just to protect your teeth? So aren't those really the six reasons?

And then you think to yourself, alright. I can nail those down, but, oh my god, which of these do I use? Well, there's really no matter how many names there are, there's really only eight honest appliance designs. Right?

Anterior bite plane, a...

What we'd call a full arch, in centric relation with a ramp. It could be a full arch in centric relation that's flat. It could be a full arch, but it's not in centric relation. The ball is not in the socket, but with a ramp.

The same thing on a flat plane, but it's not with a ball in the socket. Or you could be pulling the jaw forward, think about sleep appliances, or posterior pivot, which we'll talk about in a minute, or a full soft. Put whatever names you want to it. Those are really the eight different designs.

And, again, you can take a screenshot of this. You can do whatever you want. Wouldn't it be nice if it was just this simple? If I just said, well, this...

There's only those eight types. There's only six reasons. Take a picture of this and just do this.

Except it's not gonna go very well for you because it really is a thinking person's game. So let's spend ten minutes here talking about how appliance choice is influenced by the joint and muscle condition. That's why we did the exam at the beginning of the call tonight. Right?

So how do appliances affect muscle activity? Right? Is it gonna make it worse? Are they gonna go to the gym more often and do more stupid exercises?

And what's it gonna do to the joint? Is it gonna load the joint or or unload the joint a little bit? So think about this. If you were a clencher right now, just somebody who were to clench their teeth.

Right? So they love just bringing them together. Imagine if I just created you with for the first time an appliance that allows your body to not compensate.

Don't you think that maybe if I knew you were a clincher and I built you a full arch appliance in centric relation that there's a possibility your body is going to just go, like, I can squeeze better than I ever have right now. And that's okay. You know that. You're like, alright. Well, if you're already a clincher, your muscles might just be about to go off the hook. Right? Because I just gave you a posterior centric contacts and you might clench a little bit more.

Compared to this. So if I gave you just something that only anterior teeth could touch, then all those big squeezer muscles in the back can't really do the job they're supposed to do because there's no back teeth touching.

So now you start to think about, oh, if you're a clincher, I might wanna actually do anterior only right now. But what if you were somebody who grinds side to side and you're a bruxer? Let's talk about that.

If you're gonna grind side to side, and we talked about the job of the front teeth, what do you think is gonna happen? And this is an old study, right, one we always still use all the way... I mean, way back from '87, but it was one of the coolest studies ever.

And if you... If you're gonna if you're gonna brux and move side to side, what happens if there are any back teeth touching or non working side teeth touching? So anything that's beyond cuspid rise would be group function. That's green. You see the muscles fire up because it's those back teeth touching that fire up the muscles. So somebody who's bruxing, you're thinking, oh, I probably do not wanna have any, quote, unquote, group function because that's gonna fire up the muscles.

I'd be remiss if I didn't say why are you bruxing in the first place. Right? And I know this is not about airway or sleep tonight, but we know that so many of our patients that are having nighttime bruxism are bruxing because they can't breathe.

So one of the appliances that we already talked about quickly mentioned would be a directive appliance, would be pulling the lower jaw forward, pulling the ball out of the socket to create more space for airway and decrease the bruxing. But again, now start to think what impact is that going to have on muscles and joints. So let's just really now narrow it back down to appliances and muscles muscles.

Well, if I gave you an anterior only appliance right now, you're getting the flow of this. You're like, oh, obviously that's going to decrease muscle activity. You're not gonna be able to clench. And when you go side to side, there's no back teeth touching. Brilliant. What if I gave you a full coverage appliance or one that only had back teeth touching?

Oh my gosh, if I did that for you, what's going to happen to the muscles? All back teeth are touching, there's going be no front teeth discluding them, your muscles are going to go crazy, right? They are going to, those muscles are going to go into just hyperactivity. They're gonna be working all day long. Right? So what if I gave you a full coverage appliance that then discluded your back teeth when you went side to side? Oh, wouldn't that be great potentially?

Because now you're going to decrease muscle activity when you go side to side, but still give you a nice place to rest your back teeth.

The last one I'd bring up with respect to muscles is this: any appliance that is all soft, I would...

Is only gonna have one impact on the muscles, and that is they're gonna be they're gonna be going to the gym all day long. It's soft. It's hard to get the front teeth to exclude the back teeth. That...

Your your patient will probably have sore muscles because they're gonna be going to the gym all the time.

So what about joints then? The temporomandibular joint. Well, this is where it gets sort of fun, but not fun because you're now a thinking person. So when we think about shoving the ball up into the socket.

Right? What what helps shove the ball up into the socket? Well, it is when the front teeth touch because we...

It is a it is a lever. So literally, when only front teeth are touching, you are having 60% of the entire force as possible directed right into the joints. You are shoving the ball into the socket when there's only front teeth touching. Whereas if you've got second molars touching, because it's a lever, it is actually going to help protect the joint and decrease the load on the joint.

Now we're putting it all together, right? So if you have an anterior only appliance it's going to decrease the muscle activity but it is let me let me say that differently. It is going to increase the joint loading. It's gonna shove the ball onto the socket, but it's going to decrease the muscle activity.

What if... Let me go here. There you go. If activity decreases. If... Now imagine if you had a posterior only appliance, only back teeth touching, the good news is that's gonna reduce the joint loading. So if you really have somebody that has some current active internal joint derangement, the one we don't like where the medial pole was funny when we loaded the joint, then you might want this appliance. But it's a very rare time that you might want that.

However, a full coverage appliance, oh my gosh, wouldn't that be nice? Because it reduces joint loading during clinching, but not during excursions unless there's reduced activity because you've got anterior guidance. So you sort of get to test everything. So when you look at this whole crazy list of appliances, what I want you to see here is this one.

In my opinion, and that's what you get tonight, is why would you not, unless you are having joint pain unloading with the medial pole, you see the big red x on that on that column right there, why would you not just start with creating an optimal chewing experience for your patient and seeing how the body responds? So we can do that. And, in the analog world, it we...

It can be very predictable. I'm not gonna walk through this with you. But if you've got your articulator set up with the ball and the sockets, you've got a bite record in central...

In centric relation with the ball and the socket, a fully seated collar position. How easy could you put some acrylic, right, old school, put some acrylic in that space and close it together, and now you've got all the cusp tips touching all those flat landing areas without...

Before you even make any adjustments. The ball's in the socket, all the back teeth are touching evenly and simultaneously, And it's in the right space for the front teeth to do the job they're supposed to do. So isn't this appliance really a replica of the teeth that are underneath, but you get to toy with it a little bit and see how your patient responds. When they move side to side and front and back, you have an opportunity to create an optimal experience for your patient because we are actually creating fossils just like the natural teeth.

So the cusp tips have to get out of of those areas. Right? Are they actually getting out and clearing the areas just like natural teeth? I'm not gonna spend a lot of time on crossover night, but to get those areas out of the teeth, that means your front teeth have to do the job they're supposed to do, which is to protect the back teeth and even move beyond that.

We call that crossover. So the relationship of the of the anterior teeth beyond cuspid rise or end to end. A quick demo of the...

A description of this is here. As you see, the lower jaw is moving in that direction and the cuspid is making the back teeth come apart. Right? That's its job.

However, on the right hand side here, you see as the jaw continues to move in that direction, the front teeth pick up when you move beyond cuspid rise. We call that crossover. Right? So the front tooth picks up when you move beyond cuspid rise.

So same idea on this side. So the jaw is moving in the other direction.

That cuspid is helping to protect the back teeth, but when you move beyond cuspid rise, when the jaw continues to move in that direction, the front teeth pick up and help the jaw continue to move in that direction. So that is crossover.

So, well, we can now test that all on this piece of plastic, can't we? That's designed intentionally so that your patient does not have to compensate anymore. What is your patient experiencing right here?

Optimal.

And the good news is, again, to adjust it, you're only having to adjust the receiving areas, getting any cusp tips that happen to be reminiscent of a cusp tip on top to touch as evenly and simultaneously as possible on the bottom. And when you move your jaw in any direction, your front teeth make your back teeth come apart in a smooth, shallow manner. And you get to, excuse me, only play with half of that. So you've seen this before.

Same idea. Now you're seeing a little bit differently. It's not just a piece of plastic. It's getting as many cusp tips that are even things that are close to cusp tips touching as evenly as possible with the ball and the socket and getting the front teeth to disclude the back teeth.

Right? So what seems so complicated is really just half of that.

So now when you start to see an appliance, I want you to start to look at, isn't it really just a bigger surface for teeth? That's your incisal edge.

Those are your back teeth, and now we get to adjust those with intention.

Teeth that look pretty beat up.

Right? There's not a lot of cusp tips.

There...

There's there's erosion on all of the...

Most of the buccal cusps. Again, So maybe you...

Then maybe this is when you'd want to put an appliance on the bottom because the top teeth actually have some cusp tips and now the bottom is a receiving area for all of those upper cusp tips to come touch evenly and simultaneously, and the front teeth get to disclude the back teeth. So isn't this the same as I showed you on the analog articulator? But, yes, you can do this in the digital world, but the concepts are still the same, aren't they? We're still gonna move side to side, front to back, and make sure all of the teeth are touching evenly and simultaneously with that piece of plastic in there.

It's one and the same. Now with the few minutes I have remaining, I do wanna take just two or three minutes talking about those front teeth because this is part of appliance therapy as well, isn't it? It's the way the front teeth touch. The front teeth have what we call a pitch.

That's the incisal edge. And then they've got a leading bevel and a trailing bevel, so a bevel on both sides.

Why is that important, and how are we gonna use that in appliance therapy? Well, think about it. If right now you bring your teeth end to end as you see here, isn't that the pitch on the pitch? If they are if they are the same, the same vector, there's a landing area. And as they move in that direction, the bevel is gonna make a difference. So, again, we've got a leading bevel and a trailing bevel that gets us all the way to crossover. Cuspid rise, there's a leading bevel and then a trailing bevel on the cuspid and then the pitch of the central's pick up.

Well, how can you get good at this and help your patient see how good it could feel? It's a piece of plastic, isn't it? Isn't this really just the incisal edge we just talked about? It's just a little bit bigger and easier to play with and completely reversible.

So it's the same as a tooth. It has a pitch. It's got a leading bevel, and it's got a trailing bevel. You just have more area to play with.

And, again, it's completely reversible because when we get to the teeth, which we're gonna talk about in a minute, we still have a pitch. We've got a leading bevel, and we've got a trailing bevel. And if we're intentional with these, now you can start to see that the appliance is really just a tooth, and the appliance is going to help the patient understand what's going on and us as well. So let's spend the last four or five minutes here talking about going from plastic to enamel on teeth and then finish with the case and then be open for some questions.

So, again, now you're starting to see, oh, I could learn on an appliance that maybe I could just adjust a pitch. Maybe you can call it equilibrating if you want. I just call it doing appropriate treatment for the patient to help their body compensate a little bit less.

Right? So we start to see that we could actually adjust the pitch. Or as you see on the bottom two photos, we can we can adjust the bevel and make it nice and smooth.

On the bottom photo here, isn't that what you did on the appliance?

But now maybe this is a way to help the patient slowly move towards optimal in a way that's appropriate for them just to get their teeth to work together in harmony and compensate a little bit less.

Right? You see the pitch and the trailing and leading bevel.

You see these teeth aren't just teeth anymore. You start to see the leading bevel. You start to see the pitch.

And you know what I'm about to say. You start to see the trailing bevel.

So even on an appliance, it's not just getting back teeth to touch. It's getting front teeth to touch so the patient can experience that. And I... Again, I can't bring this up without saying, why is this so important? Why even if all we do for our patients is use appliance therapy help diagnose what's going on, everything we talked about, but help create an an experience for our patient and help us get better at adjusting?

Because here's what happens sometimes. We just... We do veneers or composites on, let's say, it's just the upper teeth. Or what if we don't adjust the front teeth at all and just leave them rough? What do you think is gonna happen if those teeth continue to rub on each other and we haven't even thought about the pitch and bevel and their rough surfaces rubbing on each other? How quickly are they gonna break down?

But what if all we do is take some time to make sure those front teeth are rubbing on each other in the right...

With the pitch and the bevel, and how much longer are those going to last?

Said differently, this patient, I want... When she bites together, I want all of the teeth touching evenly and simultaneously just like she experienced on her appliance. But when she moves to one side and continues the pitch and the bevel all line up, moving to the other side, pitch and bevel all the way to crossover and end to end. So how do we make all that happen? Well, sorry. I'm gonna run, like, two, three minutes over, but, again, we started just a couple minutes late.

So, again, let's go back to Toni. Now that she's experienced that on an appliance and we've trusted our process for treatment planning, can't we even on the very first appointment just do some recontouring of enamel? Because we saw it on the on the models first. While she's wearing a provisional on that broken second molar, I can now help her move closer to optimal health. It's the same adjustments I did on her appliance, cusp tip to flat landing area.

And now I can come in and restore just her left side.

But while I'm restoring her left side, I can still do more adjustments like I did on the appliance and make them even make them even better, more dialed in.

Right? And now as I'm designing that appliance, I know exactly where I want the cusp tips and landing areas. Because once the function is there, the structure is not so important, is it? I'm not so worried about zirconia or lithium disilicate or composite.

The left side's now done, and that's just like I did on the appliance. So now I can come months later, maybe a year later, and I can do the right side helping her move towards optimal health and make those provisionals and her final restorations with cusp tips and landing areas exactly like she experienced on the appliance. I knew exactly where I needed that cusp tip and where that landing area was going to be so that when when we're done, and this is almost done, right now she's got all of her back teeth touching evenly and simultaneously, mostly cusp tip to flat landing area, and her front teeth are making her back teeth come apart with just a few pieces of lithium disilicate and some composite and recontouring. True or false? This is a full mouth rehabilitation.

True.

And she got to experience that on an appliance first to prove that things were gonna feel good, and it gave her something to compare to as we were restoring her so that all of her teeth touch evenly and simultaneously. And when she moves side to side, her front teeth make her back teeth come apart.

So again, my hope is that whatever appliance you do pick, you pick it with intention, whether it's an upper appliance or a lower appliance, understanding the impact it's having on the muscles and the joints and the reason you're actually using the appliance and the conversations you're having with the patient. That was a lot in just an hour. It was almost exactly an hour. I know I went through that quickly just to get it all out there.

Before we take some questions, I do wanna personally thank you for any questions you have, follow-up questions, or anything you think I can do to help you in your practice. That's what I do all day every day. I have...

I have am gifted and...

I'm not gifted. I am...

I'm grateful for the opportunity to work with people like you. And I also wanna thank Catapult for their professionalism and putting on such amazing webinars and education and Pearl for supporting me and for being the amazing company they are. So make sure you grab my information if you need me. What I'm gonna do right now is stop sharing and I did have time to go.

I did see Julie, yes, there's always a concern, and again, I should have been more specific about it, so I'm glad you asked about posterior supereruption with anterior only appliances.

In my opinion, which is what you get tonight, anterior only appliances are only short term for diagnostic purposes. Right?

And again, I speak for me, it is really to let muscles release, to verify the condition of the joints and muscles, and once I know it's safe or I have an understanding of what's going on, I will almost always go to that full arch appliance that is optimal to see how your body responds. Now certainly, you can do an anterior only appliance well, like on top of an Essex and keep the teeth, you know, at least the top teeth from super erupting. But it... And, you know, lots of people will teach that. That's that's not my hope for anybody. It is short term diagnostic and then move into the full arch appliance unless there's something else going on.

Yeah, don't know if it's worn twenty four hours. Oh, I love that.

Melissa, great question. Are they worn twenty four hours? I... And do they eat with the appliance? You know, some people always say that, well, you know, it's it's a it's a nightguard. You can tell I didn't say anything about nightguards, But you can certainly wear it at nighttime to protect your teeth, but even an appliance that's worn at night to protect your teeth... Again, I'm very...

I'm I'm an extreme on this, but why would I still not make it optimal for you? Why... Whatever you're doing at nighttime, why do I still not want your muscles working in harmony and all of your teeth touching immediately and simultaneously when you grind for your front teeth to disclude in a smooth shallow manner? So I never say the patient only wear it here.

I say what is our goal for this appliance? If it's just to protect your teeth at nighttime, great. Wear it at nighttime. However, if we're trying to identify or prove our hypothesis or, you know, is the toothache going to go away or the joints going to feel better?

Is the muscle going to feel better? Is the fremitus going to go away? All of that. My answer is the more you wear it, the more we're going to find out.

The more you wear it during the day, you're going to have something to compare to because you're actually thinking about it. So for me, again, that's engagement with the patient and that's partnering with them. And it's the more you wear it, the more we're going to learn, the more you wear it, the more you're going to learn and how much do you want to learn and and what what is our goal for the appliance.

So that... That's my sort of quick answer to that right there.

Thoughts on screening all these patients at minimum with high risk pulse. Oh, well, see, now you're getting into... So, Ben, that's a great great question. That's... I gotta I gotta do, like, a full day on on airway.

But, yes, if you have a high res pulse ox and why not, do some screening? Obviously you're not diagnosing. And I will also always start with can you breathe through your nose? Right?

Do you have nasal patency? But, yes, I am a huge fan of anything checking airway. If you're using an appliance or they're grinding their teeth, there's probably a reason. And these days, we know that a big reason for that is you can't breathe through your nose.

So, yes, and thank you for bringing that up.

And a bunch of thank yous. You're all welcome.

There's some questions in the q and a box. Would you like me to read them off?

Okay. Oh, yeah. Thanks. I'm not smart enough to do that. Thank you.

That's what I'm here for. Okay. Thanks. How do you manage to create more room on the quick splint when they have too much posterior interference and can't get them on their canine efficiently? Sometimes I feel you grind away almost the entire posterior portion of the QS to get the anterior teeth to touch.

Right on. And you know what's interesting with the Quicksplint, and I love the company. I've loved them forever. I love them as a device. It is you're a thinking person, which is I don't even need the cusp of touching. Right? I just... The Quicksplint is something they can go home with that's... That they're not gonna swallow.

Right? Because we used to send patients home, don't tell anybody this, with, a Lucha jig, and we we spray or do whatever we do that they didn't swallow it while they were sleeping. So a quick splint is just a go home Lucha jig, and I don't need the cuspids touching. So I will I will take a a lathe or an acrylic bur and bring it because, mean, honestly, it goes back to some people's premolars, which is exactly what you don't want.

It's...

At least it's starting that big. So I will continue to bring it in till it's almost all the way to the laterals and centrals, and for almost everybody, that gets the back teeth apart. The other way to do it, obviously, is two quick splints. You can do an upper and a lower.

It's still flat on flat, and it's nice and smooth. Right? Or you can do a quick splint with a Lucia jig. So anything that is flat and smooth on the top and the bottom if you need more vertical space to keep the back teeth apart.

So this is when it becomes a fun thinking person's game. Great question.

Please comment about posterior teeth intrusion with a posterior only appliance.

Oh, man. You guys are great. So, again, a posterior only appliance, the only time I would...

Posterior pivot or posterior only appliance, the only time you would, in my opinion that you would wear that is when you are really trying to support the temporomandibular joint because it's got a history of nothing good. Right? All you're trying to do is decrease the load on the joint because either it has some active internal joint derangement or a big history that you're trying not to fire up, and that is you're taking a lesser of two evils. Right?

So might I intrude? Yes. But I'm also not wearing it all day long like anything else unless I am. And then my conversation with the patient is how can we help get you out of this situation?

Right? Which is, you know, I'm not gonna go into surgery tonight, but is is there a little arthrocentesis? Is there... Do you go see an an oral surgeon that's gonna help that while I'm supporting it and then get you off of that posterior pivot and back onto a full arch appliance? Great question. Catch... You caught that one.

When you make a max splint and it's in position, when patient's jaw slides forward, we don't want the front teeth touching. Is that correct? No anterior platform?

Nope. Incorrect. Oh, in any movement, any jaw movement, the front... The job of the front teeth is to make the back teeth come apart, including straight protrusion. Right, so again that's why we have the leading and trailing bevels as well. As your lower jaw is moving forward, you want the leading bevel of the lower teeth getting you to the pitch, and if you move beyond then it's the trailing bevel, And so, absolutely, I don't want back teeth... Any... Anything out of maximum intercuspation and centric relation, I don't want your back teeth to ever touch, and that's the job of the front teeth. So, yes, front teeth should be touching in every movement that's outside of clenching.

Which articulating paper is best to use when checking the bite, be it in CR, excursive, and lateral movements?

Oh, man. I wish I'd bite in if we had hours for this.

So I'm really biased. You know, any articulating paper that you are using with intention is good. I'm okay with AccuFilm. My favorite, though, it's messy, but when you start to learn how to read it, it's it's a gift.

And that is Madame Butterfly Silk. But I can't say that without saying whether you're AccuFilm or Madame Butterfly or anything else. The technique for me is I have six Miller's forceps. I know that sounds like a lot, but I have two that have some Kleenex or tissue on them, and I have the patient bite on those first.

It's way better than air or anything else to dry. You tap on some tissue paper and they are bone dry. Now they stay open, and you come in with one color. So it's red with madame butterfly.

Have them slide side to side and front and back so you can see all the excursive movements, and then put...

Then you have the other two Miller's forceps ready to go with green or blue, and you tap tap. So they were dry. You've got red while they were dry to see the excursive interference or excursive movements, and then green or blue for tap tap. So it's two different colors and dry like crazy and don't let them get saliva in when you're going through those...

Through that process.

Beautiful. Beautiful. Yeah. Beautiful.

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